I I!illl liii IEI iiiii i@ll@l       l@ll lit,
                                                                                                               -x i- 00 t

                                       7' T
                                       IY4.OOVL"R                 CO-NIP
                                                          -1@ 6 -,66

                                                                                       I!" 3
                                DE'PART@T,,"@T Or         T-,DITCATIOTL A@ID @17ELPARE
                                   P7@"PTI@@IC7 01' AD HOC CO,'@'iStjLTA.\ITS PT-,VIE@'7ITIC,
                                             MRDICA.L PROC@P"! APPLICP-TIOTTS
                                                                Conferenc.e Roorn  11
                                                                Parkl.a@@7n Ptiilc9.incT
                                                                5(,OO risliers  La.ne
                                                                Rockvill(-, @.4c-;-ryland  202-52
                                                                ThursOa-,I, !-4ay 23, 19'74
                            Panel B conlieneO at 8:40 o'cl-ock, a.ir..      14r. 'Peterson
                      ChEii.rr,,an, nre.-,iclincr.
                      TI'ATIT'T,
                                  (,As licretofore notrO.)

                                                                                        C  0  't I  T  @l,  @l  T  c.;
                                                                                                                                                                               c--.i rT e
                                                                                       -.Ian   for  Orcgon                                                                     11)   5
                                            Pr7
                                                                     Motion            for                         recommendation                                              204
                                            RerTi.ona,l                                'Dlan           for           ('aliforn-ia                                              2  0  5
                                                                     @iotion           for                        recornmen0ation                                              212
                                                                     Motion            for                        recororen6ation                                              232
                                            P,r,-qion,-il                      Pie(.ical Ill.an   for  'DLic-rto  Pico
                                                                     Motion            For                  recoTnT,,c--no',ation                                              23")
                                            P,e,crional                                T'lan   for  the
                                                        "oi-intain               @)tc7.i-of3                                                                                   2  4  2
                                                                     l@ot;-on          -rnr                       rccorr-enOaticn                                              ?19
                                                                     ',,Ioti.on        for                rccol,-,rnc-l-,f,,ation                                              r)   14
                                                                                       or
                                                                             !@'@@.-@cal -lan   -.For                                                                          2 r-,, 0
                                                                                                                                                                               1) P, A.
                                                                     @lotion           for                   r-,3cor-,-3nOati.-on
                                                                     @ioti-on          'cr                                                                                     2  5-.7
                                                                     ','@'.oticn       for                       r@co-rrenrlaticn                                              2pp@
                                             T.Zcc-ionz,.!                             @lan   i'or  'IeTir  Ter@o.-t,                                                          2    ci
                                                                     Motion            for                         recorrendation                                              29r)
                                                                     f-lotion          for                    re-cori-,cncl.ation                                              30    5
                                             P..eqional-                       I-ledical nlp.n   for  Pcchester,
                                                                     vorl-,                                                                                                    307
                                                                     Motion            --For                     reccnuien(lation                                              3ii
                                             P.,P-@ional                      Ili@(lical ',?)-an   for  @,'7@ishinrTton
                                                         an6                      Alaska                                                                                       312
                                                                     I-lotion          for                       recor@renrlation                                              31@5
                                                                     I,-!otion         for            rcc-.oT;.iir-enrlat-'@(.)r)                                              322

                                                                                            lr@'4 - A
                                                 C 0 T,'@' T T@7 T
                                                                      (Continued)
                         AFq'ERI-10011 Sr@913IO,'l                                                    -I  7
                                      ,"P-(Iical Plan for l@7est(@-rn renn-,Yl.v,-inia                336
                                        P,Ioti.on  for  r(?cc)rimendation                             3  50
                         Virc@l-i-nia. R(--gional- @4eOical TrocTrar.                                 355
                                        !,!.Otion for  rccorT,-.,en(Ic-Ltion                          36  7
                                .ecormc;nc,e.. Teri-i. c F- I T, I- F- n F o r t' -i e
                                                                     the I,ake-,  @.reci              3 r. 9
                                        !notion   -f(@--   .-ecor,.--enea.tion                        3n2
                                        Motion  for   )-occTmp-n('.E,-.i-c)n                          40r)
                                                       TrocTra.m for the
                               Peci-n-nal   -e. r, i c a'.
                                f'@tate of ila.rvlzinc7L
                                        lic)tion  7or     reccml-nn@-z;.tic)n
                         H7W Reaicnal kle@ica'L @l.an for tho
                                D-L.-,trict of Columl)ia                                              @25
                                        I'@loticn   for    rc-,co-nTnen(lation                        4 31)
                         I-T-'-r@,,7 Pegional "leeical '?]-an for
                                LoncT Islan@, @,-7e@,7 vork anO @Tassau-
                                 Suffol-% Counties                                                    443
                                        @,@otion      for       recoTmpneation                        @55
                          TIPI,T RecTional !,,eO-4.cal !'Ilan for
                                 Susauchanna N:al-lev                                                 461
                                        @40tion     for      recoplj,-en0ation                        4  72

    7t 1                                                              p R 0 c E E D I A G s
    iurs
                                                  [Th(,,  B  '2-iTicl  @.7as  called  to  order  at  8  it-0  a.m.  !Dy
            n                    a.    L@.     T-leterro,-i,     ttic,     C'@@a.irman.]
                                                                  PETERSI@)'@i:             l@,7e     are     still     missing,     a     coiinle
                                 of  peonle.
                                                  I     took     some      stuff      home      last      ni(                      is
                                                                                                            .jlit      and      this    just  to!
                                 Clive  vou  an  idea  of  -vihat .@7e  did  Yesterday.     [Indicatinq                                     the
                                 blaclcboard,l,  on  %7hich was  inscribed
                                                                                                       Rec  77und-
                                                                      Overall    Item                  ing     in     l@s      %!Zca          %  Tar&e+--
                                 Alban-,,-  (1)                       SU.?             3.0                   1.066              @100          70
                                 T,Iaine                              S u-@)           2.9+                  1,600             8   0          12,0
                                                                      AA   S           2.5                  700                67             5
                                 C,D Valle@@7                                          2 .  5          2    30   0             82
                                                                                                                                              61
                                 C-@-I  York                          Aug              1.8                  615                77
                                                                      Ai-ta            1.8                                     70             70
                                 ,.la,,.7aiit                                                                1,109
                                 Ariz  (1)                            Bi%              1.7                  860                64             50
                                 Conn                                 BA   Poon        1.6                  510                80             22
                                                                                                            $8,751         c   80             70
                                                                                It     seemed     to     me      t',Lie      realons fell     out-
                                 into  al:)otit  four  nice  cTroups.
                                                   The  first  column  indicates  that  sort  of  overall  ratin-r
                                 that revie@.,,crs aave "Sun,2rior",  ".@bove AveracTe",  "Belo%.7
                                 Averaa(--",          or         "Poor.
                                                    !4o%.i     the     second     colur,.in      is      sort      of      an      itemization.
                                 You     Still     -recall     that     you     i@7cre      asked      to      chec'i',      "Cood",   "Averacje

  t 2                "Bclo%q Avera,7e" -- and I sort of ,,Yc-,i-cThtc@ that as  11311,  "2"  and
                               t count in where pcon)-e said there i.,7as insufficient
                     and diciii'
                     basis for judgment.  And again, it seems to me those sco
                                                                                        res,
                     that itemized kinO of scorin(T is rouqhlNi consistent with  the
                     verbal score.
                                 And then I indicated i-.71-iat your recommended fundincT
                     levels Caere, in thousands.
                                 @.nd the last tN,'70 columns are the   percentc-,ige- of that
                     recorn-r.ene,ation vis-a-vi.s the request in the     first column;
                     and vis-a-vis the overall target fic-ure or level for that
                     ret73-on.
                                 So i,7e do have in,:irled disparities      II,ai..ne, -for
                     if ,ou -,.fill recall, theirs i-s onl,;, comiTic  in now (1)
                                 Connecticu@@ is at the very @ottori of the list.  -@@s
                     it ',Ianr@-cned, heir initial request was really quite modest
                     co,-,'Oared to what .je were exnectina.
                                 But this is noti'lin,,T authoritative or final, but I
                     thougi-it vou mig',--It be interested in just  -,ort of seeing one        a,,,r
                     of  .--u+-- k@-incT, ho@-i things care out yesterday.   It did seem to r,@e
                     the-,7 sort of fell out   into four ec,,ual cirou-)s,   rather than  t,@170
                     -,mall  ones  and  then  the  middle  --  we  don't  have  a  bell   shamed
                     @urve        ,@ihich I guess is something that educators are ex-
                     treriel,7 interested in.
                                 DR. TESCE@-'I:    That's  because  tliev  are   saving   taoney
                      or the nroqram.

                                                                            187
     3                       1-71-7E CIIAI@TI.I@TT: Well --yes. Those are- rouc.Th np-rceii,@-aCTC C@
                   at ti'le 'i.)ottom. You r-cco@tmended about 80 Percent of the
                   requests in the acgreqate, and about 70   percent of the tarQct
                   figures -- on the eicTI-it recTions we looked at yesterday.
                             Well, I'm not sure that we rcallv ira.nt to wait on
                   ,,',ill and Toe. We @.!ere aoin(7 to take up Puerto @,ico first, and'
                   both of those are Puerto Ri-co
                                                  people.
                             DJ.'. ,-.cCALI,: llo,,.7 about taking @,lest Virginia first?
                             TIIE             Well.  or otherwise
                             You haven't had your coffee vet, Sister    Ann, would
                   you mind if we qo to 17cst Virginia?    Otherwise,  I was aoina -Lo@
                   0 to Oregon.  S'-,ic was the orlv o-crson @,7e didn't cret tovasterday
                   9
                   -- and, T.,,ell, that wasn't entirely accidental, there was a
                   little collusion with the chairman.     It was -part of the
                   ecumenical T-iovei-.c,.nt. [Laualiter.
                             I,,,'h@,7 cbn't we start !..,,i.tli T,,Te s tVir(-inia, then, -@nd let
                   Sister -@.nn drink her coffee -- and ma@7be then bv that tirie
                   Bill Thurman and L-Joe @,7ill be here. if they aren't, they'll
                   have two Y)laci-, marks apiece   thevlve alreadv qot one.
                   (Laug'lt(--r.]
                             And on latest Virginia, @7c have  Paul Tescl'lan and ,--hari-s
                             and vou Pe
                   .-.cCall             oT)le have colluded -- or do vou @@7an,@- to flin
                                                                                       7
                   acoin?
                             DR. T@SCTIAN:  11@o.
                                            I     I            I vield the floor Author
                                                  )r. jl,,'cCall,
                   pleasure to my senior colleague; from -Le.@as.

                                                                                      188
    A                         "'HE CIIAI-T-@7'Z: No@.7 if we are going to ,jet into these
                    Senate tvpe  protocol, Caere not going to aet fourteen regions
                    done-todav.    [Laught@r.)
                              DR. !@','cCALL:  I'm not sure whether I accept the floor
                    under those circumstances.
                               I'm sorrv  Bill  is  not  here.  I  wanted  to  point  out
                    to him that I find another "SuT)erior" region, but that I'r.
                    not one that came in ,.7ith t,,.7o volums of elaborate amplification
                    Y)er Se  -- but just the onoosiLe.       k quarter inch, non-           i
                    bound, non-color, bl.acl@ and.@7'n.Lte aD-Dlication that  is  one  of
                    t'ie simplest, clearest, i,-iost  conci--e aT)nlications tiiat I've
                    read     and it's siri-c)le for a  lot  of reasons:
                               One,  is  the  state,   itself, and the  the-,7 i-iave
                                                                      v
                    developed the   nroaram, bulk-- also because this  application is
   0
                    a recTuest for  support for staff, and onlv tio continuation
                    projects     !.ii-th the plan to come in for all of their neT,,7
                    programs  in Julv.
                               And that is clearl,7 as stated here, it is a reaion
                    that came in rather late in terms of the overall            56
                    that ultiratr--lv  -,,,as our peak -- so that tl
                                                                     iev came in,
                    developed their   T)roQram based on the neeris of the region,
                    developed theix   priorities, stucl!-. with then, haven't had      to
                    shift them      they have a strong staff and region advisory
                    grouT) leadership and an integrated proaram that has been
                    consistent, right along.

                                                                                     189
  t 4                           And I have alreadv  mentioned  that  i.tls  reallk,,  a  staff
  @ge 4A
                    [3roposal, Primarily, -- just   t@,ro continuation projects           just
                                  continued in other funds.
                                I think the feasibility of their accomplishing, in the
                    lirTht of @7hat they say here. vihat they have done in the -past,
                    is excellent      and @,7hile there is  not  a  lot  of  information  on
                    7P,-P relationships -- there is nothing that indicates there is
                        nrobl---ii nO'@7 there, at all..
                                They are reauestincT,   no-,,7, 663,132.   The  onlv  thina  I
                    -qould noi.nt out there is that    there is a significant indirect
                    @ost in this that has come up      before,  about  130  some  odd  --  or
                    136,663 which -,.ias indirect cost       but that is an establi-s'-ieCi
                    'I--hi@ng that @,70 couldn't do an,ithinq ai-)out at this point in  time.
                    1 merely call it to ,7our attention.
                                1,@nci I think I'll sto-o there.
                                The @7.,ea4-onal -@@dvisor,7 Groun is a little heav@7 on  thc.
                     rofessional T,"e-wershin, but it's t@iere -- I don't think  it's  a
                    ;erious oroblem.
                                                 Pciul?
                                DT.Z. r."ESC',I-@l: T,7e have no reason to disagree -.,7it@l  an,7-
                    -hing that has been said.  It's a pleasure to read a program               I
                    --hat has not onlv ',:)een able to carry    -- not onl-,), been able to
                    ,accumulate funds   currently,   and   arrange   ongoing funding  --   lut
                    i,,,hd is able to accumulate funds concurrcntlv  in      multiples --
                     .e., -,,7here they @@7ill put in  half  a  million  and they @.?ill be

                                                                                               igo
                        running about a ti.:o to three million dollar program
     5
                        that   @.7hcn  P2-IP  was  going  to  -)hage   out,   the   Governor   and   the
                        State   Government were ready         to take the staff on.             It
                        looks  as     if they are as far        along   bccominct   the   follo@,i
                        operation     of PIIP as anv rcqion that %.!e have come across.
                                      I-.le have kno@-in Charlie, in operation of West
                        Virginia, because it's a  mer-loership in the Southeastern CROUT)
                        and @?ye have been a@@.lare of this development in the general
                        direction, un to no@i.
                                      ,hev seen to accorqnlish more          interaction, and
                        startina   of   more   services   and   devel-o-oina   of   manpower,    @,Titill
                        fe@ver dollars t-@lian almost any        group @.7c,- are aT@iare of.
                        So   mv   recommendation   --   if   I   can   nree-mot the  dignit7;,  of r,,.y
                        T)rce,eccssor          would reco!-.-Lnend   f tinO incT as  rec:i:tested.
                                                        I'll  second      that.
                                      THE                 O.Tz'.   Before    we opera that u-o         as
                        Charlie   did   indicate,   this   is   a   verv,    in one   sense,   a    verv
                        modest application            a   continuation   of    nroararq    staff    with
                        fundina  --   a   sliQht   expansion   in   view   there   and   a   cou-)Ie   of
                        projects         so   that   it   totals   @663,000.00   in    round    nu,@,ers.
                                      They do anticipate comina in with a major su_oplerental@
                        application injulv for $1.2 million.
                                      DR. I!c,OALL:   But that, added to this, would nut ther,!
                        above the target.   1,7e're recognizing that.
                                      But I tl.'Iinl@ we are in a position         to  let  them   mal-.e

                                                                          igi
                   the judgment of what 'I--hey do come in with, in their new
                   committee.
                             TFIE CIIAIP@,LV@l:  All we knew -- this is one of the
                   reasons -- this is one of ma@,,,be eight or ten, where the initial
                   application is, indeed, restricted to continuation  and to
                   program staff -- and all of their new activities will be
                   reflected in the iulv submission.
                             O.N.,, !\Torm, are there anv comments regarding CAP
                   or this matter
                             I recall @,7est Virginia has at least considered, over I
                   the years, some possibility of disassociation from the
                   University    but I'm not sure Whether that ever got much bevcnd
                   a sort of
                             @@iR. NOR@-L'V,-i A7-TDE:T-',SO-@4: Anv AgencN.7 Director is a
                    ember. of the LecTal 2%dvisor,,, (,roup, and t,ic@.r did 'recor@-n@-nc3,
                   annroval. of this particular anDlication.  @,nd as- I said, it
                   has been nreviouslv anD--oved by the aqencv, since the wor"@  is
                   continuing on schedule.
                             The major thrust  of the urocrram we can anticipate in@i@
                   the next application, will  be on the State-@@?ide basis, as
                   opposed to the individual project, or community basis.
                   Now I think it orobablv will be  the size that thev will get.
                              DR. TESCTIP,14':  They have helped build PAC aaencies
                   in an area.
                              TIIE           Tom, do you have anv particular

                                                                            192     i
                                            Virginia?
  ,it 7           'into this as regards West
                            MR. SIMONDS:  Well I think Norm summed it up very
                  well.  That's a pretty good state.
                            THE CHAIRMAN:  Most of  West Virginia is still that way,,
                  I know.
                            We do have a recommendation     but are there additional
                  comments,, questions, observations.
                            MR. BARROWS: I would like to  ask  a  question,  just  as
                  a matter of my own information:    What qualities, as  you  fellows
                  isee it, accounts for this marvelous support on the part of
                  Itheir constituency?
                            DR. McCALL:    The usual fact of strong, capable
                  Ileadership involving
                            MR. BARROWS:   On the part of the coordinator, or do
                  Ithey have a good RAG too?
                            DR. McCALL:  I  think it goes on further than that
                            MR. NASH:    The coordinator, the utiversityll and the
                  force of the medical society
                            They started off with  -- had the RAGs to start with
                  and they haven't had to shift.   They have been right on target
                  throughout.
                            MR. BARROWS:     The university and the medical
                  isociety &re united -- i.e. -- they both agree.  Now, I didn't
                  say the relationship was good between the medical society and
                  lithe university, but both units support the RMP.
        PORTING CO, INC.
   320 t@lassachusetts Avenue, tq.1.
  Wasfiingtof,@, D@C. 20092

                                                                      193
                            DR. TESCHAN:  There's a very important phrase     about
                 ihalf of one line in the application that says that, in  working
                 with the medical societies in the health  delivery  area,  they
                 have restricted their activities to their legislative franchise.
                 And then the thing goes on.
                            Well, anybody  who reads English in the context that
                 ,we have all experienced it, will know exactly what they mean.
                 That says that Charley's been very careful as a non-MD,
                 he's been very careful and he's working with full understanding
                 with the People who might otherwise take umbrage.
                            MR. NASH:  That's right.
                            THE CHAIRMAN:   I think I've observed something
                 this isn't just West Virginia -- it does seem to me that in
                 those states which have, perhaps less in the way of health
                 ,resources, institutionally and otherwise (and Maine falls  into
                 that category certainly) and during the phaseout period, they
                 seem a little more, for whatever reasons, anxious to preserve
                 .what little they've got, including the RMP, than  some  states
                 ,Lhere there is almost an embarrassment of riches, in one sense.
                            I don't know that that's an axiom,   but I have that
                  mpression that in places like Maine and West   Virginia,  they
                 I eem to be, or to have been willing -- and I  think they  have
                 i@ad good programs there, to try and preserve  the RMP with
                 I
                 ilotate and other fuhds, moreso than had it .-joeen Michigan or
  H     PORTING CO, INC.
  320 flissachusetts Avenue, N.'-..
  Wa@.ing!on, D.C. 26002

                                                                            194
                  Illinois,   necessari.ly.
                             DR. McCALL:   But I think also, in addition to that     i
   t
                  lthe good leadership, good program    a lot of needs  relative  to',
                  the resources.
                             THE CHAIP14AN:  Yes.
                             DR. McCALL:  But also, a rather  homogenous   noncomplext
                  reaion, too.
                             You know there has been a lot of competing institutions
                  land people, so that they were able from the beginning to focus
                  it, and then have not only the need  to  recognize  their  function'
                  but they were productive in it -- and therefore, you can rally
                  when the legislation gets shot out from under you.     People
                 ;come in and say:  This is a worth while thing, and
                             MR. NASH:  There's a motion.
                             THE CHAI@4AN:  Yes, there is  a motion, but are there
                  any other questions or conunents?
                             If not, we have a motion to recommend approval of the
                  amount requested, $663,000.00  which has been seconded.
                  I call for the question.
                             [Approval of the amount requested was put to vote
                  and carried unanimously.]
   ii   PORTING CO, INC.
   320 @Aass3chusetts Avenue, N.',.
   Wastlinzto,,i. D.C. 2@jOO2

                                                                              195
   wt 10                      THE CHAIP-m@N:  O.K., again we are still short Bill
                   Thurman.   He's got three black marks now -- but he can afford
                   it,' he's a dean of a medical school and he's got enough major
                   insecurities without worrying about black marks from the
                   Chairman.  [Laughter.]
                              I wonder, Sister Ann, since Bill isn't here, if we
                   could again improvise, and ask you to review Oregon?
                              This is a region where we only do have a single
                   reviewer,  Sister Ann, since Dr. James is not here.
                              SISTER ANN:  There is a staff person here.
                              THE CHAIRMAN:  Yes, there is a staff person here,
                   Dick Russell, and he's just coming up here.
                                                OREGON
                              SISTER ANN:  Oregon is presently at the $767,000.
                   level and they are asking for $1.2 million.      They are
                   bringing in three new activities, and a total of eight
                   projects, and they plan to come in, in the July review for a
                   project at the cost of $200,000.
                              The program,  from what I can read, and I questioned
                   a few people who were there on a   site visit,  and apparently
                   it has been a good program over the years.
                              From the material that is presented in the book I
                   was able  to identify a strong program leadership, with staff,
                   with t he regional group, that has a good review process and
                  1apparently it functions adequately.
        PORT(NG CO, INC.
   320 Mlssachusetts Avenue,
   Washington, D.C. 20002

                                                                         19b
                             The Regional Advisory Board select   projects and
       1           assign priorities, and they do this through    three   standing
                   committees, by which this is accomplished.
                             It was interesting to me that the  coordinator  of  the':
                   program is  really in control of three projects with a total
                   of $360,000.    You might want to comment on this, this is
                   rather interesting -- it kind of indicates the  style  of  leader-'
                   ship in this'program.
                             MR. RUSSELL:  Yes.
                             SISTER ANN:    There are  eight professional staff  and',
                   there are three vacancies that they hope will be filled.
                             Credentials could indicate that the staff    is  well
                   qualified.  Their job descriptions are well written,    and  if
                   they operate within that framework, they should be   able to do
                   a good job.
                             In the past, they have had  adequate  technical  review,@
                   problem analysis, and documentation of need and technical
                   soundness.    They have also addressed themselves to
                   efficiency and containment of costs      and this would appear
                   to be on an ongoing basis.
                             The project, submitted in two ongoing   projects
                  (approved but unfunded projects due to phaseout   directions)
                   and the new activities not reviewed by the Board -- the
                   methodology for achieving the goals listed on page 42    of the
                   project    and I won't read it      if the methodology  is
  H     PORTING CO, INC.
  320 Massachtisett@. Aveiue, N.',.
  'Nashir,gton, D.C. 20002

                                                                            198
  wt 12          'Ifollowed, it's very adequate.
                                                                              ished
                             The three priorities are ones that were establ
                 !by the Federal Government      the availability and accessibility.
                  and improvement  of  following,  and containment of  reduction  of
                  costs -- it would appear that they   would be able to  carry  out
                  the projects in the allotted period of time.
                             And the CHP relationslts  appear to be good
                  although as I looked at the letters and concurrence on the
                  last project, I noticed that there  was no return on about
                  50 percent of them, which kind  of  conflicted  Vth  some  of
                  the other impressions  that  I  got.
                             And those are the main  things that I  picked  up.
                             THE CHAIRMAN:  I think  Sister Ann was the only
                  reviewer,  but I think  perhaps  you will want to elaborate on
                  this
                             MR. RUSSELL:  Well, let me respond to Sister Ann's
                  questions, because I think they  are  very  pertinent  questions.
                             The one that you didn't quite  understand  the  50
                  percent return -- was this of letters?
                             SISTER ANN:  Yes, that's right.
                             MR. RUSSELL:  0. K.    This is a matter  of  procedure
                  as part of the Oregon structure.     They have a CHP subcommittee
                  and all the project applications come through that subcommittee
                     so they do have input there.
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      3                     And in the applications for Oregon, I   think it was
                  only nine of those did not respond formally.  But the CHP
                  relationships are
                            SISTER ANN:  Yes, that is verv good.
                            MR. RUSSELL: Now in terms of  the  staff,  they  do
                  show two professional vacancies.  Now  those  vacancies  have been
                  filled.  They, you know, knowing that it is sometimes difficult
                  to recruit just on short time, they are using interns from the
                                               Ten
                  WICHIE program -- The Western States  Commission  for  Higher
                  Education.   And these young men are on board.
                            SISTER ANN:  I think there were five they were going
                  to bring in -- is that right?
                            MR.  RUSSELL:   Well there were only  two  vacancies
                  on page  53
                            SISTER ANN: Yes, but five interns  were  going  to  be
                  hired into those vacancies.
                            MR. RUSSELL:   No, I think there were only two as I
                  understood it, and  those  two are filled.
                            Now the three projects which Sister  Ann  referred  to
                  which show the coordinator as project director  --  which,  I
                  believe would be a CHP  priority as 1, if I remember correctly.
                            The other is  an emergency medical  service  consulta-
                  tion.
                            Yet he is not project director, per se      it's  that
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                                                                             200
                                                                         Advisor
                   and all of that money will be subject to  Regional          y
      4            Board review, and approval.
                             You are right, the Regional Advisory Board is
                   aware of them -- I sat with them for their four-hour meeting
                   to look at the applications, and they have been  very much
                   involved, and it has been a very strong program.
                             DR. TESCEPQ: How many of  the  new  activities  are
                   going to be processed through, or managed by  the  University
                   of Oregon?  Just in round numbers -- one out of ten, or   ten
                   out of ten or -- there are a number  of  these  projects  who
                   will be managed through the University.
                             MR. RUSSELL:  Very few,, if I remember.
                             DR. TESCH@L:  W@ll, when I seO-. the list here    look,
                      it looks as if they were managed somewhere else.
                            "A hundred thousand dollars  to CHP priority"  was the
                   title, and I was interested in what it was.
                             SISTER ANN:  But that, then, is when it  was  under
                   [Dr. Rhineschmidt] and that -is under staff     $900,000
                   and then there's another $150,000 somewhere     it's total
                   $360,000 under his direction, so he keeps it in the program,himse.
                             DR. TESCHAN:   What do  they plan to do with  that?
                   Can you tell from that?
                             SISTER ANN:  No, I can't  tell from the application,
                   but apparently the staff-is going  to address itself  to  the
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                  management of it, but I would think that CHP is going   to be
      5           involved in the planning, and I think the various agencies
                  in the @area. are going to be involved in providing the
                  services.
                            MR. RUSSELL:  What', this is -- this   is, you  know, in
                  keeping  with the emphasis being placed on the   particular
                  relationship
                            DR. TESCHAN:   That signal, I got.  I wanted  to  know
                  the content -- I can read this myself.
                            MR. RUSSELL:  And they have  a  number  of.activities
                  that now are in the developmental stage.  These  will  come  in
                  as prO3ects -- go through the advisory group interview, and
                  then will be approved and awarded to  individual  CHP  agencies.
                            DR. TESCHAN:  I gather the decision is exactly
                  what the content would be --  it's open ended.  They  wanted  to
                  get some staff resource to move in  that direction and  to  have
                  it earmarked for committee for that  purpose, to get the
                  signal to you all and to the rest of us  on  that.  [Reads  from
                  the document.] what they are saying, you see,  the law  is  that
                  they have to do this and most CAPs or  many,  would  say:  This
                 lin our experience has not been  ready because they didn't have
                  the basis to make the judgment.
                            SISTER ANN:  I got the  impression that  the  majority
                 ,of the funds for these programs,  tha"L-. it's really kind of a
                 ,Ithrust into the future as well beginning in the  present,  and
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                  it  really would be very difficult to kind  of link these programs
      6           together in the kind of a  model  that  their  Federal  Government
                                             t time.
                  talks about at the presen
                             Is that right?     Does that reflect
                             MR. RUSSELL:-  Yes.
                             THE CHAIP14AN: Paul, with respect to  the  University
                  of Oregon and the Medical School, I recently,  on  a  flight,  was
                 I sitting next to somebody from the University of '.Oregon',  and
                  I had the -- apparently, you know      Oregon is  a  "different"
                  state you see in many respects.
                             They are trying to keep people out, and  they  led  the
                  way in gas rationing -- but also, its  University  is  one  that
                  they are at the end of the line in  feeding at the Government
                  trough     They get less money in terms of Fe era  grants
                  percentage-wise, than any other medical  school  in  the  country.
                  And the Dental School won't  even  accept  percapitation  grants
                       that, you know, is almost unheard of.
                             So it isn't surprising in one sense  that  despite  the
                  fact that the University is a grantee here, that very many
                  P14P activities  now, or in my recollection in the past, has
                  been  university-sponsored.
                             DR. TESCIIAN:  You really must have a first rate
                  coordinator out there too.
                             MR. RUSSELL:  Not too long ago there was a management
                  assessment      this was by a management program -- and the best
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  wt 17            I can remember, the only recommendation  was  that  the  grantee
                   ought to buy some curtains for the RMP Office.
                             MR. SIMONDS:  Well, that's a little exaggeration.
                   [Laughter.]
                             DR. HEUSTIS:  Well, while   you folks feel  sorry  for
                   the university, I know that they are getting $163,000.00 in
                   indirect costs
                             MR. RUSSELL: I didn't say  I  was  feeling  sorry  Lor
                   it,  Al.
                             THE CHAIRMAN:  I seldom have bled for a university.
                             SISTER ANN:  But you know, for a university grantee,
                   they get the lowest amount.
                             DR. TESCHAN:  What's their rate?
                             SISTER ANN:  Oh, 1 think it goes   up to 60 percent in
                   some  cases
                             DR. TESCHAN:   And how low
                             MR. RUSSELL:   40 percent for  salaries  and  wages.
                             THE CHAIRMAN:   Well, this is  an  application  for,
                   again, in round numbers  $1.2  million.  They  have  estimated
                   that they will be in with a  very  small  supplemental,  roughly
                   $200,000.00 in the July request     but this  is  their  major
                   request.
                             The total of those would  bet  again,  almost  their
                   target level figure  of 102 percent by our calculation.
        0
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  wt 18                       Any other questions, or any other comments?       Sister
                   Ann?
                              SISTER ANN:    I recommend that they get    the amount
                 i@.that they are asking br      $1.2 million.    Their target is just
                   102 percent.     I believe in rewarding good programs.
                              DR. HESS:  Was that a motion?
                              SISTER ANN:  Yes.
                              DR. HESS:  I'll second it.
                              THE CHAIP24AN:  We have a motion and a second, to
                   approve,  or recommending the funding at the level requested,
                   $1.2 million.
                              Is there any further discussion, comments, questions?
                              In that case, the question.
                              DR. HESS:  Let's vote.
                              [The motion was properly put to vote and carried
                   unanimously.]
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                            THE CHAIRMAN:  Again, unanimous      we're just
                  continuing the complacency of yesterday afternoon.
                            DR. HEUSTIS:  I think the Chairman should find a
                  better word than "complacency."
                           THE CHAIRMAN:    Everything, in the eyes of the
                  beholder,  Al.
                            Well, we are still missing  Bill Thurman, so we  re
                  going to continue to extemporize.
                            DR. HEUSTIS:  If they ever subpoena these tapes, I
                  would just hate to have anybody think we were complacent.
                            THE CHAIRMAN:  Well I don't think they will find
                  very many explicatives, or, on my part, many "inaudible"
                  portions.
                            As long as we are on the West Coast, and if John and
                  Al feel up to it, we might want to take one  tenth of our MP,
                  namely,  -California, which in terms of population, past
                  funding, has roughly come out that way.
                            Al, do you want to lead off?     Or John?   Again, I
                  don't  know
                            DR.  HIRSCHBOECK:  No, Al does.  [Laughter.]
                            DR.  HEUSTIS:  You see, I have a voice problem, this
                  morning.
                                           CALIFORNIA
                            DR.  HEUSTIS:  Well,  California is submitting  two
                  applications  for this year, and the one that you have before you
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                                                                        206
                11 is for approximately $8.3 million, of which about $1.6  million
                  is for the program staff.
                            And they would estimate that with the July application
                  they would come to $14 million and you can note, if you care to:@
                  look on your white sheet that the RMP are prorated figures
                  at $12.5 -- so there are approximately $1.5 million ahead of
                  what they were advised to do.
                            They served the area of California with two  regional
                  offices, both of them (note) located near major airports,
                  one in the northern part of the state and one in the southern
                  part of the state.
                            The Regional Advisory Group has established siy@-goals,
                  and six program elements, and they will implement these.
                  The goals are to be implemented through six programs, and  they
                  have assigned a percentage of funds, and have determined  their
                  priorities in this way to each of the riajbr goals.
                            The percentages are    the largest, they held manpower
                  at some 25 percent and the least is 4 percent -- with others
                  ranging in between.
                            The RAG is strong, stable, and very interested
                  and this is judged by the attendance which has a very well-
                  known committee structure.
                            In addition to the Executive Board, there are three
                  standing committees on program development, one on program
                lireview and one on evaluation -- and then they have what I like,'
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                                                                                207
                                                                           and
                   the program element committees in each of the areas
                   their charge is to develop programs and to monitor programs.
                            Here, again, it seems to me that real guiddnce is
                   provided to people that would request money, in what the
                   money should be requested for.   It came  through  strong and
                   clear to me that the P14P Central Staff plays an  extremely
                   important role in actually coming up with the  projects  and
                   trying to define what our RMP role ought to be in  each  of the
                   general areas -- and trying to define what kind of applications
                   they ought to address themselves to, and they actually have
                   pretty well defined criterias for the  program  development
                   and provide actual guidance and request preparation
                   I don't know whether they actually write the requests  or not,
                   that wasn't stated.
                             It was stated that the nine RMP  Area  Committees
                   that formerly existed, had been phased out and  that  the
                   program elements committees had replaced these, and that the
                   they were well satisfied with the fact that  the  volunteers
                   were now doing -- at least I got the  impression  from  the
                   work, that they were now doing a better job than the goo
                   job they previously thought that the staff had  been  doing.
                             The final budget, as requested, has been approved
                   by the RAG, and first of all, apparently in  the  process
                   the reports of the Program Area Committees goes to an Executive.
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                                                                              2o8
                                                                        n  of  the
                   Board, and the Executive Board recommends a divisio
      2            funds among the Program Arzas -- and then  the  RAG  makes
                   the decision as far as the -- within  that  context,  with
                   regard to  the  applications.
                             I think  they  have a really well defined review
                   and approval  process,  which is adequately  described  and
                   interestingly --  and  before I reviewed this, I didn't know
                   that this was exclusive.    They used technical  experts,,
                   apparently from outside the region --  but  the  technical
                   experts work under the supervision  of  the  Review  Committee.
                             The one matter that I felt  was  defective,  and  yet
                   I am extremely understanding, because California is a pretty
                 I complex state -- and other large states have been having
                   similar problems -- and that  is:
                             First of all, who speaks for CHP?
                             And how do they  effectively  communicate  what  they
                   think, to R.MP?
                             I gathered that RMP bas, what  I  would  consider  an
                   "arms length" relationship with CHP and that RMP was extremely
                   strong, relatively, and CHP was relatively extremely weak
                   and there was no described CHP development or input into the
                   preparation of requests prior to the  RAG  action,  except  for
                   the legal review and comment -- and that seemed as though
                 Ilat minimal, CHP ought to in some way formally be consulted
                 lilabout what they thought their needs and priorities were.
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                                                                                       209
                               Of course, the whole problem may be that they don't         have
                     any need for priorities that have as yet been developed
                     but that is rather reading between the lines rather than
                     reading what's  there.
                               DR. TESCHAN:  Well, they have had      seven years time
                     to acquire
                               DR. HEUSTIS:  The staff is well seasoned and exper-
                     ienced,  although substantially cut.       They used to have
                     approximately  50 percent of the total awards that went       to staff
                     and it's now down to 12 percent.
                               The past results that I found,      seemed to be impressive
                     both with  regard to the numbers trained     and, I guess I have
                     to interpret some of these figures, I'm      not quite certain how
                     meaningful some of this is, as far as the meaningfulness.
                                We talked about new medical power resources created
                        or "new medical people power resources created"  and the
                     number wasn't really very impressive.  I think it was a little
                     better than 2,000.
                                But the access to care -- it seemed as though the
                     two major  provider systems that had been started and now were
                     expanding  with  other funds -- they have given attention to
                     urban Indians,   and they have done some work with the
                     California Council of Free Clinics         all helping the under-
                   liprivileged.
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                                                                        210
                          The record of continuations, the projects without       i
                                                                               ing
                                               They said that out of 76 ongo
                            was impressive.
    24          RMp funds,
                projects, Or a total of 81   projects that  had  terminated  since @i
                July, 1960 -- 70 percent had continued with other funding
                 sources.
                                               it said that following the RMP
                           In the first yearr
                                                              . usly  been  funded
                 discontinuance the projects that had previo
                                    ot a total of RMP funds, in the amount of       I
                 over three  ears f
                              y
                                              ear of going along with other
                 $7  million  -in the first y
                                               with $4.5 million to continue what
                 funds      the people came up
                                                                          ressive
                            on.   I thought that that was rather   an   imp
                 was going
                   iaure.
                                                       ed by all kinds  of  moneyl
                            The continuations support
                   including voluntary funds, university  funds,  hospital  fundst
                   State Governmental funds
                             In the proposed program, they are trying to set up
                             of what they call "Health Services, Educational
                   a network
                   Adtivities" to cover the entire state --     d yet some 14   of
                   these formed ten of them are incorporated and four are
                                                                rove  the  quality
                   developing -- and these  are supposed to imp
                   of health care for coordinated state-wide system for health,
                   manpower, training  utilization  and  health  education.
                              And again, it mentioned that over a hundred colleges
                   and 120 hospitals(seemed low) and clinics
                   were  involved in this with some 200 people on the boards of

