0


                                       C  0  "I  T  E  N  T  S

                 opening  by  Dr.   Pahl
             2

                 Remarks  bv  !lr.   C. Robert  Ogden

                 Ogden Resolution                                              10
             4

             5                 '!embers of the@ Public:
                 Comments of

                            Dr. Donald Sparkman                                1,3'
             6ii

                 Response of Dr. Richard Janeway to Remarks of
             7

                            Dr.,Sparkman-                                      20
             8

                                                                               '3  6
             9   Arthritis  Report of   N4r. !@latthew Spear

            10   Comments by I-lembers'of'the Public:

            11              Mr. John Serqeant (Maryland)                       48

                                                                               5-7
                            Dr. La%vrence Scherr (ilassau-Suffolk)
            12

            13   review of  Applications for Regional Medical Programs:

                            Alabama (Plrs. Gordon)                             72
            14
            15              Albany- (Dr..-Watkins)                             74

            16              Arkansas    (Dr. @Kornarof f,)                    -79

            17              Bi-State (Dr. Watkins)-                            8,3

            18              California (Dr., Janeway)                          90

                            Central New:York (Mrs. I-lartinez)                102
            19

                            Central Wyoming    (Mrs. Martinez)                106
            20

            21   !3!ock Action                                                .115

                            Arizona (Dr. Gramlich)                            120
            22

                            Connecticut (@ir. Hiroto)@                        122
            23

                            Inter-Mountain (Dr.   Komaroff)                   128
            24
            25              Louisiana (Dr. Janeway)                           132


           1  Contents (Continued)

           2             Maryland  (Dr. 1,7ammock)                    139

           3             @lassau-Suffolk (Mr. Milliken)               14 2

           4             South Carolina (Mr. Haber)                   152
           5             Texas (Mrs. Morgan)                          1:') 3
           6             Virginia (Mr. Hiroto)                        163
           7             northern Pennsylvania (Mrs. Martinez)        i66

           8

           9

           10

           12

           13

           14

           15

           16

           17

           18

           19

           20

           21

           22

           23

           24

           25


                                                           ID 0 I',         T 1,T I- T     i- T  7' I    A   D     T,  A  T-
                                                                  1   r

                                       117',Tl( '.'7kT, @@',7Tc(@py                                 T

                                                                                    Con@erei,t--e POOM (,-17

                                                                                                         Lane
                                                                                                      ""aj'vl,-ind 20P,@)2

                                                                                    "hurscfa@:, Puqust 8,  1974.

                                                   The r7eeting convened at 9:1,@ arm., Dr. I!crhert P.

                                            Acl;-_incr D3.rcctor, Di-%7ision o-@-                     a I       i. a 1 P r,@ cl r a T-,. s ,

                                                                               c t i i, cT T) c-,,-     r c-% c

                                                   f7@PAF   J.   SII,SBEF,   Acti-ra   Cl-ir-f          OT-eraticins and

                                                       DP@IP,

                                                   I'FN@,,ETTT r;%U!-', Fi@e-cuti.@,e Szecre+--ary.

                                                   EDITIT l@l.   YLFII@L,  Pr)ise,  Ica"io.

                                                   DR.  ITOI@
                                                                 WA@@MOCY, La C-rance, Georaia.

                                                            E.   @LOOD, !'I Paso, Texas.

                                                   SFI,,7ALL 0.                                     Ol,.j.o.

                                                         Jo!:T".T P.                    C,.(,-,.,c.,nnc-

                                                                     P.  S,('T'RIT71"T P.,          ncrton, P.


                                                                                                                                                                            lic@@r Yorl-.

                                                                                C            11 I:'T, @lII                                          @,,,@ic@hi.ncTton.

                                                                                                                                                  T3oFton, !,@asFacliusetts.
                                                                                                    T 0

                                                                                                                Li                                                                             Carolina.

                                                                                        ('@'1,7A  R. CNRDOII, Creat Beiid, Fansas.

                                                                                                                             T@r                               Cal-if orrii-r-i.
                                                                                T@,             C.   IiIr.,OrPO,                -)F,   Angeleq ,

                                                                                I.IARTEL S. T@IORGA,@l, All)uc-tuercfilci, !,Im@,7 @le@,j-c!r,).

                                                                                A.nd Others.


                                                I     T-@e@--tinc lease c,,oT-.e to orL',cr?
                                      T,

                               no,.;7 -i        in,        @tl,,c head table, and I  think
                      ..e are

                              proceed  with this r,,-i@eti.ng of tl-le !National Advisory
                      w,2 can

                      Council.

                                 ijost of ;,ou were  here  yesterday  for  the  meeting  of
                 6

                      the ad hoc PIIP review Committee,  but  I  do  wish  to  @q-21come  to
                 7

                      the table ',irs. Gordon, and Dr. Ilabor, and @'Ir.                   i

                      are  very  pleased  that  you  can  re-arrange  your  summer   schedules
                 9

                      and be here with us.
                 10
                                 As you know, this  will  be,  or  is  expected  to  be,  the

                    i@ final meeting of the.National   Advisory   Committee,   called   to

                      disperse the remaining fiscal     73 funds, which have been release@,
                 13
                      as a result of the  court  or(fer.  All  of  the  1974  fiscal  fund@-':
                 14
                    i' were obligated prior to the close of the fiscal year, June       3,0@l,L.
                 15
                 16              And as  of  this  state,  we  have  approximately  28  to

                      30
                              4
                              -on dollars for mal,-lng  our  aviards  following  this  August
                 17
                      Council  meeting. ',:low,, we will  be  discussing  more  of  that  in

                      a  few  minutes,  because  we  had  a  rather  lengthy  open  session
                 20   yesterday.  And  -,any  of'the  topics  were  discussed   with   both

                      the Council members sitting as observers, and the review com-

                                   !IP-Fitate to go over all of the ma4.- --rial again,  @-id

                      perhaps    it Tight be better  as  we  oo  into  the  closed  session  to
                 24
                      taken up some specific noints.  If  there  are  qu-3stions  that  bear
                 25
                      on the po2.nts we discussed yestc--day, but             I s'lould makT-.


                         (,)n.@, of

                                             ici@,,ll@, for       nc-fit o.@L the thrc-c- who  coulc-l

                                                                                 is  iinIDortant  for,
                         not                  S          !)CC E IU@;

                         the day'.,i                   l'irst                rllb 1
                                                                                 e  O..i(l, ,,nake a

                                         and go over the current @;tE,,tus of tli@ legislation,

                     6   and  we  did  provide,,  I  believe,  a  hand-out,  did   we   not,   Gerry,l

                     7   yesterday?

                     8                    BAUM: Yc-.s

                     9               DR. @-,7AMMOCK: Ilo.

                     10              Dil@. P2\IIL: @,lell, it  was  intenO@d  to  give  a   '@iand-out

                     11  out.      Can we make sure that we set those now, toCaly.

                     12              @-IR. 3AUPI: All right.

                     13              DR. PAIIL: X@7hich summarizes the basic elements of

                         the Iiouse  bill that has been @-CT)orted out by the full com
                     14                                                                        mittce
                     15  I  won't  go  into  all  of  that   now.   Because,   really,   I   believe I

                     16  that we still have mny steps to go before we have legislation

                     17  and  by  giving  you  our  summary   statement,   I   believe,   you   will

                     18  understand what the main features are very quickly.

                     19              It is a long bill, some