                                                                          211
                   ot directors of these organizations.
                             In high bloodpressure control programs,  they  have
                   a state-wide plan, and I thought it was interesting  that  of
                   the 36 applications that had been received, the project said
                   that sixteen were selected for funding.
                             Then I think the others were,  of course, pretty much
                   there.
                             Again, as I indicated before, the thing that probably
                   bothers me the most, and yet probably shouldn't bother me
                   too 'much, knowing what the facts of life are -- are the
                   relationships between CHP and the Regional  Medical  Program.
                             THE CHAITNIAN:  Oh, I think Staff may have something
                   to contribute to that -- we spent  four  days  in  California
                             DR. HEUSTIS:  It is very difficult for a person
                   with just the information we have, to evaluate the real meanina-
                   fulness of the CHP comments -- whether they are just bemoaning
                   the fact that they haven't been recognized and want to say  some
                   things, or whether they really have a beef and maybe the staff
                   could be helpful there.
                             But before we get to that, as far as my assessment
                   was concerned, I have rated on the Review Sheet, all  of  the
                   items from -- on the first page, program leadership, program
                   staff, the RAG and the performance and objectives     in  the
                   ilgood" to "excellent" category.
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   wt 26                     On the second page, I had to break down the three
                   items in the proposal, thinking that  they  were  congruent  and
                   that they were addressed to areas of  emphasis,  and  because  I
                   didn't know about the CHP input of plans, and because there
                   were criticisms, I rated that down to "Above Average."
                             And then on CHP relationships,  I  thought  these  were
                      very -- I couldn't make the determination, and if I had
                   to vote I would have to vote that these were certainly "Poor."
                   But the column that I checked was the "Insufficient Data"
                   and then the overall assessment of the program was "Above
                   AVerage."
                             And the recommendation was made that  as  far  as  the
                   funding level, that we ought to know more about CHP.  And t en
                   I should say after that that we need  to  have  staff  comments.
                             THE CHAIIU4AN:  Well, thank you.
                             You have raised the matter  of  CHP.  Perhaps  I  would
                   comment on that before we ask John, and then Rebecca can
                   complement some other things, as relates to California region.
                             Relationships with CHP there,  are  uneven,  but  even
                   CHP relationships one to another, are uneven.  Let   me   explain
                   that:
                             There are twelve B agencies in California and I think
                   the relationship of the California RIAP, with most of the
                   medium-moderate sized ones (Fresno  and  the  northern  counties,
                   Empire Valley, which is Sacramento)  we  met  with,  during  the
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                                                                          213
                  course of our four-day visit, Rebecca and Sandy  and  I,  met
                i'with  six  B Agency Directors and the A Agency Director.
                  The relationships -- I would describe those agencies as
                   Fair to Excellent."
                             Much of this has been as a result  of  the  Health
                  Service Educational activities where the State is blanketed
                 ,by those which have been sponsored by  the  California  Rmp
                  again, the development has been somewhat uneven, but in many
                  instances, one finds that these  health  service  educational
                  activities, most of which are now incorporated as private noh-
                  profit groups, are in a very real sense, the health planning
                  arm, or at least an important adjunct of the local CHP agency.
                             Relationship, on the other hand, with the three major
                  CHPs in terms of population areas @- Bay Area,  Los Angeles,
                  and Sani)iego -- are arms length to "awful."
                             MRS. SADIN:  Well, LA  was all right
                             THE CHAIRMAN:  Well, yes, LA -- at least the word we
                  got was that LA wasn't doing anything, so that they weren't
                 igetting into anybody's way.
                             But some of that is a matter of  personalities,  I
                  think.   We found, for example, that in the Bay Area, the
                  Director of the C8P (and that's sort of  a  federated  CHP, as
                 ilthere are nine counties, and each of them with one exce tion
                                                                            p
                  I believe)--
                             DR. HEUSTIS: Yes, but it seemed to  me  that  in
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                                                                             214
   wt 28           addition to the B Areas,  that  every  county  had  its  own
                   CHP, and to kind of sort out the  comments  it  became  very
                   domplicated.
                              THE CHAIRMAN: Well, the  Bay  area.is  an  interesting
                   CHP -- certainly the most vocal, outspoken, bidder, director
                   we ran into,  that was Don Ardell  in the Bay area.       He
                   was having problems with his eight  County  Directors,  and  they
                   sort of meet apart from him.
                              Correspondingly, those  B  A;jencies, and perhaps the,
                   B  Agencies in general, but certainly the larger ones -- I'm
                   not sure it's constructive, I think there was some destructive
                   tension going on presently between the  A  Agency      and the
                   area wide agencies out there.
                              I think the RMP has, on the  wh!ie,  pretty  good
                   relationships with the  A  Agency.  Now part of that may be
                   the fact that the A  Agency is, comparatively speaking, poor
                   so that it has been getting some money from the State EMS
                   Office, or from the RMP, to do some of the things @hat it
                   really hasn't been able to get State  funds  or  State  positions
                   for.
                              But the picture is a mixed one,  but  certainly  based
                   on our site visit, Rebecca has thrust in front of me here
                   both our report to Dr. Paul and our feedback letter to Paul
                   Ward -- while we did have some recommendations about their
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                                                                            215
                  relationships, I think there are more that have to do with
       9          details, that they really ought to do a better job  in  insuring
                  that the letter, as well as the spirit of the law  is  followed.
                  If for no other reasons, the defensive purposes.
                            They were kind of sloppy in logging in things,  and
                  showing that they -- you know -- somebody wants to get you
                  over a barrel
                            But we felt that on balance, that the  requirements
                  for CHP reviewing comment were largely being met in substance
                  as well as technically.
                            We did, also, have a chance to witness at the RAG
                  meeting we attended, that there are several CHP representatives
                  on there -- one from the State CHP and the area-wide agencies
                  have a California Conference of CHPs -- it's kind of their
                  "trade union" and they have a representative on the RAG and
                  at the RAG meeting we attended an alternate member  was  sitting
                     the fellow from San Diego -- and they certainly, not  only
                  spoke out, and they had some objections, but the RAG  took  them
                  under advisement to the extent that they deferred --  they  were
                  going to look into the matter and either accept them in whole
                  or ignore them -- and I think, you know, that even  that  slight
                          ation suggested to us that in the RAG councils they
                  demonstr
                  have the ability to make themselves heard.
                            So it's kind of an uneven picture, Al, I don't
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                                                                          216
                  at least from what we've
                            DR. HEUSTIS:  From what you have said previously
                  what comes up with what I get out of the thing -- I had written
                  down a summary of the comments that had been made,  and  that
                  was marked in red -- and I admitted that the ones that I thought
                  were important, and I had   imported negative comments from
                  six of the twelve areas     at least what I thought were impor-
                  tant negative comments of the six
                            MR. BARROWS:  I don't think we can charge them with
                  the responsibility for resolving these  intramural  conflicts
                  within the CHP.
                            THE CHAIRMAN:  Oh. no.
                            MR. BARROWS:  But we can grade them on their effort
                  to relate to CHP -- and would you regard that effort (and this
                  should be a positive one)  as "Good" "Average"  "Weak?"
                            THE CHAIRMAN: I would have to ask  for  Rebecca  to
                  comment too.
                            My judgement, I guess, would be "Atrerage" to "Good."
                  I think there are some situations where my impressiot is that
                  California RMP  feels that it has walked the last mile.
                            For example, when the Area Offices  are  abolished,
                  that was a kind of a structured cross-over situation.,   When
                 lthey abolished all their area offices and with  them the area
                  advisory committees, and came up with the Program Element
                  Committees as a substitute -- there became a number of vacancies
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                                                                        217
                   on various  B Agencies     you know our slots targeted  for  the
                   PDAP, we found in the Bay Area that an issue of longstanding
                                     Director wants an RMP person, but he  wants
                      the B  Agency
                   a consumer.
                             But it just so happens that in that part of California
                   Paul has only got some providers on his RAG, and you know, I
                   think there is a real personality kind of conflict.
                             But I think on the whole -- and one of the suggestions
                   we have in our feedback letter, was that  they  should  consider
                 'II the possibility of havin  a fairly senior staff,person as kind
                                            9
                   of a liaison with the Conference of the Aqencies  --  they  have
                   met with them, and again, this is not  a  monochromatic  picture
                   at all
                             DR. HEUSTIS:  Have we any kind   of a written
                   agreement that has been either tried, or   achieved, as to  what
                   each of them have thought they were supposed  to  be  doing  and
                   what their responsibilities were
                             DR. TESCHAN:  The answer   to that is:  Yes, as I
                   recall.
                             Now whether it is current or not is more to the
                   point, but I recall that there was circulated to the coordinators
                   some two to three  years ago -- and this was the  first  example
                   of a written memorandum of agreement as to what RMP and
                   CHP roles were going to be and how each would interact   with
                   them.    I'm quite sure Paul Ward was
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                                                                        218
                                   SCHAN:
                            DR. TE         I thought it was a marvel.  As a
       2           matter of fact, when we got around to signing a statement in
                   Tennessee, we used that as one of the bases of ours.
                                          But I think it's uneven     tli,=
                            MRS. SADIN:
                   relationships are Uneven.
                             The only suggestion I could think of and we discussed
                   this -- I think we need a Rabbinical Council     you know, you
                 1 just need it, to mediate.
                             I'm awfully sorry, Sister Ann.  [Laughter.]
                             You know, in the old days, they didn't need lawyers
                      both parties just went to the local Rabbi, and I kind of
                   thought that's what they needed.     [Laughter.]
                             They are doing, you know, the legal part of it and
                   getting the review in comments and submitting the things,
                   etc, etc, etc, but it's a relationship thing that's the problem,
                   in some  areas.
                             They are now logging in, as  you can see in their
                   applications,  all of the comments that are sent out and all
                   76 projects
                             DR.  HEUSTIS:  76?
                             MRS. SADIN:    Well 75 -- hot that's a lot of projects
                   for review and comment -- and they just sent me another whole
                   batch  from the LA  -- and this is all just LA CHP  [Displaying
                   a dossier.]
                              DR. HEUSTIS:  That came in late.
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                             MRS. SADIN:    Yes, that came in late.  [Laughter.j
      33                     So it is -- you know, one of the things we suggested
                   and this is the letter sent back to Paul Ward -- and one of the'
                   things that we suggested is that they have a senior staff
                   person as liaison, to spend more time and pay more attention
                   to that problem.
                             DR. HEUSTIS:  Well I am satisfied from what I have
                   heard, that I would change my recommendation from "Insufficient'
                   Data" to at least a "Satisfactory" relationship.
                             THE CHAIRMAN:  Correct.me, Rebecca --  but most of
                   the program elements committee do have a CHP representative
                   on them.  This is really their program development thrusti
                   Now
                             DR. HEUSTIS:  Yes, it is pretty good.
                             THE CHAIRMAN:  Well, I wonder if we want to hold
                   withhold  other staff comments, and let John as a second
                   reviewer, take a look at California -- we have spent an    awful
                   lot of time with CHP but given the fact that they are probably
                 110 percent of the CHP in California, also.  At least, in terms
                   of family, I wouldn't think that was far off.
                             DR. HIRSCHBOECK: Well, I  won't  repeat  the  comments
                   which Al made because I think they hit the  target  right  along
                   the linc in most instances.
                             I am troubled in one way that in  reading  this  over,
                   I didn't see what really happened when the areas were dissolved"
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                                                                            220
       34          and they were put into two.
                              Is CHP, again, is it moving into the area-wise
                   approach here that existed with@ the regional setup?
                              I think that because of this, maybe this is one
                   of the reasons for some of the problems that they are encounter-
                   ing there in relating to the CHPS.
                             The other point that bothered me is this enormous
                   project that Dr.  White is in charge of -- it's how many
                   millions?   Altogether, I guess he's asking for
                   a state-wide consortium of colleges and universities and
                   hospitals and this enormous arrangement seems to me reall
                                                                              y
                   going too far.
                             At the practical level, I don't know how they are
                   going to work this out, but if this is the way to go in
                   California, maybe it should be allowed, but I have my
                   druthers about that enormous approach to dealing with   area-
                   wide health education aspects.
                             MR. BARROWS:   Resolving that at Berkeley
                             DR. HIRSCHBOECK:  I guess so.     [Laughs.]
                             I have made several visits, site visits, to other
                   agencies in the California region, and there is  one for the
                   California RMP and one in their Review Team consulting visits,
                   and the thing that impresses me out there  is that things are
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                    so different in different parts of the State       that to try to
  'WIN              resolve a problem on a state-wide basis becomes extremely
                    difficult and this is  recognized  initially  by  their  setting
                    up a CAP region.
                               And now that this has gone, I am   uncomfortable.
                    It's like setting up a Regional  Medical  Program  for  a  whole
                    nation, and doing it in one      as a sub-set of another nation.
                    I don't think
                               DR. McCALL:  That is difficult to do.  We tried it.
                    [Laughter.]
                               DR. HIRSCHBOECK:  So that my overall evaluation is:
                               Sure, the leadership is good.
                               The problems are difficult.
                               The program and staff is good.
                               The Regional Advisory Group
                               I might differ a little with Al on all these
                    he has perhaps read it in a little different way.  I had     the
                    feeling at least that the  Regional  Advisory  Group-  was@  not
                    really involved in the actual process    of evaluation
                    as much as other IU4Ps are.
                               In other words, they take  the word  of  others  very
                    readily, without being, themselves,   directly   involved.   Now
                    I may be all wrong on that but I sort of sensed that
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                                                                            222
       6                     Past performance and accomplishments ...
                   objectives and priorities -- I think these are well defined.
                             Feasibility -- here, again, the whole idea of
                   true regionalization on a state-wide basis, I think, is  Very
                   difficult.
                             In general, I would say "Average"  or "Good."
                   "AV3rage" would be my overall evaluation.
                             MR. BARROWS:  Let me ask a question:
                             One of the things -- California,  as you both pointed
                   out, is not only vast, but extremely complex.
                             One of the very unique com lexities is the strength
                                                        p
                   of the foundation movement.  Now nobody has commented on how
                   this program relates to the practices of the community
                   which happens to be an unfortunate bias of mine -- have they
                   been relating to these foundations at all?    This is including
                   the interplay between
                             DR. HIRSCHBOECK:  Well some of their projects are
                   involved in the quality insurance.
                             DR. HEUSTIS:  They mentioned particularly some of
                   the foundations have picked up the check for some of the
                   projects which had gone on
                             THE CHAIRMAN::  Great.
                             DR. HEUSTIS:  Now how extensive this is, I don't know
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                   or how wide.
       37                    MR. BARROWS:  Good     well boy, that's the acid
                   test to this hard-earned
                             DR. HEUSTIS:  Whether this was two foundations or
                   twenty foundations I couldn't -- I believe my notes are not
                   clear.
                             FROM THE FLOOR:  Could you tell roughly how mahy
                   grantees there are, other than their sponsoring grantees
                   programs?
                             DR. HEUSTIS:  You would have to help me there.
                             DR. HIRSCHBOECK: Let's see the agencies other   than
                   central staff that are handling the money -- as grantees.
                             MRS. SADIN:    They have subcontractors -- or
                   contracted, that is, most -- for instance, all of the   health
                   service activities are contracted to the independent   facilities.
                   They are calling their shorts
                             And almost all of  what they have, when they
                   develop a program element,  they have sent out RMPS, you know,
                   throughout the state, and in which they really outline what the'17
                   want    and then they contract it out.
                             They have in their access, which is going to be
                   coming in in July, they have had something like -- from their
                   RMP they have something like 250 -- isn't  it?   I think it's
                   250 letters of intent, which is the, way they go about -,his
                   business.,
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       8                     In answer to some of,your questions on the definitions
                   of area offices -- one of the things  the CHP -- or some   of    i
                   them, told us -- was that well  now that they don't have  the
                   area offices in California, that we could kind of take their
                   place in terms of local input.
                             And when-we mentioned that to  Dr.  Mitchell, he  said
                                                                              ? fl
                   "Yes, do you think this is the first time I  have  heard  it
                   They have never communicated this  to  us.  [Laughter.]
                             Some said that they missed the  area  offices  and
                   some of the agencies said they were glad  they were gone.
                   You know, it was kind of a 50/50 kind of  thingi almost through-:
                   out the state.
                             The result of the definition of  area  offices  really
                     you know they had something like a three-months visit when HET,@,'
                   audited them and this was the latter part of 172 -- that was a
                   fact that one of the strongest recommendations was that they
                   not have all of the area-- offices.
                             And I think Paul Ward took the opportunity to follow
                   the advice of the  HEW auditors,  and they now have  a  northern
                   field -- it isn't just a central  office, they have  a  northern
                   field office and a  southern field office.
                             THE CHAIRDIAN:  Yes, but these are quite different.
                 ifrom the old  areas.  These  are  essentially  administrative
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  wt 39            or for program development, and monitoring purposes.
                             MRS. SADIN:  Right.
                             DR. HIRSCHBOECK:  One.@ wonders whether they shouldn't
                   really make  two @MPs instead.
                             MR. BARROWS:  Right.  From a management point of View
                   this is too damn big for one
                             MRS. SADIN:  Right but
                             MR. BARROWS:  But we can't do anything about it.
                             THE CHAIRMAN:  I think that represents, though, a
                   very conscious, deliberate, decision made at the time P14P came
                   along and involving what, at that time, were a lot of the
                   influential people in California.
                             At that time you will remember, Breslow was the
                   State Health Officer, and Brown was the Governor, and they
                   made a conscious decision and they wanted a "state-wide" RMP
                   even though it might be juggled.    They came out exactly the
                   opposite from New York, which now has six or seven RMPS.
                             So they didn't blunder into it, and I'm sure,   like
                   any decision, it had both then and in retrospect both its
                   plus and minus qualities.
                             MR. BARROWS:   Well, there's not much we  can do about
                   history now.   What's the recommendation?
                             SISTER ANN:  I was interested in your comment where
                   you said the technical experts work under the direction of the
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                                                                           226
                  Review Committee of    would this be inhibitory to the technical
                  experts?
                            DR. HEUSTIS:  Are you talking to me?
                            SISTER ANN: Yes, you indicated  in  the  report,  that
                  the technical experts work under the direction of the review
                  committee. What's the purpose of  bringing  in  these  technical
                  experts?
                            DR. HEUSTIS: Well, I think  the  purpose  of  bringing
                  in the techniml  experts, as I understood it from a person that
                  made a site visit too, with me one time when we  got  into  this
                  discussion -- is that this is to get rid of the local bias
                  and the local conflicts of interest and  the  local  antagonisms
                  between the centers from which the experts come.
                            SISTER ANN: Then you said that  they  work  under  the
                  direction of
                            DR. HEUSTIS: Well, the "direction"  --  perhaps  if  I
                  said the overall direction or overall supervision
                            DR. HESS:  Or "they report to"
                            MRS. SADIN:    I started in on that     to review
                  particularly the manpower, and they do bring  in top experts
                  and they have to counteract the ones in California -- and I
                  think what was meant was that the recommendations go into a
                  review -- but  it isn't
                            DR.  HIRSCHBOECK:  But this is exactly the point I was
                  tryingtd. make a little while ago.    I think that'the distance
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                                                                    227
  wt 41         !!between the RAG and  that technical review process, is at least'
                  at the time that I was out there    it seemed to be a larger:
                  gap than really should be.   That the RAG should be much more
                  closely involved in the actual review of the  project  itself
                  and not just take the report with the badge of an expert pinned,
                  onto it.
                            MRS. SADIN:   I don't know if they changed it  since
                 lwe ve been there, but they now have a member of that RAG
                  present at every one of these    which helps tremendously, and
                  he reports back.
                            THE CHAI@IAN: They have  two  standing  committees.
                            A review committee, and;
                            An evaluating committee.
                            Under the Review Committee, the  technical  experts
                  operate in a panel.fashion, sort of.   They look at  the  new
                  projects.
                            The Evaluation Committee, on the other hand,
                  doesn't have that close line of the smaller  committees,  and
                  they are the ones who look at and then forward to RAG.
                            And then, both of these standing committees  are
                  RAG people, on continuation, so that they have that kind   of
                  relationship     And what goes through RAG, if it's a continu-
                  ation of the Evaluaiion Committee  -- if it's new, it goes to
                  the technical panel.    So it's the overall "umbrella" supervision
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                  I of the Review Committee.
                               SISTER ANN:    And then @re,   too,  on page  3  of the
                    Staff Comments, they   have  70    requiring   surveys,   four kinds
                    of positions -- they   are adding the 19 --   but  one  of  the
                    concerns is the proposals are not being monitored and
                    evaluated on a   systematic basis.
                               And here, I just wondered if adding more and more
                    people would complicate the issue.
                               MRS. SADIN:  There is some urgency to this.  In
                    fact, they have  added  evaluations  to  their  staff,  and  they
                    are asking -- part of the 70 is for more.,
                               But  we  had,  after  their  supplemental  application
                    we sent an advice letter back to Mr. Ward.        We had suggested
                    that such a  vast  program  would  merit  that  they  spend  more
                    time on surveillance and monitoring.
                               And when we were there in April -- if anything, they
                    had gone the other way.  They are  sending the people in the
                    Southern Field Office to the Northern Field Office and require
                    a monthly  progress  report.  So  if  anything,  they  have  gone
                    overboard.
                               So they are monitored       all their people in their
                    Field Offices  are  monitored  --  every  single  contract  -- and'
                    this is the contracts mostly, so that they have a condition
                    written into the contract.
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  wt 43                      DR. HESS:     I see.
                             DR. TESCHAN:  I would like to say that the evaluation
                   effort of what public accountability of funds really means
                   in terms'of output benefit -- that  whole  concept  was  jelled
                   for all of the MIPs in the country by  the  initiative  of  Paul
                   Ward and that staff in California.     And a good deal  of  some
                   of the numbers you are seeing, John, and  all  the  rest  of  us
                   are aware of how that ultimately  became  generalized  in  order
                   to get the data together, to show  to  various  critics  what
                   the numerical impact of these activities was.
                             I am interested that you consider  that  some  of  it
                   became a little bit more Compulsive than others      but I
                   understand the atmosphere in which  such  compulsion  can  be
                   generated    so that I even have some tolerance for that    as
                   well..
                             MRS. SADIN:  In terms of the H.E.      Doctor, you
                   asked a question about the manpower.
                             When we said "supplemental   funding" in July  of  172
                   California of course as usual, got the most money in the
                   supplemental funding for manpower control -- they started out
                   with something like 10, plus the  Central  Coordinating one.
                   They tow have something like 15  and they  just  about  cover
                   the state.  Some are in the planning   stage but most  are  now
                   independents consortium  with'independent,boards.
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                             It's interesting though,   that at  conferences  like
       4           the schools of  Allied Health Protection -- and they have had
                   some -- there's a national conference in Boston this year
                   they had Dr. White speaking in some of the consortia of
                   the directors.
                             The people at the conference were   so excited about
                   it that they then sponsored their regional California conferences
                      they have done some  exciting things.
                             But it  is a lot of money, though.
                             DR. HIRSCHBOECK: Well, I  would  like  to  see  it
                   sometime, to see how it functioned.     It sounds good  on paper
                   but I would like to
                             DR. TESCHAN:  Well, John, the thing that bothered us
   0
                   is that each one of their nine regions was about as big as
                   one-point-some million      as most of the other  RMPs  we  are
                   talking about -- and to  see Paul Ward, in one application,
                   with a dissolution of area offices, just boggles my mind.
                             And Ken s point of "management,  how  do  you  get ahold
                   of it?"  I am surprised at the HEW  Audit.
                             We know a little bit about the  origin  of  that,  or
                   nave suspected some of the origin of it, and I'm wondering whether
                   acceeding to it     the fact that it has some budgetary require-,
                   ments -- isn't a  "giving in" to what  would in Ken's view be
                   sound management     since we would have insufficient data to male
   0
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  wt 45            or to be able to make that judgment from here.
                             MRS. SADIN:  Well, some of the things  Dr. [Hirschfeld]
                   has said -- nobody knows this is going to happen -- they
                   had more than a norm -- they recognized that -- perhaps    not
                             DR. HESS:  You are dealing with a state of some
                   twenty million people, and $2 million for health, education
                   though it seems a lot in one lump sum, is not a disproportionate
                   amount for the population.
                             THE CHAIRMAN:  Al, you've been trying to
                             DR. HEUSTIS:  Yes, I've been trying to push       and I
                   would like to make a motion.
                             THED CHAIRMAN:  Fine.
                             We have a request here for a little over $8 million
                   and we have an indication that California will be in  -- and
                   this is a request just for continuation and program staff.
                   Roughly, they are at the $6 million level for all new activities
                   in July.
                             That would total, if my figures are correct, almost
                   $14 million.
                             DR. HEUSTIS:    If you would then look at another colLLTn
                   you would note that if they did that, they would then come to
                   111 percent of the amount that you requested for them.
                             And because both John and I have rated   this as
                   "Above Average" it seems as though, in conformity   with our
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                                                                              232
       6         ill policy of rewarding the people that do well, and taking away     i
                   from the people that don't
  INDEX                       I would therefore,  move that it be funded at the
  MOJMION
                   requested level, some $8,170,374.00
                                                  [The motion was properly seconded.']
                              THE CHAIRMAN:  All  right, we have had  a  motion  to
                   approve at the requested level of $8.170,000
                              DR. HEUSTIS:  374.  -- it's a separate item.
                              THE CHAIP14AN:   $8,170,374.
                              Are there any further  comments,  or  any  additional
                   questions?
                              SISTER ANN:  Excuse me.
                              Are there any things that you  feel  we  should  look
                   at, or that you think should be looked at, serious enough that
                   by reducing this funding (since they  are  coming  in  in  July)
                   might be an impetus for them to look at the funding?
                   Are there any points or things that bother you about     the region
                   that maybe could be looked at?
                              DR. HESS: But the point is,  there  is  no  time  for
                   them to look at anything.
                              DR. HEUSTIS:  I guess the answer, as far as I'm
                   concerned, Sister, is th
                                             at I thought it was a good program        f
                   with good management and that  the  CHP  situation  bothered  me
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                                                                            233
                  but that has been resolved satisfactorily   for the moment
                  they still ought to work on that, but at this time I think     I
                  would say "no" to your question.
                             SISTER ANN:  As I read  those notes here and  the
                  Staff Summary, I'm not all that   impressed with the good
                  management, and I think part of   it is because it is-such a
                  difficult region -- and as I have heard it reviewed from time
                  to time, and the management hasn't been  its  strong  point.
                             But as Dr. Hess says, there is nothing  that  can  be
                  done about it now except@- in terms of a recommendation.
                             MR. BARROWS:  I feel as you do.    We can't  reverse
                  history. I would certainly not recommend  this  as  a  model
                  program  for the new House Resources Agency      it's too
                  monstrous.
                             SISTER ANN: Well now I would  think  thatwould  have
                  to come through -- it would make me much  more  comfortable  if
                  that came through as a -.--recommendation.
                             MR. BARROWS:  But I don't know what     it's  bigger
                  than both  of us.
                             MRS. SADIN: The target that's  figured  though,  you
                  know, which is, I guess,  less than what they -- less than the
                  $14 million     they have communicated over the  telephone  and
                  they have allocated percentages to each program analysis -- and'
                 lof course if that came down to -- say $12  million  instead  of
                  $14 million -- the man had written 25 percent of 12, etc
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                            THE CHAIRMAN:  They have pretty well -- you know, I
   wt 48
                  assume there is some ability to make adjustments at the tail
                 ;,end of the process.  But they have gone through a process
                 lby which the RAG has said in effect:  One way of expressing
                 lpriorities is that we'll put essentially 25 percent of our money
                  into the access program -- now whether that is X-plus $2 million
                 lor X-minus $2 million -- so I do think we have a notion
                 lboth here and looking at a new application, of what the       or
                  where the cuts would come.
                             DR. THUP14AN6  Yes.   Question.
                             THE CHAI@.N:  All those agreeing with the recommend-
                  ation to  fund at the level requested indicate.
                             [The motion was properly put to  vote and passed
                  by a vote of 6 in favor and 3 opposed.]
                             THE CHAIIU4AN:  In that case, I guess thatis by
                  default.  I can't think of any better   solution.  There should
                  be one, but I canOt think of it.
                             O.K. for California.
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                                                                            235
                              THE CHAIRMAN:  O.K., Bill, since  you guaranteed  uS,
                   last night, that you could dispose of Puerto Rico in ten
                   minutes, we'll take you up on  that.  And  then  after  Puerto
                   Rico, we'll see if the group wants to take some coffee.
                   You and Joe -- I'll call on you first, since you are on    the
                   site   visit -- well
                              Maybe you were too, Joe, were you?
                              COMMENT:@  No.
                                         PUERTO RICO
                              DR. THURMAN: Just a reminder of  the  fact  that  a
                   site   visit was asked for by Council, as to whether or not
                   Puerto Rico would  get  any money at all --  whether  they  should
                   be discontinued.
                              Mr. Nash was  on the site visit with us  and  the  most
                   important  thing  about  the site visit was that we  had  a  multi-
                   lingual team, and  I  think that resolved all our questions
                   because in our meeting with the Puerto Rican group
                   the Coordinator now, he was the Associate Coordinator    before
                   he has the respect for the program and control of the     people.
                   They continue  to  have real translation problems, even  during
                   the site visit and even though we were multilingual.
                              Some of the concerns that came out were only handled
                   by a girl  who was even more fluent  than the Site  Team  was.
                              The RAG is very strong.   It's very representative
                   despite the differences involved with Puerto Rico, and poor
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                                                                             236
   wt 51           transportation     and despite the phaseout as concerned that
                  ipart of the program in toto, the RAG has continued to work
                   quite  well.
                              The real strength of the program as far    as the
                   future is concerned, is that 70 percent of all health services
                   in the' island are public, and the grantee being the University
                   of Puerto Rico which is also a public agency has forced the
                   staff to flow from agency to agency, but neverthei-esst has
                  iworked quite well.
                              I think the most eloquent thing that we heard
                   was several testimonials that came from cnnsumer groups     about
                   what Puerto Rico and   the medical program had meant   -- the
                   delivering of health   services to the underprivileged groups
                   in the continuing organizations.
                              Ther-rojects were just superb, when you really under-
                   stood them (which is not true on   paper, and this has been our
                   problem the whole time.)
                              They have an operational  VSRO which is phenomenal
                   in every sense of the word.
                              They have a ver
                                              y good plan for their EMS   and
                   they are working hard at the geographical spread.
                              I think that this program, having gone    down there
                   thinking  it  wasn't worth supporting for another   day -- the
                   Site Team came away totally satisfied that it was an excellent
                  liprogram, and I would recommend approval of their request.
   HOOVER REPOPTITIG CO, INC.
   320 fiasL@chus2tt@ Aveiue, N.c,.
        1) r9 @,-l Cil

                                                                         237
                            DR. TESCHAN:   Second.
                            THE CHAIRMAN:  Joe.
                            MR. de La PUENTE:    Well I have many  good things to
                  say about them. I have discussed with  friends  of  mine  who
                  lived there and who have been living with the government
                  structure, which is quite monstrous -- and they speak of   Puerto
                 iRico RMP as "La cr6me de la cr&me" as  far  as  entered  into
                  our conversations -- with living over there.
                            And under the circumstances I  have  written  --  I
                  wrote a lot that has  already been said, but in summary,
                 "Ithis application represents tenacity in the face of
                  austerity in that a viable program is being presented.
                  It is possible to enhance the staffing pattern with the
                  introduction of a physician who possesses some training    in
                  the field of epidemiology, and this is tremendous.
                            It is apparent that the Regional Advisory Group
                  has continued their efforts towards program development and
                  review.  Their track record in terms of the number of
                  programs that are eventually adopted by the community   appears
                  to be better than average.    Most of the present priorities
                  appear to coincide with the needs of the Island.
                            Special attention should be  paid to  assuring  the
                  dissemination and application of findings for additional sites
                 lin Puerto.Rico.
  HOOVER REPORTING CO- INC.
   320 fliassac husettsAven,-.,N.E.

                                                                          238
                            But I c
       3                           ertainly, strongly concur with the present
                  recommendation.
                            THE CHAIRMAN:  Thank you.
                            Yes, Al.
                            DR. HEUSTIS:   I am impressed by what was said.
                 lIn fact I was so impressed by what was said that I looked  over
                 Iinto the next to the last column on this tabular sheet, and
                  I noticed that Puerto Rico is one having the honor or
                  distinction (or otherwise) for requesting the lowest  amount
                  of the allocated funds, for any group.                           i
                            THE CHAIRMAN: Yes, the lowest percentage of  that  so-,;
                  called target figure.
                            DR. HEUSTIS:  Yes, the lowest percentage.
                            THE CHAIRMAN:  Yes.
                            DR. HEUSTIS:  Now, with the obvious need, and I say
                   obvious" need, it's from what you have said after  a one-
                  week visit -- and when I was there under different   circumstances
                  and not for RMP and quite sometime ago
                            Is this because they were tired, or because  they  were@
                  discouraged, or because there was a lack of understanding on
                  the part of what  RMP was looking for?   Why this low figure?
                            DR. HESS:  I don't think that's a good measure,
                 I                                                                 i
                 lat all.
  .io.@PORTING CO, INC.
  320 Massachuetts Avenue,
  Viashir,gion, D.t,. 20002

                                                                            239
                                                                      nd to  th
                             DR. THURMAN:  I think I had better respo         at.
                             I agree with you, 1 don't really think it is.
                             It's not a matter of being tired, it's not  a  matter
                  of being fed up, or anything else.    This program  has  been
                  going and again, we didn't understand how well  it  worked  with
                  all the other health affairs and activities.
                             Now they have wanted to avoid an  outward  appearance
                  of affluence, and that's why they were  so  well  accepted,  as
                  Joe points out.
                             Again, I would just emphasize that -- not in talking
                  to people  who are getting anything out of it, but  in  talking
                  to the little people -- and these people were able to speak
                  in Spanish to the people involved -- it really is the cream
                  of the program and they felt that they can use this money
                  wisely and not jeopardize the future of anything  else  --  and
                  they would only ask for the money they think they can use
                  well.
                             DR. HEUSTIS: Now in view of this, do  you  not  wish
                  to retract the statement that you made  yesterday  about  the
                  people "always asking for more than they need?"
                             DR. THUPJMN: No, these people have  asked  for  more
                 Ithan they need.    I would never retract a statement, like
                  that.  [Laughter.]
   N    PORTING CO. INC.
   320 Ma@mchucetts Avinue, N.,.
   Washinpton, D.C. 20002

                                                                          24o
                            DR. HEUSTIS: For the moment I thought  I  had  you,
  ,lie
                  but I couldn't go further
                            DR. THURMAN:  No,  I am going to defend the sheet, a
                  little later on, with the fact thatI think it's useless, so
                  I only bring that up
                            No, the only place that -- the place that  I  would
                  criticize their budget, if you still look at the core of the
                  staff program    as to what was  indicated earlier -- they just
                  pick up all the staff, and they  didn't really, physically
                  pick them up, they just moved them to  other  budgets  within
                  the medical science campus, and  try to find a place for them
                     and then they kind of flow them back.
                            And that "flow" is very worth  while for the very
                  reason you bring up -- that these people will be able  to  do
                  an awful lot with a very little bit of money.
                            So that we are approving more money  than they  can
                  truly use right now, because they are funded  through other
                  mechanisms.
                            So that I'm not defending my very dogmatic statement
                  too much.  [Laughter.]
                            DR. HESS:  The point is:  How many people are there
                  in Puerto Rico?
                            DR. THURMAN:  Higher than New York City     per square
  H    POPTIfiG CO, 14C.
  320 Massaf@usetls Avpni,,,, t4.E.1
  Wastiington, D,C. 20002

                                                                          241
                  foot      it's the most densely populated region in the United
                 11 States.
                             MR. NASHii About 2.5 million I guess.
                             DR. THURMAN:  But a higher density than New York
                  City, per  square foot of ground.
                             And yet the most of the island? you couldn't set
                  foot on if you wanted  to, because of the trees and the water.
                             MR. NASH:  Dr. Heustis, that figure may change
                  69 percent -- depending on what comes out of their application
                  that they will submit.
                             DR. HEUSTIS:  I didn't care to exp lore that any more
                     but it  just seems as though where there was need    was
                  there a language problem.
                             But I think my question has been satisfactorily
                  answered.
                             MR. NASH:  All right.
                             THE CHAIPJA-AN:  We do have a motion, and a  second,
                  on this one -- to approve in the amount requested, which is
                  $696,862.00.     Is there any additional discussion?
                             All those in favor
                                                [The motion was regularly put to
                                                vote and carried unanimously.]
  14    PORTINCI CO, INC.
   320 Mi@chLsetts A@@e nue,
   ,iv3sh,!;Igton,

                                                                                    242
                                THE CHAII"J.@l:  O.TL,@., it's ten o clock.  I-,Thcit is the
                     Pleasure, of the  c.frou[)? !)c) we eiant to take on  another  one
                     or do %.7e want to break for  fifteen  minutes  and  have  a.  cup   of
                     coffee?
                                Do @.7e have anot"Llcr ten minute one?    How  about  the-
                     Tlountain States of Idaho,    T',Iontina, 1,7yoi-iincT, and Nevada?
                                COI@l-!'F-NT: Is that al@,7ays that same four states?
                                                 It's al@iavs been a little unclear in
                     m,7 mind'. T,-Ihat -f Ive r(--@irl now su(-(gcsts it's sort- of a northern
                                                    It
                     half of ,,'4"7ominc-@ -- it doesn really  make   much   difference
                      3 T.7
                     a %,-,Iol:lina has been @l-llPs "Poland" -- there  are  three  R!I,Ps  to
                     plot over;  in the mountains:      Colorado, I.,7yoming, and     the
                     mountain states
                                         THE !IOU',-,4TAIN STATES
                                DR. 1,TcCALL:    They have aot a table of staff
                     and a priority croun, and a nriori-tv setting on a nri-oritv
                     basis, they have handled that in a hiah, medium, and low         qrouninc,
                     in this application -- which is a good application -- clear
                     and I think it presents a picture of      the  recion pretty  .,7ell.
                                Tllev  have  had  rouion  review  certification   visit
                     and manaae-@ient assessment visits which came out as, I think
                     iorettl;, r,.u ch all "T)luqes" from that rcaion.
                                Assessment of their past performance and accomolish-1;
                     ment has also been prettv aood.

                                                                                             13
                                                                                           21
    -Vyt 58                       The current proposals seem to be in accord @@7ith
                       their stated objectives and priorities, and I think they
                       are    feasible.
                                  m
                                   .Lhe CIIP   there are four A Agencies and seven         B
                       r@lgencier,   that have to be dealt iiitla by this Regional "-Iilcdical
                       Program,  and  thev  have   received   in   this   anplication,   comments
                       from all  four A t%(4cncies, and four of the seven B 7@gencies
                       are    included.
                                  The Ida@o 71@ t%cfencv disapproved one of the projects         I
                       the ',?Iivsical  assessment  field  --  nurses  --  and  the  B  Acfency
                       had neqative conT..cnts on @ibout four  nroj(-cts  --  but  i.@cr(z!  no
                       an in Jcpth study or criti-cTuc of t,iose -- it       ,.,as just one
                       sentence co@n@%ients.
                                   I state that  to sav that I don't I-lave anv              to
                       evaluate the aualitv of the CliP revie@q and relations',i4-ns       therei
                       but these there   -- the c:,,,tert of the necative t-,,,.oe col-l@T-@,ontc,
                       @L-'iat !;"Ould nece,. deali-na %.,Titi-i b,, the @j@P -- and from the
                       a-,)-olications, I  Tiould  -feel  r(-,asonz,)ly  comfortable,  although
                       I %.7ould Learn the Staff to   corimt--nt on these if they @.7ould
                       wi-s.@'i to deal ,@7ith the-,i.
                                   This  anolication  contains   27   nrojects.   11   of   these
                       Are for continuation, and 16 are new,--         making u-,o in dollars
                       an eleven continuation of about $1.5 million; and           the  si--.teen
                       new ones,  at $640,000 -- the stal'f buduct being          some    quarter
                       of a million dollars -- the total recuest $2.4 million.
     0

                                                                                 244
                                They intend to applv for asapplement of some
                     $220,000.00 in iulv.
                                I rated  this ",70DOve Averaae.
                                THE CITAIP-T.@-:I:  Thank vou, Charlie, and Joe.
                                DR. IIESS:     T generally concur with that.  it is
                     evidence to me that the T)eople i-ilio nut this -ioplication tocTetl-l r
                     thi.nj,. clearl-,7,      ly, and are i,7ell  organized,  and.  are
                                      concise
                     usinrT          a-c oroce0ures.     They have atterinted to reach
                            a n,,j r on r i L
                     out   and provi@to cood service to all four states, and they hav,--l
                     offices  in each of t@ie  four  states,  and  seem  to  have  aood
                     @7or'i-.incT relationships  .,iith  the  state  governments,  and  the
                     CTIIP and so on.
                                Just  to co.=Lent on ti
                                                       ,@iat one oroject that @,le have
                     ne-,ative coruTcnts on -- aiven a little priority in the
                     so i think that mav be a result of the C12,,'.T) Tlcvie@,7.
                                I think'the Cl,"@D comments on that narticular one were
                     relevant but that Has taken account of.
                                The onl,,- real (,iur-,stion I had a@.)out   bu(Ic-et @.7as
                     the rather larce amount    of mone@i qoinq into EIIS  from    -?.IIP.
                     I liav@, no doul:)t t-'!,at in that area of vast distances and so  on
                     that an @','!S system is an important element to aet organized
                     and   Qoina.
                                                            stantial increas in  -I!.IP
                                But there has !)ecn a su..)
                     money goiiia into that and I SU'OT.)OSC that it @.7ould be ap,?ro,,oria@-L@
                     to sort of flaa that as an issue and as]-,     then to take a   close

                                                                                 245
                    look at that when thev pet their Qrant a@iard.
                                )R. TI"CCALL:  la-
                                @T               7bc, it Tioul.d be aTDproT)riatc-, to have
                    a staff comment on that.
                                DP,. IIESS:  Yes, I was going to say, that        somethi,,-l,,
                    I meant to point out -- and because of the di-stance, of course@
                    it miaht well be justified, but vou can't tell.
                                    CI'IAIT@L@l:  Yes.
                                Some of the -- while a   good Dart of this is con'L--inu-
                    ation, sor,-- of that continuation    is really e@,.nansion, and it's
                    largely in the E',!S area.
                                Dick, T don't  1-no-.7 whether ,iou .,ould want to cor.=.cn@-
                    on this, or -,,ihe4-"Iier t'ii,-re arc any nolicv issues.
                                I I . nTiTSS@LL:  2@t this point there are no noli-C,17
                    there r-Io,@s not        to ',oc any police,,        -but @.,7 (-I ha-,,e
                    flagged this to make doul,)I.,l sure.
                                In terms of the E"S program  in the     'fountain St--.-nltes
                    area, all of these -oroarar,.s startc(f@ out l@7it,i assi-str-ince-
                              c"tates in i@-erms of vcr-,7 small contracts.
                                Like, '.Icvada, for instance, started out v,@,,itli ',17,r,),DC.
                    and as a result --,7ou can sec.
                                I.Ilontana, is t,ie same i,.7a-,I.
                                Idalio.
                                So this is one of their big
                                                                major program      we
                    do have some concerns about that larger
                                DR. TIT,SS: This is one of the thincrs that im-,)ressed

                                                                                246
                   me about their management teclini(-iticls; and that is that  they
                         ,ic contract ii(:-,c@lanis-i as a device for getting thina.,3
                   used t,
                   dona that they have  identified and Perceived as a means and
                         ,-@ave im-mcoiatelv talr(--n the initiative -- as opposed  to
                   @,7ai-tinc for it to coil,.c a.n.
                              -,%nd I think this reflects verv sound, soniiistica4--ed
                   r,anac,@-,,@o-nt on the TDzrt of !ITTIT).
                              T TI. ',TCCAT,I,: Just one other thin, one  point that
                   I think riat,7be the Staff r-t4lcr.'Iit N,7cint to cor-uient on, too.
                    It is no-,"-e(-; that t.-ic,7 clcarl,,7 SI-10@7 the allocation of dollars
                    an,', proarar@3 -- and o';Dviousl-,,,, there is a .;ti-ong C;ta-F-f, and
                         have genera-,ed and involved. in a lot  of  this  anc.  seem
                    to be involv@-ri @.7ith and mentioned in these nrojects
                    the grantee acency.
                               I n r,,, a nof t'@'le activities, I am )rctty sure  treat
                    somebody kne-..7 the rcaion better than I did, m,isel'L -- and
                    that this %.ias acceptable %.@ithin the recTion   it @,,lasn't too
                    muc'Ll@ generation.
                                              Is this il'IS ex,)ci-id4-ture, for T)rcnarati-dn
                    for a system, for the purchase of hard@.iare?
                               @ilP,. RUSSELL:  It's Preparation of -- rather than
                     the nurchase.
                               TI-IE             Sandy  Flyther  and Dicl@ aussell
                     %iere  both out in the Mountain States, I que@,s this @.,/as pro.'oal--@l-,"
                     7-,Iarch, or carlish, on a rcvie@,7 verification of the m@---acieni(-,nt.

                                                                        2LI7
                                   -)@l-)incd: i@evici,.7 Verification Of "@anac
    N-it 62                it ,I,-!3 c(                               -   Temcnt
                   Assessment --- so r3erliaps Sandy ind/or Di.cl,, V7OUld have some
                   comments as it relates snecificall.y to CHP and also the
                   aoi.lity to manage project,-, under the aeqis of T)roarart staff
                      vil-iich I thinlr. I  heard Charlie raise a question a!Dout.
                              Sandv.
                                7,TIr.HE: BasicallN7, the CIIP rclationshin @iithin
                   the rouion are good.
                              There is one probleri, Perhaps, but they are @@iorl,-incT
                   on t'liat, tr@7inq to get that ,.Iorled out -- but Generally, the
                   relationships are cood.
                              C'IP is   in fact, CIIP    generated some Drojec4.-
                   ,@7iti-iin tIi.ie rccTion rela4L--j-on-@hi,)s are '-,,asically qooc@.
                              T-
                              ,,T,nic'@-i is, just reall,7, the grantee -- thev !lave no
                   resnonsi-bility 11',iatsocvcr as far as the projects are co,@Icerne(3.1@
                              Staff and proaram staffs    @asicall77
                                                                      are  -@esnon-
                   sible for monitoring t,iat sort of tiiincT -- %,7hich is -ju-@t
                   grantee.
                                   t
                                 LIJSSELL:   I %,7ould -- you Irno@.i, we spent reall-,7
                   a -v7hole -,,zeek anu- covered, I think at least t@,,o counties ev@r@
                   da,7, and this is @.ihat it takes.
                              Before He @.,,ent out, @,7e had some concern, really
                   because @.,,e didn't understand that program  that well -- as to
                   how one mandqed the proarams in four states from that Reqlonzil
                   Office     and i-7(-- @,7(--rc- vcr@7 much irinrcssed Haiti the co-,qmunic@-iti@@'i

                      among the staff and the whole setuD.         We kept looking, and
      63              looking, and looking for something      wron(i and we really couldn'll-@
                      find it.
                                 And I talked i-7itli -Ilocl !,Iercl:er, who had the @lancigemen-'@-
                      Assessment      and his impressions were nretty much the same
                      as ours.
                                 DP,. HESS:  @,,Iell I ended i-iT), based on what I read in
                      here, civi-na them "roo(f@" ind "Excellent" i--atinqs.in nearl@7
                      everv cate(Tor,7 -- and I ti-iink it @-!as one. of the b(-:7,t orcTanizeC.@
                      and ma         .T!Ps.
                      c    managed   T
                                      BART-'O"-,S  @-7hat's the number?
                                  T
                                   .JE CIII@J-
                                                   T,'Iell, the 11 !)or is our     in the
                                     fountain I'@f--a'---c-,s -- tliicv are ar,,-
                      case of the                                       in(7 for  @'2.2 ii-.,il-licn
                         no, I'm sorr,i       2.4 million.
                                 They did indicate, as I     think one of the reviewers
                      said, that they Hill T-)e in for a verv (I)v comparison modes        4-
                      su-,or)lemental additional amount of $200,000.
                                 DR  !!cCALI,:    I recommend $2.1 million.
                                 DP,. HESS:  I had written Oo@qn $2.2   [Laughter.]
                      So ,7(-, are prettv close.
                                 T
                                 .)R. TESCI!21-r..- $2.15.    [Laughter.]
                                 THE               I,-7e Have a notion of  recommended fundi-.@c!
                      level of $2.15 million.       Is there a second?
                                           [Th(,- motion      pronerly seconcle-cl..]

                                                                                          2119
                                    DR.               4av we discuss this?
      64                            THE              Certainlv.
                                    DR. T'I'IUPj,,!N@4:I have no   disagreement with everythi.,@ic,,
                       that J:)oth  of them 'ilave said  about the --,ianaqement.
                                    But on some of these projects        and  the   funds for
                       them are absolutely unreal.
                                    Now if vou @@?ill turn back to the Staff Sheet here
                       in our little circy book -- and we have already hcard the
                       concern expressed about ""'IS -- and I share that concern
                       $131,OOiD.00 for "levada  %,,,hich is for @@,,orkinq on the THIS
                       Program on which they have been @iorkino for           ten years.
                       @',,Iow E,@IS in ilontana and Idaho both, make un     to $350,000.00
                       not to mention il.,Iievada's share.
                                    But look at some of     these other projects.          Area-
                       wide, thev would simnlv scare        you  to the tune of $270,000
                       and as I listened to this motion, we are talking about a
                       little over  8,000  -,)ersons at the most.
                                    170@,7 you fiaure that 8,000 births -- and jou are
                       going to have rouahiv       120 children that may need intensive
                       care a year -- and -,iou     divide that by the two hundred some
                       thousand dollars and it's an astronomical figure.
                                    1,7ell, N.,ie Tnove on dov7n to the breast cancer         .@71iich
                       regionally continues to be funded at $30,676.00 and that's
                       an old -)roject, again.

                                                                                               250
                                    And  the   T@ecrional   medical   audit   system   development
                       project,   $177,000.00.
                                    Let's see, there is one other here  that rocl,-,ed mv
                       ")oat, but I've forgotten @7hich one it was
                                    But 1 just, I really have no disagreement iiith the
                       management and I know the difficulties of communications and
                       organization -- but the fun(7@iiig of these orojects, I think
                       I am goi.n-t to move to a mountain state now and               [Lauqhter-I
                                                 7
                                    TIIIE C!IAI       The@r need a medical school.
                                    !)P.             They reall-,i need one.
                                                                like the staff and the P
                                    )P. TES('il2V,I:   soundr:,                                 AG
                       are   a,,,,ifullv
                                    TI-IE CT AIL@-,T,@4:  joc, Ithink  7ou  want  to  sav  3o:,-et,
                                    DR. l@IESS:  17ell, I @,,,as cToincT to sa,.y that one
                       judgment here    about nun-!De.-s of neonlo    has to   be  modified   h,,,
                       the distances    and the distribution of       t-)onulation in those areas
                       and  it's  ri@ judgment or esti,iate, that i,7ith the TDoioulati-on
                       spread out the way they are, it's qoina           to be more costly
                       ,Der  person,  %to  cret  some  of   this   more   sophisticated   services
                       organized and available than it would be           in a denseli no-oulatc@,
                       region.
                                    So  I  would  make  some  allowance  n   my   mind   for   the
                       geogra-@)liical distribution of the population, vou ],:now.
                       so that doesn't upset me too much.

                                                                                 251
                                                                               the use
                                       Al@,T@l: I have a comment to make on
                     of medical services -- because    the regions intending to
                     being in Salt Lal-,e rial.it near the University of Utah, -o7here
                     they have funds for the Reqional 1-i-edical Program for juzt
                     the same kind of service and are crying for, you ],Ino@%7, neol-)le
                     to     tiie service.
                                I,,n,,t for an air traiiF@i-)or'L' being available in terms
                     of this service, and         t',-Ic birth rate goincT down
                                    ;-i ver,7   if T.7c jiirt I-,ne-,.7 ho,
                     think tiat is                                   i this T)ro,7raT-,i
                     overlan-)(-d T-7i-th the other nrorTraTn!-,.
                                But this one DrouraiTi, I kno,,,7 is croina to ;De co@-,--)eti-
                     tive and neither of thc,,i are c,TancT  to be a';-)le to use their funds
                     effectively.
                                DR. TilUP.-'!@1-1:  @i?e could al,-L-,ost buv each babv a plane
                     for this -,OneN7, and let's fl-17 them in.   [i,auahter.]
                                '@'!TLI . B AP TZr@) -7S That's a tough thina but mou're
                     oneninq a T,,7hole new tliinc, there i,,,,,ien you start tallzina about
                     numbers of neor)lc and t'@ic other Dro4.)lems.
                                But in connect--ion @,7ith these costs, is it true, or
                     is it not true, t.-iat these -)eoir)le have further to qo in these
                     things -- and theV don't have the present resources        that
                     many other reaions    do?
                                DT-1. IIESS: 1,7cll, there's no medical school in the ar,711.a
                     nor in the region -- and the@? are trvina to relate -- you kno@@.-'l

                                                                           252
                   they are trying to relate you 1 @no@-i, they are trying to build
                  .up their secondary terciary resources in the region.
                              But for medical schools, thev tried to relate to
                   Utal-i, to Oregon, Seattle and to Denver.    Those are the four,
                   I guess.
                              DR. THUR.@@@l:  They no,,,,, have a Medical school for
                   associates --
                              ,r)R. IIESS:  There 's one developing there, yc-,,c-,
                   and t'!,Iat's the first one in the region, and it's Dust gettina   1
                   goin(7.
                              TI-IE           @,Tell, @.7c'vc heard some comments
                   reaardina budget -funds, and T),-grti-culirlN7 as it relates to
                   natal orojects.    Dicl@?
                              MP.,. P.USSi'LL: I ,,iould. like to respond to f3i-s-tcr @-nn'.'@,
                   concerns  about  the c@alt Lake  inter-mountain -,)rogram.
                              1,7e have, @.7e in    have  sort  of -out the       to
                   t'ne  inter-regional executive council  --  the three coordinator.*
                   You '@-noT,-7, that Council ,,7as formed to avoid ti@- tv-oc of
                   you are tall-,in@ a;Dout, during the phaseout, for somc ot7-aer
                   reasons, it just didn't aet  off  tire  ground.
                              It's back in action, no@q.     T.-"e have a complete
                   listi-na that came in just a counle   of days ago, of every
                   community listed, and which -@IP is   programmed there.    1'.Ie
                   are very concerned about the effectiveness of that committee

                                                                                                                                             253
                                   and     we     think     we      are      qoinq      to      see      some      improvement      in      there,
                                   in  their  action.
                                                     DR.  TIIUTITIT@4:    Yes,  and  vou  lznoi,7
                                                     TIR.  RUSSELL:    In  terms  of  transportation  there,  i7e
                                   have  found  on  tT.7o  trips,  t.Liat  to  get  to  I-T@el(,na,  "Iontan@-i,
                                   one  i-aus'L--  cfo  to  Portland,  Orecion  and  spend  the  night.    '@'hat'@:,
                                   E,,.,Dout     the      onlv        @7ou  can  got    there.
                                                     DR.  li@ISS,    Acttiallv,  ,71-iat  tliev  are-.  trving  to  do  is
                                                     @116,00,0.00  is  develop    local                       resources         and          train
                                1    peonle    on    ti-ic-,     local     le-,rcl     to     be     able     to     T)rovide     tire     hiq,qer      I
                                                                                But    that's  a  cr,.-t-i..cisr,,i  of             Tn,.i@ia(-e@@lent.
                                   l@--  shoT.-is    @lLl6  there  and  $'@.107  on  o,.ir  sheet  --  .in,,i                    117
                                   else  that  difference.  is  l-,et@-7,@e-n  that  piece  of  paper  Fnd.
                                   ti
                                                             C                    You  are_,  lcol:i-ncr  at  the  vello@.:
                                                     DR.     TEcjC--@l@"I         Could       this       be       a       typoaranl-iical       error?
                                                     DT.Z.   T'I U    !-L\@ I                    it    i.,,ould    -be    less    thin     a     hun@,
                                   babies  --  at  the  most                i- t  @.7oLild  !)e.  1'-'O  Keith  8,000  c.,-nected
                                   births      in      this      nonulation      --      and      that      would,      of       course,       not
                                   be     every      bal-),t7.
                                                       IIE                        T@7c-11    mavbc    @.7e    have     --     I     don't     know
                                   T)lclc  and  I  ,.7cre  hiicidlincT  here                     ma@7be  @,7c  have  an  arithmetical
                                   error -- but the -,,clloi,7                  slicet .ql@iich       you     have     in     your     I)oo,,z     and
                                   vihich     I     aather     Dr.     TI-iurrian     was     looki,.i(7     at,     is      a      staff      Output.

                                                                                  25)-',
                                           T                -ng at
                                                                    this too -- it does
                               DR             And I'm lool,:i
                     short 116.
                               THE             Yes
                               DR. r'LIIIU@@@l-T, But even at 116, this project is
                     alitterina in cold because -- we have intensive care over all
                     the country      and
                               DR. """cCP@LL: And thcv can c,,ct -ntensive care ever-,7
                     place else, too.
                               DP,.            But if you look at -- a lot of this is
                       if ,rou loo,". at the staff slicet and get huncT up on that,  vou;
                     are talking a!Dout 'Pl.5 T,7,illion for continuation of  eleven
                     projects and some of those -- the last time this came un       for
                     rcvie@.7 @,,,ere
                               DR. TICCALL:  @,600,000 for the eleven
                                                You're  tall@ing  about  the  continuation,
                               DP,. TT.        In the continuation t'-,Iey are asking  fo-,
                     $1.5 million for that.
                                '-HE CI-IAI@',LTu'4: If there  are  no  more  comments  or
                     questions, the Tiotion on the floor is to approve $2.15  r@illic,@-ill
                     for  -',,Iountain ctates.
                                All those in favor.
                                         [The motion was reqularl@,- put to vote and
                                         carried with 6  in  favor and  3  oidposed.]

                                                                               2 5
                             TIIT-' C I T,@. I'" think it x@iould ):)e good,, if i4-- @...7ere
                    the conc(--,-Isus of ti.Le cfrouT), tho,,Igl-i, in reT)nrtincr your
                    recommendation to Council -- and assuming they agree in the
                    feed!-)acl, to the !,Iountain States @)l@IP -- that to indicate that
                    there @,7as some concern N-7ith ti-le  dollars invested in some of
                    these projects and singling out neonatal., among others, as a
                    oood exajli,-)le of that.
                               DR. T,@SCIIP@l: I thin,',, @,ie otirTht to have a decision
                    no,,7 as to @7hat the actual n-Lui,-)er is.
                               if there are three or four      @,ie have several differ'.-,t
                              anO. there oua',,,(-- to be a @@ay to tell the
                                                   we have to  decent  thE-,ir,-rnlicatioi
                               .)R. !TESS: I thii
                    as the
                               DR. TESC'-',@-i Ti-re are tT,7o nlaces in the a-o-,-)licatj-c)
                    one is the 16 that vou are lool,inc.T at and I Plant to ]@no@%7
                               TIIE CIT2N- IT  1,7e 1 1noT..7 I can see
                               16 shoi-7s $234,000.00 and that includes indirect
                    costs.
                               DR. 'I-IIIUT@?IWl They multinlv one vear by
                               !!R. t@USSrLL:  1,7here are you aettina the 116 from?
                                                                                         t
                    What -oage is that on?
                               DR. IIESS:  Pacte  105
                               DR. TIIUPIU@'T I'md page 199.
                               @L'O. 7 I don't r-,ean to set hung uD on the intensive-  carq

                                                                        256
                   There are an awful lot of high priced and an awful. lot of
                   continuing projects, and I thought I would just go along  with
                   the  advice
                             DR. HESS:  1,7(-,ll again, this is an area-wido thingi
                   that covers four states -- and that's roughly, $ 25,000.00
                   per state for developing this care -- and I don't thin',, that
                   is excessive at all.
                                 Cli'AI     Well, there is some incongruity, I
                   tiiini@-., bet@,7oen the annlication tlie@7 have preT3ared, and the
                   fi,--rur,-,s on the T'orrq 15 and 16 -- @,71-iicii o@@viouslv don't aarc-c.
                                                                        print-
                             I'Llhe figure that @,,7e have translated to the
                   out here is tic Eorri 16 -Ei.cure.
                             DR. TT T UPI' 17\ ",I
                                           Yes
                                 FUSSELL:  I'll see if I can find it on the
                   other sheet .7hen . . .  (Laughter.]
                             THE            @iell are thev askincT for two ;,,P-ars?
                             DR. THUPIIZ@'.
                             T'IT3. PJJSSELL: If Icould call your attention to
                   page 21, Consolidated Budget  :',equest -- 21 of the Application.
                   Because I think this shows how @iountain States Programs
                   it's right in-the middle of the  page.
                             The 116 - 231 is budgeted as a discreet project
                   aotivi.tv -- and add to that @91,738.00 which is the rest of
                   t he )T'@ecional Program -- the cost of that.

                                                                                257
  wt 72                        That brinas the cost up to 207.
                               DR. T,!cCALL:  That is what I questioned.
                               That  was  the  additional  budget  allocation  on   the
                     staff    looked  like  about  45  percent  of  program  activities
                               THE CITAI,r-'-14-A@-q: Well, I think that one of the rhinos
                     we have seen, or at least I have seen, and I suspect this is
                     the case in 'L'Iountain c"tates:  Some of the more sophisticated
                     reaions (if that's the adjective to use) in California
                     certainly in this class at this juncture, from the n@anaaerent
                     standpoint -- California is budcTcting a aood deal of its
                     nroararLi staff as sort of a i,.)roj6ct item and each of- tile
                     proarar@l cle.-icnts -- at least from mv first !land observation
                     there, that seemed  to  be  a  reas.onable form of nrogtam budaetiriql
                     so that a  Chuck t ite, ,,Tho literall 7  -,.nenOs, if not full  tine),@
                     a major -)ortion of his here on health    services     educational
                     activities and       and one or t@,7o ot.,,ier -)eonle @.iho are
                     tAe way t'@i(-,17 are set un, the people l@71-io -,,ioni-tor aoarticular
                     program element theV ate sort of the cost of that       -,3rocTram
                     element -- as a separate nroject -- and there -,aV      be soTie of
                     that here,, also.
                                    -PUSS7LL:  There may be some of that.      I don't
                     think it is thouafl.
                                This is the case: say, for example, that they are
                     g,oina out into a programed area and they will call a nrojett
                     like "area wide neonatal" vou Ino%,7 -- that is a program thru@ti

                                                                                    258
                     that's a project -- thei7 may have two or three funded          activitil
                                                                                              es
                          a contract,   or an agreement etc --  affiliations
                                 So to  save tinie, they have budget set aside like
                     you know, M,@S -- if thev need to support a Governor's Conference
                     on neonatal or @@7hatever,    then that money is considered a
                      recional" budget rather      than tacking it onto an individual
                     project.
                                 DR. THUR@@'LA24:  But I think I hear what vou are savinal
                     but that says that they have qot $54,000.00 -- if          you go al
                     the v..,,a y baclr, to go to consultants to Dut on the regional
                     nroaram..   But vou aet hunq un on one nroaram, or one pro)ect,
                     and that shouldn't     be.
                                 It's the   T)hiloso,,)h,,7 that I am speaking against,
                     to do ov6rfundinq    of- orojects   for %,?hich IL-here is no  validit,,
                     and the overfunding     of continuation nrojects.
                                 11.5 million of the @2.1@or the @2.4 that tliev 'liave
                     requested for continuation nrojects           some of @.yhich are    six  I
                     and seven vears ago -- and that is tot aood management.
                                 Did vou move that the staff and          that  they  should
                     Dav particular attention to this?
                                 MR. RUSSELL:      Yes, @.7c will clarify  this  be-fore   it
                     aoes to Council.
                                 DR. H'-i,,TSTIS:  I      sunport thi-s.
                                 MR. RuSSE,;LL:  ',Tell clarify this.       O.K.?
                                 TIIE CITAIT@IAII:  O.I'@. And  this  is  a  prize  item  for

                    Council, that the Cor,,,-@,ittee, @.,Yhile it did vote a recommendation
  N,7@4             of 2.15 -- it had so.-i-o- significant concern in this regard and
                    hopefully reacted out and nrovides the Council @.7ith some
                    additional clarification so that they mialit take a critical
                    look at this region, perhans differently than thev @,7ill for
                    most, because the@r are accepting. @,7our rccornn@endation.
                             DR. HEUSTIS:    The aTaount of monev for each of these
                    activities -- it i,,,ould be helpful to the determination as to
                    @.,,hother this ,,,,as accurate or not.
                              !1'411. RUSS'-LL:  Yes, i-7cll I think I @.7ould, have to noin@
                    but here that @@7hen v-7-- looked at so,-.(-- of those activities, it
                    1.7a.,3 as a "continuation" and this P,.icans that thev are
                    continuing in that nrogram area.
                              DR. YCCALI,:  Yes  but the saj,,ie activitv  - tha4k-ls
                    the
                                  RUSSELL:       no, it does not -mean t e same
                    activity.
                                      OTTS
                              @IP,. DATI@.   I\-re .,7e on that breal: vet?
                              TIIE            Yes.    (Laugliter.]
                              Let's TDleas(-- be back !D-,7 a fuarter of eleven -- T i
                    i-iould certainly lilze to )Olis,,@.1 off at least t,..7o more recTions
                    before lunc;-i..
                                             [The assembly recessed for coffee
                                             at-10:31 a.ni.]

                                                                               26o
                                               [Proccee.inqs were resumed at 10:501
                              THE CIIAIPI--ITill:  I thought we would jumn to the Tri-
                    State, at this juncture -- that ,,iill take care  of the last
                    of the regions where Dr. @IcCall is a reviewer,   and that will
                    let hin, without any problems, get away bv-midafternoon for
                    per his earlier understanding.
                              So we have Sister Ann and Charlie on this one.
                              I don't kno,,i -,@7hether you t@,.,o have -- I saw you huddl"na
                    at coffee -- I don't l-,no@.7 @..7hether you had aareed as to who T,,as
                    aoinc to lead off, or
                                             TRI-STATE
                              TI'E C,-i.,,II ..'P2T:  Charlie -- Massachusetts, -@hode
                    Island, and @-le%q F-am-osi-iir-c.
                              Dil. !.!cCALL:  Plight.  Tliic, is three states fron
                    7-1/2 million t)eonle -- and 5.G of that 7.5 -,iillion  :jeinq
                             I
                    in '-.Iassacill-isett-,; 740,000 in liar.-osl-'Iirc; and cl'50,000 4,-,on
                    -liodc Island.
                              find at the outset, I think I would also T)oint out
                    in this particular annlication, as far as additional near
                    activities,      '-Iamoshire is not in this  application,  but
                    they were a little slower in getting their rcvic-,@,i and tiiincfs
                    in -- and nlan to come in the suDnle@-nent --.@.7hich will  be
                    in the Julv 1 aDnlicati-on.    So the "tri  state"  is  reallv
                    as far as this is  concerned, a "bistate" of ',Tassachusetts and
                    Rhode Island for  this Particular application.

                                                                                 261
    t 7 6                        I thinl: it's also r@,Fi-k7]Dr@,  a little bit helpful
                     initially to lool-I a little bit at the           histor@7  of   this
                     rc<7ion, because in m@;, jud(f,,-,.ent, in addition to a  couT)le  of
                     ,notice questions, it's not our -- the ma-;or Question is not
                     coina to be cTualitN7 of staff and program, as much as the
                     funding level -- and  it's  in  this  region  iihich  v7e'v(z-,had  a
                     rather exnonentiall-,.7 risina le7iel of funding from one 1.2
                     million to 1.9, to 2     million -- ancl t.,ieji luri-?inci to 6.8 millioii
                     in 1973, -,)rior to the nhar@-eout, i,.,,ith  a  current  six  months
                     current level of 1.4        I giaosc:, that's a six months level of
                     fund4-ng.
                                                    4
                                 So that at the L. L  0 !. ,7 'lien the-,7 hit this T)eal-, of -_hc-i.- i
                     gr@,,,th .7it-'-i tire;,, '@)ic,- staff of soi@te 46 nroQram activities going
                     on, util4-zi-nc-, tire contract             rather heavil@,- at t@IE,@L.
                     tirio     and I                                l@acl@d,,ror) it
                                       a-  i   .-Lons and thev nu@@ it into a little
                     at tn- ctrrcn4-    .Dn ' i c @,'- 4
                     botlk--e@- nersnective.
                                 It means    -It,at L@-hcl,r have hid <7oo&, experienced
                     leadership at t'lic staff -- the staff,      as I mentioned, T.!as a
                     rather 1--ia staff in '73 !Dut it has become a rather small
                     staff- at this poink@- in tiT-@ct i-7ith six full time Professionals
                     and five -oart
                                 Tind there lies also a oint that 'v7e may want to
                     focus on a little bit in terrqs of -- as it has come un
                     -,oreviouslN7    lfiat deals        ;Dart time professionals and t-@'le

                                                                           262
                    efficiency of same and  ef f(,Ctiveness.
                             The Reaional j\dvisorv group and revie@v process, I
                                                     cent rcviei,,T certification
                    thin'- arc cTobd. .-hev ',iave had re
                    and management  assessment visits also by the Staff.
                             Their program and aoals of  objectives are kind of
                    interesting.  -,hev are verv candid in pointing out, as I sav
                    that they respond floxiblir to national priorities and focus
                    and try to match these  to coincide @@7itl-i local needs and
                    that, obviou 1   ma,7 be alittle more fundina  strategy than
                               S
                    program strategy  and is not based on an analysis of   data
                    from the region, per se.
                              But it see;---@ to Pc that the counterbalance of that
                    is that as vou look at the nroqram, they are very candid to
                    say that "this is the %,.iav ,7e do it"  and v6t the,, do focus
                    as tliev respond to national focus, to cTet the dollar and
                    do deal ,iit' it -Ln a reasonable, rc-,crional @uality
                    r-nhey use this sl@-rateq,7.
                              There are a coinle o@     @-zhen vou look at
                    proposals @ielve got, in the application,   there are at least
                    one or t-,-,,o Police issues  to be- raised.
                              r-Ohey are reauest-Lr@a in the staff budget, some
                    $210;000  to contract for the p',,I,,,si.cal manicement and monitoring
                    in 1976.    I-.Tell noi-7, tlic)-t
                                              @,7e 11 have Sor
                              TIIE                          .e Staff guidance on
                    that.

                                                                                            2  3
                                       MCCALI@: @,,7c-@ll  I  mean,  that  amount  needs  to  be
                       'rest in mind, and that has to I.-.)c dealt with.        Now '@7hat is
                       the  police  on  activity  in  '76  --  and  liavincT   the   Grantees
                       dissolve a contract with someone else to monitor the continuin
                       activities so as
                                  j@nd the Pevie@i Committee             to keep in mind that
                       reaiiest  is  for  $210,000.00  --  and  it  could  go  one   way   or
                       another depending on @,7hat the nolicv decision is.
                                   P,,nd the other is, not only within the monitoring
                       thereof that request of a little over $200,000 -- it's
                       $205,000, for a fourth year of fundina of an [IVIEXI
                       a PI-iode Island !Tealth Science Educational Council,           Tnavbe
                       state wide in Pliode Island.          And  Mr4  Lawon,   former   Delouty
                       Coordinator, has returned to Rhode Island as the Director of
                       that Particular nroara,7.  --  state-T.%7idc,  in  scope  --  an@,  4L9
                       also '-he S4-at  Coordinator for the
                                       e                                     at  a  10   percent
                       nart time, as one of @-ie narl-- ti-qe             there.      So I think
                       that needs to be focused      unon.     it  seems  to  me   that   this
                       thina was -founded             is  the  second  year  of  its   fundinc..
                       It was funded initially at $600,000.00 ',Dut cTot off to a sloT,7
                       start, and I think this      is a  sioiiificant  amount  of  T-,one,%7
                       which  is  left'in  that,  that  theV  are   using   at   the   rorent.
                                   And the comments in @7our staff           you miaht
                       indicate in one visit  there,  there  @,Ta@,  E--,omp,  Question  of  the
                       effectiveness of the wav this             going      and vet since that

                                                                                                        2021
                           time and those questions Caere raised,   !lr.  I,a@@,,,ton has tal@e-n
    i,@7 9                 tile leadership of this project -- one should ma'jle a
                           point there.
                                         So   those   t@io    issues    of    the    contracting    for fiscal
                           monitoring and
                                         That   fourth    year    of    that    st,).te-@-7ide    project   on
                           that level of @200,000               I thin'--,      @,-,,ould @@,,@int to address
                           this.
                                         It seems 'clear that                  Island has 'iiad some        p r o','D I- 7-@. 7,
                           in analvzinq its Priorities and objective-,-  and                          c--ctivitiefl@'
                                                                                   cthcr   so   well   as    a
                           -,iithi-n that      state don't real].,, iiold tocr
                           pro(-Tram  but I au,--ss that is not too surprising,  according
                           to the stratcav.
                                         T@-s far  as Cl-i@P      one state aaencv is          d,-san-nroved
                           has    disannrove,-!    a project.
                                         A-.n-d  two B               carried tlii-s         thev have just.
                           given   me   a   cony   of   a   letter   from    tile    Coordinator,    dea'L-ina
                           .iitli these,  and it seemed          that   one had to do with the
                           reqj-onal4-zation of new born care activity.                           [Lauahtcr.]
                                         That @4as so,.,acthinq I.,.7anted to call to Dr.  Thurnan's',
                           attention.         [Laughter.]
                                         DR.  THtJPP4,,@      Good    thing    I'm    not     paranoid.
                                         DP,. @-IcCAI,L:      And  this   :3   AcTc-,ncy   that   voted dis-
                           anproval  of  the  thing   that   -this   i@   Iliid   rated   as   one   of the
                           hi471,lcst       Priorities     lie       since   (Totten    approval    of    tile

                                                                           265
                               as thev ii-ivc-     advised b-,/ the Project Direc@Lor
                     B Agencv
                     that their questions liav(-, been satisfactorily ans%iered.
       0
                               .And the B Naencv also had a certain hypertension
                                                          a particular coiint-,7
                     program that had -been involv(@,c, !:)v
                     but that has been resolved b7 the    fact that the  sT.@jeepincT r)roaram
                       this letter sak,-s it .7as not to  be included, to begin  @-7ith
                     but in an,7 event, it has been reraoved nov7, and $1.6,000.00
                     ir3 rerqoved from the bud,-et, i.,iiiich involved that particular
                     COU.-Tit@".
                               -@ncqL the other area of nec-ative res@onse vou see,
                     as @@.,e had to do il,,ith -- a cardionulrionarv Subcommittee
                     nroaram.for resuscitation   -- and lacl@: of coordination  Keith
                     axis -- and this '".as not baan tot,-.llv resol,.red, but it is
                     bein,7 aOdrcsseJ in this lctte-
                                And I thinl@ -L      lil@u    necCi some staff con.-ti-,@-nts
                               g
                                              ng
                     cor.cernin                                   of  three stat---@
                                                                   7
                     and not really understan(-@incl, the c,-P-ocTra-'@A-,. of the n-Li@er!-;
                     of the acencies or the degree of cl ertise, i a,@ not
                                  7
                     disturbed     these three necTaL-ive c(-,riunentf--,. I am sa@,i-s-,-c4-cd
                     thev arc beina dealt @.7ith ind would have no reason to
                     that tile C!7-P relationship bet@,.r(--en the three states ,.@,,,ould ':De
                     unsatisfacto@@l -- but if I am not correct,  I  v@iould  like  for
                               to
                     the  Staff  correct  t@iat  impression
                                     S'-"OLOIII: There   are 68 of these- in 'I@lassach-Li,-t@-ttz,,
                            ID(-licv,-. 7!r. '!.ur-)I-iy'@; neg.,tc-,F, their oric4Lnal

                                                                                      266
                      negative comments by showing that they had, in this anolicatioi,
                      erroneously sent in a letter -- and I believe it was a negative
                      one Nvnen  in  actuality,  it  @,7as  part  of  a  project  which  was
                      removed.
                                   They are also      @"lurphv has,  as  a  result  of   the
                      @leview nrocess, put on a CIIIP representative on the Executive
                      Board.  He has funded a $93,000.00  A Agency pro3ec  in
                      'i-low HamTDshire
                                   ,And so bi and  larao,  I  think  the  A  and  B  aaenc@7
                      representatives    are going along pretty ,iell.
                                                    T,-7e re vou through, Charli(-,?
                                       -@,'cCP--LL:  Ycr,, Iam.
                                                    '7e
                                   THE CIIA.1,7!@' @T:    then neri.@lans @,7e can cTet S4-ster
                      -,-@n's review of this recTion.       ,@d tlicn, certainl,,,   co,-,iin(T
                      back to the nolicy issues ar-,oncT other things, I think tl.-;.at
                      Staff c@ocs have some auidance, and sor,,.o. idea of @yhat @-7e are
                      uD to on that one.
                                   SIST--!', Z-'--IN: I really don't have anything to add
                      to that at this point.
                                   THE CHAIIU47UT:  You were on the last site visit
                                   SISI@ER @'qN:  No, I wasn't.
                                   But I would just like to kind of see how some of
                      Dr6blems I have heard over, and over again,           have been
                      resolved.
                                   rn -JE CIT        T                                       lu@ i
                                   .LI   @IAI        ,Iell, T'll leave the problem reso

                                                                                      267
                      to ri,,7 col.leaqucr:-,, 7ran3,,  [',adqE--, and @'tolo
                                                                             V.
                                 ,T,ct Lie con,,P..i--,nt,  thouc-f'@i,  on the t-@@7o polic@, issues.,
                                 T
                                 i7c-@ did in         indicate to all of the
                      it -@,,!as permissible,  and @7ou are reall,7 (foi-ncr to see 't--his in
                      Tl'!,c,,tro York this af k--ernoon, to pro!-)ose activities
                      3:)C-"ond June 30,  1975 -- if tl,,iev @,oi@ild )De carried out under
                       -Z                               .1 I
                      contracts valicil@7 entered into x@.7i.th funds obligated before
                      June 30,  1975.
                                 AiiO. there is one suc@.i i-)roje-ct      narelv       the
                                        :r -A 11
                              I-an@              But .,iti-iin tl-Le parameters of   our
                      uolic,@ that doesn't       that 7,ce,-,Is to be o.'r..
                                       rcsrect  --,o t,@i,-           @.71iich Tr-i.. ,,tz,,tc
                                                   -if -tor t'i -1 e
                      T3roinoscd for iionitorinc,              c r 4 o ci @.:?e are
                      -,,7aiti-na   Lol4@c-,,, c!ui@,ance. E@'.r a i,@ J, a r, I itold !-)Before
                      ,,ic roconvr@nc@,. -14--i-iat there is @ T@c3-,Io that hopefull,7 @@7ill
                      some sort of decision t'@iat T.7E,- @@ioulO,  @@.,,'.'IatcvLr  funding,
                      level @.@iould be rcco,-jar-,nc.@,c2 D"?, t'@ii.s groun to@a%7 -- tla@t it
                      in   affect   nal-   a   condition   or    a    hold    on    t'-iat    $210,00o.r.10
                      until the issue can be resolved.
                                 ,,'ie Oton't have an ans@,,7er to it.
                                 It does brina   up an interesting issue on        @@,7hici-i
                      there ,@!as somc. agonizing debate among some staff and others
                      about      that if @?c arc croin(-, to see activates,  at least
                                                   I                                           I
                      nro,3oseci  for   continuation        June  I-Oth next year,
                      at @.z'fiicii ooin@, at leaslt--      sta.L-fs at this point in tiT',)(@;

                                                                          268
                   we are not allo-,,7ina     (iram sta     ding beyond that
                                      anv pro.,       ff fun
                   date -- and, you know, who i,7as goinu to monitor the projects.
                            We had all kinds of@glib answers, grantees, which
                   is at least conceptually valid -- where there is a grantee
                   that is not a free standina corporation.
                            In those instances, i.,ie felt that this hadn't been
                   the first time that a Federal Droqram had been phased out and
                   the monitoring of activities bevond its authorization and
                   funding did seem to got taken care of -- not necessarily 1.7ell,
                   but I can remember the chronic disease orogran that became a
                   part of @TLP three or four vears ago   and there was some
                   Federal monitoring of it.
                             So we, in effect, have in a sense    I suppose --
                   said "that issue will just have to take care of itself, 7.-Tid
                   t@7eire not goina to
                             DR. McCALL:  One aiiestion that occurred to me
                   that might have some relevance there- or grounds is the
                   region -- at the time this region had the high level of
                   funding of almost $7 million and multiple activities named
                   in the contract -- they have indicated currently -- there
                   is some, maybe $3 million in these contracts still under
                   way.    Will these be continuing into '16?
                             Even not considering net activities, were there
                   rhinos contracted for that long, that there's going to have

                                                                          269
                   to be a monitoring of, regardless of @,7hit,ls done here?
                             TIT-IE         1.7c].l maybe rrz,,nl,,., or Gerrv can
                   e.nsi,fc-r that question. I don't I,,no@,@z.
                                 NASH:   I  lno,@i of none by -- except PIITISEC
                   the onlV one hangina on  is PJIISEC.
                                 STOLOV:  -- because the exocnditures are now
                   reaching a point of projected rionthly exnenditure rate
                   and tillev need ti-,at money to carrNI them over to the ne@q
                   legislation, so  we  don't
                                 @.,!%-,CALL: 'IlLirfnhv said, "I-I@,7 did thev arrive at
                   the fiaure of @210,000.00 ncc@s@,arkl to m(-,nit
                                  [@,IAST4 T .@tink the anF,@,i(---r t.,-icre is t' @,t
                   ,I"'-;F,C pr j-cct,    is a lo- of- monc--@, left over from the
                   first fe@,7 7ears.
                             Ccrr-,?,, do @7ou       I.Tolll-7 much @-,,as that?  @@'@,out
                                                                   little over
                                             The77 spent @-200
                   200    so it ,qa7 at 593 -- a little  1(--ss than 400,000
                   398.    Tilley told me t:-iev @,7,anted the $1@00,000.00 for a fiscali
                   officer, a booll-.1@eeiDer  a se--rct,.ir,,,7 and an evaluator the-,7
                   needed some supplies,  some travel, frinae benefits for those
                   crrouns -- and there is definitcl,,-.a budget schedule.
                             The coordinator @.7z-tnte@l, lv7lien discussing, this @,7ith
                   i-rie, was ver-,r practical x@7hen he said, "I-ilien thev get their

                                                                        270
                   award notice, half of the Council meets in August."
                   There is "x" number of months for these projects to
                   be VLable.   If the grantee, which is a free  stand,  has  to
                   close, he reallv has to terminate his projects around
                   February,'for him to close shop in June.
                             So it hurts the project, and at the  same  time  it
                   would not be practical unless they  could  find  out  whether
                   the free standing grantee
                             SISR."ER A-",TN:  Is this goinc to be kind of an
                   excepl-ion,in this case? Or is this the beginning of a  ne@,7
                   policv,.>
                             I-!R. 7,IASII:  Tell as I sa-,i -- all the free stan inal
                   corporations Drobal3lv face the same thina.
                             THE CHAITEU!Pll:  They are the onlv ones that have
                   proposed to deal with it this i@7ay, and as I said, clister Ann,
                   we in staff, after some agonizing discussion to date,
                   decided you know, that that problem x,7ould have to be
                   handled in some wav.    But that ,@ie %.7ould permit, on the one
                   hand, oroaram activities  to continue bevond that point in
                   t im
                             I think, you I-.noi@i, this is an issue qruite apart from
                   the unsettled,policy -- will- it be permitted     is something
                   that the groun can address itself to.
                             T,,7e mav not have  as a result of the decision, we
                   ma,7 not have any ontibn, it mav be precluded.    On the other

                                                                               271
                    hand, the group nay have some views unon -the desirability
                    of it in any case, I don't 1,@no@,7.
                                        OT,7S
                               PIP,. BARR       I don't think tl-iere s much dispute
                    in some cases.  I don't know whether these are the an-oropriate
                    ones or not, but there will be a legitimate need for continued
                    monitoring b@rohd the life of the program, and there should
                    be a reasonable mechanism for dealing @@yith that.
                               Does anybody feel differently about that?
                               !To@tT @,7@@iether these present a legitimate need or
                    continued monitoring or w'i'leth(@,r this is the best mechan3sm,
                    I just don't knoo,@.
                                                      '."ha-t  i
                               DT.Z.                       s wiat has been the experience
                    ,.,7ith the  Ohio Proaram that was ohased out -- then s@.@.e of
                    their activities being monitored
                                I    .L@l,      I (ion't
                               T'IE                      inow if anything -- i can
                    sneal: to it, ,jTohn -- one of the Ohio activates, for exa-,Pnlo,
                    there was an  [P@HEC7E',]-lilze activity up in the Cleveland area      i
                    which .ias continued after the Northeast Ohio Areas phased out         i
                    it was continued under a    T4910 grant, ..,Yith funds ao'-na directly,:
                    to the [;UIAC-I-,].
                               I assume, but  don't  really  know,  that  the  P-,Onitorinal
                    that has taken nlAce in that instance has been essentially
                    sta@f monitoring, you ]-.no@@l, from here.    There is not a
                    ,@ortheast Ohio li'll,4,P, I don't think (Case Western 'reserve]
                    @%T'liC'Ll was the arantee in the old -@,Tort).-ieast Ohio it!IP, has cast

                                                                                   272
                  any lona shadows over that.
  t 87                       MR. NASH:  No, they are doing the evaluations from
                  that activity.
                             By the i,7a-,I, @,ie will see that activity in a later
                  application in Western P.A. if we get to     it today.
                             "HE CHAIP,'i'.IP-l@: Well, we have heard from
                             14R. NASFT:  Excuse me.     In view of the RIIISEC
                  thina ,.ihich concerns me a little bi'L-. -@,--rom Staff -- the fact
                  t@iat i,@e have about 400,I),)O. left over from the first t@-70 years
                  and here thev are asl-.-@ng for  200 000. more -- I don't know
                  -,7heL@-her that concerns any of N7ou people or not, but
                             DR. 41@-CCALL:  Well yes, it does.
                                             T,@7ell, Charlie did bring to the
                  attention     Derhans vou .iant to elaborate.     --here ,Tas a
                  staff visit -- and this is pre-7@a@,7ton --'@,,,hic7.,i involved.,
                  I )-,elieve -,,-ou said Dr. [@iargulus] and he was the Director
                  of the program, is that ri(7ht?
                            "PI  .'TASH: Yes.   1 equestioned as to @.7hethe-- t
                                                                                hat
                  orograTn was on target or not.    He felt they were cfoina bac'rz
                  into the traditional sort of Health nanpo,@7er activities
                  rather than -follol,.7inc7 tile T,,IP concept.
                            So iDer.@,aT3s with La@,7ton there-, they can get the thing
                  back on track     but I just ..,onder if thp-v rcallv need that
                  much iioney-
                            SIST'-PR       I was just looking at this  6.8 here

                                                                                 273
                     on the line-here and the  1.4  next year --,and you @@7oiAld just
      8              kind of knower that     @.ierc overfunding.
                                              S?eaking of funding, I have a
                     COI'Icern:  From these captioft descriptions, the real .nerits
                     aren't  clear -- at least in the Countrv rjuide -- but here
                     l@7eive got 4,7,7o projects for @,.7:iic'@'i thev are asking a most a
                     half million liudks -- a stud'7 of Health nolicy in !a-,sachusett!l
                     for '@238,000.   Health services in tir,.ie of economic transiti
                     $250,000.
                                'J,,Toi.7 1cq-on't kno,,.7 ,7hcit they are li.]-,e, but sicTht unseen
                     I l@7ould like to take -L@hose on, on an entrepreneurial basis.
                                DR. McCALL:    2\.nd the last one, that naval base
                     in Rhode Island
                                               Bc- careful navy, the're goina to call
                     vou a "Tliu@-nan" if vou're not careful.  (Laughter.]
                                7@17. B@@T?)-,,. -,IS I don't Grant to annear cynical or
                     aree,-Iv
                                IJIV-
                                                T'.Iiio are the snonsors?-
                                jl!R. STOL@7:  @@he Covernor of Rhode Island s-,)onsors
                     the rhode Island one; and @!orris(Donnahuel, t,Lle former
                     President of the Massachusetts State Lecrislature ana no@7 ,,7it-h
                     the Tiniverrit,,r of Massachusetts, ,@as asked to loo,'c- at the
                     state policies  issue  as a.transition to JL-.ne legislation.
                                T'.,ie (.T.Uestion staff raised in reference to -,'-iode
                     Island     and @.,e called t,-Ie '117,7 negional r)-C-cice to cr
                                                                                  a

                                                                                      274
                       better handle on it -- N.ias the need for this in P-hode island
        9              for  two  counties  in  Pjiode  Island  --,but  the  8taff   told   us
                       that one out of every ten peonle in         !-Ihode Island i.%iere unemz)lo@7@e,
                       as a result of the Defense pullout,         and in the tivo counties
                       one out of every five jobs @,7cre hit       as a result of this.
                       And half  of  the  jobs  were  ',j'avv'and  the  other  half  was  for
                       civilian sunnort of the Navy installations.
                                   @nd tile (7-overnor  is  bringinc!  ne,7-  industrv into the
                       area, and  there-is  ci  vacuum  iiiti-iin  that  area  of  the health
                       services -- @-7hether it be later T)erforTPed by I@-L.1-1-0  or TDreoaid
                       health practice or something like        t.-iat.
                                   But they felt that this      ..,Tas an area for focusing
                       on at this tire
                                   @IR. BAP,'Pol-,7S:  T,Ielll @,.Tith res--ect to this nolicv study,
                       in ',Iassacliusetts, mvlc-,tue-@tion @,7OUld i-)e:  17hat in the hell is
                       CHP and @7,'P been doina for  the  T)ast  six  or  seven  -,.7ears  if
                       it's qoing to take 1,2'@18,000 buclzs to come u-o @7ith      that
                       I iiould think that @;7ould have been the auts of iihat thev
                       had been doing.
                                   THE               (7,r--rr-t.7, do -,7ou !'lave any
                                  -MR. STOLOV:      Well, I can only say that if you
                       read the CHP reports, both the A and 13, thev do suT3T)ort
                       the project, thev feel it's a necessary oiece of unfinished
                       business that tillev need in the health planning transition.
                                   Thev did question               the U  of  @lass  Has  the

                                                                               275
                     proper  agencv  or  a  governm(:-iital-agency,  since  the  governmental
                     agency  is  clos@  to  where  the  policy  is  beina  made.   Bu
                     they did support.
                               This came from the A and B          and PIIISEC     @@7ell
                               THE CITAITb',W--I: T,7ell I hear questions, being raise
                     at least by Mr. Barrows, about tiio of those large studv
                     nrojocts.
                                I can only speculate, but 1-iavina sat in I,-Iasiiincyton,
                     I do ),-,no%.7 that the closi@,icT of t'.ic 1-laval base at l,'.Ieil,por t,   there
                     were literally full naqe  ads  in  both  of  the  Ilas,,iincfton  papers
                     over a neriod  of --   I sun-pose a month -- not everv dav
                     -",ou kno@q, sort of public ads Pleadin(7, @,7it",l the T?resident not
                     to close the 'LTaval base at                ,,7hich eventually @ias
                     done, of course.      Pyid no doubt it had a verv sial.-lificant   economic
                     impact.
                                And also, 1   also hapnenod to kno@@7 that     the nov--rnor
                     of !Id-iode Island is  the Cliairman of the Governors     Conference
                     you know the Conference of governors       held a committee -- he
                     testified in that           L-.,7 before the Senate on the IT.ealth
                                          canaci4
                     @@sources Planninq legislation.
                                Those are just facts -- but vou knot@7 the pressure
                     I am sure for getting as many Federal       dollars to fill that
                     17,avy vacuum in R@'iode island, you know   the  political   and   other  i
                     pressures, I suspect, have been very fierce.
                                DR. TESCII,,@'@:    l@,Tell, I sort of read the question

                                                                               276
        t            as: Ilol,@7 @,iould you spend a quarter of 'a  million  dollars  in
                     a vear, and get  something  out  that  is  worth  a  quarter  of  a
                     million?
                                .7knd studies in general., tend to be pub  lished    and
                     never  read.
                                7-IR. BA-RRO'IS: 'tTo, this is the type of tliina -- I
                     don't kno@,.7, ,.7e can't resolve it   but I don't know  m@i
                     Conaress  can  intelliaentlv  evaluate  anvthing  when   thev   get
                     this Nickel,, !,!6use stuff.
                                T-lere @.7c are, dealinri @,7ith this clisaste  -o
                                                                           r  roble,,i
                     with a rec,,ional m--didal nrocrain mechanism      using  this   to
                     treat   that
                                DR. TT--'S C 1      this is merely nutting a Band-Aid
                     on it.
                                DR.            Exactlv.
                                                                      million bucl:s is
                                     BATII-TIOT,,7S:  @O a cfuarter of a
                     just   cone.
                                T17. S'LOLOV:  I discussed this with [Ilr. T7alker]
                     Tqho is the new Coordinator of I-Ili-lod(-- Island, or fill be  the
                     new Coordinator, and I mentioned                stqdN7 Of  the
                     $1.40 Der capita goina into Rhode Island, as opposed to
                     45@ in  Mass, and  75@ in       Ilampshire -- an d  although   this
                     is an economic disaster area, when you look at the whole
                     state of Rhode Island, it is a large project           and   Lawton

                                                                                     277
                       said:  We i-7ill be lookina at it, not only from the two
                       counties, but possibly utilizing it for the State
                       But this is sort of off the record, but the question            has
                       been raised, at least to me.
                                   IIT.Z. BARRO@IS:  To me it looks like two professional
                       staff goodies.
                                   THE               -@ut to get back -- sorrv
                                   DR. HEUSTIS:      Can I refresh my memory, can        I have
                       P,i-,l Pip-morN,- refreshed?
                                   TIIF, Ci'-IAI     r@,o ahead, Al..
                                   DR. ilEUSI@IS:  Is the -- is this the same mro3ect
                       as has  t'@ie health olan education T)rolect that already has
                       $400,000.00?
                                   THE CII-@II7,-t-@l@l:  Yef" that's their    i@T.Eci@  i-@- e
                       activity, @.7here there is annarently a carryover annroachinrT
                       $400,000.00 fro-i -,orior a@.,ards -- so @,,e are talkincT about
                       rouahlv $600,000.00 for t,.Io ?earr, for that activity.
                                   DR. HEUS'LIS:  This is leaal -- just 7es, or no
                                                          ."he moneN7 is
                                        STOLOV:  Yes.                     obligated.
                                   DR. HESS:  Could we qet a,descridtion a little bit
                       more?     I think it's very, very difficult to make an,7 kind of
                       essential judgment on a one line statement of a            title  of a
                       project and 1 thin    k it @,.rould be helpful, to me     at least,    0
                       knoi-i where to fit in this thing      -- if @,ie could  hear a little

                                                                            278
       3            more descrintion as to @.ihat these tx,.io projects are
                    the science and  (Science  Council)  and  the  health  services
                    in time of economic transition.
                              DR. t@,!cCALL:  The  Health Science Educational Council
                    tal,,es in -- the ir,@-)ershin includes all educational  health
                    services institutions through the State -- public and
                    nrivate consortium molded into a data base which coupled
                    i-7ith the sophisticated determination of their needs and
                    result of manno@,7,--r su-)-ol   I
                                               and distribution changes -- maxiinum
                    benefit.
                              Specifically, tais -oronosal is asking for a fourth
                    vear.
                              DR. '!'-OSS:  lqhat is the monev used for?
                              DR. -@,'CCNLL:  I don't kno@@7.
                              D'.Z. HESS:   I knoii these one-nage summaries are not
                    very explicit about these.
                              T
                                     for example, is this to      some of it  I  am
                    sure, is for administrative ipurnoses, or       is it to nay
                    for faculty, or for conferences, or partly sunoortive     --
                              DR. Tic,-'ALL: Of the 8200,000 rc(-uest,  123,000  is
                    salaries and iyages,
                              In that request is 5,000 consultants,
                              $13,000 rent
                              $5,000  communications

                                                                             279
                              $7,500 cori-outer data processina.
                              A,-id of course I have nothing at all concerning t e
                    $400,000.00 carryover.
                              And maybe -- I have not been to the Region at all
                    so I really can't --
                                          TTC)@,7 M
                              DR. IIESS:        anv schools are involved in this
                    thing?
                              DR. McC-@LL:  The nuTrO,,-)crs aren't in the summary list
                    at all.
                              'F'411. STOLOV:  All the institutions in Tz;iodo Island
                                   CI-IAIT?I"@l@,T-  Tv,,Iell ho,,7 ranv are there?  That's
                    Bro,.,n, Tler.-broil@-c, and
                                   -D@-OOLOV: @d there are community colleces as
                    'T-,7ell, in 'Rhode Island, and  La@,.itonis letter r,,,aV be riore
                    spedif-ic -- it does smell out some
                              As to the $400,000 figure ti-iat @,7as as of a fe@q
                    rfionths ac-io -- so the sr)endina rate at the end of this fiscal
                    year nrobablv v7ould be  reduced
                              They do nlan   to do a lot of subcontractina locally
                    and if you Granted to corr,.cnt on that, Dr. -!,@cCall, as to
                    whether
                              DR.  T-ICCALL:  This letter is dated ".'@ay 10th, from
                    Bob Lav7ton to Jerrv --  says that
                                 . . . interests of 7,hode Island in terrms of

                                                                       28o
       5                regionalizing its health  manpower  and  the  continuing
                        education of health Professionals, lies in a fourth
                        year of support for !!I.,TSEC" (Or @-7hatever it is)
                        "In its developmental neriod.  This is the product
                        in part of a- slo@.7 start, @4hich is perhans not so
                        unusual  considering  the  difficulty  of  establishing  a
                        viable and coordinated consortium of many forces.
                              "First T- @.7ould sav, and mv presence here  is  the
                        proof of this, that the concent behind !ZIHST@'C and t'@,-l
                        corinitment of the Dul)lic and nrivate nartners  to  its
                        success is still excellent.    The eleaance of  -@IIIS-@C'--,
                        design i-iill be co".@lir-,,.enteci b,,r the productive results
                        of its nrocTram.
                              "Some of the irliAediate and specific    objectives,
                        ne-,,71y crystallized, are -L-"Ie follo@-i-ina-.
                              "The develon,-.ent of criteria for need in t.',,.e !-.a]or
                        health Professions.  This is essential to determining
                        the gaps after  the  completion  of  a  current  inventory
                        of active  professionals,  no@v  in  process.  I  consider this@,
                        a difficult  and pioneer
                                                ina, but necessary effort.
                              "2.  A major    exploration and development of a position
                        on  Phvsician  extenders  of  all kinds and their certificate n
                        or lidensure.    This @,7ill include an inventory of tic
                        authorized and informal  extenders, plus a determination

  wt 9G                  of the needs for them, ly type.
                               "3.  The application of a   successful desian of
                         core curricultirt and career ladder  already developed
                         exnerimentallv for inhalation therapists, to other
                         professions.
                               "4  A  coordinated  Program  for  continuing  education
                         of Physicians similar to the 'comoactl successfully
                         developed in Florid.a.
                                5 A-malor  effort  for  the  continuing  education  of
                         physicians, r)iiarmacists, and nurses on the @robl6r,.s of
                         drug interactions
                               DR. HESS:        can ,.7ou tell from the budoet   sl.'iect
                    or an@,-,.7hcre, ho@,7 much  the colla'@:)oratina institutions are
                    contributing to this overall nroject?
                               DR. @-,!cC7-k-LL:  .@zo, this is not sho@.,in
                               DR. HESS:  into monev is sno@@in
                               DR. McCPTL:  '@To money is shol@7n as comina from  other,
                    sourcesp on the record that I have.
                               DP,. HESS:     In some of  this there is a legitimate
                    concern of the educational institutions, and I can      see %,7here
                    RT,IP can form a linking, a coordinating function.
                    But you no,,q, you kno@,: the hard ,,iork of doing this is basicall@)'i;
                    an institutional resnonsibilitv.
                               DR. TilSCHPI,,T: You don't have to provide them @.4-ith
                    a link
                               DR. HESS:  Yes

                                                                            282
       7                      TIIE             In response to your other question,
                    the $250,000.00  studv health services in a time of economic
                    .transition --  skipping through here, this is in the office
                    of the Governor of L@'iaode Island -- but some of the specific
                    activities -- and I an reading:
                               "7mticinate that during the funding period, include
                          an assessment of the impact of base closings on the
                          deliverv and financing of health care in the affected
                          cop.1munit'.7.
                               "A forecasginq of sundly-deriand relationships
                          for health services  resulting from information obtained
                          in the assessment,  formation  0, policy ontions and
                          the coordination of  various  olanning efforts with
                          State plans and resources
                        and then thev go on to talk about   economic and  ot,ier  rqattnrs
                        I sunpose -- I suspect that there's an a@-ifull lot of
                     economic as well as health in that       but again, I can't
                     that's a backdron.
                               DR. TESCH7'@Z: T)o @you have to get do@.,Yn to brass tacks.!
                     I,ie don't have enough information here to get a'Llold of this
                     one in the kind of detail that would justifv  utting a     half
                     million into something we don't kno@,7 @@ii-iat. it looks like
                     a pig in a pbl-@e situation.
                               A  site visit would be in ord6ri and seems to me          i

                                                                             283
                    since @,i'       site visitinct- 56
                          e are noT,7                  proarams, or 53, @,7e might
                    as well site visit this one.
                              SISTER AIRT: Pit this time, at this point in time,
                    @.7e have a demonstration pro4ect that can't be completed in
                    the demonstration time -- so  their @,ii'lole project system
                    needs to be looked at in the  way they @ve desianed these.
                             @And then there's one here "for regionalization
                    and maternity for newborn care in Massachusetts And this
                    hasn't been brought un with peonle Ratio are going to be tiie
                    providers and the consumers     and there will be some
                    emotional issues, -o7e could stir ulo a hornot's nest if they
                    are not ready to Use this.
                              So I mould concur that this      this seems to m---
                    a program that needs to be looked at, at this noint in
                    if @ie are going to give funds.
                              n.'IIE CH2      Iho is the (-,u@,, @7it-i the action in
                                              T                  L
                    this arouT)?
                            DR TESCHZ.,A: Thurman.  (Laugliter.]
                              TIIE C'.'iAIP@WI:  Seems to re that more than almost
                    any region @.7c-have looked at, T have heard a lot of concern
                    exnre8sed about individual projects which by an larae, In
                    terms of dollars, are significant.     @".vo studies, each a
                    quarter of a million, the continuation of Phode Island (7.-IJ.1,NC
                    whic'@i, if you @.7ill look at the carryover funds, is at least
                    a half a million.

                                                                        284
                             So those are certainly -- and between  the  three
       99          or among the three is getting -- and I don't mean to  e
                   because I think the neonatal. one is around $80,000.00
                   about $600,000 out of an application at this point of  $1.9
                   or roughly one third of the project -- the group  has  some
                   serious concern with and I think we need to flag  that  for
                   the Council.
   ll,qD'zrX                 DR. I'@EUSTIS: I move we approve it at a  million
  MOTIO"Q
                   dollars.
                             DR. THUPI!D@,l:  Second
                                                         mean to co
                             .tESCII.P@'.': Second I don't          m,,oete i,7ith ,-ou
                   but
                             THE CHAIr@@tV-1:  We have a motion and a second, to
                   approve at a million.
                             Chuck, I think I saw a little strain
                             DP,. P!CCALL: Excuse me, I think vib haven't heard
                   from Sister Ann on this
                             SISr."EP, @.iN: "4o, ilm
                             DR. HETJSTIS:  If mv motion is premature -- I'm
                             DR. @-icr-ALL:  I assume that v7ith the time restraints
                   it may not be practical, at least in mummers, to have a
                   site visit. I'm. hot  sure.
                             If it were, I would support that.    But if .ie are
                   not going to be able in these unurual circumstances, to have
                   one                                  f'
                       and @..,e've got to come un @,iith igure   and it's certain

                    that whatever we recommend -- zeroina in on all these concerns
       00           -- specifically -- so that if we took the $600,000  back
                    that would  leave almost $1.3 million and surelv it's not that
                    simple in mv mind
                               I was thinkina about $1.4 million as a recommendation.
                               DIR. BAR.010@,IS:  I think that is ref lectihg the ,.y lole
                    pattern of their approach.
                               If @Tou were to describe this as you do meat, this
                    has more fat in it that anv cut we have seen to date,    and
                    probably ever @,7ill
                               DR. THT,'R@@@,T: Can @.ie speak to the issues raised,  i
                               I-I.ow June and Julv are not bad months to cet tne     I
                    citations rai.sed if there are available personnel.
                               Can we advise Council that this oroaram,   because
                    of all the rhinos  that have been discussed here this mornina,
                    badly needs quick site visit.
                               THE            Tlini-site visit
                               There mav even be the possibility, although I can't
                    vouch for this, that one could mount a mini-site visit     bet,,veeni
                    now  and the Council A-leetin   which one of the Council       ers
                    might -- a one-dav sort of thing.
                               DR. 7,!cCll,,LL:  I think that's highly desirable.
                               DR. TES(711,7%2,1:  Because I certainly couldn't supoort
                    this figure -- I'm havina difficulty supporting      million.
                                                              7        a
                               DR. HEUSTIS:  I agree.

                                                                                286
                                 I.-IR. BARROl,.7S:  I agree, yes, I'-a with voui
                                 DR. IIEUSTIS:  I'd like to get this in as      soon as
                      possible,  I guess
                                 DR.  HESS:  I  think  you   have to recognize that
                      currently  funded  at  an  annual  rate  of about $2.7 million
                                 j)R. TI.-T@UR@i-kTT Joe , vou we 1 1knoiv that ,,76 have never
                      discussed this Drogram       but everybody has said that it has
                      been overfunded.
                                                  'I@@ell, is the suggestion  one of
                      reallv ttvi.nq to mount a mini-site visit,      either  before  the
                      Council convenes or certainly immediately       after     before a
                      funding decision is --ade to really Shane      the reconi-,endation
                      as to the funding level?
                                 Or do you want   to out a base fundina recommendation
                      in and
                                 DR. T--@-CCALL: I %'70U'-Li like to see us go that route
                      of the mini-site visit before, preferrably before the
                      Council
                                 DR. TIIURI-lu,@,",':  Could I make an alternate, substitute
                      motion suggestion?      Or whatever we reallv want?
                                  If you read Stan's first paac-., here, they are
                      as]-@ina for 1886     tv7o continuation projects, and     eleven  ne%-i
                      projects -- that gives them a       T.)rogram before the  $671'000.
                      and if you add $324,00 to  continue       the two  pro3ects for   a

                                                                          287
                    period of time, you do come up with a base of a million,
      102           really.
                              And so  I thin],,, @@7hy not let's -- this 671 fiaute
                    they don't currently have those people now   -- why not let's
                    arrive at  eialit, or a million, with an understanding that
                    the site visit would either add to or subtract from
                    but no fundina  is possible without
                                  NP-ST-1:  ,%nd no continuation fund.ina     just
                    @qant to mal-,e sure I understand N),ou no,,.7 -- no continuation
                    f iLndino next vear   the @200,000. for the [,'\,IIAC@.%] until
                    that.
                                             T,-iev have @,@-00,000 no@,7, so it-
                    hurt them at all
                              TI-IE           Would  @7ou accept that as a Gul-)Stitul@---,
                    notion?
                              D--I. HI@USTIS:  I didn't understand that vou've c'ianc.,--,a
     DE X
   ?@,IOTIO'-.1     it any    except to add the site visit
                              DR.            '.T--ll not really.
                              I said, going @@ac,- to the fact  that @.7e don','- o,,@7e
                    ther..,, anything,, in -@hat sense of the word, for ',iealti,@ science
                    council because they are carrvlnff this monev for-,7ard.
                    I was shooting for @300,000  which really wouldn't hurt them
                    by the time we@ran  the site  visit here.
                              DR. HEUSTIS:  1',Iould you change a million to $COO,000'
                              DR. THU-R:.@T4:  Yes.

                                                                           288
                               DR. HEUSI@"IS:  Well, I would support that.
        3                      DR. TESCiT@-IT:  P@-id I second that also.
                               "@'HE           O.K.  what I have heard -- what we
                    have then, if I understand it, is a minimal, interim --
                    or not "minimal" necessarily but interim funding level recom-
   iiidl' )"        Ytiendation of $800,000.00 %-7ith a strona recommendation that
   IOT I O@; T
                    some kind of a mini-site visit be made to @.ristate, lookina
                    at some of these new activities, and also the  [..@hacl,:]
                    to determine @-7@.lother that figure should be u Ped, and if so
                                                                    p .
                    ',-io,..7 much -- or indeed, that it i-.iicT!,it even be lowered.
                               Ts that rcuahlv the sense of the notion, T3ill?
                               DR.            Does that include the $200,000 for
                    r,ionitorinc,- activates?
                               DP,.           ',,:Io that Tiir)cs that o
                                                                    ut.
                                    T
                               Dr.,. IL@EUSTIS: You are eliminating that.   0 .
                               DP,. TESI-'.Ttl@'@l: ,r\nd we would love to Ir-,nO@-7 iT'-iat the
                    P,Ar, has been thinking.
                               MR. NAO-H:   @-lo, the RAG didn't really approve this,
                    I don't believe.
                               THE CHI%IPI,"@ 'J:  T:Ilerb is here, let's tr@7 this idea o t[
                                                                                     u
                    on him, to see if this is reasonabl   e the Regional
                               il'I!?.i T@IASFI:  He'll be sorry he -i-iall;ed in on ti-i i s a t
                    this  tine.
                               TIIE CHAIRvL7"'l  Herb, we have spent a good deal   of
                    time with Tristate, recentl@7.  @,.Ie are concluding now, and

                                                                        289
                    perhaps more than a@v other region, serious questions have
        4           been raised about a  small number of projects -- several
                    new ones that total  half a million -- continuation of that
                    i@iode Island  PIT.P.C'-@  for which an additional $200,000.
                    is being asked, but -.For which there is some $400,000.00,
                    or mavbe $300,000.00, in catryover funds.
                              And the arouT3's recommendation, which  hasn't  been
                    voted on, but which is  on the table now is  to  recommend  an
                    interi,-,i funding 'level of siri
                                                 oly $OUOO,000.00 in  the  place  of
                          ,il,r    million request -- Y;7ith a strong recommendation
                    a roucr.
                    ti
                    iiat some kind of mini- one-dav site visit be made to
                    Tkistate to look at several of   these large, new stud,7-lil:,e
                    activities that are being oronosed, as i,,iell as the  -orogrcss
                    and needs -- future needs --   for t,qe r@.-,-Iode Island [A!-II
                       bit-@ier before Council -,..Ieetinc,-, @.,7hich is a short @-ire at.-ta,,,,,
                    or about three r@7eels',s or less than tl--irec i.,7ecks; or be--Fore the
                    final funding decision is made.
                              -@joi@-i this is the first tir.,.e we have come to anv kinc,
                    of a recommendation.
                              I think there are enough serious concerns    about
                    specific activities, and questions
                              I,IR.'PAEL:  l@lell ..ie, of course, have not beet  site
                    @visiting other regions, but I think  it's an unusual set of
                    circumstances, in some-thing like this, there is no reason
                    that we couldn't accommodate that recommendation.

                                                                  290
                             But I @.7ould much Prefar to have the site visit
      05           prior to Council l-Leetina than after Council
                             THE CHAI,@IA,@-1: And presumably,  includina  somebody
                   from Council
                                             bod@;, from Council and liaison.
                             i4R. PAT-IL: Some
                             I think the Tristate one,  particularly,  has  given
                   us some questions, internally also, and this certainly
                   reflects, perhaQs a little bit more em-aiLatically the  issues
                   that have come to my attention.
                             Ile can accommodate that recommendation, and  -@ii 1 1
                   act on  it.   We can't accommodate many  site  visits  because
                   of the tir@ie involved, but certai.nl-,7 in unusual circumstances
                   N,7 e c a,-L i
                             11'2,. B,-NRIZOIIS: I-,7cll this need is dramatic, too.
                             '-,HE           T-.Ie do have a motion to t@iat e---fect,
                   ti
                    ,ien   let's call for the question if there's no further
                   discussion.
                             All those in favor
                                             [@-he motion ;ias Droperly put to vote
                                             and carried unanimoa@-lv.]

                                            !.!El@l JERI;EY:
       6                          CTIAIP-2,@l:  O.I'\,. Paul.
                             DR. TESCll-7VLi:  Well, the New Jersev application is a
                   little longer than West Virqinia, but has about the same
                   aeneral qualities in being able to describe simply and
                   in relationship to the  tegion's needed goals and their
                   shorter term objectives which have been arrived  at  by  explicit':
                   process, so that you can follo@,.i it.
                             '@"h6re are corporate arantees -- tlie,prograin. serves
                   7.2 million Deople.    Thev have  established  sixteen  professions
                   al.s and some eight clerical beoplo a proximately, and they
                                                          p
                   are asking a Drogram  staff  support  to the tune of  $825,000.0@-.@
                             They have ciaht nrojects, as far as I see it, and       i
                   this gnans, reallv, the entire set of goals relatina to
                   access, sunoort of categorical -- suDnort  of  quality  assurance!,
                   activities and some efforts in the area noi-7 of cost contain-
                   ment, and a beginning exploration as   to hoi,7 the 10-1.IP and the
                   P@,T mav be getting readv for  the  next development in tle
                   legislative activities.
                             Thbv also function on the contractual svstem.
                   -,hey have a large contractual buduet -- that's essentially
                   how they are functioning.
                             Thev have an interesting staff organization so that
                   in addition to the usual essential managers, that is the
                   fiscal, development and evaluation type thing, they also have

                                                                                 292
                                                                              11 time
                      a procTram develoT.)Tient who has a  named,  on-line,  fu
                      manager that has to do with the subject matter -- so that
                      there is somebodv free -- and so vou qet the sense that
                      there is a very discrete program     assigned responsibility for
                      the  conduct  of  these  affairs  throughout  the  region
                                                               If  you  read  a
                      and sort of a tiaht, e)tnlicit X-ray.                    c,@-iart
                      you,can understand exactl-,T hoi,7 thc.--,i are proceeding.
                                 Our past e'xnerience is 'coherent @.,-ith the idea that
                      the P2'IC- appears to be extreT-.t--l-,r explicit and  active, and has
                      some of the -most effective neople        including one of the
                      !'Ien't)ers of this Council in the otl-ier oanel    this committee
                         on the panel -- who has been not only extremel-,7 'j',no@.;ledcTe- i
                      able, but verv articulate about the Program in nresentincT
                      hot the PJIP should be- @-ior.@ing in  developing  not on y CIIP
                      capabilities,  but  the  nrojects  in  virtually   all the areas.
                                 I am interested that there are  t@@ient@.;, arantees a@-io,7.c-,@,
                      the thirty some nroject-,.     They had 30 operational i?rojects
                      but not all of them are current, I might add -- and 7
                      developmental ones.
                                 So th t anona that entire groun there  Are quite a
                      nu@--r  of arantees @.7hich annarentlv are the recipients     of
                      the'contractual funds -- Primarily      operating    out of Program
                      Staff.    So that it's not either centrally managed or
                      grantee managed, or an@7thing of the sort -- you qet the
                      feeling  there  that  there's  a  good   dissemination of resnonsi-
                      bility in the operation of the Oroaram.

                                                                                   293
                                 One  of  the  fascinating  thinas  about  llow  Jersev
       08            has been the @,7ay thev have been on top     of  so  many  of  the
                     new  issues  in  terns  of  better  access  --  emergency   medical
                     services  --  quality  care  insurance   including   assistance   in
                     'OSRO  development  --  but  also,  more  explicitly  than   almost
                     anv other program I l@nO@,7 about, though  the  Staff-ina  kno,,-.7
                                                                                 y
                     better than 1, of course, for good reasons.          But  the   most
                     expelicit  e-@,nerience  I  have  had  in  setting  standards  for
                     (.Tualitv  for certificate  of  need  tvne  activities   --   i.e.
                     the technical review crrour)s, or the     committees   have    put
                     together  standards  of  excellence,  or  standards   of   aualiL-Y
                     care, in a whole varietv of specialized and snecial'L--@i 7,crvicesi
                     P-nd  one  gathers  from  the  narrative,  that  these  have, in fact,
                     been used in certificate of need and that the 122,T Corn,-iittees
                     have  been  used  b  CIIP  certificate  of  need  t   e   activities    i
                                         y                              yp
                     for advice  on  the  basis  of  standards  --  but  not  onlv  the
                     standards have been  adonted  bir  CIIP  but  the  staff  has
                     Participated in the review of      certificate of need and
                     given the professional and technical advice to CIIP delibor-
                     ations.
                                 !Tow that's reall%7, one of the first e,.-Dlicit
                                                                                     IL
                                                                                      D
                     el,<arLi.nles in my e.-.nericnce that in fact, CIIP has  used
                     in an appropriate wav.       I think it's a  real  credit  to  t.-ie
                     history of that development.

                                                                           294
                              Now the -Final thing., that I x,7anted to go into --
        9           tliere's a fair amount of detail
                              But the other thing I wanted to mention was --
                    a good deal of back and forth Oiscu@,sion, esneciallv in one
                    set of correspondence .,@iiich Frank has got a nice coverina
                    .Letter on -- from apparently the "'.,Iort'@'lern No@,7 Tersey
                    Conference of Clinical Council"      I can't tell @,ii-ietlier it's
                    an t@ or .3
                                               It's D -- area-,,@7ise.
                                DP.. TESC@l@@T:  ..nci tilo- discussion of the letter of --
                    the   @xecutivb r@)irector of the 3 Pgencv  is sort of a cantankerous
                    buckshot   tvne of vituperation, @,7to which, there is one of the
                    -mot  beautiful responses that I have ever had the pleasure
                    of reading-
                               Al [F@lorin]  has gone, in five pages, to dovelon
                    the histor-7 of ho@,, Ci-!P existence in ",T@@,7 @7ersev, is laraol-@
                    a result of  ?,,"!P effort, throuQh three Generations of
                    executive directors      and he takes each of the issues
                    relative to each of the projects, and beautifully O.-ve oDs
                    ther@i in some verv sirple, clear lancuage, in a hial@
                    professional and hi(-hl,7 unvituperative and u,-i emotional way
                    givina the facts of the case.
                               You knoti, this little correspondence file, to me,
                    is one of L@-,.ie most beautiful pieces of ex6hange that I've
                    had the pleasure of reading.,  I'm just delighted that %@7c

                                                                               295
                    had this for suT)plenentarv material -- it's the basis of
        0           reallv a more acneral recommendation that I @-iouU  like
                    to leave 1,7ith you all, and that is that -- not in my own
                     feeling -- is that recognizing the legislative mandate of
                     C-,-IP -- recognizing the relations the regulations of !U@IP
                     for interaction -- I feel that we should recommend to
                     Council, for Council policy, that says that:
                                1,7e urge that Council bring to 'Ir.  [Ravell'>]
                     and other anDronriate T)eoole's attention, that interaction
                     is a reciprocal nrocess and that we should have Mandated
                     bv regulation       quite aside from legislation         reciprocal
                     interaction and     re-@nonsi!Dilitv, mutual responsibility,
                                        4-
                     e-,-iolicitlv direCL-ed frori the head of the CIIP P,-gency
                     here, to all  B  -@3,qenci.es particularly, what thev do with
                      the @ls is a different strv, of course, and it's       up to then.
                                 Secondlv, that so far as our deliberations in
                      this Committee and    in Council, that we should ignore the
                      negative C'@"P comments, except as
                                  (a) number one     the B Aaency informs the local
                      P,l@4P of their criteria and  revie@q  in common Drocess
                      nreciselv as our P-@IP informs the B     kgency of the @.!P"-,
                      review  of common oro3ects -- total       reciprocity.
                                  (b) number ti,7ol  that the   B Aaency shall furnish
                       to the MILT' acTency, e,."-,)Iicit statements of the objectives
                       and priorities and as need statements, against which

                                                                                         29b
                        targets their development.
                                    So ml,, feeling is, yes, vie recognize and feel
                        entirely appropriate the PTIP should respond to CI-IP
                        4ust exactly as said -- no argument.             f-.@ut  that  it  needs   to
                        be done at the sane professional level to i,ihich  ',R!,,P is
   1 N! LT-i 1,"
                               called.      That needs to be established as a
   .PBCOI@ll,!F,I,TD    being                                                           Sim-ile
                        issue of basic integrity betv7een the t@170 nrograms
                        Darticularly if thev      are aoina to be legislated into some
                        kind of relationshin.
                                    I',o@'T that's a formal recorr,,.endati6n I would like to
                        have this aroun discuss and cbnsic',er at some point.
                        It's a digression from the current thinking and
                                    And no,,,7 m,,7  final,,  to  sum  it  un,  I  think  this  is  a
                        beautiful   n roarar..i,, a ton level oneration:         Our    feelina    is
                        that w6 would probablv recommend the funOina a-ooroxi.r,,atel@y
                        15 to 20   nercent above     the current taraet          but minus a out
                        $600,000           is duo   about JtlN7 lst        and that comes out to
                        be a!3out  @ll-.9, million.
                                    And that the Reqion essentially should be congrat-
                        ulated  for the .iav t'i-le-i r have proceeded.
                                    r)'.1. IIEUSTIS:  IViat  @,,7as  vour  figure   IcTain,   please?
                                    D R.   E, S C,     $2 . 9
                                    DT-Z. IIEUSTIS:   And   then   you're   qoincT to   knock    them
                        do@"7n by  amillion?
                                    MR.  ilASH:   T'Aii8   application   is   3.9.

  wt 112                     I,,T . BARROI@',,'S:  Yes, Nie are knocking them do@,7n bv a
                   million bucks.
                             DP,. TESCIIAII:  I thought that the recommended funding
                   relates to the taraet, about 15 to 20 nercent above the tarae@-
                      minus.about ,@601),000.00 in Jul-,r.
                             The@,, are over target b@r some  I forget @.7hat
                             D',n,. IIESS:  Tliev are currentl,.7 funded at 1.6.
                             DR. T'-SCHPjq:  And I thought that from 1.6 to 2.9
                   it's a substantial rise anct it allows a little monev for the    i
                   Julv 1 Council situation, and it brinas it a little closer
                   in line -;ii,--h -;Yhat the -ficTures a-,)t)ear to be, ,,.7hich are available
                   for the nroqram.
                                 I ,iould have no objection if some-hod  T%7anted to
                                                                      y
                   fund there. @-lly or in some larc,.Ter amount, Vou knoi-7.
                              u
                             TITE CH.@I !A@l:  @,.Iay'-,)e .7e ought to, since l.'Ilr. Barro@.@--
                   was the other reviewer on this, hear from him before .je carr@,
                   the matter of fundina level, or other comments or
                   observations  further.
                             MR. BARROWS:  Ply revie,.i  is pretty much a  reflection!
                   of j st what Paul has said.  In  short,  the  program  leadership'
                       u
                   ranks, participation, I thought, Has su,,oerbi In  fact,  overaill
                   I came out i-iith the impression that this @ias  particularly
                   in depth, the type of  program I i,7ould recommend.  Period.
                             @.h6 relevance of their nast activities and the

                                                                             q8
                     proposed activities in the broad, PIIAP mission, was just
                     top notch, and more than that, the,,7 are relevant to the
                     needs of their area -- Particularly the underserved,
                     seemed to be just right on target.       I was deeol-,7 i-iirressed.
                                They had another attribute which N-7as outstanding
                     and this to me, and really this is maybe a philosophical
                     matter with @,71lich you P,,,av not all acTree,: We need the ideas,
                     the (--xt)ertiso of acade-.iia and we need the suT)-r)ort of t e
                     GoVernrtent if we are rcallN7 goina to (Tet anything reall@7 done
                     in the mainstream of ir..@nrovina.    It's cTot to come from tiie
                     T)racticincT, Professional level, and th6v have done more
                     than anv program I have seen, to act the practicing nrofessionj
                     involved.
                                With -t.'Llat, I came out !.,7ith juf-7,t this ver77 ton rati-nc,@
                     and 1 dismissed the CIIP thing as a ventilation of n,--r@,onal
                     pique @7hici-i had to merit.
                                 I ECT.IAIT'-?!@p@ !@.aybe I ought to ask Franl,,.
                                I think we have   an issue that is resolved here,
                     Frani@ on the
                                '!!Z.. NAS@"@: You mcaa on the C"-P?
                                               Yes, riaht.
                                    '@@@TASH Yes
                                                   7oll, of course Dr. Thurman
                     is certainly accurate in his description of the letter
                     Dr. [Pord?]'s affair -- it Has ',Deiutiful.
                                Pnd I have since heard from t'tie region  that the

        4           B Agency Board anvroved, I mean, recommended anproval of this
                    application -- so I thin]-@ thit this ]:)it of "spleen venting"
                    by the CHP Director who has onl-,r been  on  the  board  about
                    five months in that Particular   agency anywaxr    is
                               'LIIE CTiAIR!,@l@l: Have vou oot anv more insights on
                    the warfare in Nev-7 JerseV, ',Torthern NL@w Jersey, Tom?
                               FROPI TIIE FLOOR:  That's not my bailiwick.
                               TA"@ CHAIPJT@@i: Oh, oli, that's right. Ne@.7  Jersev
                    that's a conout.   (Lauahter.]
                               DP,. T4@ISCHAIT: T'm lust callin@! for fairness and
                    ecualit@,
                                CIIAI@!@,l T,IDll that is a -- the letter  ,7as  a
                    Director's letter,  but the Board --  under  v7hat  duress  or
                    -oror@inted by @,,,hat reason, did tai@c,- iction criii-tc on.-po.,3i-te to
                    that, abnrovina  the      Jersey anT)lication.
                               I realize you're just as,'-Iin(T for fairness and
                    equality
                               I'@R. @.@ASi'!:  r-Lo reneat, i-7e iyiav have a -Dolicv question
                    in this particular region.     One of their proposals is to
                    establish 3  PS70s and   1  don't  know whether i-ic can use  our
                    money for the actual establishment    of  PSP-Os or not
                               @14P,. BARROI,TS:  Is that to be establ ished, or just to
                    provide  the  Preparation   activities?
                               !,,IR. PAHL:  Ilri not sure, it's backun support.

                                                                     300
                            COI.1,@r'ilT: It isiil-t actual. support here, though.
                                        u                             't
       5                    TIATE          It may be an issue that i@,,c want to
                  flag, though, and get into some consultation, if  we  haven't,
                  with the appropriate-PSPO staff here, and defending  unon  the
                  outcome of that, we mav, or may not, i-7ant to highlight
                  something for Council.
                            I have the same question in my mind.  It  certainl,7
                  is, in one sense I think, verv consistent with the kind of
                  qualit-,7 assurance activities and standards settina   or
                  standards development, that has characterized one r@iajor thrust,
                  Of the Jersev -rl@LIP.
                            on the other hand,  'Bureaucrats have a ,t7av of
                                BARRI,)I,7S: Pete, I read that as sinT)ly a resnonse
                                                    act readi
                  to helT)incT the ri(--dical coruiunitv      for this program
                  and
                            '@IIE CHAI@L@il:  11-c nav want to c'-Icclr, un tiat @S7.0
                  -staff, I think., in anv case   just so that neonle don't have
                  their noses out of joint around  here.
                                     T
                            DTLZ. T'-7SCIT 121..-'T: T.ic basic funding of the PSRO comes
                  from the nrocessincf of the business -- so '1,7ou knout, it  isn't
                  goina to take    the actual financing of the DSRO-is not
                  a   problem.
                            @IP,. PAHL:  '@'.,iev want to T)rovide the same type of
                  sun',Oort  but it's a B a@encv.
                                           T.Zo,li are there anv other matters or

                If
                                                                        201
                   or coi%-nents or questions of the two reviewers, or of the
                              that matter, that relate to 1',Iew
                             4
       6           staff,  for                                @fc,,rsey R'klP?
                             DR. HEITSTIS:  Do you think Barro@.-is will acree with
                   the money figure?
                             I-IR. BAPROI%7S:  Well I was a little more generous.
                   I'ri not as qood at nickina figures out of the air as vou
                   fello@,.,s are but I would sa@7 that when we wind un, this
                   should be in the nreriiium category -- verv clearly in the
                   nteiiii,an,i Cdtcqor-,,.@.
                             A.@TOT,I, There that fioure is, I Oon't IJ7,no@,.T.
                                            T.-7p-]-l, the@7 are askincT, as raul has
                   indicated, t'-ie7 are r(--aiiestiiid in this a-)nlication alriost
                   84 million -- 5,3.970.
                             They have indicated, and that does not incl-uOc anN,,
                   neT,i activities in one sense, alt@-i.-IOUC7,-l t'@iere is sor,,e nc,q
                   'oroaram staff activi-L.-%i, I gat'ier, and scnic e:@nansion
                   and t'ie@y       in  @.7it:-l a Jul,i an@-Dlica4L-.ion that tIL,@,el,, s ti,7. a,
                   at @1'000,000.
                             DR. T"l)rlT:41- 11 like I  sa  I have no objection
                   to UnDing that amid, but I just  didn't know ho@.,, to'do it.
                             DR. HESS:  Let rtie ask you a cou-,:)le of questions:
                             -,.,Iu@?er one
                                          !,That t" c -  lation of the rea4.on?
                                                      .L)ouu
                                   SCTT,?VL
                             DR. TE  Li    Seven and a iialf.
                             "!P. NASII: 7.2, really.
                             DR. IIESS:  And is this just the state of     -Tc@,rscv?

                                                                                 302
                                  HE c:-T  @r  i   @,ight, it follows the state line.
        17                       There  is  some  overlap  with  Treater  T)elaiiare   Valley
                      in  the  Southern  and  less  populated  --  Philadelphia   and   Camden
                      area, and the Cranberry   I Bogs and the resorts
                      But I think certainly ilc3T.7 Tcrsey ?!,IP  has  defined  itself  as  the
                      entire  state  and,  indeed,   have   conducted   activities   throughout
                      the   state.
                                 7,-IP,. i:@'.A.SH: They sent a staff nerson down  to  Southern
                      @Te@@7 Jersey, and T)aid the salary and all bxnenses for a year
                      in establishing   the    South Jersev CAP agencV.      Thev    consider
                      themselves a state-wide program.
                                 Rod  r,urT,,)I.-.y?
                                 TI'@E CIT7 I\ I @ 7',Tl @l                       -)ac-  today
                                                   Oh, t.7es, -,ocl literall,.7 is
                      from a management-a8sessinent     visit to I'@@ew Jersey earlier  this
                      week.
                                 '-;-4R* MERCKER: I spent Tuesday and T,@Tednesda@,r -,,,ith
                      the Proaram Staff of    the @le,-,-,7 -urersev reaional ',",Iedical  Program
                      and their management    is excellent.      The   nrograr.    nanaacment
                      in -)articular     they are ii the nrocess      of tal@incT    full
                      corporate responsibility from the                       the  TJniv-crsltv
                      medical School -- and thev "lave dcvcloned the additional pol'ICI,,
                      basis for this, @,ut they still have some administrativ        e
                      rianaaer,qent policies to develop.
                                 But  their  nroaram  management   was   5uDerb.   Thev   have
                      a wav of operating hv health specialty areas,        @,7!iere:their staf.L-

                                                                         303
                           interact extensively and effectively with the
  @-it 118         members
                   projects.   It was very, verv impressive.
                             THE CHAIPJ@,9-,IT:  I don't think we have -- unless the
                   Chairman missed it -- a formal recommendation on the floor to
                   -- of course  a fiaure iias mentioned, but I didn't ask for
                   it, nor did I hear a second.
                             14'-Z. BARR(Y,,7S:  I'll second that.
                             DP. TFSC@IA',-,T:  I m beginning to hear a concensus
                   because if- ,.7e have a 7.2 -- and it's on a per canita basis
                   Tell be talking about 3.6.
                              T l@' C@TI
                             T'i             !,.re you revirinq your motion?
                             DP.            I',-i raising the Question.
                                  T@'ARRO'1'7,c@:  I would br-- more comfortable with
                   something like 3,or 4, or 5.
                             '-HE CiT!@IPI!Ll@T-.T:  2.9,  3.4, 3. 3.5 V7'@-iat   do   I
                   ,iear next?  [Lauchter.]
                                        PUT@
                                  de La    ' ..ITB: lqell  in vie@i of i-.7liat I have
                   heard, and in vip_@@7 of the budact t.-iat I have seen, and -i-n
                   view of .,7'ilatever I know of the @,,TeT,.7 Jersey proaram, and in
                           ti
                   view of  ie other suggestions that  have been made during
                                  T
                   this session, - think that  @,l million do@.yn from the figure
                   they have reaiiested is too much.    So I would go  al.ong i,:ith
                   71r. Barro@.7s.
                             T,",-IE CHAIP-Jl7j4:  Sister, you have better connections
                   than we do     what do -,7ou sa-,,7? [Liuqlllter.

                                                                       3o4
                                              Barrows, there is one thina   I
       9                     SISTEP, IVIDT:  ?-,Tr
                  haven't worked out, and that is the process of discernment.
                     [Laughter.]
                             DR. THUPJ.IPII:  After T,7!iat Joe just said, I aaree
                  with this, and I am certain that all of us who have seen
                   et..7 Jersev,         verv pleased 1,7ith the N-7a,
                               are very                             it runs.
                             But @,,e are talking about a reaion right none that
                  is go-ttinalyl.4 million -- and then we are talking about
                  suddenly 16aoinq to $3.4 million.
                             CO@'r,IE'-!T:  -.oTo, @Y3.6.  on the other sheet.
                                 TTLIU@,,@-3,T:  T'-,,en I go back to my criticism of
                   the  sheet.
                             But on the other hand, I think that's an unreal
                   lean into --
                             TL". BAP,,2,0',IS:  @,,Iell, @7ould vou buV $3.2?
                             DR. THT7RrvT@,l: I @.,,ould go back to 2.
                             SISTEP,, AIIN:  And I go back to $2.9 too   that's
                             DR. TESCIIAII: T,,P-iy not riove for 6,2.9?
                             Now that's with the point that this is the superlati-,,
                   storv,l and if the Council felt disposed to increase still
                   further, that the Review Committee would take no umbrage
                   of that.
                             DR. IIESS:  I would like to just make a point here:

                                                                         305
                                                                        egion that
       0                     I hate to see us uiidulv influenced by a r
                   comes in with a huge recuest and grant a lot of fundst just
                   because they ask for a lot of money.
                             In other @@7ords, @,7e look at Puerto @'ZICO -- a top
                   notch program, that comes in with a modest request -- and
                   ,.7ou ]-.novr, prettv close to @ihat we think they can use- and
                   vie mi-ve then, that.
                              @loi-I this is a first rate program, but they come in
                                     you 'Izno@,v -- @7ha-t they have previously been
                   royal", 1.7ay over
                   qettina in the last year of funding.     And somehow, that
                    just dobs-n't sit richt.
                              DR.            Could I add sor,-Lothina aqaj-n?
                              '@PHE CHAI@T--,@T: Certainlv
   0                                                     Bill.
                              DR.            Do you see anv need for an extra
                    Slug OIL rrione@i for them to carrv out their corporate L--hitQ?
                                              A modest sur.-.i of r@ionev. Thev have  i
                    requested  an added accountant to the staff.
    -N T)r., X
                                                     I second the motion for 82.9.
                                                     we have a motion to recommend
                    fundina @eN@i -rersev on this annlication of @2.9, with the
                    sense, I believe, of the qroun that certainly it reflects a
                     favorable  task toward the reaion and T.)resumably (but again
                     one-iias to see the Proposal  their supplemental uronosal
                     should be lool,-,ed at in July by this cfroup)  in a quite favoral)

                                                                            3o6
                             That should I)c-- around @,600,000.00
                              Is that essentially the sense of the motion?
                              DP,. IIESS: Yes.
                              !,IP,. BARROI 7S Yes.
                              TIIE CH,7\IPJt@4: Is there any more comment on this?
                              If not     all those in favor --
                                               [The motion was r6gularly but to vote
                                              and iDassed favorably by 3 and
                                              unfavorably by 1 vote.]

                               THE C
                                               0.1', it's (as they say in lioll)n-7ood
   wt 122           "High 1,Toon"  and I think ,,7ith the concurrence of the   aroup,
                    this is about the busiest time in the Cafeteria and I t     hink
                    we do have time for --
                               DR. TESC',IAIT:  T@-io more.
                               THE C'n'AIP@.4Tll:  Ti-io more?
                               Well then, you will have to help me identifv the
                    eas@7 ones.
                               !Iochcster has been Suggested     is that one on which
                    you are not the reviewers Joe?
                               D:',.  TI@v,SS: 1,7ell, I couldn't make the judgment  if
                    I @.7eren t --  [Lauc!hter.]
                                               Oh, I don't kno,@,7.
                               DP..          The humor is qcttinq  strong.
                               I"T
                                                 think @.7c are coina to have to cat
                    in about half an hour, things are &ettina but    of hand.
                               It!ell, @.ihv don't @.yp- just lead off i-Tith TZochester
                    and ask Joe to lead  off.
                               DR. HESS:   Hess volunteers.
                                                 ,IOCT-IR  TR
                                                     ,ST-
                               DR. HESS:  T,,Iell, this is the third aT)Dlication which
                    we have discussed this morning in which  there  is  an  inverse
                    relationship between the size of.the --  the  amount  of  paper
                       and the quality of N,71,,Iat's on it, at least in r.,.y estimation.

                                                                               3o8
                                 In terms of the overall organization of       the  M-SP
                      thev seem to be  well  organized  in  terms  of  their  overall
                      goals and objectives, and they are consistent with the
                      national aoals and objectives.
                                 Their review Process is  clear  and  @.7ell  defined.
                                 As near as I  can  tell.,from  the  application,  the
                      leadership on the part  of  the  program  staff,  seems  to  be
                      hiqh quality.                identified  within   their   region
                                         hey have
                      the areas of need --  thev have apparently done some          good
                      bac!<.cTround .-,ori@ in terms of the identification, and th--1,7've
                      got a -Ileaional Plan @.7or,@:ed out wl@h displays it  clearl@,-
                      and si-inl-,r on a na-o -- -oarticularlv in terms of their
                      undersurvevs and tie nee--I of nrir-.arv care, and that tvne of
                                 One of the thincTs @.7hich I enjoyed about this
                      anDlication -- thev  have  their  aoals,  and  then  at  the  baci.
                      t"
                      ,,ev have their objectives of  the  orojects  relatec@  to  4--'ie
                      goals -- and the funding is dis-olaved riclit alone             it.
                      (Disnlays a document.]
                                 Their overall goal here, and listed in         nriorit
                                                                                      y
                      order the  way  thev  nriorize  the  Projects  --  the  non6y  that
                      goes @-7iti-I it. PTIO then the cumulative total that ,.7ill  ',-)e
                      sDent on that particular goal.
                                 ';'To@,i this Particular application is onlv for a
                      continuation of a core staff, with a small increment            blIs

                                                                       309
  ,r,,7t 124       two small increment -- two small projects -- and  the  rest
                   of what we see listed here under "goals" will be coming
                   in in the form of projects in July.
                             So that basically, all we are asked to do here, is
                   to proof the cumulation of a relatively small  corps  staff
                  land ti@io small projects, and this is communicated in such
                   a well orcfana-zeo. fashion. that it just seems to me they got
                   their heads together in that region prettv i-7611 -- and I
                   was favorably impressed and I see no reason why we shouldn't
                   give them i-7hajl-- they ,.-,ant.
                             Din. I-r@@SCIT7',,-.T: Is there r,-..ore coming in i
                             D@@. I-IF@SS:  Ye-s, the@7, are comi-i-ig in --  there's  a
                   big increment cop-incT in  in   Jul-v L-iie zDro]ects.  '%-"ou  can
                   alr_ad@7 see clearl,), ,,,hit those -orojectg are going to be
                   and     t,iey r.7ill  relate  -Lo  t.icc
                             So I have rated -Llic,,.l on eit'@,ier "Satisfac4L-,o@@,_,,"
                   or "FI-Icellent" in every catecor,,,T.          j us t t-70 tl- at
                                                         ierc @.7cre        L J6
                   I put "Satisfactori" on hoiiever, @.,,ith rore information
                   perhaos at staff level, the,,7 mial,.t ,.7ell be categories of
                   excellence -- and overall" based on Nihat I see ',-iere, I have
                   rated it as a "SuT.)erior" region.
                                    L:  What's t' c "T"P?
                              AR. PA.TI
                             DT-11.  TIIUP-",Wq:  Ed  Lane he sent in a nice letter
                   savina he sunDorted the @,7holb thina

                                                                         310
                              TH-- CIAIPJAP.'-,T:  You have a region here, an R@.IP,
    -125            @-,,Iiich qeoqraphically  is defined in exactlv the same
                    configuration as the single area'iliide B Aaency Genesee --
                    they have, I think, good relationships, and I think N..,,e  may
                    even have an incestuous relationship developing in the sense
                    that I believe Peter  i@lark"s  brother may become the B P@gency
                                    T 7
                    Director, Zenith @alter's retirement  this summer.      l,o@,7 this
                    may not helD -- havina kno-,.7n other brothers, but
                               DR.            -..4o sisters?
                                               1,3ill, %7ou @,7ere the other revi-e@@?er on
                    this an-olication     it is a vcr,7 modest one in -- both in
                                                                           'P
                    amount and in        it is t--hev are proposing notq.  -,ut i-Te
                             tt,K 1-7 11    their $1.4 million a nlication is qoi    g
                    kno@,7 -ore   c      a,'                      n-                n
                    to look like in terms   of s.beci-4ic activities.
                                              Joe said everything that i @-,o-Lild have
                    said about those priorities       @,ioll organizcj, stron(,  @-G,
                    grantee situation is a separate from the standpoint of              i
                    never having had a real evaluation group; and the C171P
                    voted unanimously  to recommend  a proval of the annlication
                    and sent a very good letter.
                               So that I @-iould support everything  he  said,  and
                    recommend  the absolute figure of  $361,437.00.
                               Tli--v also bring up the. cTu@2stion in their aT),olicitoni
                    though, that they have put    out an RFP of September 1,     174
                    June 30th, '76, in the @FP    that t.,iey @ave distributed  all

                                                                     311
                   the way down -- this is the health care deliverv program
       6           and always has been -- @?1,300,000
                             THE            What vou are sayina, I  think, is
                   that we may see a nun,Dcr of activities.proposed in the July
                   application, T-7liich would run beyond the end of nel,ct fiscal
                                                              missible to be
                   year -- which .qe have said is at least  per
                   looked at.
                                                              ill see @@ihat we
                             Again, I don't knout whc-!tl er i,7e w
                   are trvinc, to look at in PI-.etro ',Tc,@7 York later this afternoon
                   There almost ever@:ythi-ng    be proposed for tr,.7oT-ars.
                             @@'.Iell Bill, 'IOU iianted to sav somethings
                             D R. T'@' TLUR7t@-T: I .Ioul(." second.
                             '!'TIE Cllt'    You @@7ould second  o.k.
                             DI",. HESS: I  so move.  laughter.]
                                            [-Lhe motion was regularly out to vote
                                             and carried unanimously in favor.]
                             THE             O..TL@., I think ,@ie have it.I
                   think that is a record     we even beat Puerto Rico on  that,
                   Joe.
                                                                                   t

                                                                           312
                                           V127'@SHIIIGTO'.,l & AI,A-!.',il
        7                     THE CHAIP,,"-IP-@T:  I think x.ie could, again, probably
                   take up one more region.
                              Dick gave me a  nod from his end -- he  has  been  in
                   Contact i-7ith Washington a lot this mornincT, because he did
                   have some  Cfuestions i,7e thought might have some partial
                   ansi@ers to as it relates to CA-P here.    I don't kno%,i @--i'liether
                   @,i- 1,@7ant to nroceed t7itill I,,-,ashincton and Alaska, or another
                   region.
                                                    T@'T
                              rp'-i- t,(.,Yo reviewers on ,.ashinaton and -?klaska are
                   T-Ar. -@arro-v7s and de La Puente. Do vou Grant to take it un?
                                             Y(--r:-,, Ithink @.7e can.
                              This, in m-, judament turned out to  be another
                   fine program.
                              I rate them nretty hici'ill,,,, in almost ever@7 catea6r,,,
                   T@ie coordinator Donald [r-lar@-,,lan]  I understand, lias a
                   very  fine reputation.
                              @RAG Chairman, is a Dean of the University  @i.edical
                   School.
                              Four mer,wers of-the University of l@Tashinaton are
                   on the Executive Committee,, @,7hich concerned us a  little  bit
                       and that's'out of seven.
                              They did suffer quite a  depletion  of  staff  during
                   the phaseout  problem.  They dropped from 52 doiin to 35.
                   They planned to rebuild, and the    re-beefing up may  constitute

                                                                             313
                    something of a problem  for them.
        8                      M'-q. de La  PU,@INTE:  Yes.
                               MR. BARR(Y@IS:  Their staff organization loo'@-ed
                    to me, logical and simple.
                               They've got a regional advisory group of      42
                    and six or seven of them are from the University -- the rest
                    from the standpoint of interest    the representation is oretty
                    well balanced.
                               P,A('7 seems to be forcefil  and active, and    is still
                    presticcou.9 enough to attract a good ciualit-,7 of neo-,ole to
                    replace those @.,71-iose terms have e,.,.nircd during all of the
                    surveillance  of   that.
                               "Lhev've  cot something like fourteen'corLmitt---as and
                    subcommittees       they are nrettv specialized, but they seer,
                    to be functionally effective.
                               Past Performance      continuation after @T.IP
                        in the to7o dra,.%7er.
                               ml,Lleir direction has been right on target, whereas
                    both the mission and their snecial     area needs -- i@d I
                    might point out in that connection     that they are dealing
                    three catecories of problems:
                               T,-he-t,, are atertiarv  center for a large aeoatanhic
                    area.    There  are metropolitan areas   which are fairly clasr@ic.@
                    And then thev   have tremendous remote   area problems -- Alasica
                    and I-',Ias,iinciton both and the,,7 seem  to deal with all of t.,.,emi

                                                                         314
   29
                             They have been responsive to other federal
                   initiatives.  Their regional iledical P.gencies and network
                   all the way UT) the line, is good.
                             They assist the CIIIP -- the ad hoc studies --
                   close collaboration.
                             --,heir objectives are, again, on target.  They are
                   specific and relative to the needs.
                             -.he proposals seem to be, to me, consistent
                   with the expressed objectives and Priorities and they have
                   T)laceCi the ric-'Lit kind o--c c7,inhasis on it.
                             There has been abundant  exnosure to CHP fetdback
                   on everything - and they have aotten some feed@oack and that
                   is not being studied.
                             Feasibility, based on a trac@-- record -- the nature
                   of the Drogram and special cohditio ns, looked orettv aood
                   to me
                             Their CHP relationships     I might mention a little
                   bit about that:    Thev have t,,,7o CHPs and seven full tire staff
                   functioning Bs, nlus some others in various stages of
                   development.    Thev maintain a reaular communications contact
                   xqith the Bs and thev nroviO.<-, them @,,-ith -technical support
                   and some modest funds on their enterprises.
                             Both @ directors are on the PA.G and there is other

                                                                                 315
   130               cross -mcip-be rsiii p.
                                 And one  of  their  projects,  Project  number   88
                     for $75,000.00, is    to develop a test idea for combining of
                     CIIP,  TUT,  and  to  prenare  for,the   upcoming   legislation
                     and I thin]-, that tileN,, x-iill do a good job.
                                 I had, to start @,,,i-th, one reservation, which sort
                     of vanished as I @.ient tl-,,irouqli it -- this ijas a  program
                     %,iliicli was su'Lficientl'v highly dominated  by  the  University
                     of T7a:-,'@llinrTton -- but it didn't seen to come out  in  the
                     product that came out.       I could  find  no  evidence  of  tiat
                     dominance.         @@7het@,,ier I am @.@rona or not, I don't 1-no,,-7
                     but I couldn't sunnort  the  conclusion  t.iat  there  @,7as  test
                     dominance.
                                 In summary, I rated them as a "Sunerior" aroun
                     sifostantiall-,7 better than the average R@IP       loo'A-ed to i-,--a
                     relevance   to mission, neecis, involvement       both Drof--8sionall,,
                     and  public  communities  and  their  efforts  rate  -  there   is
                     aggressive  preparation  -for  the   upcoming   transition   in
                     planning  and t-,ey  seemed to be very well oraaniz6d.
   ,7 TDEv,
                                 And so I  Tould recommend them, aaain beincr     one of
     co-",I
                     our better programs,    if there is a nremium treatment      availablc@
                     that they @7oulcl r-iualif,,, for it.
                                 TIIE            Thank you.
                                 Joe, -,)'OU @-7ere  the other reviei.,cr on this.  T-,".'.at do

                                                                              or    en    iiasize?
                            you have on this to add,  s@itract                       p
                                           R. de La PUE-@ITE:         l@ilell   I   iyant   to   emphasize    that
                            they   are   areas   of   program   cmoiias-is   on    target    ,7ith    the    needs
                            fror.i @iliat I see.       T,iey 'Have ver,,7 good relationship Keith
                            the CI'IIP -- and that in that state CHP Director proposed
                            Washington and Alaslj-.a mc:,jDers of the Reaional Advisor,7 Board
                            and tl,.at the staff Dartici-pates and is assigned specifically
                                                                      of the CIT
                            to @ior,',, i,.,ith tilde development                 LP Agencv.
                                          I think this is iT-@.,nortant.
                                          Thev have created  many things                         are outside of
                            the univorsitv enclave.              I-rhe,,,, -,,.,or]-,ed @.,,it'ii the General -1@ason
                            ,Research Center,  the Seattle   T-I,eqional                         oar
                                            I
                            t"ie Seattle s C>c'.-Lool Districts,,            r-rhe  University   bit   :-',las.lza
                            the State I'llosT)ital @@s::-,ociati-on, the @-TashinrTton State '-4urses
                            -AssociaL@-ion, the 17as',.incT@on State .;-eclical T,ssociati-ori,
                            the 3cl@-ter Administration of Iosi-)it,-Als in f7--attle -- and,
                            last   but   not   least,   t',e    -,Tort,@',7CSt    Chicano        Force,     --From
                                      -iese pco,n                                     fav
                            @ih i ch t(           -le   I have heard ver-,7             ora' le cornj-,ients
                            in term!:-, of  T,,7ashinaton ',r-iati-n @,,-icrican neople.
                                           So 1 an .7itli "70U.        1 an im,,or@-sscd @,7iti-i 17ashinc.-ton,
                            what they iave been   doing.
                                                     about all I have.
                                                  ESCTI:L7,,I:                          ng that they i;7cre @,ia
                                           D TI. T             Somebody   ,,7as   sa-,,7i
                            ahead in     the quality of assurance                  ind this @.7a[, .iell before
                            the quality'of assurance

                                                                        317
                             At the conference thev had motion pictures rho,@,7ing  il
       2            the currents of standard setting and studies of patient
                    management -- and in comparison with what happened to patients
                    and what standards of staff were put together -- an
                    showed the feedbacl,, b-,i which chan(Tes in management x.,,ere
                    effected by the output of that c.,,.ercise.
                              I..Zo@%7 that's acomplete renal circle done on 16 mm
                    color motion pictures while the rest of us @7ere still
                    learning ',10-,.-7 to Spell "c,,ualitl afsurance.'l Tmd I ust
                    felt t';iat this should be
                                  BT-@-PP.Oll'S I felt the same thina core throuah
                       ir demonstration of foresight and orderlv    nlannind for
                    the'
                    anticipated events.
                               I 1 E C'@@ 1. r@),I !',I !L@,, -T I thin,'-, T,.ic-, riaht want to hear -from
                    Dic'jc, because while relationships i-iith CIIP have been descri'--e-,'@.@
                    as good 1 think it was also clear from this application t'.,iaL'
                    happened to be one that I lob},,ed at, n-,,-self, by accident
                    when they first were cor,.lina in. I was just trying to aet a
                    sample of @-,-.,-iat the applications loo1r.ed lil@.e.
                              ,@d certainly, their applications   drew sone fire
                    from some of the CIITI ag-cncieF,, as you note -- indicating
                    their @.-,.ccutive         was meetina yesterday and Diclz
                    had been in contact by phone with l@-7as,iington and 71,laslra this
                              to aet some feedback on that                7nd that's
                    morning,                                situation.
                    one of the reasons @,ie held over on this one.

                                                                              318
       t                      Dick, what   do you iiive for us?
                               "R. RUSSELL: 1 think the concern that I had with
                     the application was that they did not snell out how they
                     Caere going to respond to CIIP comments. That was one concern
                     I had.
                               I was amused when I read the one from Sioolrane,
                     the CIIP n Aqencv, to see this type of consiont coming frorq
                     an aaencv which .3U.lPs in phaseout devoted 50 percent of
                     their field iianiial to this particular ac-ro-ncv.  I thought
                     that -@ias interesting.
                               T,7,e I 1 ,anN7ho@.i, the @@@,,ec-Litive. (committee is going to
                     res,)ond, in @-7ritin(,, to eac;-l OA, tll-,,e neuative co-mments, and
                     v7e will .1@iave conies of those.  I felt it @7as iir,,nortant for
                     the,@n to have a formal resnonse -- for their oi,7n record.
                                                 Council ,@7ill have the ')cnefit of
                     this letter.
                                                                over that, but trie,;7
                                1 1. BARP..O@-7S I didn't qloss
                     met riN7 criterion. They are in good cor@ntnication to
                     they get feedback and thev have a legitimate and fair T,)rocess
                                  with that.  ilor,,i I think that's -ill @,
                     for dealincT                                         .7e can ask for.
                     1-7e can't aslir, for evcry'oodl,l to loblr. up --
                                !IR. PUSSRI.L:  no, I agree.    But I just felt that
                     for their  protection, they should resnond.
                                DR. T17,SCT@l-7VN:I%.7on6er, to see if you can

                                                                              319
                    if your current readina agrees that Donald Sparkman came out
      134           with probably one of the first carefully drafted revisions
  0                 of bylax,7r, to accommodate the Pugust 1972  EP-@IPF policy for
                    the clianae around -- and has, therefore, a free  standing
                    self-pernetuatinq  PAG.
                               I @.?ould infer from what vou said, then, that
                    r. ey.1 r)ers
                            are not appointed       ere is no special ri.cTht  of
                    appointment, as I gathered there -- and if  there are lia-a
                                                                                _peninc!7,
                    before 7 TI@EC E:cec neonle -- that that happened  in  the
                    fair nlav  of standard no-@ninati-iicr -)rocess.
                               Is that correct?
                               IITI B -AIITI T-7S don't recall seeing their nominating
                    process,, but the end result Of N,:7'lat,-vc,-r their process, loo',-,s
                    like aood balance e,-cent for this one thing I     mentioned.
                    And I could find no  evidence  of  the  University,  or  pro-
                    universitv bias in @@7hat thev were doing.
                               TAR. RUSS@--ILL: jmhe voice in -klaska, was Drobablv
                    the first program that dame up and dre@.7 up a very clear
                    letter of understanding between the University and the @IP.
                   'I know there has not been that dominance.
                               'Ooi-,T there was one occasion where the university
                    has, as grantee, cone into the proqramatic doncern, but
                    as grantee -- thev couldn't exercise  the T3roaramatic
                    aspect     SO that it 'nasn't been a oroiDlern., let's sav.
                                               I don't knot x,7'i y people should be

                                                                                       320
       135             surprised by the Phenomenon o@        "])itin(      hand that feeds
                                                                    j the
                       ,Z,-ou.    It seems to Pe that much  of the no.-,t-!,7orld T,7ar I,
                       economic   assistance would suggest that as a natural and,
                       ner'@ians, not even unhealthy phenomenon.
                                   once you help a guv get on his feet, he will take
                       a @.ihac'IZ at tlou as (7uic)r- as he @-ill.1 t c next cTuy.
                                   !!P,-. BAPROI.'@7S:  Well, there iq -i certain amount of
                       feeling your   oats in that kind of thing
                                        TESCT
                                                    POv.-7 r..ian,7 @neonle arc involved in  this
                       thing?
                                   Ti'IE             I ani not sure       it's a,@out t@,-,,o anc,.
                       a '@ialf or three million -,)eor)l.C.
                                     'r-Ino,@.T @llaska:   nuarter of a T-.illio-n. l'i-,Iien 1 7,?a@,
                       there it was less than rai.rfa:t CoiAnt,7, ten vears a@o.
                       But thev are scattered out all ovcr.
                                   DR. il@7-ISS: Seattle is less    than a ,-Allion.
                                   Spokane
                                        B7'.:R-@o@7S-  Snokane, their snace oroblems and
                       dulturan nrobler,,s are horrendous.
                                   THE@,' CT         I think   it's @)roba@Dl-,,, a  little  over
                       a million, Joe.
                                   MR. T-ZUSSELL:  But I don't have that           I'v(,- got t@,le
                       figures in mKi briefcase, but not here.
                                   But for the record, the applications you revi@ied
                       did not   have the salaries of the nrogram staff.  Thej were

                                                                                       321
                        submitted in the reaional an7Dlication, and i@7e do have those
   @l,it 136               but they are not out of line.
                                     Dr,.. TIITJ TI,@ W,, I :I just Grant to as],, vou one question:
                        You are satisfied that they are able to utilize the additional
                        half million dollars that @7ou're c-loing to recommend,>
                                          B@,.RROT,.'.'S: T @iould have only one reservation
                        as @,,-as said on these neople -- thev  have suffered  a fairly
                        substantial staff depletion.
                                     1 @,7OUld thin!-., thoucT@n, based on  the competence of
                        the Coordinator, and t'iej.r relationship @,7it:a both academic
                        and  nrovi6er centers -- tlicv could mount a good team.
                                                                       .,orried about that.
                           has aood management.   I'r,,.     not too
                                     2.1@d I think t-,-Lat th,--@7 are bcinc7 fairly modest.
                        ".,iie,,r are juri7inrf from, no
                                                            a f-i,.ndi@   evel of about 1
                        to 2 million        and i tiiinlc- they can
                                     S@l-jec@t to this staffi-no lDro,-)lcm, I thin],, tl-ie@7 can
                        adjust to it.
                                     DR. 1-1@-,SS:  All riaht, if vou have this vie@i, their
                        current fuhaina level of 1.3 -- so that if
                                          B@PPCO,-iS:   I have 1.4 or 1.47.
                                     DR. IIESS:  Ti-,7ell, there has been a discrepancy
                        bet@7een that sheet and this one.
                                     MR. iTIUSc-'-@--LL:   The latest figure i7e have, is 1.4
                                                   T
                                     DR. @TIESS    ,"There do the figures come to on this
                        sheet?  The first six months?

                                                                        322
                             DR. HEUSTIS;  P@re these figures not  six   months old?
     137           The onlv date I can find on this document is January, 1974,
                   and I i-7as  led to believe this was nrenared as of January
                   1974.
                             MR. RU@r'),c,ELL:  No
                             T)R. !IESS: This i,,iould be the funding  level  for  the
                   six   months  one through six.
                             DR. TRU@@L7-@'l: I based this on the other one,  T,7hicli
                   is 1.5 to 2 -,.,.illion -- c@i,-i thev handle the extra half million
                   dollars?
                                 DT@Pi",OT,7s: -- total T.)].anninq -- tallj'.in(i a!-)out
                   Julli of another @ialf million -- I Oon't thing thev T@7ill '11)C
                   (-etting --ver,,,th-Lnc, the,, ask for.
                                           But are vou satisfied he can
                   rc-,asonat)1,7 use this?
                                 PTIE)S@-Ll,:  Y--s.  :@3ut let mn@ ans,@7er,  n@cirro,,,,-.
                             @-,-@n this nliasc came out, ti-Li:--, ctave tieri an onnor-
                                                                           7
                   unity to revarn their staff so that it @,asn't all loss.
                             Yes, I think thev can manace the r@oney.
                             DR.           I T,Yould rov(- @,7e ao-n. rove the re-uestc-c!
                   level.
                               L
                               . I
                             [T-.Le -,,notion was properly seconded.]
                             THE CIIAIP-1,UUI: That's 2.77 -- as requested.
                             is there any further question, additional  comments
                   or  corrections

                                                                          323
      130                     All those in favor
                                               [-Llhe motion ,ias r)ut to vote and
                                              carried, unanimously.]

                                                                                 324
                                     C'IIAI@,-L',Il it is 12:20 and this mav be a qood
      139            tiTno to I'Dr@-al,,.  ,,-7e have completed n,-ne regionp. and i,ie have
                     eialit left to do.
                                COIr@IF,NT: Do vou think i,ie can @,7ran this  up?
                                Ti!E               I think that is still -- and tliatis
                     w'L'I.y I need to consult @.:ith r,-,y cc)lleacUes -- but if @,7c., do
                     ilave it @.7ithin our ..7jiere,,Yithall to com@l.ete them all todav,
                               't thin',, on the other hand      that I have. tte a:--)ility
                     ,)ut 1 aon                               I                  -'I
                     and the other staff, to .7r&r) sorio-, of these things un and
                     dicl!nlay them for you.
                                1 thin!,. @@ic Proud have to as'lr, 17ou to sit cirouriA' here
                     an hour after that.
                                f.,o I think, realizing   that sorie of you are -bin,7
                     to have to leave toOa,,7 anNr..7a,.7  C-,arlj.c, @7ou are coinc., to
                    i have to leave todav fairl,T earl,7              tiat x.7e
                     still are faced %.7ith a brief session to,-,.orro,7.      @@ut
                     don't kno@,@7 ,ihat   colleagues are  doin(.-T.
                                I think 1,@ie can -)robil)l,,,, act throual-i N,7ith t'IC
                     applications todat;,.
                                T@IT". r32',.RPol"7s:  Could i@ie shoot for that, and then
                     -v7hatever time @.,re have tomorroi.,7, we could just loo,@, baclr.- and
                     see ,.7hat @ic nave don(--?
                                TIIE              Yes.
                                We can't do this in8tantlv  [Indicatina Blackboard
                     not that this has anything to recommend for it, but i thin'@-

                                                                                                 325
   wt 140               wave can shake some things out and aive you some idea of
                        what your actions ,7ere, @,7.,Iat thav     look like, collecti-,Ielv
                        and the others naV want to look at it a little, too, and
                        see maybe adjust something un, or do,,qn, something here
                        or there where something seems to be inconsistent.
                                     But I don't think @,7e can give you that immediatclv.
                                     D@?,.. Ti7@SC'.IAII:   'L'hat is a ver-,.7 helpful chart.
                                         TTIU.T,.'!@,',I:  Are 1.7e required to keep these?
                                     D". TIIUT-@,!-",'  Do v7e tiaVe any other easv recTions
                        v.ic could knock o-ff-?
                                                                ,7ou  T)eoole  are  the  revie@.7ers.
                                     I @..,ould think -@ravl-)c @'Tertern Ilennc,@71vania is an
                        easy region
                                           ITU@VW
                                     DR. T.L      J:  I'ri tr%ying to see if the groun
                                          Cl-l@kI@.1, I.: o, 'Testcrn ilenn,@vania
                                      ,Z. IIASTI   -,Io,    ;.7eSt
                                              .L                  Virginia is nrir,.iarl 1,,,- a
                        continuation of --",'estern        iou nav get a lot of questions
                        on that.  .  .
                                     T'2@E              John, ,,lou  and  1.1r.  Barrows  we-re  tiie
                        revie@,!brs  -- do vou recall any difficulties                is   that   one
                        that @,,,e micFht -oolis'i'l off in a brief period?
                                     DP,. fljp.@,CTIBO,@C-zl@: IIell I t'nink @@7c had better  V7,ilt
                        Until after ltnch anT,.Ya-,7.

                                                                          326
  ,.7t 1 4 1                  TI-IT-@' CITAI@'@l: O-K-
                              i think i-ie're doing to come to having lunch  novI.
                   So it is 12:25.    Could  @,ye trv to be back bv 1:10 or T:15
                   at the latest?
                              You see, we have four hours and eight regions, and
                   if 1;7e can do that
                                               [TI.ic proceedings were recessed for
                                               luncheon at 12:25.1

    HEW                                                                  327
  Ns-1                                     AFTERNOON SESSION
  fis arc
  hws-1       2                                                1:15 P.M.
                              MR. PETERSON:  I guess we are ready to commence.
              4               Joe is not back, but before we do, I did huddle
              5    briefly with Bob next door.  They broke a little later than
              6    we did.  We are just about neck and-neck now.  They have six
              7    left to finish. We have eight, but I think our  view  was,  and
              8    I wanted to check it with the group, that we are going to
              9    be able to finish the applications today, but there seems  o
                   be some need for a meeting# however, of a very brief duration@
              10
              11   an hour or so, perhaps two hours tomorrow morn ng to sor  of
              12,  take a step back and look at each of what the panels  has  done
                   and ratify it as a whole group., that is the actions of the
              13
                   respective panels, so that just Bob and I made  that  decision.
              14
                              I see all kinds of problems that we try at the
              15
                   end of a long hard day for both groups to try and come to-
              iti
                   gether briefly.  It is going to be late.
              17
                              How do you people feel about it?
              18
                              DR. HIRSCHBOECK:  I agree with you.
              19
                              MR. PETERSON:  I know you are going to  have to  go,
              20
                   Charlie.
              21
                              You know, if there is someone else who feels as
              22
                   Bill or others may, that in one sense the plowing of the
              23
                   field has been done, and I think you know one would be able
              ?.4
                   to take off at the end of the day.
              25
            co, INC.
             ue, N@l.
  W4$ in on', D .200(

   hws-2        1             DR. HESS:  If we can, as a group, look at the ones
                2  we have reviewed, and satisfy ourselves within that review thiat
                   we have been fairly equitable based on  the  factors  that  we
                4  identify, and then the basic work is done, and it is a matter
                5  of seeing if the two groups can function.
                6             DR. HEUSTIS:  To do that don't we have to have
                -1 something up on the board?
                8             MR.  PETER SON:  I don't think the board is  large
                9  enough,  I started doing somethings with respect to the morni@g
                10 applications. This is something that I think the  two  groups
                11 are debating a little bit.
                12.           This percent of target figure column I don't think.
                13 that important.
                14            What I was doing was to show a figure if there
                15 was any for a July application so that I was keeping the
                   first three columns, or that is, the fitst.fout columns,  but
                   then indicating the estimated July applications again  trying
                17
                18 to group them so  tha-t, you know, looking at this  mornings,
                   I find New Jersey and Rochester and several programs sort  of
                20 up in that first group, and Joe did ask, and I will try to get,
                   this data so we can incorporate it for all of them, a rough
                21
                   population figure like 3.2 million, or 2.1 million.
                22
                              I think if you can settle for a legible Xerox copy
                2.1
                   of a legible longhand sheet.we can have'that for you  first
                24
                   thing in the morning,, and we would, on Panbl B, take a look
                25
         TING CO, INC.
         tts Avenue, N.C.
     in ton, O.C@ 20002

                                                                        -i- @
   hws-3         I  for 30 minutes at what we have done before we reassemble,
                 2  and if that means we get together at  8:30.instead  of  nine,
                 ili that I again leave up to you, but again I sense  it,  and  it
                 41 seems to make sense to me if you look at some of these things
                 5  -- well, we won't have that job done, obviously, at five
                 6  Oiclock.
                 7             DR. HESS: Can we find out, or  do  we  know  which
                 8  of these two figures are the most correct on this previous,
                 9  or let us say, the six-month current funding level?
                 10            DR. THURMAN: I think Al is  correct  when  you  look
                 11 back on the applications,  I think this really goes back to
                    January, and I think this sheet, although I, don't particularly
                 12.
                 13 like it, is the sheet.
                 14            DR. HESS:  This one?
                 15            MR. PETERSON: I am  embarrassed  by  numbers  that
                    I don't agree with, thus I tried to either only  have  one  set
                    of figures in front of people, or if one is going  to  put  two
                 17
                    sets of figures to see if they don't agree before you place
                 18
                    them.
                               The first column in this figure I believe is cdrreC,t
                 20
                    in this sense. It is the current  six-month  award  times  twoi
                 21
                               MR. NASH:  No.  It is the annualized level, on t e
                 22
                    third level.
                 23
                               MR. PETERSON:  Y.es, that is the way it was explaine@
                 24
                    to me,
                 25
                 INC.
  Washington, D 21
  1202'@546-666

                 1                                                        330
   hws-4                       New Jersey currently, for the current six-month
                 2
                    period has a grant of X number of dollars.  The figure that
                    is shown now in this column is X times two.  That is one of
                 4  the always surprising things.
                 5
                               DR. HESS:  I wonder if there is some staff person
                    we can call on, whoever put that together.
                 7             MR. ARNOLD:  I don't know where   that came from.
                 8             MR. PETERSON:  Let's not introduce another set of
                 9
                    figures.
                 10            DR. HESS:  I think somebody on the staff level
                 11 ought to be checking these out.
                 12            MR. BARROWS:  Let us have someone look into it.
                 13            DR. THURMAN:  I think your point earlier that Dick
                 14 White's sheet is a sheet that was put together months ago, and
                 15 I think this sheet is fairly close to up to date.
                               MRi SIMONS:  This one is correct, but it will take
                 17 Larry to explain it.
                 18            MR. PETERSON:  It is always a puzzle as to why we
                 1!) pass out three of them.
                 20            MR. SIMONS:  This first column does not have such
                 21 things in it.
                               MRo NASH:  it may not have the Region's portion
                 22
                 23 of the 6.9 that was held and later released.
                 24            It may not reflect 1972 dollars for EMS and HSEA'S.
                               There are a lot of basic possibilities, and maybe
                 25
         RTING CO, INC.
          ettsAvenue,N.I@
     iligton; D@C. 20002
   (?02) 6-6666

                                                                         331
  hws-5         1   Grant can explain it.
                2               DR. THURMAN:  It does not reflect carryovers?
                3ii             MR. NASH: It is taken off  the  last  award  notice.
                4   it doesn't  tell you the real fund B picture in the Region.
                5               MR. PETERSON: Can we sort of  make  this  our  prime
                6   reference?
                7               We will entertain an explanation from  staff  as  to
                8   what the disparities are.
                9               DR. HEUSTIS:  After we get through with all of
                10  the material?
                11              MR. PETERSON:  I am always reluctant.  I know I
                12. should be saying yes, but I don't differ myself, and I am
                    looking around and saying who is going to deliver.
                13
                14              DR. HEUSTIS:  No earlier than before we get
                15  through with all of this.
                                MR. PETERSON:  Mr. Pullett, Review Panel B and
                    its Chairman, humble Chairman, sort of wanted a brief explan-:'.
                17
                18  atioh as to spake sets of figures, column  one  of  a  printout.
                                I just tended to ignore it.  I was lucky.  I
                19
                    thought one was more credible than the other.
                20
                                What was the recent point in that case that gav
                21
                    us a problem?
                22
                                In New Jersey we show a current and annual annualized
                23
                    at roughly  $1,458,000.  That I understood, and correct me if
                24
                    I  am  wrong, was literally New Jersey's current six-month
                25
         RTING CO, INC.
          ettsAvenue,N.E.
  Wash[ gton, D@C. 20002

                                                                          332
  hws-6             award times two.
                21              MR. PULLETT:  What you do is, you double   what you
                    had in the  1974 funds that they received, plus the   carry-
                4
                    over.
                5               MR. PETERSON:  That includes the carryover?
                6               MR4 PULLETT:  Yes.
                7               MR. PETERSON:  Their share of the six?
                8                             That truly represents a total figure
                                DR. THURMAN:
                9                                      in the six-month period
                    of the dollars they had  to spend
                10  multiplied by two.
                11              MR. PULLETT:  If it is carried out.
                12,             MR. NASH:  If they contracted it out.
                13              DR. THURMAN:  That is obligated funds.
                14              MR. NASH:  It would not even show here, you see.
                                DR. THURMAN:  As we look at it  we are not con-
                    cerred about obligated funds.
                17              We are talk4-ng about an operating figure, and
                    this is the total actual operating figure on this printout.
                18
                                MR. PULLETT:  No, it  is what they received out
                20  of 1974 funds, plus their authorized carryover.
                21              DR. THURMAN:  That is what I thought I said.
                                MR. PULLETT:  You said their operating level times
                22
                    two, and it is not.
                23
                                DR. THURMAN:  I see.  I stand corrected.
                24
                                DR. HESS:  The total amount of money that they
                25
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   hws-7           have to work with during those six months.
                2              MR. PULLETT:  We made a distribution of 1974 fundsli
                   which was  approximately $24 million, and that went into the
                4  awards beginning in Award 1.
                5              To get their annualized level we doubled that, and
                6  added their authorized carryover, so when you say an annual-
                7  ized level in a 12-month period it is not doubled what they
                8  have been operating on in the six month period.
                9              DR. HESS:  Are you familiar with this sheet?
                10             MR. PULLETT:  Yes.
                11             DR. HESS:  These figures are geherally.higher if
                12. you  double the six month present funding?
                13             MR. PULLETT:  They would be higher than the
                14 annualized  level in a lot of cases.
                15             When we made the initial awards they were for a
                i(i six month period, so we gave their distribution of the  24
                17 million for six month period,, and authorized any carryover
                is from the previous period, but to get the annualized level we
                   doubled the 1974 funds and then added in the autho ized carry-
                   over, because that was only for a six month period.
                20
                21             DR. HESS:  So this would be plus the carryover
                22 figure,
                               MR. PULLETT:  The six month  period would at least
                2.3
                24 equal the  annualized level, and  in most cases exceed it.
                25             MRO BARROWS:  The working capital that they had to
            CO, INC.
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                                                               0            334
  hws-8         1   work with last year.  It was this figure, was it?     I mean
                21  up until now.
                31i            MR. PULLETT:  That is another projected 12 month
                4   figure.
                5              MR. BARROWS:  So in terms of real money this is
                6   what the program was operating with.
                7              MR. PULLETT:  That would be projected over a 12
                8   'month period.
                9              MR. BARROWS:  That is the base that we wanted.
                10             DR. HEUSTIS:  On this document the only date that
                11  I see is funding award January 1, 1974.
                12.            Am I to assume that this was as of January, that
                13  everything on this hseet is January 1, 1974?
                               MR. PULLETT:  If you look on the face page of
                14
                15  that, there was a face page.
                               DR. HEUSTIS:  Never mind.  Tell me what is on the
                    face page.  I don't think I ever saw one.
                17
                18             MR. PETERSON:  I certainly never saw a face page.
                               DR. THURMAN:  Is this the face page?
                               MR. PULLETT:  That is the summary page.
                20
                               DR. TESCHAN:  Region 17.
                21
                               MR. PULLETT:  The six-month level was actually what
                22
                    they are operating on, on a six-month period.  They are the
                23
                    funds we have authorized.  That includes the carryover plus
                24
                    fiscal 1974 money.
                25
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  hws-9                        Now, to project the  12-month  budget  period  we
               2    doubled what we gave them out of our 1974 money, which was
               3@l  approximately $24 million, and that added  on  to  that  any
               4    authorized carryover which was based on two things, their
               5    distribution of the 6.9 plus  any  unexpended  balance  they had
               6    under the previous budget period.
               -1              DR. THURMAN:  He has answered my qu6stion.  I know
               8    what it  is.
               9               MR. PETERSON:  Okay, we want to get bacc to our
               10   business here on the review of applications.
               11              I think we have already highlighted both Western
                    Pennsylvania and Virginia as regions we  did  not  feel  too
               12.
               13   prepared to deal with before.
                               Having had lunch we might start off with Western
               14
                    Pennsylvania.
               15
               17
               18
               14
               20
               21
               22
               23
               24
               25
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                                                                         336
                                                                        LVANIA
  hws-10                       REGIONAL MEDICAL  PLAN  FOR  WESTERN  PENNSY
               2                         REVIEW  BY  DR.  HIRSCHBOECK
               31i
                               DR. HIRSCHBOECK:  The  application  is  essentially
               4
                    for continuation of funding, except for the  addition  of  one
               5    project, which is the Health, Education Network.
               6               As stated here, this constitutes  $170,825  of  our
               7    total request, which I understand will not be counted against
               8    the total amount appropriated with PRFP.
               9               MR. PETERSON:  I will explain that.
               10              Because of the court order which reads these funds
               11   are to be made available to the plaintiff, that is to mean th
               12@  RFP'S, and we had funded this particular project  under  910,,
               13   and thus in order to give it a legitimate  umbrella  we  asked
               14   that it be submitted as part of the Western Pennsylvania RMP
               15   application, but what you people really need to do is vote
                    a recommendation for Western Pennsylvania, and  then  take  an
                    auxiliary, or adjusting the one in effect.
               17
               18              it is a matter of administrative convenience in
                    the event the court order would not be modified, which it
               19
               20   probably will not.
               21              MR. NASH:  Really two applications.
               22              MR. PETERSON:  It is really.tw6 applications, but
                    in order to be able to continue to fund that AHEC  it  had  to
               23
                    com    der the aegis of an RMP at this time.
               24
                               DR. HIRSCHBOTCK:  Another factor that is confusing
               25
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                                1      is  that  funding  for many  projects  terminated  on  April  1.
         hws-11
                                                           There  is  a  gap  of  two  months,  or  three  months
                                2
                                1!'                                                                                and what  appears                  to
     0                                 really,  between  the  end  of  the  project
                                4      be  a  start  up  again  of  some  of  these  same  projects,  with  a
                                5      gap  of  no  funding*
                                6                          Now,  I       am  getting  this  information  principally
                                7      from  the  Forms  15,  and  I  think  we  ought  to  have  that  explained
                                8      by  staff  a  little  later  on.
                                                           As  far  as  the  Region  itself  is  concerned,  at  the
                                9
                                       time  of  phaseout  they  were  grappling with  the  possibility
                                10
                                       of  becoming  an  independent,  free-standing  corporation#,  and
                                11
                                       they  are  now  the  grantee,  that  is  the  grantee  is  the  University
                                12
                                       of  Pittsburgh,  and                 apparently  the  cost  figure  was  very  high,
                                13
                                       almost  $500,000,  and  the  question  was  raised,  I  suppose,  by
                                14
                                       central  staff  here  that  maybe  they  should  look  into                                             a  re-
                                15
                                       arrangement.
                                                            At  least  it  sounds  that  way  in  the  way  the  text
                                17
                                       reads.    They  set  up  a  task  force,  and  the  task  force  decide
                                18
                                       to  stay  as  they  are,,                 and  that  is  an  independent,  freestanding
                                       corporation.
                                20
                                                             The  University  of  Pittsburgh  Health  Center  is  the
                                21
                                       grantee.    The  bylaws,  of  course,  do                               not  even  mention  it   but
                                22
                                       that  is  okay.
                                23
                                                             The  bylaws  are  arranged  such  that  they  function
                                24
                                       very  independently.
                                25
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   hws-12                    However, the Regional Advisory Group, the Coordin-
              2    ator, Dr. Kiefer,who is the Coordinator of the program is
              3
                   also a member of the Regional Advisory Group, and is in
              4    various positions along the line, and still the coordinator,
              5    and yet, what I am trying to say is that he has fingers in
              6    many pies.
              7               The relationship with CHP is difficult to assess
              8    because there is only one communication which says that they
              9    will apply in the near future regarding the comments.
              10              I would like to find out a little more about the
              11   CHP relationship here.
              12.             Well, they distributed quite a bit of project
              13   support for the insurance development as a one shot venture.   i
              14              The statement is made by the Joint Commission on
              15   Creditation on Hospitals, which is found in quite a few
                   hospitals, and this area has not had the working expertise  to':
                   deal with the medical audit situation and other similarly
              18   newly acquired activities by the Joint Commission,
                              The Western Pennsylvania RMP provided funds for
                   some six or seven hospitals or related agencies in  the  Region,
              20
              21   to get quality assurance and medical audit, and  so on.
                              As.I interpret this, this was a single one  shot
              22
                   deal that was given to these institutions,,
              23
                               In general, I would say that this is an average
              24
                   program all the way down the line.
              25
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  hws-13         1             I do not see anything outstanding about it, nor
                 2 is there anything that  would  seriously  criticize,bther  than
                 3il possibly a relationship with CHP, which is not well expressed!,
                 4 here.
                 5             Also, I should say a word about the staff.  The
                 6 staff seems to be quite complete.  There are hardly any
                 7 vacancies, so there should be the  capability  of  carrying  on
                 8 with the additional funds which they intend to ask for in
                   July.
                 9
                 10            MR. PETERSON:  Thank you, John.
                               Ken?
                               MR. BARROWS: My  observations  were  very  parallel
                 12
                   to the doctor'S.
                 13
                 14            To show you my skills as a  planner,  I  approached
                   my five projects alphabetically, and I have considerably run
                 15
                   out of gas on Western Pennsylvania, as it is  the  end  of  the
                   line.
                 17
                 18            Generally, I came up with the same conclusion that
                   this was a  pretty good average type of program.
                               The management and administration of the thing
                 20
                   looked a little bit cumbersome to me.  They have a number of
                 21
                   regional advisory groups, area advisory groups,
                 22
                               This did not look like a very skillful thing from
                 23
                   the management point of view, but now I will  have  to  eat  my
                 ?,4
            I      words and come back with this.  They have done an     excellent
                 25
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                                                                           340
  hws-14            job of community interest and participation in this thing.
               2               I might say they are really one of the better in
               3!i.
                    that respect, and there is commendable honesty in this report.,'
               4
                    They talk about a lot of programs that are terminated, and,
               5
                    in fact, come out and said the program laid an egg because
               6    the people found out it was too much work.
               7               I think it is an application you can take at face
               8    value, but I came out with a good average type program.
               9               MR. PETER80N:  Norm, I don't know if you want
               10   to come up to the table.  It seems to me that there were at
               11   least three areas that questions were raised about.
               12,             One is what appeared to be A gap in funding.  The
               13   other is CHP relationships, and the third may be the ubiqui-
               14   tousness of Dr. Cleary, but that is something we have lived
               15   with.
               1(;             MR. ANDERSON:  I imagine the survey was made a
               17   year or so ago, and we have determined that Dr. Kiefer was
               18   not in line with the grant relationship.
               I!)             The recommendation was made at that time to rectif
               20   this, but during the same week, at the time of the survey,
               21   also a notice came out from RMP that we were to be phased out.
               22              We sort of let it slide at that time, and Dr. Kiei r,
               23   as I understand, is to retire sometime this summer, and as
               24   you have very adequately observed,, Dr. Kiefer is a member
                    of the Executive Committee, and also plays a very active role,
               25
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  hws-15       1   in determining program policy.
               2             I won't try to minimize this, as that is a fact.
                             On the other hand, I think Dr. Reed has pretty
               4   much determined what the r program priorities are, and has
               5   tried to allow to promote these through Dr. Kief6r.
               6             The second point was there has been some animosity
               7   I am not sure what precipitated this,, but nevertheless it has
               8   existed, and I think over the past two years my experience
               9   with the Region is that they have made every effort on both
               10  parts to try to rectify the problem, and here again, I would
               11  be the last to try to identify what the problem really is.,
                             Now, in terms of the third area -" what was that.@
               12
                             MR. PETERSON:  The gap.
               13
               14             DR. HIRSCHBOECK:  Some of these projects ended in  1
               15  April, and they were asking for funding beginning July 1.
                              MR. ANDERSON:  Part is due to the phaseout and
               16
                   terms of priorities to try to complete certain activities
               17
                   within a timeframe, and they do have a very good selective    i
               18
                   procedure to determine their own priorities,
                              I think in all due fairness to them, they felt  this
               20
                   was some of the things they ought to complete within a  certai'
               21
                   time period.
               22
                              There has been a certain amount of lag time, but
               23
                   that doesn't mean the activity has completely stopped.
               24
                              DR* HIRSCHBOECK:  It is, as you read these Form 15,,.
               25
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  hws-16           I got the impression that there is going to be  a  gap  in  fund-!
               2
                   ing between, or beginning July  1, 1974  and  what  apparently
               3
                   was a termination on April 30,  1974.
               4             '-It has either been improperly placed there, or
               5   don't understand what it is all about.
               6
                               MR. ANDERSON: I am not  quite  sure  I  understand
               7   your question.
               8               MR. PETERSON: I think if  I  understand  Johho  he
               9   sees some projects which presumably are going to stop at the
               10  end of April and renewed funding beginning July 1  which is
               11  being requested.
               12.             That does seem a little unreal, and it may be.
               13              MR. BARROWS: I got the  impression  these  were  somei
                                                                                    i
                   programs they would like to have carried on, but,t  ey  ran  out,,
               14
               15  of money, and they have some programs  they  want  to  revise.
                               MR. ANDERSON:  Local support may come to their
                   aid for a temporary time period.
               17                                                                   1
                               DR. HIRSCHBOECK: Here  is  one  discreet  activity
               18
                   summary -- Laurel Mountain Quality Assurance Program, Mercy      i
                   Hospital# Johnstown, and the progress period, in the progress    i
               20
                   section which is from July or from January lst, 1974 to
               21
               22  April, 1974, and then the period of   the.project is July, 1974  i
                   through June, 1975.
               23
                               In other words,.there is a period of April,,   May
               24
                   and June.
               25
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  hws-17        1             MR. NASH:  What is he doing there?  This is some-
                2   thing they initiated in January, and he is giving you progress
                31; on the four months up until the time they formulated their
                4   application?
                5             MR. PETERSON:  I was just comparing notes with
                6   Tom,, and he said he really didn't have anything of substance
                7   or concreteness.
                8             I think both he and I can speculate about some of
                9   the reasons for the less than cordial relationships between
                10  the major fee agency, and I am not sure it is called Alleghen
                11  County, but anyone, the one that encompasses Pittsburgh and
                12, the surrounding area, and I know something I observed, I
                    think I observed out there two years in the review process#,
                13
                14  and it was out on the table and Bob Carpenter was in the next
                15  room and it caused him a great deal of travail as long as he
                    was in that post.
                               MR* BARROWS:  You think they feel competitive?
                17
                18             You see, this has an apparatus of local advisory
                    groups that RMP might treat as a threat or something.
                1!)
                               MR. PETERSON:  Some of it may have been, and con-   i
                20
                    tinues to be personalities.
                21
                               I don't know if the same gentleman who was   there
                22
                    when I was out there two years ago, and would dome down from
                23
                    Buffalo, where Jack Angle had encountered him,, but is he
                24
                    still the same person out there -- Mitch Roth?
                25
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        n r. gnnii?

                                                                                 e
  hws-18                       MR. ANDERSON:  On the positive side they do shar
                    the same types of review committees at the local level which
                 31i       Is participate with RMP.
                    the CHP
                 4             DR. TESCHAN:  I don't think we can resolve the
                 5  question here, and if it is an important question in an out-
                 6  going way we have to cite it to them.
                 7             MR. NASH:  The question came up about Dr. Kiefer.
                 8  I don't think,he is in the budget for next year.
                 9             MR. PETERSON:  He is retiring this summer, and it
                 10 was always a kind of strange relationship.  He was the name
                 11 coordinator, but in recent years he never drew any salary
                 12. from the RMP budget.
                 13            MR. ANDERSON:  He was never on salary.
                 14            MR. PETERSON:  I knew in recent years he never
                 15 had.
                               Whdn Bob Carpenter was the Director, the full time
                    sort of direct management program has always been in someone
                 17
                    elses hands, but Kiefer was not to say adamant, but he didn't
                 18
                    want to step out of that symbolic spot.
                 20            Maybe our problem is being solved by retirement.
                 21            DR. THURMAN:  Looking at the staff document for
                    a minute on the projects, the first five really are all pro-
                 22
                    gram staff, is that correct, as I read   this, $731,000?
                 2.-3
                               MR. ANDERSON.-  The first four, yes.
                 24
                               DR. THURMAN:  So we are talking about a corps
                 25
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  hws-19            figure of $731,000, and the request is for $1.9 million when
               2    we really get right down to it.
                               MR. ANDERSON:  I accept your figures.
               4               DR. THURMAN:  obviously they are correct.
               5               Then I have just two other questions.
               6               Are we conflicting with ourselves in the Regional
               7    program because it is carrying over for two  years,  and  the
               8    statements in it show no reference to reality  about  what  is
               9    going to happen over the next two years,, and they  have  not
                    fulfilled the prima   criteria initially that  was  to  limit
               10                      ry
               11   transplantation to one area, and instead  we  are  supporting
               12,  two hospitals that are doing it in the same county.  They did,
                    it  themselves.
               13
                               MR. ANDERSON:  I didn't read that.
               14
                               DR. THURMAN: Regional  renal  project,  to  ration-
               15
                    aliz6 transportation resources within the  Health  Center  and
               iii                                                                  1
               17   program due to inadequate numbers, and they  said  they  still
                    have not solidified the four Allegheny hospitals to bring
               18
                    together for one transplant thing.
               19
                               I am not so much concerned about that,  or  are  we
               20
                    really, for over a two year period here, looking at the
               21
                    Regional renal transplant in the way that it should be done.
               22
                    That is a' staff question,  I don't know.
               23
                               MR.  ANDE       The limitation of my knowledge
               ?,4
                    here is that the University of Pittsburgh is doing transplant
               25
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  hws 20            only within its particular Region, and they have attempted
                2
                    to set up some satellite facilities in community hospitals
                3t!
                    that can participate with the so-called network.
                4               DR. THURMAN:  Everybody does that for bringing   in
                5   cadaver kidneys, but the way this reads, they are doing the
                6   transplants in other hospitals.
                7               DR. HESS:  Read that again.
                8               DR. THURMAN:  "Rationalize transplant resources
                9        within the Health Center and the limitations imposed
                10        on transplants from cadavers."
                11              This is a major question of the Xidney Panel about
                12  whether or not they were doing it, and for hospitals.
                13              DR. HESS:  You didn It read the sentence you did
                14  before, but it sounds to me as though they were coordinating
                15  four hospitals, not transplanting in hospitals.
                                DR. THURMAN:  You have to read the whole thing,
                    and I may have misled vou,
                17
                18              MR* PETERSON:  This is an issue we need to get
                if) some specific concrete information of  how  many  hospitals  in
                20  the Pittsburgh area are actually doing transplants.
                21              I think the Council ought to be aware  of  it,  be-
                    cause we had the same sort of situation in Philadelphia.
                22
                                MR. ANDERSON: If you are right,  we  will  have  to
                23
                24  put  a   stop to it.
                                DR. THU       One last question.
                25
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  tYb-21        1             On Project 225 we are talking about $239,000.
                2             MR. ANDERSON:  Project 225?     You are gett ng
                3t ahead of me.
                4             DR. THURMAN:  $293,000, and we are going to educate
                5  less than 40 nurses.
                6             DR. HEUSTIS:  That is $490,000.
                7             DR. THURMAN:  It is going to cost us $10,000 a
                8  nurse, and it is a two year project, but if you  are  going  to
                9  put it on a one.year basis it is still $10,000  A  nurse,  so
                10 that is an awfully high figure.
                11            MR. ANDERSON:  We have flagged this, as you have
                12, to.
                13            This is a policy decision that has  to  be  deter-
                14 mined.
                15            DR. THURMAN:  I don't argue with the need for
                   these people, but I have never seen a budget  quite  that  high
                   for this kind of a program, and I j ust wonder about it.
                17
                18            DR. HEUSTIS: How much of the  $1.9  million  is  for
                   projects that will be carried out in the second year?
                              MR. ANDERSON:  There are only two projects identi-
                20
                21 fied, 25 and 26, and the one Dr. Thurman has  identified'.  and
                22 the renal project goes into 1976.
                              MR* PETERSON: Those two projects  all  add  up  to
                23
                   roughly $725,000 out of.$l..9 million budget if you  assume,,
                24
                   which I don't think we can necessarily can have in one year and
                25
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                                                                             3Lt8
                                                               about $            s
  hws-22            a half, and in another year it is saying          350,000   plu
               2    would dangle over into FY 1976.
                               Those are the two other than program staff, the
               4    two larger projects, renal and  adult nurse practitioner
               5    education program are the two in that carryover4
               6               DR. HEUSTIS: They  would  probably  get  around  the
               7    one year grant by making a contract  or some people to provid.
                    services and the GAO will allow this kind  of  thing  for  ger-
               8
               9    vices to be provided in the future.
               10              MR. PETERSON:  I cannot answer that.  We    have
               11   said as a matter of policy that we would permit it,    and I
               12   think it also includes grants management, which was    in on
                    the discussion, and if the obligation was a valid one enteredi
               13
               14   into prior to June 30, 1975 that the basis for taking an
                    audit exception by GAO-HEW would not be there.  It would be
                    a valid expenditure of the funds.
                                DR. HEUSTIS:  Is this any different than entering
               17
                    into a contract for someone to maintain your typewriters
               18
                    for two years?
                                In that case I think there would  be  a  valid  GAO
               20
                    objection.
               21
                                This is something that was brought up earlier, and,
               22
                    I didn't follow it at that stage,.and    this is something that
               211
                    1 think ought to be referred to'staff    for clarification o
               24
                    policy.
               25
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   hws-23                      MR. NASH: Is your  question  whether  to  contract
                    this for two years or one year?
                               DR. HEUSTIS: My question is  is  it  possible  for
                    someone to use fiscal 1975 funds to provide services that
                    obviously will be provided in 1976, that is fiscal 1976,, and
               6    the only reason for entering into a contract  is  to  subvert
               7    well, that is pretty strong.
               8               In my opinion the reason for entering into the
               9    contract is to get around the one year limitation,
               10              We can't answer it, but it should be resolved.
               11              MR. PETERSON: It does seem to me  it  may  tot  be
               12   good procedure, and indeed might be illegal.
               13              I don't know about the latter, but this is not all
               14   that unusual in terms of either Federal granting operations,
               15   forward funding, and indeed in many situations, and I can
                    remember AHEC activities, many of the RMP's I believe in
               16
                    effect are contracted for a period well beyond one year    in   1
               17
                    the early fiscal year.
               18
                               That doesn't make it right, but there is a great
                    deal of practice and precedent there.
               20
                               DR. HEUSTIS: It seems to me  the  funds  for  1976
               21
                    ought to come out of the text year's budget rather than here.
               22
                               MR. de la PUENTE:  A person in good   faith makes an
               23
                    application in a certain year.   This application is suppose
               24
                    to do a certain amount of work,  and supposed to take one year,!'
               25
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  hws-24           two years, three years, and when this period or this applica-
               2
                   tion, if it is awarded that year, he is entitled to do his       I
               3i
                   work regardless of how long it takes.
                li                                                                  I
                f
               4               DR.'THURMAN:  What is your recommendation?
               5                     MOTION FOR RECOMMENDATION
               6               DR. HIRSCHBOECK:  I was waiting for the Chairman,
               7   but I move  that we approve this application for the cohtinu-
               8   ation phase, and this amounts to   $1,814,588,, and we will  havel
               0   to take up the others separately.
               10              MR. PETERSON:  Your recommendations John, if I
               11  heard you  correctly, is for the continuation of Western
               12. Pennsylvania, and the amount requested Norm tells me ought to
               13  deal with the total figure.
               14              We will put them together.
               15              MR. ANDERSON:  Okay.
               I(;             MR. PETERSON:  We havea motion for Western
               17  Pennsylvania, and that is the amount requested for the RMP
               18  separate from this one AHEC which is an appendage to their
               19  application.
               20              Do 1 hear a second on that?
               21              DR. THURMAN:  Before we offer another motion, can
               22  we go off the record?
                               MA. PETERSON:  Off the record.
               23
               24              (Discussion off the record.)
                               MR. PETERSON:  Back on the,record.
               25
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      hws-25    i              Parliamentarily we have a motion with no second.
                61             MR. BARROWS:  Does it die?
                               Informally then I didn't share the doctor's
                4   enthusiasm.   They are now at a level of $1.2 million;  and
                5   they are talking in terms of this and their upcoming applica-
                6   tion is going to amount to about $2.6 million.
                7              That is well over a 100 percent increase in activ-
                8   ity, and 1 don't think based on what they have done to date
                9   they have the horses to take up that additional work
                10             I would be much happier, let us say, they should
                11  talk in terms of $1.4 million, or something like t at.
                               MR. PETERSON:  We have in what effect is a sub-
                12
                13  stitute motion of $1.4 million in terms of the $1.8 million.
                14             Is there a second to that motion?
                15             DR. TESCHAN:  I will second it.
                1(;            MR. PETERSOIN:  Any more discussion or corrections?
                               DR. HEUSTIS:  May I say  the current level of
                17
                18  funding according to this summary sheet I have is $1,193,000,
                    is that right?
                               MR. BARROWS:  I said $1.2 mill on,
                20
                               DR* HEUSTIS:  Okay, and you are saying $300,000
                21,
                    more?  You are saying $1.4 million is what you said.
                22
                               MR. BARROWS:  Yes.
                23
                               DR. HEUSTIS:  I think it deserves more than $1.2
                24
                    million.
                25
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    ly Is-26                 MR. BARROWS:  I refuse to answer it on the grounds
              2
                  it might incriminate me.
                             I was trying to come to a figure that would be
              4   appropriate for an average program,
              5              DR. HEUSTIS:  This is an average program.
              6              MR. BARROWS:  But apparently some more new vital
              7   direction.
              8              DR. HEUSTIS: If you were increasing it you  would
              9   be treating it the way we were treating some of the better
              10  than average programs.
              11             MR. PETERSON: I don't think we really have  those
              12  programs at hand.
              13             DR. HEUSTIS: In my opinion you would be  treating
                  that way.
              14
              15             I call for the question.
                             MR. PETERSON: Well, $1.4 million had been  recom-
              17  mended for Western Pennsylvania.
              18             All those in favor signify by raising your hands,
                             (Showing of hands.)
                             MR. PETERSON:  Those opposed?
              20
              21@            (Showing of hands.)
                             MR. PETERSON:  The motion fails for lack ofA
              22
                  majority.
              2t3
                             MR. BARROWS:  We are ready for a new one.
              24
                             DR. THUIOIAN:  I make a new motion to present
              25
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  hws-27        1  operating levels, and let's make them $1.2 million with a
                2  provision that staff try to clarify, number one, the legit-
                   imacy of the renal regional program as we now know it, and
                   much better clarification of the nurse practitioner program,
                5  025.
                6              MR. PETERSON:  It is still a motion of $1.2 million,
                7  and those two clarifications I think are inherent.
                8              DR. HEUSTIS:  Can I ask a question?
                9              MR. PETERSON:  Surely.
                10             DR. HEUSTIS:  In that $1.2 million which is the
                11 current operating level, is there not included $170;000 in
                12. this extra separate project?
                13             MR. PETERSON:  No.
                14             MR. NASH:  That is funded by a 910 grant currently.
                15             DRi HEUSTIS:  So that does not include the $170,000.
                               MR. PETERSON:  No.
                               DR* HEUSTIS:  It would limit their current level
                17
                   exclusive of this added net worth.
                18
                               MR. PETERSON:  This is just coming into the same
                   package.  It really is not reflected in their base.
                20
                               DR. HEUSTIS:  I think we are giving them $200,1000
                21
                   too much.
                22
                               MR. BARROWS:  I will second that.
                23
                               MR. PETERSON:  Any further comment?
                24
                               The motion is for $1.2 million.
                25
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   hws-28                      Those in favor show your hands.
               2
                               (Showing of hands.)
               3@'             MR. PETERSON:  Unanimity, and this does include
               4
                   the clarification by  staff both on the renal project and
               5   apparently cost per  capita of educating our training nurse
               6   practitioners.
               7                                                          state his'
                               MR. ANDERSON:  Can we  ask Dr. Thurman to
               8   concerns   about that project?
               9               DR. THURMAN:  Before we do I move that we approve
               10  Project 0044 in the amount shown,
               11              DR. TESCHAN:  I second.
               12.             MR. PETERSON:  Any discussion?
               13              Those in favor show your hands.
               14              (Showing of hands.)
               15              DR. THURMAN:  With  the Chairman's permission we
                   can  do  that without holding uD the progress here.
               17              MR. PETERSON:  Certainly.
                               MR. ANDERSON:  May I be excused?
                               MR. PETERSON:  We have disposed  of Western
               20  Pennsylvania.
               21
               22
               24
               25
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                                                                        355
    hws-29     1                VIRGINIA REGIONAL MEDICAL PROGRAM
               2                REVIEWED BY SISTER ANN JOSEPHINE
                             MR. PETERSON: I think  again  one  of  the  Regions
               3
                   we sort of hesitated in getting involved with before   lunch
               4
                   was Virginia, and if it is okay with you, John, I am going to
               6   put you on two in a row, but I am going to ask Sister Ann to
                   initiate the review on this one.
               7
                             SISTER JOSEPHINE:  Virginia is a program that for
                   a long period of time kept a categorical orientation, and
               9
                   once they changed from their categorical orientation to projelqt
               10
               11  and subs6quently a program, total program orientation, I
                   think that Dr. Perez has to take care of needs in the whole
               12
               13  State of Virginia by meeting with all of the  different  agenci6Is
               14  in the State and parceling out the funds to meet these needs
                   in rather small increments in the total state.
               15
                              The first time I went there on a site visit;  which!,
               17  was around 1970, the first place he took me was to the State
                   Capital, and the first thing that happened to me, I was the
               18
                   only one who was searched, to be sure I had no bomb, so the
                   next day we went along with the sia,htseeing.
               20
                              The soldier said to me when I said it is inter-
               21  esting that I am the only one you searched, well,  he  said
               22
                   the Berrigan brothers made you suspect.
               23
                              The whole climate in Virginia -  and I assume
               24
                   there will be someone going to help with the  staff  review
           1   25
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   hws-30           there is something very different about the climate in
                 1
                 21 Virginia.
                 31!           There is something different about this Regional
                    Medical  Program.
                 4
                 5             Once they get the direction of what it is the
                 6  Federal Government wants, it  appears  almost  verbatim  in  their@
                    objectives, in their thrust and  everything,  and  this  type,  but
                 7
                 8  it is a little difficult to evaluate if it represents a con-
                 9  viction, represents a way to go, or represents a way of coh-
                 10 forming so they can move on with their business.
                 11            I think possibly this is  not too fat  from wrong.
                    At the present time I have conflicting figures on the number
                 12.
                    of staff.
                 13
                               On hand there Are.14  members, and as I see  it  therL-,
                 14
                    are  20  budgeted positions that are vacant, I believe this is
                    right,  and  this has been, as Iremember  it,  an  ongoing  problem
                               They have always overbudgeted the number of people
                 17
                    that  they  would like on board from one time  to  the  next.  They.i
                 18
                    never come on board,  but the figure keeps stayin  high.          i
                                                                      9
                               MR. NASH:  This is a convenient way of    perhaps
                 20
                    having some additional funds to take advantage of    an opportunity
                 21
                    that might arise.
                 22
                               DR. TESCHAN:  We have also seen some diagrams and      i
                 23
                    charts -elative to capital ekpenditureso so that on any
                 24
                    correlation plot, Virginia seems to be out of line on the low
            I
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  hws 31        1             SISTER JOSEPHINE:  Presently the program staff,
                2  plus the program of $368,000 they are budgeting for $559',OOO,j,
                31
                   but that includes over $200,000 for these 20 vacancies that    i
                4  I doubt they will be able to get.
                .5            On July 1 they are planning on coming in with
                6  another proposal that will cost $1.3 million,  making  a  total
                7  of $2.8 million for this program.
                8             As of this time I reviewed the pro'ects that are
                9  listed, of the 1.9 projects listed on the yellow sheet, you
                10 will notice that seven of these relate to hypertension.
                11            My question would be could  these  probably  somehow
                12 or other be coordinated a little  differently.  I  don't  know.
                13 You may want to comment on this, or this may be a way of just
                   involving different agencies in this whole  project  of  hyper-
                14
                   tension, or maybe they are doing some research  that  is  going
                15
                I(; to generate statistics or some,papet, I just don't know,
                17            MR. NASH:  This is an ongoing project'. and I  cannot@@'
                18 really answer your question.
                19           SISTER JOSEPHINE:  There  are  seven  hypertension
                20 projects.
                              MR. NASH: Gene, do you have  anything  on  th  s?
                21
                22            MR. NELSON:  No.
                              SISTER JOSEPHINE:  This program has generated a
                23
                24 lot of community activity. -I would say  the  leadership  is
                25 satisfactory and probably the leadership Dr6 POrez, is a
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                                                                           358
    hws-32         very sensitive to the different groups he has  to  work  with
               2   in Virginia, and probably one has to work with many for some
                   period of time to appreciate this fact.
               4
                              The Regional Advisory Group, I  think, it seems to
               5   me is doing a good job.
               6              I notice that Dr. Neuno is Chairman of the Group
               7   at the present time, and Dr. Neuno is a young Spaniard from
               8   Malesia, and I have seen him stand up  on  several  occasions
               9   to Dr. Perez, which is interesting, in making the decision.
               10             They have indicated when this  program  is  phased
               11  into the new program that is going to be  developed  by  the
               12  Federal Government there will be no  difficulty  in  phasing
               13  these projects out.
               14             they have also phased out a certain number of
               15  projects.  I can't remember now how many, but they have phased
               i(i out without any difficulty in  getting  additional  funding.
               17             Their objectives and priorities follow the national
               18  guidelines specifically, and they have listed their projects
               19  under the objectives of  improved  availability,  continuity,
                   improved quality, efficiency and economy, and improved health
               20
                   data base.
               21
               22             The health data base is one of the projects   that
                   is just beginning to be developed in the State.
               23
                              The CHP relationships are good.  In fact,, I  got thel
               211                                                                 I.
                   impression on two site visits that the Regional Medical Program
               25
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  hws-33        1  funds a number of projects through and in conjunction with
                2  the CHP.
                3             Dr. Hirschboeck, any comment?
                4             DR. HIRSCHBOECK:  I have nothing to add, partic-
                @5 ularly.  I am not very familiar with this Region.  I had nev=j.i
                6  visited nor had much to do with it.
                7             On the other hand, it may be a judgment just on
                8  the application, and data presented.
                9             I would rate this as an overall average type pro-
                10 gram, nothing unusual about it, struggling to meet the changing
                   times  and that sort of thing,
                              MR. PETERSON:  Okay, we may or may not have a
                12
                13 CHP problem here, and perhaps Tom Smith, who is from the
                14 Philadelphia Regional office, and Virginia is serviced out of
                   that Regional Office, has something to say in this regard.
                              Tom?
                              MR. SMITH:  We have had  a special concern, one in
                17
                18 particular.
                19            MR. PETERSON:  Which one is that?
                              MR. SMITH:  Is that necessary?
                20
                              MR. NASH:  Probably Tidewater, isn't it?
                21
                              MR. SMITH:  Tidewater, correct.  Everybody knows
                22
                   that.
                23
                              This may be another sort of Western Pennsylvania
                24
                   situation, I don't know, but the spec
                                                         ifics had to do with
                25
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                                                                         36o
   hws-34              ect review by-the RMP, particularly regarding the BMS
                   pro]
              2    project which apparently was not considered for review, and
              3 1  CHP thought it should be.
              4               Apparently the agency was not advised of this fact,
              5    and interestingly, on paper it seems the relations are excel-
              6    lent, because the agency director is a member of RMP, and I
              7    am quite surprised the project was being considers
              8               I guess I can't say much more than that.  At
              9    least one agency is very unhappy, whether that has to do with
              10   personalities or not, 1 don't know.
              11              MR. PETERSON:  Is Tidewater Norfolk?
              12.             MR. NASH:  That is right.
              13              Pete, the gentleman which you are speaking about
              14   is a member of the Regional Advisory Group, and the Regional
              15   Advisory Group in Virginia is likely to include no new
                   activities in this particular application.
              17              This is a request for continuation of staff and
                   ongoing projects,
              18
              11)             They have sent out, or solicited new project pro-
              20   posals for the July 1 application, and our last communication
              21   with Region 5 of the 18 agencies have submitted a total Of
                   12 proposals which in Virginia RMP's review process at this
              22
                   time.
              23
                              I think what we.have here is a personality cohilic
              ?,4
                              DR. TTSCHAN:  When you get this kind of news what
              25
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  hws-35           happens?
                2              MR. SMITH:  Can he stop punching that thing over
                   there?
                4              MR. PETERSON:  Let's go off the record.
                5              (Disdussion off the record.)
                6              MR. PETERSON:  Back on the record.
                7              SISTER JOSEPHINE: All RMP  planning  has  been  closel.@
                8  coordinated  with the Governor's Committee,
                9              This is a program that has stayed very closely to
                10 the Governor's Advisory Committee, and originally then I think
                11 the Chairman was the head of Public Health, and then finally
                12 we got someone else as Chairman of the RAG.
                               Then this close association with the Governor's
                13
                14 Advisory Committee may well be the thing that will make it
                   possible for this program to phase into a State program, and
                15
                16 there are a lot of different projects.
                               MR. NASH: This  particular  project  you  are  speaking@
                17
                   of, if I am not mistaken, has been submitted by Tidewater CHP
                18
                   to the Regional Office in Philadelphia for consideration of
                   funding by John Reardon's shop also.     It is also considered
                20
                   for the July application.
                22             Now, whether the RAG will   approve it or not, no  one@,
                   knows as of this time.
                23
                               MR. PETERSON;  I-wonder if any of the other reviewers
                24
                   have any observations or comments they care to offer, or           i
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  hws-36           perhaps have some comnlents?
                2              MR. BARROWS:  Just from the caption and titles of
                3!i these proposed activities it would appear that they have pretty
                   good program direction.
                5              That is they are working on the right theme.  is
                6  that a reasonable observation?
                7              SISTER JOSEPHINE:  Yes, I think that my impression,,
                8  that the Virginia Regional Medical Program is that Dr. Perez
                9  keeps very close tab on what everyone is doing, and then also!,
                10 keeps tab on the  agencies with whom they are working.
                11             I don't think he is the greatest developer   of
                12 personnel,  you know.
                               MR. BARROWS:  I wasn't talking in terms of manager
                13
                   ment, but talking in terms of purposes and objectives.
                14
                               SISTER JOSEPHINE:  These are the needs identified
                   by the people, apparently.
                               These are really in response to needso and they
                17
                   don't look  spectacular, or anything of this type,, but I think,
                1.9 they are in response to the heeds that can be identified.
                20             DR. TESCHAN:  it is undertargeted.
                21             MR. PETERSON:  Dr. Thurman, as a displaced
                22 Virginian,  do you want to speak?
                               DR. THURMAN:  I think it would be inappropriate,
                2 tl
                   having really left the State.
                24
                               Nothin  hurts me more than to be constrained to
                                     9
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  hws-37      1    science.                                              363
              2               MR. PETERSON:  Do any of the other reviewers have
              3@i  any  questions?
              4               DR. HEUSTIS:  I understood, Sister, you said the
              5    beginning  they parroted what came out of the Regional medi---
              6    Program.
              7               SISTER JOSEPHINE:  I think the objectives and the
              8    guidelines they line up for themselves are just as close as
              9    they can make them to what it is that the Federal Government
              10   dictates, and then I think they try to fit into this program,
              11              MR. NASH:  They suffer from being too close to
              12,  Washington.
              13              DR. HEUSTIS:  I would have problems under similar
                   circumstances,
              14
                              DR. TESCHAN:  We have agonized with Gene  or years
              15
                   in the Southeastern Group with these things, and I get the
                   sense from what I am hearing, you know, coming in with that
              17
              18   background, 1 am hearing a much more positive type of situ-
                   ation there now, and the thing I don't think is that we couldl
              20   accuse Gene of, as it were, conformity as a subterfuge,
              21              I think that Gene is conforming on two grounds4
                   One is that he is lost, you know, he realizes that you really
              22
                   do have to play ball with the front office, and the other
              23
                   feature about it is that the front office is asking is not
              24
                   so different from what the situation is in Virginia as in
              25
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  hws-38        I   most other States, if not at all.
                2              The main national priorities of health we are sup-i
                31; posed to be recognizing are really what the problems are.
                4              I don't find that an artificial situation at all.
                5              MR. ANDERSON:  May I say something?
                6              I am not responsible for the program in Virginia,
                7   but I did have the distinct honor of being on the site with
                8   the Sister and two or three others two or three years ago.
                9              At that time I was very impressed with the  act
                10  that they laid the program out in a very honest and straight
                11  forward manner, not trying to please Washington, or the rest
                    of usi but they laid the  robiems out in terms of this is
                12,                          p
                13  our problem, and this is the way we are trying to  deal with
                14
                               In my limited experience with the State of VirginiA
                    and the RMP's throughout this has been their approach to
                17  trying to resolve the problems.
                18             SISTER JOSEPHINE:  You know, I have no reason to
                    question the way they have gone.
                20             In fact, After the first visit# when I wen  on
                21  the first visit, I came with some preconceived notions, but
                    after the first visit I realized that there their response
                22
                    was a very sincere response.
                23
                               I realized also that they were making an attempt
                24
                    to identify the problem, and they were making an attempt to
                25
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  hws-39         1 listen, and then to design projects that  were  in  response  to
                 2 the problems and, you know, whether they were reading it
                 31@ correctly or not, that is another ball game, but they did
                 4 seem to be responding.  But then it has been several years
                 5 since I have been there,
                 6             MR. NASH:  I think the hypertension activity is
                 7 an   example.
                 8             If you will recall, on our site visit they were
                 9 just proposing that at that  time.  They  had  some  representa-
                 10 tives from two or three communities that  were  present  at  the
                 11 site visit, and explained the need for this sort of thing.
                 12.           Sister, I certainly agree with what you say.
                 13            MR. PETERSON: We have a  request  here  for  roughly
                 14 $1.3 million with an indication that Virginia, and it is
                 15 essentially a continuation, that Virginia will begin all of
                 1(; its new activities in July with an estimate that this will
                 17 be a little larger than the $3 million plus.
                 18            1 don't  k.now whether you, Sister, and/or Dr.
                 I!) Hirschboeck have a figure in mind with respect to the current
                 20 application.
                 21            SISTER JOSEPHINE:  I would like to ask a question.
                               Do you feel those 20 vacancies, that it is realisti@
                 22
                   to assume these 20 vacancies are going to be filled?
                 23
                               MR* NASH:  You put me on a spot there.  My personal
                 24
                   opinion is  they probably will not, if we  consider  the  length
                 25
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  hws-40       1   of time remaining for RMP.
               2              You see, this is an award that will not  be  made
               ii  until July.
               4              MR. PETERSON:  Late June, for a period of July 1
               5              MR. NASH:  This gives them one year, and their
               6   ability to recruit that number of people for one year s
               7   employment I think would be questionable.
               8              Dr. Teschan doesn't agree with that.
               9              DR. TESCHAN:  Yes, but coming down to the question
               10  of employment of the people under those circumstances, I
               11  would go right along with the conclusions you woul d draw that
               12  in terms of hiring and firing, there is no question about it,
               13  because the people hired and fired would not have the exper-
               14  ience, the background in the context in which to make those
               @15 judgments.
    (3)                       We cannot expect them to go out on a limb.
                              DR. HEUSTIS: I note in a program  that  has  been
               17
               18  described as average, if I understood correctly,  they  have
                   proposed overall to increase their total request  about  100
               20  or some 100 to 150 percent.
                              Is the program much more than maintaining  it  at
               21
                   the current level the way we have done at the other average
               22
                   things?
               23
                              SISTER JOSEPHINE.:  Yes, it is   question   also.
               24                                           MY
                              It is one of the reasons I asked  about the
               25
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  hws-41           possibilities of bringing in people who they will have to
                2  have to maintain or develop the kind of program to carry on
                   the kind of program they have indicated, and I would think
                3!i
                4  they could not.
                5              I would think that in the July review all the
                6  projects are going to be there, and I think one is going to
                7  have to take a hard look at this,
                8              This present May 1 request I would recommend that
                9  they are at the game level that they presently are, with t e
                   indication that there is concern about the number of projects
                10
                11 that will be coming in in July with the 20 vacancies on the
                   program, and it may be that can give some indication where
                12
                   they plan to get these people, whether they plan to  ring
                13
                   them in from CHP staff, I don't know.  They may know where
                14
                15 they are available.
                               MR* PETERSON:  When you say at the present level,
                17 you were thinking then, Sister, in terms of that $971,000?
                               SISTER JOSEPHINE-.  $1 million.
                18
                               DR. HIRSCHBOECK:  I second it.
                19
                               MR. PETERSON:  Any additional questions or Comment9?
                20
                               MR. de la PUENTE:  I call the questions
                21,
                               MR. PETERSON:  Those in favor of $1 million with
                22
                   concerns being expressed, and hopefully some of this can get
                23
                   in with the larger projects coming in the first of July, and
                24
                   their real ability to filling some of the Vacancies,
                25
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  hws-42                       All those in favor raise your hands.           368
                               (Showing of hands.)
                2
                3              MR. PETERSON:  It is unanimous.
                4              I think we are now at  225, and  I would  like  to
                5   have one of the staff people we asked to come down specifically
                6   for out next project, the Metropolitan  New  York  and  Lakes
                7   Area, which is Bert Kline, who previously handled those
                8   Regions when he was with RMP.
                9              Bert is now in Planning and Legislation, and if
                10  there is no objection I would like to move on to that Region,
                11  because this is a very unusual application in one sense.
                12             I donI.t know whether, Bert, you or  Frank,  or  I
                13  should set the stage, by the nature  of  this  next  request.
                14             Suppose you come to the table, Bert, and het us
                15  have a brief comment or two so that everyone will have the
                IC'. backdrop for the reviewer comment in the nature of this next
                17  application.
                19
                20
                21
                22
                2il
                24
                25
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   hws-43       1               HEW  RECOMMENDED  MEDICAL PLAN FOR THE
                2               METROPOLITAN NEW YORK AND THE  LAKES AREA
                31!                   DISCUSSION BY BERT KLINE
                4             MR. KLINE:  Well, Mr. Chairman,  what kind of back-'
                5   ground would you like, a little on the program,, and how  it
                6   got where it is right here now?
                7             MR. PETERSON:  I was  thinking of  everything  for
                8   two years.
                9             MR. NASH: If you gave a  little  rundown  on  what
                10  has happened to the organization down there, because we used
                    to have real problems in that region,
                11
                              MR. KLINE: I will take a  couple  of  minutes  for
                12.
                13  those not familiar with some of the history of New York
                14  Metropolitan Area, which in approximately 1971, I think New
                15  York Metro had some severe communication problems between the
                16  then Coordinator and the grantee.
                               At that time I was associated with the Metro Board
                17
                18  of New York and the staff, and also the  Regional  Advisors,
                    and it just seemed it was sort of a shell game.
                               The grantee could not very well keep  track o  whati
                20
                    was going on at the program level.
                21,
                               The staff was  kept  fairl y well shielded from what
                22
                    was going on, and likewise  the  RAG.
                23
                               As a result of all this the situation with eVeryonO,
                2,4
                    was sort of reaching in to see what they could pull out of
                25
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      hws-44              I     the program in terms of support for their particular efforts,
                          2     a little lobbying going on within the RAG, lobbying going on
                                within the grantee, a little bit of lobbying going on with
                          4     the Coordinator.
                          5                      Staff     morale was some kind of shot.
                          6                      Well,     any way, some dynamics beg                 an, and we started
                          7     off with the management assessment visit, and started into
                          8     getting into some of these problems, documenting some of the
                          9     problems.
                          10                     This went on with some recommendations.  Some fund
                          11    were cut back, some were reprogrammed.
                                                 All during this time  the staff turnover was
                          12
                                tremendous,  and          through the course of eight or nine months
                          13
                                with    some pressures perhaps  from here in the ways of money
                          14
                                being held back,  and so oh,  things began to happen by Novembe
                          15
                                of 1972,  that the Coordinator had resigned,  and by December
                                of 1972,  if my memory serves me correctly,  Dr.  Thurman,  the
                          17
                                grantee,  resigned,  and we had more or less  during the-course
                          18
                                of the year of 1972              sort of cleared the deck, which was kind
                          19
                                of interesting, because at that point there had been a
                          20
                                residual staff which was waiting and somewhat eager to get
                          21
                                on with the job they              could see very clearly,  but could not
                          22
                                get to.
                          23
                                                  Dr4  Harrington, who had been the Deputy Director
                          24
                                at the time, was named as  the Acting Director.
                          25
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  hws-45        1             Jack Ellert who had been the Evaluator at   the time
                2   was named as the Acting Deputy Director of the Program, and
                311
                    they began to make some changes which had long been recom-
                4   mended, and to do it rather effectively, and it was  about tha
                5   time that RMP's became the phaseout victim of the budget.
                6             This, then, throw everything into sort of chaotic
                7   situation  but I think in terms of looking at this  ar ticular.
                             01                                         p
                8   application, in terms of talking to some of the people up
                9   there, I tend to suspect now that their staff is getting just'!
                10  a little better.
                11             In any event, their application has been certainly
                12  stronger than it had been in the past.  Their organizational
                13  structure is a little better.
                14             What they did do in  this  particular  application
                15  was to, 1 think, they read the  directions  rather  carefully
                1(j as a matter of fact, and what I can gather they assure
                17  within this application the grantee  would assume responsibility
                    for all activities which extended beyond the period of June
                    30, 1975, so they asked for monies for two years, by and
                    large.
                20
                21             I have broken it out in the little yellow   sheet
                    there about $3.0 some million for the second year of   activ-
                22
                    ities, and a total of about $4 million for the first   yearis
                2 t3
                    activities, which include staff and  other  activities,  with
                24
                    the grantee saying, and being recorded herein,  that  if  RMP
                25
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  hws-46        1   is phased out at June 30, 1975, they, themselves, will take
                2   responsibility for monitoring and surveiling t at money*
                                I think in the instructions that went out, I  thinki,
                4   this was deemed As somewhat illegal,  so they took the legal
                5   approach and requested almost $7.5 million, and that is kind    i
                6   of where it's at.
                7               I don't know if there are any further questions
                8   on this,
                9               MR. PETERSON:  There may be after the reviwerse
                10              We have Dr. Bill Thurman on this one.
                11              Dr. Thurman, you want to lead off there?
                12              DR. THURMAN:  I think Bert has filled us all in
                    quite completely,  and excuse the term, Sister  and  other  ladies
                13
                14  present, but I have never been more bastard  on  a  site  reunioni
                15  than we have been there.
                                We had to meet with all the medical school deans
                    who wanted to quit because we were there.
                18              We had real concerns, as Bert indicated, right
                    then about  Arronson's ability to take over a bad situation.
                    He had nothing but fighting going on in his staff; and there     i
                20
                    was absolutely no question that the staff  was  totally  blodkedi,
                21
                    off from participation in this program.
                22
                                It is just unreal, and yet, there was a talented
                23
                    staff there.
                24
                                I think the present application reflects the fact
                25
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   hws-47          that Arronson has taken over very well.  He  has  pulled  to-
               2   gether a staff that is adequate.
                              They have also put together an  application  that  irl
               3
                   it was inconceivable they could have put together before.
               4
                              Our real concern is that he looked  at  that  moment 1
               5
                   like a terribl weak sister -- and that is  not  a  pun,  Sister
                                 y
               6
                   Ann -- we didn't think he had it.
               7
                              I think our other major concern that is still
               8
                   reflected in this application, and that is one that I have,     i
               9
                   is that this, in essence, was then, and is now, a  one-man  RAG'@
               10
                   in the presence of Mr. Popper, in a way, and I think if there
               11
                   is anybody who did read every fine line and  figure  out  how
               12
                   they would do it, and swear he-could monitor it for the coniin
               13
                   two years is the RAG Chairmant who is a  very  unusual  indi-
               14
                   vidual.
               15
                              This RAG Chairman is  very  much  dollar-oriented,
               16                                                                  1
                   and he orients the dollars to the RAG, and that does show       i
               17
                   through in here occasionally.
               18
                              There is no question in my mind that  the  staff  is
                   far superior to what it was, and there is  no  question  Also
               20
                   that in the preparation they have much better morale  than  theyi
               21,
                   had  before.
               22
                              I think that the weakness of the RAG is not  becausei@
               23
                   of lack of interest in that some of  them really took  us  over
               24  the coals, but they also were not informed, and  I  think  that
               25
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   hws-48       1  again I would question whether or not they are truly informed
                2  now about what is going on.
                3              They were not informed then about the difficulties
                4  with the schools, which I think was unfortunate, and made it    1
                5  very unfortunate for us,
                6              I think the school situation now is well handled,
                7  I mean because they got outof it.
                8              You will notice from the list of projects in here
                9  that there it still an attempt to carry forward to each
                10 school some RMP money, or we have used the term the day   of
                11 political payoff to keep things running smoothly.
                12.            On the other hand, some of those projects are
                13 quite good  and strong.
                14             In reference to the projects there are some very
                15 strong ideas, but most are carbon copies of other programs
                16 within the Region itself.
                17             My question was whether or not all the projects,
                18 that the same thing could be strengthened by corps staff
                I!) leadership with multiple outreach indications.
                               The examples are kidney, manpower and hypertension
                20
                21, problems, and so on.
                               I feel the money here is going to be wasted, but I
                22
                   have been wrong before.
                23
                               We have spoken of the problem of the continuation
                24
                   of the money past June 1.
                25
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      hws-49    1             The CHP has never worked out of New York.  Th   eir
                21  relationship is good -only because CHP does not have the stren.
                31  to react yet, so it has given it a cursory review.
                4             The CHP is becoming much stronger, and if this
                5  program goes on, the CHP will get into it.
                6             All in all, I feel this program has significantly
                7  changed since the days of our last visit there, and it is well
                8  reflected in this document; the changes that have occurred
                9  and have taken place.
                10            For that reason I support the program,, and  would
                11 call it now a slightly above average program.
                12            I think it is clearly better than some of the other
                13 programs we have classed as average in the past two  days  in
                14 leadership and direction and everything else,
                15            I will come back to the figure after Al has had
                   his say.
                16
                              DR. HEUSTIS: Al worked under  the  constraints  of
                17
                18 what he had available to him, which was the written document,
                19 and I take respectful exception to the staff saying that they
                20 followed the direction that at least in my copy they did not
                   number the pages, and I never had so much trouble to find
                21,
                   anything in trying to relate back and forth, to try to get
                22
                   things going.
                23
                              I did not have the appreciation, not  having  done
                24
                   this before, when I took a crack at the first because it was
                25
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  hws-50            the thinnest, which was Connecticut's, and the one I took a
               2    crack at second was Metro New York.
               3                MR. PETERSON:  Is that when you called and said
               4    you weren't going to be able to make it?
               5                DR. HEUSTIS:  Just from the document I am not pri
                    to this other information, but just from the document I was
               6
               7    not too impressed, and as you have said'. I certainly wasn't
               8    impressed with what they have done in the past, and it seemed
               9    as though they had great difficulty in sorting things out,
               10   for example; and it was very confusing.
               11               For example, there is an item that has a different
               12.  project number that is in twice for $947,632.
               13               MR. KLINE:  Project Numbers 50 and 62.
                                MR. PETERSON:  This is the EMS?
               14
                                MR. KLINE:  Number 50 was their pilot of last year
               15
                    which was not supposed to have the money attached to it this
                    year.
               17
                                DR. HEUSTIS:  My problem was this was widely
               18
                    separated in the organization and getting discouraged, I
                    wondered 1'f somebody said let's just duplicate this without  1
               20
                    too much thought.
               21
                                I guess you folks have so much more valid inform-
               22
                    ation than I have that my very discouraging report, and my
               23
                    rating as far as this goes was below average, and as far as
               24
                    the other kinds of things, it looks as though the program
               25
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    hws-51          leadership was satisfactory; the program staff didn't impress
                 2  me too much.
                 3i
                               The RAG which was satisfactory in the past in
                    performance got a low rating.
                 5             The objectives and priorities again were satis-
                 6  factory.
                 7             The proposal is satisfactory, and one feasibility
                 8  I just didn't really think it was very hot., and CHP relation-
                 9  ships again, you tell me there is no CIIP, and I rated the
                 10 thing as pretty good.
                 11            MR. PETER80N:  There ibnlt any, in one sense.
                 12. There is a funded areawide C'fiP, and in so many major metro-
                 13 politmi areas, Washington, D. C., still doesn't have one.
                 14 It was very slow in getting organized, in getting funded,
                 15 and even now I suspect that Bill suggested it is not  ea  y
                    functioning, and it is difficult not to have at  lease  Adeauate';
                 17 relationships with someone who is not functioning.
                               MR. NASH:   Pete, I was up there in P6bruary and
                 18 March to take a look at their review process, and we had a
                 19
                 20 representative from the CHP Agency also Visiting with us, and    I
                    I don't know how far along they had gotten with their mission
                 21
                    of developing-a plan,, but certainly from what he told us the
                 22
                 23 relationships between the two organizations douldn't be
                    better.
                 24
                               MR. KLINE:  This was interesting too, because all     i
                 25
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   hws-52          the way back to, I guess about 1971 or early 1972, 1 am losing,
               21
                   track of time now, they did have good relationships with
               3
                 .1 whatever existed in the wav of  CHP.
               4
                               THE CHP was coming  into existence at the time, but  I
               5   there was a good working relationship right from the outset
               6
                   with the CHP.
               7               DR. THURMAN:  I didn't mean to imply it was bad.
               8   It just didn't exist.
               9               The problem is there was nobody  there  to  argue
               10  with.
               11              MR. KLINE:  I think the CHP, although I am not sure@.
               12
                   if it advanced along the same kind  of  slope  and  graduated
               13  advancement that was going some time back, it should be
               14  functioning reasonably well now.
               15              DR. TESCHAN: There is a  $1  million  proi6ct  on
               i(i this, Health Care Services. That  is  a  pretty  big  figure, and
               17  it is a one year -- well, I guess two years.
               18              MR. PETERSON:  All of those projects which have a
               1!) C are essentially two year activities so the annual cost againi
               20  is roughly, I guess, about half of that.
                               That is still a $550,000 activity,
               21
                               DR. THURMAN: That in  actualitvo  the  design  of
               22
               23  this program is superior probably to most other programs    we
                   run across of this nature,
               24
                               DT. TESCHAN:  To what?
               25
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   hws-53                       DR. THUP14M   They are trying to make all of the
                    hospital rooms and clinics operated by the City of New York,
                    and also by private hospitals much more in touch with each other
   0           4    and much more of a regional type of referral, so that the
               5    lady in Queens who decides she needs a ceasarian operation
               6    can go to a hospital there rather than come to a hospital in
               7    downtodn New York.
               8                That is what the impact and the plan was, an
               9    their ability to get the great majority of the hospitals in
               10   the area to at least consider this.
               11               It was easy to get the City of New York, the city
               12.  hospitals,  but they brought in a lot of  the  private  hospitals
                    There is a  lot of fighting going on in Westchester County,
               13
                    and certain parts of Queens, which have never gotten any
               14
               15   money at all, and metro New York City.
                                It is overly priced here just like the EMS prograipE
               17   are overly priced, but it is a great idea as  far  as  trying  to
               18   deliver health services to an  amorphos  population  that  cannot
                    be reached well at this moment.  It is overpriced.
                                DR. HIRSCHBOECK:  Are we going to judge these
               20
                    projects on the basis of one year funds,  or  two  year  funding,
               21
                    or what?
               22
                                How do we handle the desire on their part to circun-
               23
                    vent   these?
               24
                                MR. BARROWS:  Let me get some preliminaries here.
               25
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  hws-54                       Is the nature of these projects such that they cou d
               2    have been presented as one year, or will it  take  two  years  to
               31
                    get the job done?
               4
                               DR. THURMAN:  Of all the C project in   here, prob-
               5    ably about 40 to 50 percent of them, that  is  a  tough  guess
               6
                    now, need two years to really come to fruition.
               7               Take the program we are referring to, the $1
               8    million program, on the other hand is  going  to  be  financed
               9    either by the City of New York hospitals, or the consortium
               10   of New York hospitals if it goes into a secon  year.
               11              MA. PETERSON: I  guess  John's  question,  I  wouldn't
               12   want to provide an official RMP response,  this  is  almost  a
               13   case of one,, the extent to which Metro New York  has  asked  for
               14   two years support, and my own  personal  view,  and  underscoring
               15   the word personal, is that 1 think we need  to  look  at  this
               1(;  in terms that say to Metro New Yor:k, or any  other  Region  that
               17   really has done this, here is an amount of money if you want th
               18   do some activities over two years you  are  going  to  perhaps
               19   feel the pinch in other areas, because most Regions, you know,
               20   if we were to consider most regions, I  suspect  there  are  some
               21,  activities which they could have looked forward to multiple
               29   funding on a grander scale.
                               I think it disposes  of  a  difficult  question.  I
               23
                    don't have a real answer to it.
               24
               25              Maybe Bill Thurman's  recommendation  will  help  come
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  hws-55        I  up with an answer.
                2              MR* KLINE:  I would like to comment on that one
                3  point really, the $2 million project in particular.
                4              That project has A series of discreet activities.
                5  Were they to receive reduced funding on that particular thingd
                6  they would fund particular activities on a priority basis
                7  within that $1.2 million.
                8              DR. TESCHAN4.  Was there evidence of some priority
                9  setting?
                10             DR. THURMAN:  It is not in order, on that list.
                11             gert's point is a good one.  It was asked for undet
                12 RMP from the standpoint they could involve everybody with
                13 RMP dollars, whereas otherwise'the City of New York is going
                14 to fund it for all the City of New York hospitals.  They
                   believe they will combine with  some of the others, and the
                15
                   County
                          Medical Society is going to fund it with Queens.
                17             Its availability as a plan will become somewhat
                   more difficult.
                18
                19             DR. HEUSTIS: That makes very  good  sense,  I  think,
                   that is that approach.
                20
                               MR. BARROWS.-  Looking at the thing in a very   broad
                21
                   sense, and taking into account the population we serve,     which
                22
                   is what, seven million or eight million?
                23
                               DR. THURMAN:  They say 14 million.
                24
                               MR. PETERSON: That is probabl  a  little  too  high..
                                                              y
                25
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  hws-56                       MR. BARROWS:  We are talking about, let us say,
               2    ten million people. We all go by the  extraordinary  expenses  1
               3                                                                   1
                    in New York, the extraordinary amount of time it takes, the
               4
                    extraordinary difficulty in getting things together,  as witne,@s,
               5    trying to get a CHP.  They have been  working on that for
               6    eight years now.
               7               When you look at all those together  And you con-
               8    sider there what they are asking, it is really kind  of  modest,
               9    it seems to me.
               10              MR. PETERSON:  Bil , you said something which
               11   suggested to me at least that you might have a  motion  in  your
               12.  hip pocket, or recommended funding level.
               13                 MOTION FOR RECOMMENDATION
               14              DR. THURMAN:  I move we approve it as a slightly
               15   above average program, and we throw out for discussion here,
               i(i  discussion of $2.2 million.
               17              I think if we do that, my own opinion   is, and t  at
               18   is all it is, is an opinion, they will look hard   at some of
                    these projects.
               20              I am afraid some of the buroughg of New York will
               21   go out.  But there are some very significant steps they can
               22   make in developing health services in Metro New York with that
                    kind of money.
               23
                               MR. BARROWS:  It is about 30 percent lower than
               24
               25   last year.
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     hws-57     1              DR. THURMAN:  No, they are operating on $1,142,000
                2  now,
                311            My figure is in the range of $2.2 million to $2.5
                4  million.
                5              I have read Bert's recommendation, and  I  can't
                6  @gue with   it too much, but I have ended up with $2.2
                7  million.
                8              MR. PETERSON:  Did you say $2.5 million?
                9              I was thinking $2.2 million.
                10             They have indicated to us Metro New  York,  that
                11 they will  be in with an application in July of around $2
                12 million in addition.
                13             MR. NASH:  That brings it to a level of $441,000,
                   five percent above the target figure, assuming both applica-
                14
                15 tions are approved in the amount requested.
                               DR. THURMAN:  They requested $7.7 million.
                17             DR. HEUSTIS:  My problem, I go along with the $2.5
                18 million, and my problem is really this.  I wasn't anywhere
                19 nearly impressed with the written document, but  I  sure  am
                   impressed with some of the things that they were trying to
                20
                21 do together involving Metro New York hospitals, and certainly
                   am impressed with the problems of doing things  such  as  an
                22
                   area of New York City, and this two year business,,  I  just
                23
                   am not particularly impressed with that.
                24
                               What I was really trying to do is wrestle with the 11
                25
   "DOVER REPORTING CO,
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                                                                         384
  hws-58           fact that really on the past record they didn't deserve very
               2   much, but it looks as though maybe they have a  new  lease  on
               3
                   life, and that they could do something, and if you   could come
               4   up with some kind of a figure that would give them   a  little
               5   help, but certainly not everything that they wanted.
               6              DR. THURMAN:  That is why I gave them $1.3 millions
               7   That is not an insignificant amount of money, except when you
               8   look at.8.5 million, nine million, or ten million people.
               9              DR. HEUSTIS:  I look up there at the greater
               10  Delaware valley.  Is that Philadelphia?
               11             That is really the only Problem I have in this.
               12             DR. THURMAN:  Well, if somebody wants to go higher
               13  and
               14             DR. HESS: I wonder about going  up  to  $3  mi  ion
               15  or something.
                              New York is a health care jungle, and my guess is
                   that New York probably hat had it.
               17
               18             This is a small staff, seven full time professional;,
               19  no planned incremental, so that was one of  my  concernsi  can
               20  a staff that small handle it.
               21             Do they have the administrative mechanisms to
               22  handle this much money?
                              Mr. Kline?
               23
                              MR. KLINE:  I had the  same kind of cbncerni and I
               24
                   cannot answer it, because I have  almost  an all new staff.
               25
  HOOVER REPORTING CO, INC.
   320 Massachusetts Avenue, N.C.

   hws-59                       The only new people being carried over are the
                 2  Deputy Director and Director.
                 3
                                MR. PETERSON:  How long ago was it?
                 4              MR. SIMONS:  Bert was up there in 1972.
                 5              MR. PETERSON:  Really, that information on the
                 6  staff is completely new.
                 7              It always has been a small staff, as you know.
                                MR. NASH:  Pete and I were up there, at least on
                 9  a part time basis, some 60 percent, four physicians, and these
                 10 are people with excellent reputations in New York City, an
                 11 it was their proposal then to hire a full time nonmedical
                 12 staff to assist these four people in various program areas
                 13 in which they are working, so this would add tremendously.
                 14             DR. TESCHAN:  How about the financing?
                 15             MR. PETERSON*.  Maybe Tom, who has been part of
                    the management assessment effort has some insight.
                                MR. SIMONS:  The grantee does all of the accountin
                 18 for them.
                                I don't think there is any of that going on, on
                    the staff level itself.
                 20
                 21,            DR. HESS:  So we don't have to worry about that.
                 22             MR. SIMONS:  One other thing, as far as staff.
                                Jack Eller was with me on a management assessment
                 23
                    to    another place.  They have hired on a part time basis a
                 24
                    physician to work with them.  These are physicians who have
                 25
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  hws-60           reached a stage that       don't want a full time activity,
               2@i but they still              -,Lnvolved.
               3!!             14R.            Iked to Jack Eller on the phone
               4   the other  day, and he ha@4 extremely high praise for the part
               5   time  people.
               6               I queried him about the size of the staff once
               7   again, because that has been a c hronic problem with him, and
               8   I said I noticed yov have some part time people, and he said
               9   they are very helpful.
               10              MR. PETPR'-;ON4  I think that is a case where the
               11  proposed additional positions would come in, would it not?
               12              MR. NASH:  Yes.
               13              MR. PETERSON:  We have hot been consistent.
               14              DR. HESS:  Does that mean seven additional pro-
               15  posed   full time professional clinical people?
               16              MR. KLINE:  Yes.
               17              DR. THURMAN:  To get back to the staff sheet one
               18  more   time, the $88,000 is in overhead and is what pays for
               Iq  all the accounting and financing mechanisms, and at the New
                   York   Acade my of Medicine in the program staff figure there
               20
                   is a $88,000 overhead, but that pays for their accounting to
               21
               2:>. the New York Academy.,,
                               DR. HEUSTIS:  I would like to support the motion
               23
                   as made with the proviso that when this comes to the Council,
               24  and should there be extra money, that the Council look upon
               25
  N     ORTING CO, INC.
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                                                                            87
  hws-61           the needs of New York in a fa-,7orable fasA@Aion and that my
               2
                   thought about increasing, is whalt.- 1     about the needs of
               3 it New York City more than anything else.
               4              MR. PETERSON:  You have any problem with that?
               5              DR. THURMAN:  No.
               6              MR. PETERSON:  We have a motion for   $2.5 million
               7   for this May 1 application for Metro New York.
               8              Any additional discussion?
               9              DR. HESS:  I may just ask what will that do now?
               10             Let's say.that they come in with a  batch  of  new
               11  applications in July, and a certain number of  those  are  again
               12, passed. They still have the freedom  to  reallocate  within  the
               13  two decision making periods, so if they want  to  boost,  for
               14  example, this Medical and Health Care Services, they can out
               15  of that total package that we are not bypassing a lower figure
                   now, we are not necessarily restricting  their ability to
                   increase funding in that particular project.
               17
               18             MR. NASH: No. As a matter  of  fact,  about  a  month
               19  ago Dr. Arranson And the RAG Chairman came in  and  met  with
               20  Dr. Paul, and they explained at that time  that  their  applica-
                   tion is going to be roughly $7 million.  That  is  the  first
               21
               22  application, and the fact that they would be asking for support
                   for many of their activities over a period of two years.
               23
               24             Obviously, Dr. Paul told them that  seems  like  a
                   little high figure, but go ahead and send it.in.
               25
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  hws-62        1             There is very little else you can tell them, becau    e
                2  they c.,a-n request anything they want.
                                                                                   I
                              They did say that they would take whatever was
                4  recommended in this award, and would have their RAG meeting,,
                5  and they would look at their total @gram.  They would
                6  prioritize the activity and select those that they wished to
                7  fund.
                8             MR. PETERSON:  I think in response   to what I heard
                9  is your policy kind of question, that New York Metro, or any
                10 other Region, would have the kind of discretion and lattitude
                11 within the two awards which becomes a single pot of money
                   again within the Councills policy regarding discretionary
                12
                13 funding to move things around.
                14            The problem that they would have in the short run,
                15 of course,  is that they are not sure of how much they will get
                16 out of a July application.
                               There may be some things that they have got in
                17                                                                  1
                18 this application that they would want to defer starting  until   I
                19 they see that, or some things that they might start at, start I
                   at a minimal level, and depending upon the outcome of July
                20
                   extend it.
                21
                               But the general answer to your question is yes,
                22
                   they would have that kind of discretion.
                23
                               DR. HESS:  Then these projects will not be in the
                24
                   next package.
                25
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                                                                          389
    hws-63     1               MR. PETERSON:  No.
               2               DP. HEUSTYS:  But there is nothing to  prevent  them
               31  for funding these projects after they get  their  July  money.
               4               MR. PETERSON: No. There are  a  few  caveats,  but
               .5  I didn't see any projects that involve  construction  of  some
               6   kind.
               7               DR. HEUSTIS:  I look at this arrangement as perhaps
               8   simulating  the use of non-RMP money that I feel confident is
               9   there, and whereby perhaps instead of paying  for  the  whole
               10  thing as far as this working relationship,  the  city  emergency
               11  rooms, that they might pay for part of it, and  the  city  might
               12  pay for part of it.
               13              MR. PETERSON: We do have a motion  on  the  table
                   for $2.5 million providing for the Council  looking  at  your
               14
               15  recommendation given the needs of New York  City,  that  there
                   is some leeway, and that we look upon it favorably.
               16
                               Any additional comment or questions?
               17
                               If not, all those in avor signify  by  showing  your
               18
                   hands.
               19
                               (Showing of hands.)
               20
                               MR. PETERSON:  Okay.  We had one  member  absent.
               21
                               We did what I was trying to avoid doing,  if  that
               22
                   clock is correct, and the cafeteria is now closed, but I was
               23
                   wondering, we have five applications left, and I think we
               24
                   can get them under our belts if we probably  work  until  5:30
               25
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                   or so,
               2              Would you people  like, despite the fact that the
               3   cafeteria is closed, to take a stretch a t this point?
               @4             (Short recess.)
               5              MR. PETERSON:  Well, let us proceed now with the
               6   Lakes  area.
               7              Mr. Barrows:
               8              MR. BARROWS:  I will try to be brief.
               9              The Lakes area is a nine county area in Western
               10  New York ancl Northwestern Pennsylvania. I think  they  are
               11  asking $2,072,000.
               12             I do not have the last year figures here.  Last
               13  year they were running about $1.4 million.
               14             Their Executive Director is Dr. John  R.  Angle.
               15  He has been in the program since its inception.  He spends
                   80 to 90 percent of his time with it.
                              The RAO Chairman is Father Garrard, an educator.
               17
               18  The Executive Committee is composed of four officers.
               19             The professional staff has 19  full  complement.
               20  They have 13 on board of the complement, and need six.
               21             I might add that by my guess they are well supplied
                   with chiefs, but they are short of the  important  Indians.
               22
                              In the Regional Advisory Group they have 43 people,
               2.3
               24  two from each of the nine counties.  The rest are fairly
                   diversified by interest and background.
               25
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  hws-65        I              There is a substantial non-provider representation,
                2   In fact, it is almost like a CHP Advisory' Gz,oAv"p, usua  y
                3   routine about their processes.
                4              They have a very  elaborate  structure.  They  have
                5   25 committees,, and it looks to me as if there are  a  certain
                6   amount of overlap, and what have you.
                7              It appeared to me that their processes were demo-
                8   cratic, but awfully complex.
                9              Their major thrust normally has  been  along  three
                10  lines.  The main one seems to be education,
                11             I, too, think we are giving more I.ip service to
                    the Current RMP mission than they were actually.
                12
                13             For example, these are things that I  am  not  that
                14  particularly acquainted with. They  are  asking  for  $154,000
                15  for the telephonic electronic program, $200,000  for  a  tumor
                16  registry, which I understood was pretty well half full.
                               Area prospects for success undertaken seemed to
                17
                18  be fair, reasonable.
                               Their objectives and priorities are adequately
                20  stated    transmission of new knowledge, regionalization,
                    and improvement of delivery, but they seem  to  treat  cohtin-
                21
                    uing education as the way to achieve all of the goals.
                22
                               The proposal looked to me like something of a
                23
                    residual rural mission.
                24
                               The feasibility is good and bad.  They have a fair!
                25
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                                                                           392
  hws-66        1   showing of State and local cost sharing on some of their pro-
                2   grams which would suggest some commitment        -@f them.
                3              They have two CHP B's that they         6n Western
                4   New York and Northwestern Pennsylvania.  Each has a repre-
                @5  sentative on the RAG.  Five of their county committees are
                6   joint.  They share in their development review with CHP.
                7              When New York expressed its concern whether the
                8   large majority of these proposals relate to the major goals
                9   of LARNP, of 21 proposals they disapproved eight, because
                10  they were not related to the-goals, where they had weak planning,
                    and they approved two with major conditions.
                               Now, I would say that ordinarily I can understand
                12
                13  the sibling rivalry between CHP and RMP, and there is a lot
                14  of ego trips and petty bickering, but this letter from the
                15  Western New York B Agency struck me as being a pretty darn
                    rational critique under a proposal that had been submitted    tol
                    them.
                17
                18             That was my impression, in any event.
                                Generally, I would say that this is a weak average
                19
                20  program, slow in responding to the 1971 mission.
                               They have a staff shortage of what I think are
                21
                    fairly key people in any implementation activity, and    that
                22
                    will limit their capacity.
                23
                                I have some question whether the staff and RAG
                24
                    structure are functioning effectively.
                25
  110 REPORTING CO, INC.
  320  chusettsAvenue,N.I. @l
        n p )Ann,) I f

    hws-67      1             As I say, I wind up.with a no  better  than  average
                2  rating,, a kind of wea,,@ -,lj.erage.
                3             I would be glad to hear somebody  elsels  view  that
                4  might be more cheerful.
                5             MR. PETERSON: I am not sure I  can  satisfy  you  on
                6  that  score.
                7             Dr. Heustis is the next reviewer, and  I  can  say
                8  that.he  is charitable, but I cannot say he is going to be
                9  charitable about the Lakes Area, and perhaps the  best  way  is
                10 to ask  him.
                11            DR. HEUSTIS:  In general you almost read my notes.
                12            This was one of the ones that I think  that  I  made
                13 the  remark that the first time I went through this  I  lot  a
                   pretty decent impression when I went through it fast.
                14
                15            Then when I went back and read it more carefully
                10, and tried to put things together, I had great difficulty
                   trying to pinpoint the reported specifics, for example, short
                17
                18 term goals and priorities may well in fact e 3st,  but  t  ey
                   were not emphatically stated, and not  with  sufficient  speci-
                19
                   ficity at least to satisfy me.
                20
                21            I found it interesting  in  the  classific.ationdf
                22 the projects that some, if you classified them by the so-called
                   major thrust, there were three of them on the use of knowledge,
                23
                   one on Regional linkages, and nine had to  do  with  personal
                24
                   health in one wayi and they also classified them another way,
                25
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  hws 68        1   three for health screening or assessment, three having to do
                211 with patient care, one coordination, and six on manpower
                    dexelopment and education,
                4             That, you can see, is where the emphasis is.
                5   couldn't find any information that was very helpful on how
                6   the staff planned to implement the major thrust, and I could
                7   not find any information on how the relative priority of the
                8   various components was assessed, although they do  say  the
                9   priority was assessed.
                10            My comments as far As the CHP, I  have  the  same
                1.1 reaction to the letter from Western New York, in which they
                12  very specifically commented on the new projects.
                               Of the five new projectsi two were not approved,
                13
                    and three were approved.
                14
                15             Of the two that were not approved, they had to do
                1(5 with regional hpertension and the preparation of ntrse@@,
                    faculty.
                -17
                18             The three that were approved had to do with ambu-
                    latory health planning, somebody in the household.
                19
                               I think with the extent and capabilities and,the
                20
                    program staff, I just can't help but wonder why they couldn t
                21
                    provide sufficient information in health planning to put some
                22
                    of these things together to stimulate those asking for grants
                23
                    to get something done,
                24.
                               Apparently they didn't, because  as  I  analyzed
                25
  Ho ER.IEPORTINGCO INC.
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        n r )nnn,)

    hws-69      1  the money figure here, somewhere'that out of the total recfuest
                2  of $2..072,000, almost $800,000 or slightly less than one-thi-ti
                3  was listed for the program staff.
                4             In addition, almost $1.1 million was   liqted for
                5  Activities for program staff activities, leaving sponsore(
                6  projects only some $215,000 as far as others were concerned,
                7             It would seem to me that in one way it could be
                8  a little onesided.
                9             DR. TESCHAN:  You are saying the staffing isn't
                10 adequate enough to handle that amount of business?
                11            MR. HEUSTIS:  No. the staff ought to be concerned,
                12 to be responsible, and to get others to try to handle the
                13 projects, rather than running it themselves.
                14            it looks to me if you have  a  difficult  Region  and
                15 a capable staff, the easiest way, at least to my thinking, is
                16 to distend it and carry it out with  your  own  group,  probably
                   a very limited usefulness in the long run, because it goes
                17
                18 when you go,
                               The harder way in the long run is  to  get  somebody
                19
                   else interested in carrying out the good idea  so  that  it  has
                20
                   a greater chance of  staying.
                21
                22             I guess my general belief is that those projects
                   that are carried out by others probably have got, on the whole,
                23
                   a greater probability of being funded into projects.
                24
                               DR. TESCHAN:  Continuation funding?
                25
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   hws-70                     DR..HEUSTIS:  Yes, yet dealing with strong  medical
               211 schools, and with a strong situation we know the difficulty at
                   least in getting started.
               41;            In the overall specific assessment I  thought the
                   program leadership was good to excellent.
               c-             I thought the same about the program staff, the
               7   Regional Advisory Group, a little lower, satisfactory; per-
               8   formance and accomplishments,, satisfactory.
               9              I have trouble with the objectives and priorities,
               10  and I had to break those down as poor, the proposal I wante
               11  originally was higher, but again it is on the poor side.
               12             The feasibility again is on the poor s de, an
               13  CHP working relationships, in spite of the disagreements, it
               14  looked as though there was the opportunity to communicate,
               15  and on that my judgment is good, even though there was differ-
               16  ences of opinion expressed.
               17             I weighted the whole program the same as my
               18  colleague did, on the low, average side.
               1!)            MR. PETERSON:  Well, I think there have been a
                   couple of concerns expressed that have been shared by staff,
               20
               21  and I will call on Frank, and also ask Bert two or.three
               22  things that we had some questions about.
                              MR. NASH:  I will make a comment about the CHP.
               23
               24             What Dr. Angles did,  was as soon as he got a pro-
                   ject in and before it had gone  through his own review process,,
               25
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   hws-71          ne sent it to CHP agency for review.
                               As it ended up he sent in  21 pr ojects.  The   com-
               3
                   ments were  received by CHP.
               4
                               The Regional Adv-;.sory Group approved  themselves
                   only five of the 21 projects.  They did approve one that the
               6   CHP recommended disapproval for.  This was the one submitted
               7   by Niagra University for  training  nurse  practitioners,  and
               8   the Region explains to me that the CHP agency there does not
               9   have a nurse on their staff.
               10              The Regional Advisory Group thought  from  a  tech-
               11  nical standpoint the CHP's comments  in  this  particular  case
               12  were not really accurate.
               13              MR. PETERSON:  There were a couple of projects
               14  or activity concerns that you at  least  noticed  or  mentioned
               15  to me.
               16              MR. NASH: You will notice  Project  1,  the  Tele-
               17  phone Network, that activity they have been supporting now for
               18  about seven years, and they propose to  continue  this  in  the
                   coming year, and even a year after that.
               20              DR. HEUSTIS: There were  some  two  year  requests
                   I failed to men ion.
               21
               22              MR. NASH:  That is right.
               23              This for me is a staf f person.
               24              1 think in the past if they didn't have a    policy
                   we practiced it at least that RMP would usually fund    an
               25
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                                    11                                                                                                                       398.
                                                                                                                                                      s,    perhaps
                                    1  activity  for  three  years,   and  then  on  rare  occasion
     hws-72
                                    2   for  another  12  to  18  months,  at  the  most.
                                    31                         Staff  would  wonder  if  this  concerns  the  Committee
                                    4   any  that  they  would  continue  to  fund  this  thing  into  the
                                    5   1970's.
                                    6                           MR.  PETERSON:     Let  me  mention  one  thing  in  that
                                    7   regard.
                                                                my  offices  a  couple  of  years  ago,  we  contracted
                                    .8
                                    9    for     a  study  of  these  types  of  networks.     I  don't  recall  t  a
                                    10   the     New  York  one  was  one  of  the  subjects  of  it.
                                    11                           The  contract  was  an  abysmal  delivery  product    y
                                    12   Systems  Development  Corporation,  but  one  of  the  things  that
                                    13   we  pretty  well  knew  beforehand,   and  they  did  manage  to  d6cu-
                                         ment  the  ability  to  find  continuation  funding  for  these  kinds
                                    14
                                    15    of  telephone  radio  networks  was  fairly  low.
                                    16                           Now,  I  think  in  Wisconsin  there  was  about  as  much
                                          success  as  anybody  had,  and  that  was  in  percentage  terms  of
                                    17
                                    18    what,  50,   30,  20?
                                    191                           DR.  HIRSCHBOECK:     The  University  extension  con-
                                           tinues  to           support  it.
                                    20
                                                                  MR.  PETERSON:     I  know  in  Wisconsin  it  really  was
                                    21
                                           the  University  Extension  Service,  and  you  were  looking  at
                                    22
                                           nurses,  as  well.
                                    23
                                                                   DR.  HIRSCHBOECK:    We  were  just  augmenting  their
                                    24
                                           program.
                                    25
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                                                                                d
   hws-73                      MR. PETERSON:  But there had not been a very goo
               2
                   track record on the whole.
                               Wisconsin is the exception.
               41              Anybody seeming to get much money to  cost share
               5   or to continue funding these activities, once they are empty,,
               6   to pull its dollars out.
               7               I think that may be a reflection of-what is
               8   happening in Western New York.
               9               I don't know  but this is the  staff's  concern4
               10              This seems to have been part of the Western New
               11  York - Lakes area package of projects since  the  year  one.
               12              MR* BARROWS:  It has never been my impression
               13  that RMP was designed to provide continued operation of
                   service.
               14
               15              Here, you are asking for about one-third of a
                   million dollars for this network that is  seven  years  old,
                   and their tumor registry, that alone they are asking $200,000.
               17
               18              I would think once you establish whether  it  is
               19  going to fly or not fly on its own, that is the time for RMP
               20  to  get  out.
               21              MR. NASH:  I asked them for the tumor registry,,
               22  and they said they had funded it for three  years,  but  you
                   need at least five year support to gather enough data to make
               23
                   these things useful in feeding back information to physicians.
               24
                               MR. KLINE:  Can I comment on that?
               25
   HOOVElt REPORTING CO, INC.
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   hws-74                      MR. PETERSON:  Surely.
               2                                                      visit
                               Mr(. KLINE:  In 1971, December, a site
               3   strongly suggested that the program get out of that tumor
               4
                   service registry because it was not felt  at that  time  that
               5   it represented a very strong project.
               6               At the time the indication was that  it'had  been
               7   contracted  or planned for a five year effort.
               8               This plan as it now shows carries it into the
               9   fifth year  and on into the sixth year.
               10              I tend to have a little bit of concern about
               11  that.  The  other concern that I have about this  program  is
               12  that it doesn't look very, very much different  than  it  looked
               13  three years agoo which is kind o  amazing.
               14              This is sort of like a static program.  The rural
               15  program has been going on for three or  four  years.  The  tele-
               16  phone collection network, from the day  the  program  opened.
                   The tumor service registry almost from the  day  the  program
               18  opened.
               191             The two activities essentially are  there,  emer-
               20  gency medical service and their area  health  education  center,
               21  and the other activities they have are relatively.small and
               22  new.
                               I guess my primary concern is I looked at this
               23
                   with a tremendously huge staff, and they do have  a  very  large
               24
               25  staff,, and they do have some very excellent people  on  that
  H    PORTING CO, INC.
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  hws-75         I  staff.
                 2            The problem is they essentially haven't come up
                 11 witn a  roctram.
                 4            MR.  BARROWS:  They don't have the leadership.
                 5             I have concluded that the program  that wasn't
                 6  doing much probably wouldn't change, and the upper limits Of
                 7  my responsibility would certainly not warrant coming forward
                    withIA proposal that does much more.than continue their
                 8
                 9  present funding level, which would be about $1.4 million.
                 10            MR. PETERSON:  Let me add one thing regarding a
                    specific activity which Bert singled out as being one of the
                 11
                 12 few newer things, and that was the Lakes Area Health Education
                 13 Center.
                 14            Now, my information is roughly 18 months old, but
                 15 we did staff visit a large number of the health services
                    educational activities back in May, June and July of 1973.
                               The old one that I went on happened to be the
                 18 Lakes Area one, so I don't have any personal comparisons to
                    be able to make, but I do know in talking to people who were
                 19
                    on that site visit, and more importantly, the others who
                 20
                    would have been on a far broader range of site visits, that
                 21
                    was one at that point, one of the weakest ones4  They had
                 22
                    real problems with getting any kind of commitment,
                 23
                                This  asn't a matter  of domination.  They had what
                 24
                    was admittedly an extremely difficult, nasty situation in
                 25
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  hws-76       1    Erie, Pennsylvania where you have two hospitals jockeying
               2@   for some sort of number one position, the medical staffs,, the
               3;   physicians in the community being staffed sort of, you know,
               4    their appointments with one or the other, and at that point
               5    was one of the weaker looking ones, and I don't know whether
               6    we have any later information, and it wasn't in the prog-
               7    nosis for good progress, and was not all that good in the
   (5)         8    health educational center.
               9               MR. NASH:  They still have the same Project Direc-
               10   tor for this.
               11              MR. KLINE:  Pete is commenting on the Erie,
                    Pennsylvania Health Education Center.
               12
                               I visited five emergency health service projects
               13
               14   last year.
               15              Of the five we visited, 1 tended to suspect that
                    it probably ranked at the top so probably offsetting the
                    possible deficiency in the health activity, their  medical
               17
                    service activities were performing very highly.
                               DR. HEOSTIS:  I wanted to ask Mr. Barrows if he
               19
               20   would accept a slight amendment to his thought of financing
                    at the current level -- that is financing it at the   current
               21
                    level less or a deletion of all of the money for project
               22
                    that have already been financed for three years, less a
               23
                    deletion of one-half of All the money that is requ6sted for
               24
                    the two year projects.
               25
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  hws-77                     Staff is going to have to helD  figure  that  arith-
               2i metic out.
               3             MR. BAR-ROWS:  That would be suitable to me, pro-
  0
               4  viding the net answer isn't more than they got last year.
               5             DR. HEUSTIS: It would  be  substantially  less  than
               6  they got last year.
                             We should probably indicate on that, that our
               8  Committee is dissatisfied, or  expressed  soma  dissatisfaction
               9  with the way the program has developed.
              10             DR. HESS: I do not think you  can  be  that  strong.
                             You can give strong advice, but  you  cannot  delete
              12  line items, can you?
              13             MR. NASH:  The only thing we can do is give them
              14  X number of dollars and advise that they  then  rechooso  these
              15  things in the seventh year.
              16             DR. HEUSTIS:  I am not deleting the project.  I
                  am deleting the money for the project.
              17
              is             MR. PETERSON:  We are not arriving at a figure.
              19             DR. TESCHAN:  That is your 3ntent, but the net
              20  effect is a bundle of money.
              21             DR. HESS:  Rearrange it any way yo.u want.
              22             MR. PETERSON:  I think what we have heard reflects,
                  in part, the concern that the staff has  whatever  the  figure,
              23
                  assuming Council goes along.with this, because  this  is  their
              24
                  policy, pointing out and taking notes of it, and the fact that
              25
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                                                                           4o4    I
                                                                                  I
     hws-78       several of their activities are well beyond that point and      1
              2   that they ought to be governed, hopefully, accordingly without,
              3;!l in effect, saying you can't do it, but they are.
              41              Whatever figure, if we are talking at  the  present
              5   level, or something less than that, this request as I loo
              6   at it totals roughly $2.3 million.
              7               If they get a significantly less amount  than  what
              8   they have requested then it seems to-me they are going to
              9   have to make some hard decisions.
              10              MR. BARROWS:  Let me see if I understand this.
              11              If my arithmetic is right, we would come out not
              12  too far apart on this.
              13              There is $200,000 for registry, $154  for  electra-
                  network.  Those would be out, and half of this remaining
              14
              15  $150,000, another $75,000, knocking those out would reduce
                  this thing by $225,000.
              16
              17              They are asking for $2 million.
              18              DR. HEUSTIS:  My statement was their present level
              19  of   funding.
              20              MR. BARROWS:  Excuse me.
              21              DR. HEUSTIS: I propose to knock  the  $225,000  out
                  from the $1.4 million.
              22
                              MR. BARROWS:  That might be a little severe.
              23
                              DR. HEUSTIS:  Do
                                               you understand the process?
              24
                              DR. HESS:  That takes it down to $1 million.
              25
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  hws-79                     DR. HEUSTIS: The process is we do  not  provide
              211 money for projects we have already financed for at,least
               li                                                               1
              3!
                i three years, second, the report shows that they have  been
              4   advised on at least one of these that they had some advice
              5   back in 1972.
              6              The other is that we provide only half the  money
              7   necessary for any -- that is half of the money requested for
              8   anything that they have requested for two years, which really
              9   doesn't do a very great disservice to the remainder of the
              10  program.
              11             DR. TESCHAN: I don't like that. It  crea  es  a
              12  problem.
              13             You are,handling it in a way that riles everybody.
              14             DR* HEUSTIS: I make a motion to bring this  to  a
              15  head, that we say that staff has to do some arithmetic,
              16  because I cAn't come up with the figure, but $1.4  million
              17  less the other two items.
              is             MR. BARROWS:  Let's round it off to $1 million.
              19             MR. NASH:  What figure are you using as their
              20  current funding level?
              21             Apparently we have two different figures  here.
                             MR. BARROWS:  1 wag using the one on this  sheet,
              22
              23  the current and the annualized.
              24             DR..HEUSTIS: We rounded it off to  $1.4  million,
                  and we started to subtract from $1.4 million.
              25
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                                                                            4o6
  hws-80                       MR. NASH: The sheet I  have  shows  $1.81  million
               2   current, and the annualized level.
               311             MR. PETERSON:  We are really in great shape.  We
               4   have two sheets that have separate figures.
               5               MR. NASH:  Mine is dated May 20.
               6               MR. PETERSON: What is  the  correct  figure,  $1.4
               7   million?
               8               MRS. WILSON:  Yes.
               9               MR. PETERSON:  It seems to me with having done
               10  some hurried arithmetic, if we were singling telephone,
              .11  tumor registry as having gone beyond the three years, having
               12  those three other small projects that were asked for two
               13  year support, that rough analysis is  about  $400,000,  and  I
               14  think that is what you are talking about.
               15              DR. THURMAN:  It is $1.370 million minus $354,000
               16  minus $65,000, which is $419,000, so  $1  million  takes  care
                   of your recommendation.
               17
               18              MR. PETERSON:  You would make that as a recommends-,
                   tion?
               19
               20              DR. HEUSTIS:  I accept your arithmetic*
                               MR. PETERSON:  I take comfort from the fact that
               21
                   Bill Thurman agrees with me.
               22
                               DR. HEUSTIS:  He was agreeing with me.
               23
                               MR. PETERSON:  l.was not at odds with someone
               24
                   elsels number.
               25
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                                                                         407
  hws-81       I              Is there a second?
               2              DR. TESCHAN:  I second.
               311            MR. PETERSON:  Any additional discussion?
               4              I would just point out that we do have an estimate
               5  that roughly a $500,000 plus application would be coming in,
               6  in the July cycle.
               7              If there is no further discussion or question,
               8  those in favor raise your hands.
               9              (Showing of hands.)
              10              MR. PETERSON:  Those opposed raise your hands.
              11              (Showing of one hand.)
              12,             MR. PETERSON:  We have a seven to  one vote.
              13              Before we dip into the next application, could I
              14  ask a question of the group, because I have been handed a
              15  note asking me what time will be good for us to reconvene
              16  with Panel A tomorrow as a single group, and I am Assuming
              17  that if we are going to allow ourselves a little time to review
              18  our own actions, that whatever time I tell them we will need
              19  to allow ourselves a half hour in advance.
              20              Is the group willing to get together at 8:30
                  tomorrow?
              21
              22              If that is satisfactory I will do that.
                              Now,, we have four Regions.  I am going to try to
              2tl
                  get away so some of you who.have been reviewing more  than others
              24
                  here at this particular point in time I wonder, Sister Ann,
              25
           co, INC@ would you be ready to takea look at Maryland?
           enue,   N.[.
    ngton, D.C. 20002

                                                                            4o8
    hws-82     1                  HEW REGTONAL MEDICAL PROGRAM FOR
               2                       THE STATE OF MARYLAND
               3:              MR. PETERSON:  Now, here again I think the staff
               4    person involved, Frank and Gene Nelson, need to be pcepared
               5    to supplement this.
               6               We have the free State of Maryland.  It was seoar-
               7    ately set up from the beginning.
               8               MR. SIMONS:  Hopkins is a grantee.
               9               SISTER JOSEPHINE:  Johns Hopkins is the grantee
               10   agency in Maryland, and one of the  criticisms  of  the  ongoing
               11   criticisms of the Maryland program has been its very close
               12   affiliation with Johns Hopkins University.
               13              The program leadership  is  relatively  poor.  I  get
                    the impression, and these are just impressions at this point,,
               ]@4
               15   but I do get the impression that the strength of the Maryland
               16   medical program has been to kind of maintain a broker image
                    in the area, and to use regional medical program funds to
               17
               18   just give to other agencies so they could carry out their
                    work, and I think they describe this  type  of  available  money
               19
                        . .-contracts.
                    as mini
               20
                               When we were there about three or four   years   ago,
               21
                    I remember there was a question raised by the site visit
               22
                    committee', whether or not this was a good way for them to
               23
                    proceed, and after it was discussed with  the  group,  the  con-
               24
                    sensus was that this practice should, if not be eliminated
               25
        PORTING CO, INC.
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  ih*- 8 3        be modified.  But I notice it is still being carried out.
               2             The program staff is satisfactory.  However, they
               3i! draw very heavily on staff from affiliated programs, partic-
               4
                  ularly of the other universities, and that is not altiays bad.
               5             The Regional Advisory Group looked, on paper, to
               6  be adequate, but I would have to ask the staff person working
               7  with the program whether they are really aware of what is
               8  going on in the program, or whether they simply go along
               9  with programs that are outlined.
               10            Past performance and accomplishments have been
               11 satisfactory to poor.
               12            It was difficult for me as I looked through this
               13 program  to identify, to really identify a program that was the
               14 program  of Maryland rather than the program that is going on
               15 in other institutions without close coordination from their
               16 Regional Medical Program.
               17            The objectives and priorities are satisfactory
               18 as they are stated.
               19            The proposal is inadequate in many ways.
                             Featibility is checked inadequate, and the CHP
               20
               21 relationships in the written document appear to be good.
               22            The overall assessment I gave the program is  e ow
                  average  but I am simply going on the material that was here
               23
                  in the book.
               24
               25            MR* BARROWS:  Let me ask a question, as I don't
           CO, INC.
            ue, N.L
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                                                                           i)lo
    hws-84         know the area that well.
                2
                               In Maryland can you get very far without being
                3
                   pretty closely identified with Johns Hopkins?
                4              MR. NASH: Either that or the  University  of  Mary-
                   land.
                6              SISTER JOSEPHINE:  It may be there is no other way
                7  to go about it.
                8              DR. TESCHAN:  Where is the element of limitation
                9
                   you are implying?
              10               SISTER JOSEPHINE:  I think I am probably reading
                   that into the proposal from the impression I had  on  the  site
              12   V'
                    isit, where it was very difficult to sit down with the staff
              13   and to have them, you know, really identify a program and tal
              14   about a program.
              15               The ones who could really do it effectively were
              I(;  those who were carrying on the program.  It  was  usually  from
              17   one of the universities, and it was always someone from Johns
              18   Hopkins.
              19               I would be interested, and I may be over reacting,,
              20   but I would like to have the person who works  on  the  program
              21   reflect on that.
              22               MR. NASH:  Unfortunately, the person who has  worked
                   on this program for the last three years now has other employ-
              23
                   ment.
              24
              25               That person is not here, and I think one of the
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                                                                              411
   hws-85      1    things that has been pretty typical of this program in     the
               2    past, the observation of site visitors  and  people  who  study
               31   the Region is that this particular  program  has  never  really
               4    taken a good look at the needs, and then  made  an  effort  to
               5    develop a program within the State  that  would  help  overcome
               6    those needs; that the projects and activities they have
               7    engaged in appear to be opportunistic.
               8               Somebody comes up with an idea,  and  they  say  let
               9    us fund it. That has been one  of  the  major  complaints  about
               10   this region in the past, and to a certain extent it may still
               11   be true.
               12              MR. NELSON:  I might say my identification was
               13   about two weeks, and I am no authority.
               14              Basically, I made some  notes  saying  in  reviewing
                    that they were criticized in the past  for  three  major  things
               15
                       failure to Acquire sufficient staff to do the job, depend-
                    ency'to concentrate in Baltimore, and  I  mean  Baltimore  City,
               17
                    and a tendency to keep the program to themselves.
               18
                               It seems to me we are looking  at  a  different  pro-
               19
                    gram this year, and, in fact, whereas  they  had  22  projects
               20
               21   last year, a great number of w YLch were in Baltimore and
                    environs, we are now talking in terms of, let  me  see  --  let
               22
                    us talk about these three concerns, and first failure to
               23
                    provide sufficient staff.
               24
                               They have, in fact, as a result of Advice letters,
               25
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                                                                            412
    hws-86      1   moved from 4.5 people to nine people in this application.
                2              This is something that they have been constantly
                3   prodded to do.
                4              The second concern is concentration in Baltimore.
                5   They have five projects.  One provides planning and services
                6   in Ocean City.  This is planning for health services in the
                7   Ocean City area.
                8              One is a CHP Planning Seminar  for Consumer Orien-
                9   tation  throughout the State of Maryland.
                10             They are requesting $25,000 to, in fact, un(er-
                11  write orientation of consumers to the CHP Plan.
                               DR. TESCHAN:  Is that the Health Plan for Maryland  ?
                12
                13             MR. PETERSON:  Except for the title.
                14             MR. NELSON:  I think it is quire indicative of
                15  the good relationships between RMP and CHP.
                               I might add that I talked to Eugene Gunthries,
                17  who was former Director of Chronic Diseases, Public Health      I
                    Services.  Ho just left under questionably circumstances two
                18
                    or three weeks ago.
                19
                20             Up until that time the limited information I had
                    is that his successor is continuing with his concept, very
                21
                22  close cooperation between the two hospitals.
                               A third project, even though it is centered in
                23
                    Hopkins, involves care services for the poor in out atient
                                                                         p
                24
                    departments, correlating with Hopkins in the outpatient
                25
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   hwk-87          department.
               211             DR. THURMAN:  That is Number 056.
                               MR. NELSON:  The Manpower Planning and Data System,,
  lie
   0           4   mor,,, effective use"of manpower and related services in hospite1
               5   outpatient service department.
               6               We have a fourth program involving SAEA concepts,
               -1  30 health education agencies.
               8               DR. TESCHAN:  Which one is that?
               9               DR. THURMAN:  That is 058.
               10              MR. PETERSON:  Those are the most undescriptive
               11  project  types.
                               DR. TESCHAN:  Let us come back to that.
               12
               13              MR. NELSON:  The third concern, the makeup of  the
               14  RAG now shows involvement of an amount, a large number o
                   consumer groups, and groups representing.@ the poor,, and  so
               15
                   forth, so I think the program has turned itself around.
                               The percentage of increase in staff  would be  9
               17
               18  percent.
               19              As to projects they have $760,000, a little less
               20  than half of which is for projects, a little more than half
               21  of which is for programs.
                               DR. TESCHAN:  Another $442,000 due in July.
               22
                               MR. PETERSON:  Well, we have requests here,   as
               23
                   Sister Ann indicated, for $762,000 or $763,000, if  ou   round
                                                                        y
               24
                   it off upwards, which is slightly above  what their op   ating
               25
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                i                                                       414
  h b-88          level is now.
              21             They have indicated they will be  coming  in  in  July
              3 !I
                  for about $400,000.
              4
                             DR. THURMAN:  Could I ask a question?
              5              MR. PETERSON:  Surely.
              6              DR. THURMAN: On @e total program  staff  they  have
              7   a figure of $144,000 under "other."
              8              Do we have any idea what that is?
              9              Is that beyond salaries and wages?  They have a
              10  total of the other category.
              11             MR. NELSON: $125,000 requested for  contracts  and
              12  studies.
              13             DR. THURMAN: Then Maryland has not changed  in  the
              14  $125,000 plus the $57,000 listed under 058 which goes  to
              15  Johns Hopkins Computer Center, which has always been  the
              i(i biggest argument we have always had about Maryland, so it  has
              17  not changed.
              18             MR. BARROWS: It sounds like a program with  a  lot
              19  of paper shuffling to me.
              20             DR. HESS: An indirect measure of  RMP  impact.
              21,            Last month I was at Hopkin,s on a site visit for
                  another program which is supposed to have an outreach  compon-
              22
              23  ent, and it was evident from the level of thinking on that-
              24  proposal that for this, this had a lot to do with the  school
                  of public health among other things, but RMP's had little  or
              25
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  hws 99       1   no impact on the thinking of those people, and  they  did  not
               2   know really how to go about, you know,  needs  assessment  and
               3,  this whole ball game, and effective RMP would be educating
               4   somebody about it.
               5               I rather mused to,my8elf that this seemed to be
               6   further evidence of a rather weak RMP.
               7               DR. TESCHAN:  It didn't occur to the Project
               8   Director to ask to get the project data.,
               9               DR. HESS: Neither were RMP's  mentioned  once,  and
                   the people  didn't seem to know how to do it.
               10
                               This was really a very  self-serving  application,
               11
               12  as I viewed it, self-serving to Hopkins,  but  not  necessarily
               13  to the community and the State at large, which it was supposed
               14  to be.
                               SISTER JOSEPHINE: I got the  impression  the  com-
               15
               16  munity at large doesn't really know what the RMP  is,  and  the
               17  Program Director really has funds that he gives  out  to  other
                   agencies, and the people in the agencies are the receivers
               18
                   of the service, and really aren't aware where the money comes
               19
                   from.
               20
                               DR. TESCHAN: It seems to me we  have  an  inactive
               21
                   RAG in terms of directing it, an inactive coordinator as
               22
                   defined here, and we have a  self-serving  unconcerned  grantee
               23
                   in terms of the principles of the program.
               24
                               If I remember the basic notion of the essential
               25
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                                                                       Li 16
  hws-90       1  ingredients of an RMP as defined in the August 1972 policy,
               21, those are the three essential ingredients so that if we don'ti
               3@@ have the essential ingredients it says we don't have an RMP.
               4             Why isn't a motioii in order to discontinue Mary-
               5  land?
               6             DR. HEUSTIS:  Make a motion, and I will support
               7  it.
               8             DR. TESCHAN:  I so make it.
               9             MR. BARROWS:  I don't share your Abrupt change at
               10 this time.
               11            In support of what you said, there is a fourth
               12. striking deficit in this, and that is the end product is
               13 useless.
               14            I don't care if they give it to this guy or that
               15 guy if they are coming out with something that is beneficial.
                             There are a lot of play things for the computer
                  people, so I would say in addition to these other weaknesses
               17
               18, their end product is not impressive.
               19            DR. TESCHAN: There are four important  reasons
               20 not to spend the money.
               21            MR. BARROWS: But you get the other point,  the
               22 reason, and that is for the Council.
                             I don't think it would be appropriate  or us to
               23
               24 make recommendations, but yesterday we pretty well agreed you
                  are not going to get a leopard to change its spots this late
               25
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                                                                        417
     hws-91        in the day, that we are not going to create any great changes
               2i
                   in any of these programs in their remaining life scope.
                              I think probably in order to avoid capriciousne-bz$
               4   we better continue the policy basically of the past without
               5   any wild swings up or down.  That would be my conclusion.
               6              DR. HETSTIS:  We have here, for the first time,,
               7   that has been spelled out the three things, and the one you
               8   added, and it would teem as thougl) quite a part of our func-
               9   tion was to make a recommendation to the RAG according to the
               10  motion that hat been duly made, and supported, and I would
               11  like to see those four items put in the motion so we dot't
               12, lose them somewhere and let the Council see what we think
               13  about this overall situation.
               14             MR. BARROWS:  I will buy that.
               15             DR. HEUSTIS.:  The motion you say that You would
                   now buy is to give them no money, and that was my intent, and
               17  see what happens, because probably there isn't anything that
               18  could have a better influence upon the whole IRD structure
               19  fok someone to stand up and take the bat and swing it.
                              MR. BARROWS:  Let me ask you a question.
               20
               21             We have been told by legal, who has wiser And
               22  finer minds than ours, that part of our job now is to prepare
                   for this transition to a new type of combined agency, and
               23
                   what the impact of ending one right at this time instead of
               24.
                   retaining a leap year fund upon which to build
               25
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     hws-92    1              DR. HEUSTIS: If you will pardon  me,  the  egg  that
               21  is rocking in &the box doesn't do much good to keep it  in  the
               3.. refrigerator.
               4              DR. TESCHAN:  I feel that the new planning corpor-
               5   ation is going to need a widely based representative operation
               6   with clout, that the worst place to start from would be one
               7   of these, and that we do the entire process of representatives
               8   of health planning a greater service by getting rid of
               9   grantee.
                              MR. BARROWS:  Right now  you have reason in there
              10
              ,l  that I can buy that this future entity will be A lot better
              12.  off by starting from scratch than it will be  trying  to  build
              13   on some pretty weak foundation.
                              DR. TESCHAN:  Especially when you have all the
              14
              15   years of badgering.
                              Now, Hopkins and company have to learn,  in  my  own
              17   view, it is long since time that somebody got somebbdy's
                   attention.
              18
              19              I know some of the people who-are involved in this,
                   and they have been disastrous in other places they have
              20
                   attempted to manage.
              21
                              MR. PETERSON:  Let me see if I have a sense of what
              22
                   1 hear the Review Panel saying in effect is it  would  like  to
              23
                   propose to the Council in effect that the Council give serious
              2,4
                   consideration to terminating or phasing out, I think we might,
              25
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  hws-923       1  you know, whether it would come to  an end June 30, the Council
                2,1 doesn't meet until June 14 and 15, so I think really the
                   termination or phaseout would entail some money based upon
                4  a conclusion by this group that what we have here is a largel@
                5  inactive,, ineffective RAG.
                6             I had written down, and I don't think you had used
                7  the word, and I am searching for a word --. a  coordinator  who
                8  is ineffective, a grantee that has been self-serving in the
                9  sense that it has managed to use the program for  some  of  its
                10 own interests for a long period of time, and this  is  a  situ-
                11 ation of longstanding, where there is really  little,  if  any-
                121 thing, to show in the way of accomplishments, any output.
                13            MR. BARROWS:  The end product is the thing t at
                   impresses me.
                14
                15            You don't have anything coming out with these
                   bucks.
                16
                              MR. PETERSON:  Is that the sense?
                17
                              DR. HEUSTIS: If you would not  object  to  the  word
                18
                   termination, and we have a full idea that the Council being
                19
                   a reasonable body will probably give them some  time  to  phase
                20
                   out if they accept the sense of the motion.
                21,
                              MR. PETERSON:  I was trying to summarize what I
                22
                   heard said, not necessarily putting my views on the table, and
                23
                241 I certainly would like to hear some response from Sister
                   Josephine, who did review the application,  and  you  conducted
                125
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    hws-94                     the  site visit.
                        211'                     SISTER JOSEPHINE:   I would agree w                      ith  this.
                        3i!                      The question  I would raisc  at this point is  to
                        4      phase this        program out.
                        5                        How much of this  $684,000  do they have?
                        6                        MR.  PETERSON:   Current?
                        7                        Gentlemen,  do we have  any idea of what Maryland
                        8      may have  in an unobligated balance  come June  30?
                        9                        They have been operating at  a fairly modest level.
                        10     I  suspect their balance  is not  likely to be large,  Sister.
                        11                       SISTER JOSEPHINE:   You see,  that would maintain
                        12.    staff during the phasing out period.
                        13                       DR.  HEUSTIS:   There  is nothing to preclude the
                               Council from putting in whatever money is necessary to do
                        14
                        15     whatever they want.
                                                 SISTER JOSEPHINE:   Yes,  and between now and July
                               we might have  some  communications.
                        17
                        18                       DR.  IIEUSTIS:   I hope this  is  the whole purpose of
                        19     the arrangement.
                        20                       DR.  THURMAN:   I move the question.
                        21                       DR* HESS:   Just speaking  for myself,  I  am not
                               prepared to vote on that at this point.
                        22
                        23                       I would like  some time to study this  application.
                        24                       This is,  I think.,  the most drastic recommendation
                               that we have considered today.
                        25
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  hws-95        1              DR. THURMAN:  We made this recommendation   twice
                2  before,, though.
                3              DR. HESS:  Termination?
                4              DR. THURMAN:  Yes.
                5              DR. HESS:  I don't remember that we have.
                6              SISTER JOSEPHINE:  This was conside
                7              1 think when this was reviewed these same questions
                8  came up..  But I think this was reviewed the same way the
                9  same questions,  that is this morning.
              10               DR. THURMAN:  The Sister is very charitable.  The
              11   person who reversed us the last time was the Council.
              12,              DR. HEUSTIS:  It is Council's responsibility to
              13   do what they think.
              14               MR. BARROWS:  I think we ought to do the honest
              15   thing and Pass the buck.
              i(i              MR. PETERSON:  We do have a motion,
              17               Rod Merker recently, I understood from Frank,
              18   that he recently -- well, I don't know if that is within the
                   past six months or past two weeks, had made a management
              19
              20   assessment visit to the Maryland RMP.
              21               MR. MERKER:  It wasn't recent.  It was two years
              22   ago, and I  think you have a good acceptance of what I found
              23   two years ago.
              24               I found no overt domination by the medical school,
                   but a lack of leadership on the part of the Advisory Group,
              25
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  hws-96        I  which enabled the medical school to get what it needed from
                2  the grant, and I think you all know there was a large
                311 epidemiological body or school supported  in  the  school  for i
                4  four years.
                5              DR. HEOSTIS: Mr. Chairman, the  question  was  calle(
                6  for, as I recall it.
                7              You remind me of an Episcopal Bishop,  Pardon the
                8  pun,  Sister.
                9              MR. PETERSON:  The question has been called.
                10             I will make.a specific point because  we  will  be
                11 getting together tomorrow, and you will have  a  chance  to  look
                12 at an application.
                13             Some of these people will have slept upon what I
                14 understand  to be the motion.  There is no reason that we
                   could not,  if you and others see fit, make the motion tomorrow
                15
                   that would, in effect, modify or remove this item, but given
                   the motion to recommend to Council  the  termination  of  this
                17
                18 program within a reasonable period of  time  with  such  funds
                19 as may be considered, and we  don't  know  the  carryover  situa-
                   tion for the reasons indicated which  I  tried  to  summarize.
                20
                               DR. HEUSTIS: Did you say this  has  been  done  twice
                21
                   before?
                22
                               DR. THURMAN:  Once before we asked for a site
                23
                   visit, because the point he just made  that  we  were  supporting
                24
                   an epidemiological study.
                25
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     hws-97    1              DR. HEUSTIS:  Have we ever recommended to Council?
               2              DR. THURMAN:  It was recommended t o Council that
               3   consi
                        deration be given to terminate the Regional Program.
               4              DR. HEUSTIS:  Would you object to an editorial
               5   change to the motion that we repeat the motion that was made
               6   by whatever it was, the previous Review Committee, that this
               7   be terminated?
                              I think this gives further emphasis to it.
               8
               9              DR. THURMAN:  The only thing I would have to say
              10   to it is that it was recommended to Council that it be con-
              11   sidered for termination, and Council voted to keep them going.
                              DR. TE8CHAN:  Put something in there like a conna
              12
                   and then quote in view of the past recommendations
              13
              14              MR. PETERSON:  I am not sure I have that.
              15              Well, the question has been called for about ten
                   minutes ago.
                              Those in favor raise your hands.
              17
              18              (Showing of hands.)
                              MR. PETERSON:  Those opposed raise your hands4
                              (Showing of one hand.)
              20
                              MR. PETERSON:  There is just one opposed, and the
              21
                   motion is carried.
              22
                              MR. BARROWS:  Pete, may I ask one thing?
              23
                              MR. PETERSON:  Surely.
              24
                              MR. BARROWS:  In this message that we transmit to
              25
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                                                                           4p- 4
  hws 98         1  the Council, do you contemplate including the fact that we
                 2  faced up to the impact on the upcoming legislation, and came
                 3@@ squarely to the conclusion that we would be better off start-ii
                 4  ing from scratch?
                 5             MR. PETERSON: What exists is there  is  not  a  re-
                 6  source for HRP, or anything else that might come down the
                 7  pike.
                 8             This is just my praseology of what I heard.
                 9             MR. BARROWS: I thought we said  it  would  be  more
                 10 harmful to have them around than to start from scratch,
                 11            MR. NASH:  If it is to be a State Health Plan
                    organization, it is highly unlikely to be the agency.
                 12,
                 13            DR. TESCHAN:  I think it is arrogant.  I keep
                 14 hoping that our encouragement to a transisti6n stance will
                 15 allow them to tidy up their relationships so at least they
                 iti are in the running.
                               The alternative is to lose what is there, and the
                 17
                    health field hardly can afford to lose any more  than  it  has
                 18
                 19 already lost.
                               MR. BARROWS:  I am not quarreling with you.
                 20
                               MR. PETERSON: Okay, we  have  three  Regions  left,
                 21
                    Metropolitan District of Columbia, Nassau-Suffolk, and
                 22
                    Susquehanna Valley.
                 23
                 2A
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     hws-99                                                         HEW  REGIONAL  MEDICAL  PLAN  FOR  THE
                                2                                                  DISTRICT  OF  COLUMBIA
                                3ii                           MR.  PETERSON:     I  wonder  now  if  we  could  turn  to
                                4      a  sister  jurisdiction  of  Maryland,  namely  the  District  of
                                5      Columbia,  or  the  metropolitan  District  of  Columbia  RMP,  and
                                6      Joe,  if  you  would  lead  off  on  that.
                                7                             DR.  HESS:    The  Metropolitan.Washington  RMP  is
                                8      one  that  I  know  from  past  reviews  that  has  been  of  some  con-
                                9      cern.
                                10                            It  is,  however,  in  a  ttiannium  status.
                                                              The  grantee  is  the  Medical  Society  of  the  District
                                       of  Columbia.
                                12,
                                13                            The  Coordinator  is  new  since  I  remember  the  last
                                14     review  of           this  Region.
                                15                            Their  broad              goals  Are  to  provide  assistance  to
                                16     CHP's  in  developing  plans,  and  incidentally,  within  the  last
                                17     few  months  the  CHP  has  been  organized  in  Washington.
                                18                            A  second  goal  is  to  increase  availability  and
                                       access  to  primary  care  services,  and  to  improve  along  with  that
                                19
                                20     possibly  the  hospital  care,   and  a  third  one  is  to  regional-
                                21     ization  of  experience  and  secondary  and  tertiary  health  care
                                       resources,
                                2ix
                                                              The  letter  of  submission  which  is  signed  by@the
                                23
                                       Chairman  of  the  Regional  Advisory  Committee  is  quitd  enthusi-
                                24
                                       astic,  and  I  would  like  to  read  some  sections  from  that.
                                25
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                                                                           426
  hws-100        1            This is written by Dr. John A.  Kenney,  Jr.,  Medica'
                 2 Doctor, Chairman, Metropolitan Washington Regional Advisory
                 31 Council.  He says , and I quote:
                 4             "First I would like to address the past perform-
                 5       ance of MWRMP.  I have had the privilege of serving on
                 6       the RAC since the inception of  MWRMP.  From  this  vantage
                 7       point, and from my faculty position at Howard University,
                 8       I have been greatly impressed by  the  significant  contri-
                 9       bution MWRMP has made by improving  the  accessibility  and
                 10      quality of care of the underserved  areas  and  populations
                 11      in the metropolitan region.
                 12              "Certainly the activities with which I am most
                 13      familiar are those at Howard  and  Freedmen's.  Houever,  I
                 14      W'll cite several of the most noteworthy projects:
                 15            "Howard's Cancer Radiotherapy project provides
                         the seed funds that have assisted in developing one of the
                         highest quality cancer treatment centers on the East
                 17
                 18      Coast.
                 19            "Freedmen's Stroke Project has demonstrated that
                 20      the mortality rate and the cost of quality care can be
                 21      greatly reduced.
                 22             'The Kidney Project (Howard, Georgetown, George
                 23      Washington, D. C. General and Arlington) has demonstrated
                         that the three medical. schools can cooperate And further
                 24
                 25      involve D. C. General and a suburban hospital in t e
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  hws-1         1        implementation of a coordinated regionwide attack on
                2        kidney disease.  This project is moving.   Alrea    one
                3        facility has indicated that they need no additional
                4        funds.  It appears that all facilities now participating
                @5       will be self-supporting by July 1, 1975,  thereby  per-
                6        mitting any new funds to be used for expansion  or  new
                7        locations.
                8              forecently initiated activities include the EMS
                9        regionwide planning contract, a nurse midwifery pro]ect in
                10       the inner city, and expansion of hypertension control.
                11             "Several other significant projects include:
                12             "Coronary care nursing training - Howard.
                13             "Cancer Registry - Department of Human Resources.
                14             "Inhalation Therapy   Washington Technical Insti-
                         tute.
                               "Pediatric Pulmonary    Georgetown and Children's
                         Hospitals.
                17
                18             "Second, I would like to  comment on the  current
                19       viability of the Program.  The  RAC is enthusiastic and
                20       active.  Even with the on and off directions of the
                21.      past 15 months the RAC and its Committees have  een
                         active in promoting the principles of RMP'S.
                22
                               "In the past three years the  RAC  has  developed
                23
                         into an "action" group.  In the first few years of MWRMP
                24
                         the RAC reacted to proposals that were submitted.'  In
                25
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  -iws 2               developing the last applications the RAC  has  appraised
               21.
                       the needs and acted to allocate 'blocks' of funds to
               3ii
                       help meet these needs through requests for  roposals
                                                                  p
               4       and subsequent contracts. The  current  application  has
               5       again been developed within this concept."
               6             From that, you can get a flavor of the view of
               7  the Chairman of the Advisory Committee.
               8             Just as one issue in the composition of the   RAC,
               9  which is comprised of 73 members, 15 of these are minority
               10 members.  They have a current professional staff of eight,
               11 and they want to increase this.
               12            Now, I may have, myself, misinterpreted these
               13 white sheets. Apparently they propose to add  nine,  if  that
               14 is  correct.
               15            I thought this was an increase from eight to nine.
               16            MR. PETERSON:  I am not sure.  I would have to ask
               17 staff.
               18            In most instances I think the proposed was  a  new
               19 total, but in some instances -  well, I think this  again  is
                  a total.  They are simply proposing to increase the staff
               20
               21 from t6n to 134
                             DR..HESS: Well, in terms  of  the  accomplishments
               22
                  they have establishe d several primary care clinics, and have
               23
                  been working on improving specialized services in the area of
               24
                  heart disease, coronary care, hypertension, patient education,
               25
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                                                                           429
  hws-3       1    and obstetrical care.
              2               In the area of quality of care  they have initiated
              3'i  projects on review, utilization review, a  Regional Cancer
              4    Registry, a Stroke Station, Cardiovascular follow  up  and  a
              5    bacteriological screening project at G6orgetown.
              6               Projects which they cite as increasing efficiency
              7    and utilization include their cancer, heart disease structure,
              8    high blood pressure, and kidney project.
                              They have a fairly good record of jo int   funding
              9
              10   and phasing into other funding.
                              Ten of the 19 projects are  jointly  funding,  and
              12   seven have been phased out, seven of 19 phased  out  and  con-
              13   tinued under RMP funding.
              14              In terms of their CHP relationships  there  was  no
              15   active B agency in Washington until recently.
                              Their coordination seems to  be  satisfactory  with
              16
              17   the B agency in Maryland and Virginia.
                              There is some funding of B  agency  activities  in
              18
                   this proposal, and there is an agreement,  a  written  agree-
              19
                   ment in the application between  Metropolitan  Washington  RMP
              20
                   and the Washington B agency as to how they will work togethet.1
              21
                              It seems to be a fairly clear and well defined
              22
                   document.
              23
                              In terms of looking at the  program  priorities,  I
              24
                   think this is an indirect measure of where the influence,
              25
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     hws-4     I   that is, much of the major influence in the Metro Washington
               2   RMP is at the moment.
               3              The-number one priority is kidney activities.
               4   Howevdr, the amount of funding is not excessively large.  It
               5   is about one-tenth of the total.
               6              They are proposing $100,000 for kidney Activities
               7   out of the total program budget of $1.1 million.
               8              The second is nurse midwifery, $71,000.
               9              Next is primary care activities, $332,000.
               10             The next is health care for senior citizens,
                   $150,000.
               12             Next, hypertension for $150,000.
               13             Next, emergency medical care for $100,000.
               14             Next, chronic constrictive pumonary diseases,
                   $165,000.
               15
                              Assistance to CHP's is for $132,000.
                              Now, the largest single proposal is the one
               17
               18  relating to primary care of patients, $332,000.
               19             I thought it might be worthwhile just to discuss
               20  this proposal in a little detail so that you know what is
               21  involved in this rather major project.
               22             Their objective is to develop facilities at
                   hospitals to provide more high quality primary care to non-
               23
               24  urgent.patients who appear.at hospital emergency rooms.
                              The approach is to go to hospitals which have
               25
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    hws-5        I  emergency departments and to work with these hospitals to
                 2  determine the quality of urgent and non-urgent patients who
                 3.1 appear there, and develop a body of information which will
                 4  then allow these hospitals collectively to plan for better
                 5  primary care services to help take the  load  off  the  hospital
                 6  emergency rooms.
                 7             There are also in this budget  some  funds  for  some
                 8  facility reconstruction, as well  as  some  equipment  purchase,
                 9  so that it is more than just planning,  but  also  some  reorgan-
                 10 izational facilities, in order to be  better  prepared  to  take
                 11 care of the patients who appear at the emergency rooms for
                 12 primary care.
                 13            SISTER JOSEPHINE:  How many hospitals do they
                 14 have?
                 15            DR. HESS:  Three to five.  They want the best
                 IL@ alternative system.
                 17            MR. PETERSON: They are  D.  C.  General,  Freedmen  s,
                 18 maybe George Washington, Georgetown, and --  wells  is  that  it?
                 I!)           DR. HESS:  The hospitals are not listed here.
                 20            MR. PETERSON:  They said three to five, so there
                    may be a couple of others, too.
                 21
                 22            DR. HESS:  They don't list them in this synopsis
                 23 of their plan.
                 24            It was unclear, just  to further comment on the
                    project, it was unclear whether  the primary  care  project  will
                 25
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  llwb-6       I  need funding after the first year, or whether it  is  something
               2  that could be accomplished.
               31
                             It looked as though it was a  steady  reorganization
               41 and some revision of facilities, but I am just  assuming  that
               5  although it is not stated, that the hospitals, or some  of  the
               6  sources will pick up the cost after this first year.
               7             Looking at the overall project, program  proposa S,
               8  the medical schools are still quite heavily involved.
               9             There,is a project in here for something like
               10 $55,000 for health care for senior citizens,  which  indicates,
               11 in a short synopsis, no provision for continued support.
               12            It did appear to me like this was, to a large
               13 extent, direct services to senior citizens, showing an area
               14 of need, but not reflected in this description.
               15            What their thinking was, was about  future  funding
                  beyond the funding of RMP.
               17            This particular one was sponsored by TV&A in
                  Washington.
               18
                             Overall it seemed to me things were a little bit    1
               19
                  better than the last time 1 heard this program rev ew, but
               20
               21 still overall I could rate it no better than  average  program.
               22            The.thing that I found that offered some  hoDe  was
                  the fact that they are trying to address, and  apparently  have
               23
                  addressed in the past primary care in trying to  expand  these
               24
                  services to the underserved population of Washington, and I
               25
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                                                                              433
   hws-7       1    am sure they are considerable.
               2               I checked them.  I might say there was a farily
               .3 'I well developed and outlined review process, the Committee
               4    structure, and the staff structure, which appear to me to be
               5    satisfactory.
               6               MR. PETERSON:  Well, thank you, Dr. Hess,
               7               Joe, do you want to give your report?
               8               MR. de la PUENTE:  I found the program, in my
               9    opinion, and considering past experience, as better than
               10   average at this stage of the game.
                               I mentioned its priorities, you know, no  neces-
               12,  sarily one, two, three, four, five, and mentioned the reasons
               13   for these projects.
               14              Let me say that  the  projects  are  timely.  They
               15   are addressed to not only the present but the future needs
               16  in an area where there is a great deal of  need,  in  an  area
               17   where if health insurance comes through we are going to have
               18   a lot of expenditures.
               19              In the particular areas that  they  happen  to  be
               20   attending to, ergo, the elderly, and ergo, the needy, I was
                    impressed like you were in terms of the primary activity
               21
                    that because what they are going to do as far as the descrip-
               22
                    tion that I read is going to be an operational research and
               23
                    analysis in which they will consider all the present resource
               24
                    of personnel, equipment, floor space that is being utilized
               25
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  hws-8        1   right now to serve the groups that have to be served.
               2              Then they will follow this study in proceeding to
               31,1' alternative programs to these hospitals, and help serve these'
               4   populations.
                              I agree with you.  I think it is a one-shot invest-
               6   ment, but       going to be a worthwhile  investment  and  a
               7   system in which you get these different hospitals, Georgetown,
               8   George Washington, D. C. General, et cetera to decide, you
               9   know, what type of priorities they can attend  to,  or  what
               10  type of priorities they cannot attend to, and where the
               11  patients will go.
               12.            In addition to that, they are going to be helping
               13  and providing monies for working  with  the  planning  agencies
               14  which relate to this particular project.
               15             The other project I was  impressed  with,  and  this
               16  is Priority Number 4, is the one for senior citizens, because I
               17  at this point, since the senior citizens are  poor,,  and  they
               18  happen to have Medicare, they go to eitner the nursing homes
               19  if they are able, or to private facilities, or they are in and
               20  out, one admission after the iiext, and from what  I  read  the
               21@ visiting nurses would be providing care in the home, and also
                   they will have preventive programs in areas where theyare
               22
                   allowing the senior citizens in terms of making  sure  t  at
               23
                   emergency episodes do not occur,  and if the  emergency  epi
               24
               25  8odes do occur, that somebody will take care of them.
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       hws-9                   1                             I  think  this  program,  in  my  opinion,  will  save  an
                               2      awful  lot  of  money  for  the  District  of  Columbia  in  the  near
                               31
                                      future.
                               4                            DR.  HESS:    The  thing                    I  was  looking  for,  and  may  be
                               5      just  an  oversight  on  their  part,  but  I  hope  the@,are  thinking
                               6      about  it,  is  that  they  can  demonstrate  that  for  the  population
                               7      that  they  reduce  the  hospital  costs.,  that  what  seems  the
                               8      logical  outcome  of  that  is  to  go  to  sources  of  payment  and
                               9      say,,  look,  put  some  of  your  money  in  the  home  care,  and  not
                             10       so  much  in  the  hospital.    But  that  was  not  written  in.
                             11                             MR.  BARROWS:    That  is  always  under  consideration,
                             12,      and  I  Am not  too  optimistic  about  that.
                             13                             From what  you  fellows  have  said,  and  for what  it  is
                             14       worth,  it  sounds  to  me  as  if  these  people  are  tackling  some
     4p
                             15       monumental,,  very  real  problems,  and  the  amount  of  money  they
                             I(;      are  talking  about  is  relatively  small  for  what  they  are  trying
                             11       to  undertake.
                             18                             I  think  we  ought  to  resolve  any  doubt  in  their
                             19       favor.
                                                            MR.  PETERSON:    How  about  some  of  the  other  reviewers
                             20
                                      here?
                             21
                                                            DR.  HEUSTIS:    I  have  nothing  to  add.
                             22
                             23                             DR.  THURMAN:    Just  two                    .procedural  inquiries.
                             24                             The  $132,000  is  for  assisting  CHP.    Is  that  proper?
                                                            MR.  PETERSON:    It  is  something  which  we  in  out
                             25
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                                                                         43'0
    hws-10         instruction guidelines for applications, it was one of several
                2  areas that we were asking to assist with CHP planned develop-I
                3
                   ment.
                4             I cannot be sure from  looking at the computer prin
                5  out that that is what it is.
                6             We do have a case here, though.  I was unaware,
                7  Joe, and you corrected me properly, that there just has been
                8  an areawide B agency organized for the District.  They have
                9  long been without one, and the one in Northern Virginia, they
                10 never could resolve the Virginia-District-MAryland problem.
                11            There is probably a lot of catching up to do in
                12 one sense, and I think it wouldn't be considered inappropriate!
                13 in a policy sense.
                14            Whether the money could be effectively used is
                15 another question, which I cannot speak to.
                              If anything, we sort of pushed them in that direc-
                17 tion, at least as far as Mr. Bell i s concerned.  He is prob-
                18 ably looking over our shoulder.
                19            DR. THURMAN:  I support the need.
                20            My question was purely policy, and the other is
                21 policy also.
                              There are $80,000 here in kidney projects, all of
                22
                   which on July 1 are going to be funded from other sources.
                23
                1)4           Other than that I support it.
                              That is a policy question.
                25
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  II                          MR. de la PUENTE: As far as  the  kidney  project,
                2 if I could  speak- to that, as long as Georgetown is involved,
                31! and I feel confident that they are upqradinq in  the  total
                4 eastern complex, they have tissue typing, and they have some
                5 transplanting, and they are operating in the eastern complex,
                6 which is from Atlanta to Boston, and  which  they  interchange
                7 patients with the computer, and with tissue typing information
                8 oh the computer, which in my opinion helps.
                9             DR. THURMAN:  Don't misunderstand me.  All four
                10 of those can be paid for as of July 1 out  of  other  funds.
                11            I am not sure that it is proper, because  mine  is
                12, a procedure and I am all for  supporting  them  but  all  four
                13 of the things that are listed can be  supported  from  other
                14 funds as of July li this July 1.
                15            DR. TESCHAN:  Which other funds?
                              DRi THURMAN:  Medicare and the Kidney Dialysis.     I
                              MR. de la PUENTE:  They might well go into that
                17
                18 type of funding, but if we don't have this complex in which,
                19 for instance, they started deciding-how much  do  ae  charge
                20 for procurement for an organ, cadaver, how much is it going to
                21 cost to tissue type every patient  on  hemodialysis  waiting
                  for a transplant; start making all those  cost  values,  and
                22
                  they won't have as good a chance of  certifying  those  costs,
                23
                24 and some of the people will-have to pay for it.
                25            DR. THURMAN:  I was asking a policy question.  That
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   hws-12       I   is all.
                2              MR. PETERSON:  That sort of thing you might want
                3   to note,
                4              MR. BARROWO-:  Might I ask a question?
                5              MR. PETERSON:  Surely.
                6              MR. BARROWS:  I know that Medicare and Medicaid
                7   will be paying for reimbursement for services delievered.
                8              Do they also have funds for development costs?
                9              DR. TFIURMAIQ:  All of us are building in develop-
                10  ment  costs.
                11             We are being reimbursed for Medicare for organ
                12  procurement,, tissue typing and dialsysis right now, and we
                13  have the lousiest system in the country out there,
  ip            14             I was under the impression that none of these
                    types of programs were going to be funded, other than that
                    by July 1.
                17             DR. TESCHAN:  One of the projects is to reimburse
                    the institution for the procurement of unused kidneys.
                18                                                     1
                               You know, that is not, so far as I knov7, in the
                19
                    Medicare reimbursement.  You get reimbursed for the ones you
                20
                    use and transplant.
                21
                               One of the projects talks about reimbursing for
                22
                    the cost of the harvest of the unused.
                23
                               DR. HEUSTIS:  But isn't it built into the cost of
                1241
                    the ones you used?
                25
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  hwls-13                    You divide the total cost by the total number  of
              21@ patient days served, and that is it.
              3i
                             DR. THU@IAN: I didn't mean to get us  off  here.
              4              Let me say again I am in support of the two  re-
              5   viewers.
              6              DR. HEUSTIS:  Can we hear again where you rate
              7   this program in terms of average, above average, or below
              8   average, from the two reviewers?
              9              DR. HESS: The first time I read it I  checked  it
              10  in the above average.
              11             The next time I read it I went through and  looked
              12, a little more carefully, and I put it on a line between  the
              13  two, so in looking and thinking of its past history,  instead
              14  of being on a plateau, I think this program is on  an-upward
              15  curve, and because of that I am willing to extrapolate a
              I(; little bit and give them the benefit of the doubt based  on
              17  recent past performance.
              18             With that in mind I would like to propose a  level
                  of $1.1 million.   They are currentl  at  $1,756,000.  They
                                                      -Y
                  asked for $1.27 million.
              20
              21             As I look at their priority ranking and their
              22  programs there is onei the pulmonary diseases for  $65,000,
                  and assistance to CHP's of $132,000, it seems to me that  the
              2,3
                  CHP's @hould be able to stand on their own two feet now,  and
              24
              25  1 don't see why RMP should need to support that, to that
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   hws-14        1
                    tune.
                 1
                 2             That accounts for $200,000  right  there.  They  seem
                 3 l@i' to be moving in the right direction.
                 4             There is an area of substantial need,  and  so  forth
                 5  Mr. Chairman.
                 6             I would make that as a motion.
                 7             DR. HEUSTIS:  This is the full yearly HEW pro-
                 8  rated amount,, your $1.1 million?  It is 100 percent of the
                 9  targeted available funds now in Column C?
                 10            You see, what I was getting at in my other ques-
                 11 tion was they are  going  to ask between this application and
                 12 the next application  for  a50 percent increase over their
                 13 money that they  have  right now.
                 14            DR.  HESS:   They are going to ask for another
                 15 $500,000.
                               DR. IIEUSTIS:  Or a total of $1.7 million, and the i
                 17 targeted allocation is $1.1 million.
                 18            If we give them more, then we have to  take  it  away
                    from somebody else.
                 2.0           DR. HESS:  I don't think  we need to worry About
                 21 that for the moment, because that is not a target type figure,
                 22 and I think this -- I don't know the  population,  ut  my  guess
                 23 is it is probably in the neighborhood of two million people.
                 24            MR. PETERSON:  I. am glad you asked that question.
                               DR. HESS:  It is an urban area.
                 25
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   hws-15      I               MR. PETERSON:  It is a little over two million
               21@ people, 2.1 million.
                               The District of Columbia, I think,  has  just  under
   0           4   one million people, but you have two big bedroom areas in the
               5   suburbs.
               6               DR. HESS: There it seems to  me  the  management  is
               7   picking up  now, and that there is an area of need.
               8               DR. THURMAN:  I second the motion.
               9               MR. PETERSON: There is a  motion  of  $1.1  million,
               10  and we have a second.
               11              Any further discussion?
               12,             MR. de la PUENTE: I just wanted to  add  I  hate  to
               13  limit them  oh the CHP that much.
               14              MR. PETERSON:  I don't think I heard Joe say he@
               15  was going to cut it out.
                               DR. HESS:  We are going to issue t e money.
               17              MR. de la PUENTE: Is there any way  we  can  put  in
                   a recommendation there  phasing  out as many of the kidney
               18                         )I
               19  activities as soon as the self-stpport is available?
               20              DR. HESS:  Some of these they have listed.     T   y
               21  state no additional funds requested on there.
                               They have already phased out some.
               22
                               MR. PETERSON:  These are the residue of a number
               23
                   of kidney Activities, but even these are continuations, and I
               2,4
                   am assuming, and I have not looked at the application that
               25
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   hws-16       1  close, that most of these will really have come to an end
                2  sometime during the next year.
                               DR. HESS:  They have a priority 1 ranking, so we
                4  can't go in on a line item and scratch out something they havt;
                5  on Priority 1.
                6              I just don't think we can do much with that., Mr.
                7  Chairman.
                8              MR. de la PUENTE:  Then I have no objection.
                9              MR. PETERSON:  We have a $1.1 million recommenda-
                10 tion..
                11             Any further discussion or question?
                12,            All right, those in favor raise your hands.
                               (Showing of hands.)@
                13
                14             MR. PETERSON:  It is  unanimous.
                15
                17
                18
                20
                21
                22
                2.3
                24
                25
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                                HEW REGIO14AL @IEDICZ@ PLAN FOR LONG
    hws 17      1
                2               ISLAND, NEW YORK AND NASSAU-SUFFOLK
                                              COUNTIES
                3!1
                4             MR. PETERSON:  Well,  we are down to two Regions,
                5  and it is a quarter to five.
                6             I think we are going to switch gears and touch
                7  upon Long Island of New York and Nassau and Suffolk,
                8             Do you want to lead of f on this?
                9             DR. HIRSCHBOECK:  This was to be the model combin-
                101 ation, twin agencies, and it was split off from the Metro-
                   politan New York, and put under the aegis of Stoneybrook for
                   a while, at least.
                121
                13            With the phase out of RMP the Nassau Regional
                   Medical Program lost its Coordinator and I believe mush of
                14
                   its staff, at least there are a lot of vacancies here, and
                   there was a shift from this program priorities.
                              Incidentally, the NAssau-Suffolk Medical Program
                17
                   and the Comprehensive Planning Council jointly produced the
                18
                   priorities for the Region.
                              With the split, with the phaseout of the RMP
                20
                   resulting in the split, all of the planning projects were
                21
                   deleted from the RMP priorities, and the remaining ones have
                22
                   to do wi-,h increasing health manpower availabilityt increasing
                2.1
                   coordination, cooperation, resource sharing, instituting hew
                24
                   preventive health measures, innovative improvements  in
                25
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  hws-18           professional continuing education and priority number 5,
                2  developing within the purview of 89-239 RMP legislation,
                   ambulatory care services.
                3..
                               This seems
  0             4                         to be --he project that they have put
                5  the most emphasis on in terms of their priorities and planning
                6  for the future.
                7              Also the PSM project is underway, and a kidney
                8  project.
                               One gets the impression that this application, whe
                9
                10 he reads it, is really dealing with the.broad plan worked
                11 out prior to the departure of the  Coordinator,  Dr.  Hastings,,
                12 and there is not much room pro3ected here,  other  than  a  data
                   base development for ambulatory care in Suffolk County.
   QL           13
                14             Everything else apparently is a  holdover  from  the
                   grand design of the previous activity and programing4
                15
                               As far as the leadership is concerned, the staff
                16
                   Dr. Hastings has, it is extremely weak.
                17
                               Everybody on the project is at a Master's degree
                18
                   level, including the Coordinator.
                               Those proposed for employment are mainly from
                20
                   social work, and then there is a serious  question  in  my  mind
                21
                   as to whether this staff is going to be able to follow through
                22
                   with the project in terms of leadership and evaluation as
                23
                   described in the document.
                24
                               The relationship with the CHP agency, one gets the
                25
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  h,vis-19    1    feeling that CHP is sort of taking over.
              2               The Regional Advisory Group is still a discreet
              31
                   entity.
              4               The CHP agency has endorsed everything in one
              5    letter.
              6               The projects that are being proposed  are  contin-
              7    uation projects, except for one, that is the data  base  con-
              8    tract for ambulatory care.
              9               They-do expect, however, to bring in  six  projects
              10   in Julyi new ones, and there are some continuations,  so  that
              11   I think we ought to hear from staff about the real  state  of
              12   affairs that exists between the CIIP and the RMP there as  to
              13,  whether there is any prospect of this staff being improved
              14   back to what it originally was.
              15              Doctor Hastings is the Coordinator.
              16              MR. PETERSON: Do we want to ask  Paul  to  present
              17   his review first, or would you want us -- well, I  don't  know
              18   to what extent the staff has any comment.
              19              we really are down in one sense, and not  only  did
              20   Glen Hastings leave, but Harrison Owens, who had been  in many
              21   ways, I don't recall it was his name, but he certainly was
                   functioning as Glen's deputy. He was acting for  a  period  of
              22
                   what., six months?
              23
              24              Harrison has left, and went to  NIH.  The  present
                   Coordinator who has been there a couple of years, he was
              25
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   hws-20                                                               446
                   their evaluation person.  He is an East  Indian.
               2
                              I site visited Nassau-Sqffolk.  I was on the last
               3(j
                   visit. I had some contact with  Persade.  My  impression  of
               4   him would be that maybe he holds a few things together, but
               5   I don't see, for a variety of reasons, his  background,  and
               6   what have you, by that I don't mean the fact that he  is  an
               7   Indian, but he is a numbers man by and large.
               8              I think he is fairly new to the health field, and
               9   I certainly wouldn't see a great deal of positive, imagina-
             10    tive leadership coming out at least through his person, and
             11    I think the other staff there have some problems as relates
             12    to the grantee.
             13               MR. NASH:  Why don't we hear from the second
             14    reviewer?
             15              bR. TESCHAN:  In reading the document it is put
             i(i   together with a good deal of mental confusion on the part of
             17    the author, or the Conunittee didn't talk to each other, or
             @18   was put together at different times with interruptions.
                             It is hard to follow with groups of projects they
                   are talking about and what the status of the projects that
             20@
             21    are being described are. so there are some projects-that are
             22    not described in the narrative, or their rationale developed
             23    in the overview, and there are som ethat are described
             24    several times, or more that. once, in different ways, so you
             25    can't tell whether they are talking about a rejuvanation  of
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   hws-21           of an old project, or a new project, or the relationship
               2    between them.
               3;,i            There is a minor confusion point here to tidy
   0           4    minds in the sense that in the one form,  the  158,  there  are
               5    the progress reports that relate to 1971-73, and the proposal
               6    relates to 1974-75.
               7               There is a one year's gap in the situation, which
               8    doesn't overly distress me, but it sounds as if there is a
               9    problem in terms of accounting for what happened to the
               10   projects in the meantime, and how do we now ask for new funds
               11   if, in fact, in the meantime either the project died com,-
               12.  pletely, or survived with other funds since then.
               13              Should we not be over  on  new  funding  altogether?
               14              Why do we recur after a year's absence?
               15              Now, that may be just a technical question on how
               i(i  the numbers appear. It may  be  an  administrative  type  staff
               17   thing, but I don't understand it, and it doesn't make any
               18   sense.
               it)             The priority statementsi these  things  are  two  or
               20   three years old.
                               I was on a site visit when  Glen  was  still  theret
               21
               22   and I remember distinctly the long discussion how they got
               23   the priority, and this is really  .Hastings' work, and-it hasn't
               24   been revised since, and you get the sense, the end of review
               25   process is sort of a Xeroxing of something,
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  liws-22       1            DR. HEUSTIS:  This is what I wanted to convey.
                21           DR. TESCHAN: I get the feeling that if  this  docu-
                3,i
                  ment is reflecting sort of the state of affairs then it  says t!
                4 that 66 members of the RAG have been asleep.
                5            It says the grantee has been asleep, and it  says,
                6 that I don't see a focus around which you can organize a  next
                7 step.
                8            I don't know where to turn to fish for that  focus
                9 of the new entrepreneur relationship that is needed in the
                10 thing, because one thing on the CHP business, the two agencies
                11 say they are going to reexplote what the lesson is from the
                12. experience they have had.
                                                                              f
                13           If the document is any indication, I can't tell  1
                14 there has been any.
                15           Well, in view of this, I think that we are  tending
                  to go somewhere between a below average and a poor  situation,
                  and one where I don't see where there is viability,
                17
                18           I frankly don't know what to do about a funding
                19 recommendation on it.
                20           I think maybe we ought to hear from staff, and maybe
                  we will be a little more illuminated than I am at the moment. II
                21
                22           MR. PETERSON:  Jerry, you have any comment that
                23 speaks specifically to the point?
                24           To put the question crudely, how bad is the  situ-
                  ation?
                25
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   hws-23       1             MR. STOLOV: VTe. have members from Grant's  manage-
                2  ment here.
                3ii           We are about in the fourth recite of  their  bylaws
                4  and RAG grantee relationships.
                5             When we tried to review their process, their RAG
                6  was rally dominated by the corps in terms of  numbers,  and  we
                7  asked that there be a change in numbers, and  they  did  adjust
                8  that change.
                9             The auditors were out there for ten weeks, and they
                10 came up with a whole pot pouri of items  which  represented  to
                11 Dr. Paul, Mr. Silbus and operations people.
                12            They felt, though, the RAG was dominating the
                13 corps, but this is only a sideline to what they did find.
                14            They did look into some of the projects you have
                15 mentioned, as to the gaps in time, the Nassau-Suff6lk believes,
                1(; they can reinstate from all indications.
                17            DR. TESCHAN:  I did have one more comment on the
                18 project, that there are two kidney projects, the relationship
                   between which is unclear, and we don't, or the  don't seem to
                19                                                y
                20 have a lot of content and don't have a specified relationship.
                21            I am a little less critical of  the  same  situation
                   in the EMS story, because the counties appear  to be big enough
                22
                   and the divergency between them sufficient,  and  the  location
                23
                24 of the population centers sufficient to  justify  two  separate
                   operations in that case.
                25
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  hws-24        1              The kidney game is different,  because both  of  them
                2  talk about relationships to metropolitan   New York and  the  big
                   eastern consortium, so there is  reason  for  more  coordination
                4  than I find.
                5              MR. STOLOV:  Could I just ask that we get to the
                6  issues that staff looked at?
                7              MR. PETERSON:  That is what we want to get to.
                8              MR. STOLOV:  EMS  Communication  Project.  We  touche
                9  base with Region 2 Office, and the same people applying for
                10 the equipment dollars were the same  people  applying  under  Mr.
                11 Rearden's program and RSA under the new law.
                12.            This was almost the identical  Proposal,  even  more
                13 dollars to  them.
                14             Well, it was briefly presented.  We  asked  the  EMS
                15 Communication Specialists to look at  it,  and  we  consequently
                   heard from Region 2 that they turned it down.
                               One could draw a grey line between whether they
                17
                18 did mention communications  in  their  original  proposal.  How-
                   ever, we were asked to highlight it  because  of  the  magnitude
                   of the dollars.
                20
                               That is where we stand in EMS.
                21
                               In Kidney, we asked the Region, before they sub-
                22
                   mitted their project, to have it  reviewed  by  outside  consult-
                23
                   ants.
                24
                               They got one consultant, got one one  night  in  the
         R ING CO, Nc.
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   hwa-25           Kidney meeting in Chicago, and he dictated something over the
               2    phone,, and we called him today to get his impression, and he
               3
                    agrees with Dr. Teschan, that the two projects should be
               4
                    brought together into one, and this shows suppoktinq two
               5    institutions rather than getting a new thrust.
               6               DR. TESCHAN: He shows no  CHS  function,  and  it
               7    shows no RMP coordination, so it is a total bust, no matter
               8    which way you look at it.
               9               MR. STOLOV: In terms  of  the  proposed  staffing
               10   pattern and the present staffing pattern I think we asked the
               11   Region, and they only sent in -- they were allowed to budget
               12.  the $6.9 million, and they elected to put into sta      -@c,
               13   prior to this application what  they actually
   QL                                                              sent in was what!
               14   they were budgeting into.
               15              We haven't seen the new coordinator function.  The.
                    RAG had a committee, and they have 70 applications to coft-
               17   sider, so@ from the nearby regions,  et  cetera,  and  other
               18   people.
               19              Well, they chose their own man for the job.  we
                    have not seen him function.  We did ask him to expand on the
               20
                    organization chart, and he had four health analysts reporting
               21
               9-2  to a girl who.was in the program since it started, for four
               23   and a half years.  She was the grant's management gal, and
               24   did a good job at it, and we were concerned the poor people
                    reporting to her, she has a BA, and she has four and a half
               25
  HO E REPORTING CO, INC.
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                                                                             4 F- 2
  hws-26         I  years of experience, and her experience was another factor
                 2  he looked at in the decision, but the organizational chart
                 31@ has changed.
                 41            He has sent in a new one, having two report to
                 5  his evaluator, and two reporting to her.
                 6             Again, we questioned the decision, but haven't
                 7  seen it in operation.
                 8             The seven vacancies are social workers, as you saic,
                 9  Dr. Hirsdhboeck.
                 10            MR. PETERSON:  Tom, did we have a management
                 11 assessment visit at the same time as the review verification
                 12, visit this year?
                 13            MR. SIMONS:  I have almost lived with that Region.
                    I have a very hardnosed view.
                 14
                 15            I think Frank better talk before I do.
                               MR. NASH:  I think it was over two years ago it
                 17 was recognized that the structure and relationships between
                 18 the grantee institution and the Board of Directors of the RAG
                    of this program there was something very much wrong there.
                 19
                 20            I think they had a 25 member Board, each of w om
                 21. was also amember of the RAG.
                               The normal procedure for   the Board is to meet, dis-
                 22
                 2.3 cuts the business.  They would adjourn, and 30 minutes later
                    they would convene a RAG meeting, and most of the time some
                 @14
                    of the RAG members didn't show up.  All the Board members
                 25
   IOOVER REPORTING CO, INC.
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        nil ')nnnl)

     hws-27                          were there, so the clear dominance of the                                        RAG in the whole
                            2        decision making process was by the Board grantee institution.
                            3                                                                                                                           d
                                                           This gave us a lot of concern.  They were advise
     0                      4        they should be concerned about this.  They would send us                                                       back
                                     letters assuring us that they would do this.
                                                           Then they would get involved in phaseout, and so
                            7        from our part we didn't follow up on it until we got the one
                            8        year's  extension.
                            9                              We  have  been  after  them  again  to  straighten  out
                            10       this  situation,  and  that  is  why we  are  now  looking  at  their
                            11       revised bylaws,  and  I  think  Tom                          is  later  review  of  those  indi-
                            12,      Cates  there  is  still  the  possibility  of  dominance  of  the  RAG
                            13       by  the  Board.
                            14                             I  don't  know  how we  will  straighten  this  situation
                            15       out.
                                                           Does  that  cover  part  of  it?
                            17                             MR.  SIMONS:    Yes.    I  don't  think  it has  come  out
                            18       that  RMP  and CHP  has  separated.
                                                           MR.  PETERSON:    Yes  it has.
                            20                             MR.  SIMONS:    There  was  mention  of  the  HEW  audit
                            21.      that  has  been  up  there  ten  months.
                            22                             They  came  in  and met,,  and  had  a  very  long  report
                            23       on  the  Region.    They  selected  five  projects  that  ran  when
                                     they  first went  in,  based  strictly  on  the  time  the  project
                            ?4
                                     occurred,  and  the  dollar  volume,  and  they  traced  it  from there
                            25
    HOOVER REPORTING  CO,  INC.
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     11 b-28       I  from the time it started up until it was complete.
                   2               Now, all five of them they considered a dismal
                   3119 failure because of the poor management by the program staff.
                   4               They now ask them to select two more teams, to           give
                   5  it  to   them.
                   6               MR. NASH:  The audit report doesn't bother me
                   7  quite  so  much,  because  this  is  a  reflection  of  what   went   on
                   8  in the past,
                   9               The question that concerns me is what is the future
                   10 for thisprogram.
                   11              MR.  SIMONS:  I'have  two  more   points   I   would   like
                   12 to make.
                   13              I  think  the  philosophy  of  that   region,   the   three
                   14 or four times I have been up there, seems to be we are going
                   15 to do what we want to do.
                   16              We will try to write it to make RMP's and the
                      Councils believe we are going to do what they say  but we are
                   17
                   18 still going to do the things we want to do          here,
                                   As far as the domination of the        program by the
                   19
                   20 corps, as Frank said, I don't know how we          are   ever.going   to
                      get them to stop that.
                   21@
                   22              The climate is still ripe for the corps to domin-
                      ate  the   bylaws still provide for domination by the corps.
                   23     ol
                                   The only way that they are ever going to change is
                   24 a very   hard approach from here.
                   25
   H     PORTING CO, INC.
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   Washingioni D.C. 20002

    hws-29                     I think the recommendation you made for Maryland
               2    would be a little kind to them.
               3;              DR. TESCHAN:  You made the funding contingent on
               4    their compliance, either get with it or ship out.
               5               MR. STOLOV:  The letter from Dr. Paul said exactly
               6    that.  Unless those bylaws are changed to meet our conformance,
               7    and the Region -"
               8               MR. SIMONS:  No if 8, ands . or buts.
               9               DR. THURMAN:  I move that we approve this program
                    for a  level of approximately $150,000 for staff phaseout.
               10
                               DR. TESCHAN:  I second.
                               MR. PETERSON:  The motiono if I understood it
               12
                    correctly, was $250,000 for staff phaseout.
               13
                               DR. HEUSTIS:  Aren't you rather generous?
               14
                               DR4 HESS:  I don't see how that is consistent
               15
                    with the decision you fellows made on Maryland.
                               DR. TESCHAN:  Then I am missing something.
               17
                               DR. HESS:  I wasn't ready to vote with you for or
               18
                    against  it.
                               But it seems to me, from all that we have heard,
               20
                    that this program in New York in nearly every dimension is
               21
                    worse off than Maryland, and the vote, as I remember, it was
               22
                    to recommend termination for Maryland.
               23
                               Now, if Maryland deserves that kind of vote, I
               24
                    don't see how you, in any consistency, can vote any money
               25
       PORTIKG  CO,  INC.
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                                                                       456
     hws-30     I  here.
                2              DR. THURMAN:  That is not what my word was.  I
                3! don't think we ought to fire these people tomorrow by term-
                4  inating all funding, and $240,000 will  carry  them  until  their
                5  staff can find other jobs.
                6              DR. HESS:  You didn't make that proviso with
                7  Maryland.
                8              DR. THURMAN:  Yes we did.  We said terminate it
                9  with adequate time.
                10             DR. HESS:  Okay, the same general language.
                11             DR. THURMAN: Except to make  it  worse  in  Maryland.
                   How is that.7
                12.
                13             DR. HEUSTIS:  I thought the motion we voted on
                   before was  we recommended termination, and left it up to the
                14
                15 good judgment of the Council to bring about an orderly term-
                   ination, without out getting involved.
                               DR. THURMAN: I will rephrase  my  motion,  and  let's
                17
                18 make it the same as Maryland, but a little worse.
                               In that way we will have the same terminology,
                20 because I think the program ought to be terminated.
                               DR. HESS:  I call for the question.
                21
                               MR. PETERSON:  Let me be sure that 1 have the
                22
                   motion correct.
                23
                               The motion is termination at  the  earliest  possible
                24
                   moment.
                25
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                1                                  st the termination.
     hws-31                    DR. HEUSTIS:  No, ju
                2              MR. PETERSON:  Termination with only such funding
                3   as may be necessary to provide for'the orderly termination.
                4              DR. HEU8TIS:  Bu@- you didn't do that for Maryland.
                5              MR. PETERSON:  I think what we are hearing now is
                6   we are really acting on a kind of generic motion that we will
                7   rephrase the Maryland one accordingly.
                8              MR. BARROWS:  Funds sufficient for an order y
                9   termination.
                10             MR. PETERSON:  It may require slightly more funds
                11  than one or the other for the orderly termination, but that
                12, is a minimal amount of funds, really.
                13             DR. HEUSTIS:  Why cannot we  as a review committee
                14  recommend to the staff, as I understand  it, we recommend
                15  termination, and the staff, under whatever it deems best,
                    make whatever it thinks is a proper recommendation to the
                17  Advisory Council?
                18             MR. PETERSON:  As to funds?
                19             DR. HEUSTIS:  It puts us firmly on the record as
                    far as termination, and what you do with it is the orderliness.
                20                                                                  1
                21@            MR. PETERSON:  Termination with such funds as staff
                22  finds necessary to make that an orderly process.
                               That is poorly phrased.  We don't know.
                23
                24             MR. NASH:  The Department would insist on this,
                25  any way.
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                                                                             458
   hws-32       1              DR. HEUSTIS: with such funds  as  are  necessary.
                2              MR. PETERSON:  I want to make sure whether it is
                3   in the motion or not that we have the sense of that.
                4              Termination is a guillotine.
                5              DR. HEUSTIS,. There has been  so  much  pussyfooting
                6   around on this thing, I would like to use  language  so  nobody
                7   misunderstands what we say.
                8              What they do with the language  after  that,  after.
                9   I understand it, is fine.
                10             MR. PETERSON: I think  I  understand  the  language.
                11             DR. HEUSTIS: I am glad you do, but  do  you  have  a
                    vote on the Council?
                12,
                13             MR. PETERSON:  No, I don't.
                14             DR. HEUSTIS: I would like to  be  sure  the  Council
                15  understands what we say.
                               MR. PETERSON:  I will reduce the motion to one wor
                17  which will be "termination," and we will supply appropriate
                18  parenthetidals.
                               Again, I am just trying to get a sense here.
                19
                20             MR. BARROWS: It is very  important  to  avoid  an
                    appearance of capriciousness and arbitrariness on  o  r  par
                21
                    that this termination be provided with  whatever  is  necessary
                22
                    for an orderly termination.
                2.1
                               MR. PETERSON:  Early, orderly termination.
                24
                    Termination with only such funds as is necessary.
                25
  HOOVER REPORTING CO, INC.
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                                                                           459
   hws-33      1               MR. NASH: Any program that I have  ever  seen  in
               2   HEW that has been terminated, the Department  insists  on  an
               3!  orderly termination.
               4               MR. BARROWS:  We should mention that.
               5               MR. RUSSELL: RMP would go to any RMP  and  say  send
               6   us your plans for going out of business,
               7               DR. TESCHAN:  They will either roll over and die,
               8   or scream and come in here with all kinds of important reso-
               9   lutions.
               10              I wouldn't mind July 1 in that sort of situation
               11  to review if the y have more life than we have seen in two
               12. years.
               13              MR. PETERSON: On both  Maryland  and  Nassau-Suffolk
               14  I have a sheet of paper in front of me, I am filling in the
               15  last few figures on, in both cases I am  showing  the  figure
               i(i of equal to or greater than zero.
               17              There is a motion now.
                               All those in favor of the motion raise  your  hands.
               18
                               (Showing of hands.)
                               MR. PETERSON:  It is unanimous.
               20
               21              MR. BARROWS: This will include  the  proposition  we
                   faced on the impact on the new program.
               22
                               DR. HEUSTIS: This has the same  reasons  Mary  an
               23
                   had.
               24
                               MR.-PETERSON:  The set of problems are not all that
               25
  HOOVER REPORTING CO INC.
   32 MassachusettsAvenue,N.E. 11

  hws-34           different.
               2              Grantee Number 1 is of a different order.  It is
               3'
                   not a  Johns Hopkins with a grantee domination vis-a-vis the
               4
                   RAG, questionable leadership, and certain results of no
               @5  significance.
               6              Well, we are down to the wire now with.just the
               7   Susquehanna Valley, which is the central part of Pennsylvania.
               8              Let us move ahead.
               9              Joei you were one of the reviewers here.  I wonder
               10  if you wanted to lead of
               12.
               13
               14
               15
               17
               18
               19
               20
               21
               22
               2tl
               24
               25
  HOOVER REPORTING CO, INC.
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                                                                            4bi
     hws-35                       HEW REGIONAL T-EDICAL PLAN FOR THE
               2                       SUSQUEHANNA VALLEY
                                MR. de la PUENTE:  This is an application for
               3@i
               @4   $721,606.
               5                On July 1 they are going to come in for $705,000.
                    They have 14 positions, including  three  physicians  devoting
               6
               7    25 percent of their time to staff functions followin  t e
               8    recommendation of management.
                                They have been successful in filling  three  addi-
               9
               10   tional key positions with former RMP staff who are rejoining
               11   the  program.
               12.              The present request is for a fully via le program.
                    Their activities are addressing themselves  to  the  Regional,
               13
                    what the Board concedes as need in the  primary  health  care,
               14
                    availability of services for room area and accessibility to-
               15
                    the urban service.
                                They are with the Pennsylvania @ledical Society,
               17
                    which is providing excellent physical management sources4
               18
                                The staffing pattern coincides with their program.
                                Many parts of their program are grants.  The grants
               20
                    present an opportunity for realigning their staff pattern in
               21
                    a manner which coincides with their new plan.
               92
                                The present application is for support of_their
               23
                    positions from July, 1974 to June 30, 1975, as well as two
               24
                    months of support.
               25
  HOOVER PEPORTING CO, INC.
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       C- - -----

                                                                           462
    hws-36      1              Their July 1 application  will  emphasize  project
                2  support.
                3              At that time they will  present  approximately  18   i
                4  projects presently under review  by  their  Regional  Advisory
                5  Board.
                6              While they represent present activities, their
                7  application does not include comprehensive updating of their
                8  plans.
                9              I have not seen anything as to how  they  are  up-
                10 dating their plans.
                11             They intend to continue the AHEC activity in South
                12 Central Pennsylvania, as well as  the  Area  Health  Education
                13 System in North Central Pennsylvania, and the ambulatory
                   patient dialasis is also going to be continued.
                14
                15             What they are going to do as far as new activity
                1(; is concerned, is to facilitate  the  development  of  Regional
                17 Health Authorities, and adequately address the need of inte-
                18 grated functions of health plans, implementation, and regula-
                19 tions.
                20             As they develop their plans they will have active
                   participation of the B agencies in the Susquehanna Valley
                21
                22 Region.
                23             One of the major concerns regarding this Region is
                   the evaluation of their activities.
                24
                25             This is the problem I have with this Region, how
  HOOVER REPORTING CO, INC.I
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                                                                                                                                                     463
      hws-37                            do they evaluate what they are going to do, and how do they
                               2        decide what they are going to do next, and what are their
                                        priorities,
                               4                               SISTER  JOSEPHINE:    I  have  some  of  the  same  problemi
                               5        that  Joe  has.
                               6                               As  I  looked  over  the  proposal  I  got  the  impression
                               7
                                        that  they  got  on  the  bandwagon  very  quickly  to  phase  out  the
                               8
                                        program,   and  they  ended  up  with  three  people  from  22.
                               9                               Then.they  hired    and  they  are  at  a  level  of  14  now,,
                               10
                                        and  they  propose  to  build  it  up  to  the  original  level,  and
                               11       they  realize  when  they  get  the  whole  group  in  they  are  going
                               12,      to  need  to  develop  them  to  have  some  program  to  work  on.
                               13                              All  they  are  going  to  do  now  is  to  tie  up  for  a
                               14       poor  staff  and  a  development  program  which  is  the  only  thing,
                               15       a  development  to  develop  that  corps  staff  so  they  will  be
                               i(i      able  to  identify  some  projects,  but  there  are  no  plans  for
                               17       how  they  are  going  to  implement  the  projects,  or  how  they  are
                               18       going  to  develop  the  project.
                               11)                             This  creates  a  real  problem  for  me.
                               20                              MR.  de  la  PUENTE:    Maybe  staff  can  help  us.
                               21                              What  was  the  story?
                               22                              SISTER  JOSEPHINE:    Another  thing  here,  too,  their
                               23       past  performance,  there  are  three  things  that  they  identify,,
                               24       and  one  is  that  they  have  been  able  to  elicit  qrassroots
                                        involvement,  but  you  don't  know.
                               25
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                                                                           464
   hws-38      1               They talk about the coronary units which were one
               21     the first types of things, which began when the program
                   of
               3
                   first evolved.  There were five.  Now there are 30.
               41              They had a management consultant firm come in and
               5   help them learn how to develop a program.
               6               I feel they are very much in the same place as
               7   when they first started the program.
               8               MR. BARROWS:  Sister, you better be careful.  You
               9   are going to acquire a reputation of a hanging judge.
               10              DR. TESCHAN:  She is helping us to be one.
               11              SISTER JOSEPHINE:  This is the way I have to rea
               12,  it.  They are going to get the kiss of death any how.
               13              MR. STOLOV:  I thought maybe Tom would comment
               14  since he was on the management assessment*
               15              My visit was the last visit, where the RAG met on
                   this application.  I could supplement maybe what the reviewer,
               17  had  to  say.
               18              MR. SIMONS:  We were up there in January.  There
                   were two people at that time, plus the secretary.
               19
               20              There was the Acting Coordinator, the Fiscal man,
                   who has been there since the day one, I suppose, and the
               21
               22  secretary.
                               They had spent the entire year of the phaseout
               23
                   doing absolutely nothing, just sitting there reading the news
               24
                   papers,
               25
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    hws-39                     MR. PETERSON:  In Harrisburg?
               21              MR. SIlfiONS: They were reluctant to  hire  people
               3.1 because the Coordinator had almost a paternalistic attitude,     i
               41  although some of the staff wanted  to  come  back.  He  didn't
               5   think they were fair to themselves to want to come back.  But
               6   now with more money, they will come back, he thinks.
               7               This was just a very inactive operation.
               8               MR. PETTRSON: You were at  the  RAG  meeting  when
               9   this application was considered.
               10              What kind of life did you see?
               11              MR. STOLOV:  I attended not only the RAG meeting,
               12.  but the Executive Committee meeting.
   1  41       13              The first thing that impressed me was that it was
               14  at the Pennsylvania Medical Society Headquarters, which is in
               15  Camp Hill, and the grantee is an ex officio member of the
                   Executive Committee, so most of the people in attendance at
                   the Executive Committee meeting were physicians, and if you
               17
               18  are in the Medical Society building, which is quite impressive,
               lo  but there was adequate-participation  in  the  Executive  Com-
                   mittee.
               20
               2@l             This wag around April 17, so one of the physicians
               22  just paid his  taxes, so he was carrying the torch at that
               23  meeting, and he was trying to question the Coordinator as to
               24  dollar.expenditures.
                               Most of them, I  still believe, are similar to one
               25
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                                                                           4.66
  hws-40           of the comments we made in another Region,   that this  is a fund-
               2   ing strategy rather than a program strategy that at    this   timei
                                                                                     I
                   due to the conservatism -- well, they just appointed a
               3
               4   Director at that meeting.  He was Acting Director, so     there
                   was a sort of sitting on the fence sort of attitude there,
               5
               6   as well as due to low  salaries that the grantee  has  in  this
               7   structure.
                                                                                 v
               8               This was a negative  force.  However,  the  Executi  e
               9   Committee  is behind the Coordinator, and the RAG was well
               10  attended at this meeting. It  was  a  well  attended  RAG  meeting
                                                                             p
               11              They had  minority  representation  there?  and  eople
                   made their voices known, and after the RAG meeting, And they
               12,
                   reviewed the arthritis applications, as  well,  and  we  did  note
               13
                   some positive progress.
               14
                               The Chairman was also well liked, and is a good
               15
                   Chairman.
                               Staff went just  like  Nassau-Suffolk  staff.  They
               17
                   were at the position where you  are  today,  because  this  Region
               18
                   wanted to put its rebudgeting into staff at that time, and
                   they sent us their staffing pattern, and  we  asked  them  to  link
               20
                   it  to  their goals, objectives And priorities,  but  I  think,  as
               21,
                   Tom mentioned, they are very slow to move,, and  have  to  have
               22
                   the dollars in hand before they will move,  and  I  think  this
               23
                   was a negative point to them.
               24
                               As to evaluation, this last Saturday  they  had  an
               25
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   hws-41      I   evaluation.
                              One of the reasons was one was just appointed a
               3!@ member on the staff.  They evaluated the two AHEC's there
               4   with outside consultants, and they were  at a point where they
               5   were handicapped because of the dominance of this medical
               6   clinic, and one of the physicians in charge is on the Executive
               7   Committee as well, and up to this point they were really
               8   handicapped by not performing an evaluation.
               9              However, they did conduct evaluations on Saturday,
              10   and the evaluation report will go to RAG.
                              They did, however, use their outside Consultants
              ,2.  and staff, and this is the first time they have probably
        (8)        evaluated something on a scale like they did.
              13
              14              MR. BARROS:  It seems to me, from what you have
              15   said, what we are dealing with here is essentially a rebuild-
                   ing of the budget.
              17              Do you think that is going to bear fruit?
                              MR. STOLOV:  I think that we iden tify about $142,OOD
              18
                   in vacancies in this budget, and the question is when you read
              20   their narrative, and realize what they went through in the
                   steps they have to take, this is one thing, but they were
              21
                   quite honest to say that they may not fill all of these
              2 --.k
                   positions, yet their RAG and Executive Committee gave them
              23
                   authority to go ahead with the strategy
                              DR. HESS:  Can you tell us more about Chad Holmes?
              25
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   hws-42      1    Apparently he has been appointed in May of 1974.  That is
               2    this  month.
                 i
                 it
                               MR. NASH:  That is as Coordinator.
               4               MR. PETERSON:  Maybe I could offer  a little
               5    historical impression of this Region.
               6               One of the first times I visited I spoke  to  the
               7    RAG in the early days of the program, and while I  have  not
               8    been a frequent visitor, I have sort of kept an eye  on  it.
               9    It seems to me this is a program which is in  a  sense  almost
                    like three distinct faces to it.
               10
               11              In the early days when the  Pennsylvania  Medical
               12,  Society was still the grantee, but in the early days the firs
                    Coordinator was McKencie, and I don't recall the first name,
               13
               14   who had been an employee, I think he had  been  the  Ekecutive
               15   Director, and at that time there was indeed,, a great deal of
                    pulling and tugging between the grantee and the RAG, that
               17   was trying to make itself felt, but did not have a great deal
               18   of, it seems to me, moxie behind it in there ind  vidual  y.
               19   and certainly collectively.
               20              Well, that issue began to  get  clouded.  There  is
                    the new medical school over at  Hershey,  Pennsylvania.  I
               21
                    don't recall if the Dean is still there, but despi te  the
               22
                    fact that the medical school at Hershey was put in the business
               23
                    of training primarily physicians, some of  the  impressions  1
               24
                    got, and I can remember a Dutch uncle talked  about  that,
               ')5
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    hws 43         that Harold rolled with some of the people from Susquehanna
               2   Valley.  The medical schoolls interest was to get some money
                   to do some things that were pretty, at least some people who
               4   knew better than I, was certainly exotic, and totally in-
                   congruous with any  total  primary  care.
               ,5
               6               It sort of shifted  from  the Medical  Society  and
               7   got clouted by the  medical  school,  and as a result  of  that
               8   Dutch uncle talk they did bring in a  Doctor  Ector,  who  was
               9   from Philadelphia# and I think he started working in trying
               10  to build some sort of program objectives which had never
                   really existed before, but really got caught  up  --  well,  I
               11
                   don't think he had been in the post more than ten or 12 month
               12,
               13  before  the  ph.aseout order came, and I don't know what his
                   motivation was.    He didn't stay around very long.
               14
                               Since that time, Chad Holmes has beeft first Acting,
                   and now he has been recently confirmed as a Coordinator,, but
                   they not only have looked forward to  a  fairly  rapid  phase-
               17
                   out, but I think it does sort of reflect a Region which prob-
               18
                   ably never did have much momentum or sense of direction.
                               There was not too much to reach back toi and Holmes,
               20
                   he was job hunting actively for a while,  but  with  his  con-
               21
                   firmation as Coordinator, I guess he stopped doing that.
               22
                               DR. HE8S:  Was he the fellow sitting around
               23
                   twiddling his thumbs?
               24
                               MR. PETERSON:  I  assume  so.
               25
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  hws-,44       1             Well, any way, they. got down to the Acting  Coordin
                2 ator or Finance Officer to close the books, and  the  secretary
                31@ to do the typing, and they all read the newspaper, according
                4 to Tom.
                5             Holmes was there the whole time.
                6             DR. HEUSTIS:  Is there anything there worth
                7 salvaging?
                8             DR. HESS: No point in trying to gear up  a  program
                9 for a phaseout.
                10            MR. PETERSON:  Do we have any idea?
                11            Susquehanna Valley has indicated they are  asking
                12.  for a little over $700,000 now, which is about their current
   CL           13 level, and they have indicated they are going to come  in  with
                14 another $7OOiOOO package.
                15            Any idea of what it specifically looks like?
                              MR. de la PUENTE: They talk about  improving  the
                17 quality, the high quality care in the Valley Region.
                18            The Second Region is to improve the high  quality
                  health care, and then they speak of each mission, and how they
                  are going to do it, so I think in here an awful  lot  depends
                20
                21 on what they come up with in the other application.
                22            How they do that I just don't know.
                              MR. STOLOV:  There are some plusses, when they started
                23
                  getting.rejuvanated that they have supported the B agency
                24
                  directors at one of the B's previously not supported,  and  his
                25
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      15
  hws-          I  name is in, referred to by the budget staff.
                2             The second point is the Region is in the State
                3  Capital area, actually, and there is a need in that area to
                4  coordinate with the three unidentified B agencies  and the
                5  RMP.
                6             I believe this Coordinator can do it.  He has the
                7  personality.  He has a Mastor's in Theology.  He calls it
                8  theracit medicine.
                9             Any way, he is well liked, and the other point I
                10 want to mention is the RAG Chairman is a specialist in cardi-
                           uite devoted and a good leader, and he has the RAG
                11 ology, q
                12, support at this go around.
                              MR. BARROWS:  Would it be fair to say at the mini-
                13
                   mum this will be a built-in block for the transition if we
                14
                   keep this program going?
                              MR. STOLOV:  I would ask the Committee to encouraged;
                17 that.
                18            When Doctor Ecort left, prior to his leaving they
                   were going to come in for a triannual.  they actually had
                19
                   100 applications in-house.  This is an indication of some
                20
                21 identity in the community.
                              What they plan to do is to try to bite on some of
                22
                   those back applications.
                23
                              MR. BARROWS:  Lets give them a reasonable budget
                24
                   and see what they come up with in their next one.
                25
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   hws- 4 6                     DR. TESCHAN:  That  sounds  great,  except,what  I
               2
                    think I have heard up until now,  until  you  just  said  what
               3i)  you just said up to now we are going to need a     couple of
               4    Dutch uncles.
               5                One did not carry very far here, so it seems to me
               6    that the Chairman and the Coordinator, or whatever else needs
               7    to be invited down here has to come,  and  you  have  to  line
               8    up and lay it on in te      of what needs to be done up there,
               9                MR. BARROWS:  Could you give them    a  transcript
               10   of this discussion?
               11               MR. PETERSON:  I prefer not to do that.
               12,              DR. THURMAN: As  you  look  at  their  budget,  what
   OL          13   they have proposed is $498,000    in staff, $95,000 in definitive
               14   projects, and $127,000 in grantee administrative costs.
               15               Going along with what  Mr.  Barrows  said,  why  hot
                    think about $95,000 for the definitive projects, because
               17   most of them are transitional  projects  for  a  few  agenc3-es,
                    and added to that, $250,060 for program staff.
               18
                                I am making a motion  that  we  not  terminate,  but
               19
               20   we ought not to commit this kind of money until we see what
               21.  is going on.
               22               MR. BARROWS:  Your recommendation makes,a lot of
                    sense.
               23
                                We have a good Coordinator.  We have a good      RAG
               21 1                                                                    I
                    guy up there.  I think the two give you a ray of hope.
               25
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     hws-47    1               MR. STOLOV:  And the grantee follows the financial
               21   practices as to their philosophy and  their  whole  salary  is
               3    something else.
               4               DR. TESCHAN:  You will need a bellows in addition
               5    to the dollars to get them started.
               6               DR. HESS:  In  circumstances like this I wonder if
               7    MPq7be I am just thinking here, if he could  so  how  learn  a
               8    little something from the fellow  in  Rochester,  Peter  Mott,
               9    as judged by the grant application, and I never met the man,
              10    except I like the way he thinks, as represented in the appli-
              11    cation, that organization that is there, and the way he got
              12    that thing lined out, I wonder if  a  little  apprenticeship
              13    with a first rate Coordinator, and looking  at  what  a  first
              14    rate Coordinator does with an application,  if  it  would  not
              15    be helpful saying, you know, much more  than  you  have  to  o
                    better.   He needs some direction as to how  to  do  better.
              17               I gather from what you say he  has  the  interest
                    and motivation.
              18
              1.1              MR. STOLOV:  He did expand from three to 14, and
                    a lot of his staff are following him.
              20
                               He does have some leadership that did come to
              21
                    work for him.
              22
                               MR. PETERSON: Let me  make  sure  what  figure  you
              23
                    were coiDing up with, Bill, and what the basis for  it  was.
              24
                               You said leave the $95,000 in projects?
              25
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         48
   hws-.@            1                 DR. THUPJIAN:     $250,000    in    programs    staff     activities1
                     2  which   would   also   bring   then    $60,000    in    grantee    administrative
                     3'fi; costs  which  is  $310,000   and   $95,000   they   have   asked   for   in   the,,
                     4  projects they have, which is $405,000, so why not  00,000?
                     5                 That will not make him lay off any of the 14.
                     6  It will give him some room for expansion in that 14.   This
                     7  will carry his projects, and pay his overhead.
                     8                 MR. PETERSON:   And try and see what their July
                     9  application looks like in terms of any hint of A program
                     10 there.
                     11                MR. BARROWS:   Is there any way of gett ng t e
                        reasoning to them?
                     12.
                     13                Could you do that, Jerry?
                     14                MR. STOLOV:  We have to send a policy feedback to
                        the   Coordinators,   but   we   expect   whatever   comes   out   of   this   --
                     15
                     I(;               DR.   HEUSTIS:   There   are   only   about   three   or    four
                     17 instances   in   all   of   these   discussions   we   have    thought    there
                     18 might   be   some   real   value   to   get   some   information   back   reason-
                     19 ably soon.
                                       Would  it  be   possible   for   the   staff   to   discuss   this
                     20
                        with   the  higher  ups,  to  see   whether   or   not,   in   a   very   small
                     21
                        number of cases an exception to the general rule could be
                     22
                        made, and that maybe some of these people could go?
                     23
                                       DR. TESCHAN:   I have a question.
                     24
                                       Out   recommendation   is   to   Council   who    has    charged
                     25
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    hws-        I   us, and  it seems to me if Council says we don't want any parti
                2   of that, we will do this.
                3'              DR. HESS:  I recommend staff do that.
                4               MR. PETERSON:  Your recommendation is for a feed-
                5   back?
                6               DR. HESS:  No,, officially.
                7               DR. THURMAN:  That letter you signed made us repor
                8   to the Council.
                9               MR. PETERSON:  You have an official legal status
                10  now,  You are legal.
                11              DR. HEUSTIS:  Shouldn't they give us a copy of
                12. that letter to make it legal?
                13              DR. TESCHAN:  It is a little techinical point  and
                14  we might be overridden by Council.
                15              DR. THURMAE:  Staff has the option to ask if Council
                    approves, ask somebody to go with them to explain all of this.i
                17  The staff can ask about that.
                18              MR. NASH6.  If Council approves this, and of course,
                    this information goes to the Advisory Letters, you know.
                19
                20              MR. PETERSON:  I thought I heard Al say something
                    different.
                21
                22              Here and in a few other instances we won't have
                    Council action until the 14th or 15th.  I don't know if it
                23
                    makes any difference, but I.thought I heard Al suggesting if
                24
                    it is  agreed at a higher level.
                25
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   hws-50                     DR. HEUSTIS:  I gather from the discussion   there
                2
                   was no great enthusiasm for the suggestion I  made, so  forget
                3
                   it.
                A
                              DR. HESS:  There was, indeed.
                5             DR. HEUSTIS: My suggestion is, as  soon  as  possibl
                6  after this meeting, that in a very small  number.of  instances
                7  where you believe it important, that the staff seek the
                8  approval of a higher level in this organization to  at  least
                9  informally discuss with the local people what we  have  talked
                10 about in those instances where it will be thought to  be  bene-
                11 ficial to the program.
                12.           DR. THURMZLN:  I second.
                13            MR. BARROWS:  I move it.
                14            MR. PETERSON: In this instance if  it  is  concurred
                15 in by Dr. Paul that we would get back to, I hope, if  t@-  RAG
                i(i Chairman is an impossible mover, indicate to them in frank
                17 terms the Review Committee's recommendation will  still  have
                18 to be looked at by the Council, That we  have serious  reser-
                   vations about the Susquehanna Valley program, but would be
                20 looking at their July application largely in terms  of  whether
                21 there is any indication of some kind of program being performed
                22 there, and they need to keep that in mind.
                              I don't think they are going to generate  any  new
                24 projects, but it may make a difference in terms of their
                   priorities, and how they present what they have in the pipeline
                25
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  hws-51           now.
               21              DR. HEUSTIS:  When is the deadline?
               31i             MR. PETERSON:  July 1, but for most Regions this
               41  means their RAG's are going to be  looking  at  things.  Most  of
               5   them are scheduling meetings in mid-June, or early June.
               6               MR. RUSSELL:  We have a precedent and can handle
               7   this and accommodate the concerns of this group.
               8               What I hear this group saying is  that  there  should
               9   be a staff  visit.
               10              MR. PETERSON:  Maybe we ought to ask Holmes.
               11              MR. BARROWS:  Let's clarify this thing.
               12@             We are not preempting the role of the Council, or
               13  reporting  decisive action, but we do feel under some obliga-
               14  tibn to help the programs.
               15              We think it would be in their best interest to
                   know some of the concerns and some of  the  reasoning  that  went
                   into this discussion.
               17
               18              What they do with it is  their own business,  and  we
               19  are not reporting any definitive action.
                               DR. TESCHAN:  The site visit isn't the term.
               20
                               MR. RUSSELL:  It is a staff visit.
               21@
                               MR. PETERSON:  I think in some ways it is particularly
               22
                   more effective  since we are not that far away.  Harrisburg
               23
                      a little over a two hour,drive, and let's see if we can't
               24  is
                   get the Chairman and Dr. Holmes to come down for a half day
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  hws-52        1  visit.
                2              Sometimes the direction in which you  move  is  most i
                3  helful.
                4              DR. THURMAN:  Excellent.
                @5             I call the question.
                               MR. PETERSON: The question is  on  a  400,000  recom-;
                6
                   mendation for Susquehanna Valley with the communication to
                7
                8  Holmes, the Chairman, that he meet here  as  soon  as  possible.
                               Does that meet with your concurrence?
                9
                10             DR. HEUSTIS:  The appropriate division of that
                11 within program staffs and projects.
                               MR. PETERSON:  All in favor raise your hands.
                12
                13             (Showing of hands.)
                               MR. PETERSON:  The vote is unanimous.
                14
                               MR. NASH:  Remind them of the confidentiality of
                15
                   deliberations particularly in the case of Maryland.
                               MR. PETERSON:  Yes, particularly Maryland and
                17
                   Nassau-Suffolk Counties.
                18
                               Are we agreed then that we will try  to  get  together
                19
                   at 8:30 tomorrow?
                20
                               I will have something in some kind  of  rough  shape
                21
                   to pass around then.
                22
                               We are planning, according to  the  last  communica-
                23
                   tion I got from the other side of the wall, to reconvene as
                21
                   a single group, or as a whole, between  nine  and  9:30  tomorrow.
                25
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     hws-53                                             One  final  thing,  if.there  are                         any  of  these,  partic-
                                   ularly  as  thev  relate  to  Nassau-Suffolk  and  Miryland  that
                                   have  not  been  turned  in,  please  let  me  have  them back.
                            4                           We  will  meet  again  at  8:30  tomorrow  morning.
                            5                            (Whereupon,  at  5:50  p.m.,  the  meeting  adjourned,
                            6                to  reconvene  at  8:30  a.m.,  the  following  day.)
                            7                                                      -  -  -
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                          10
                          11
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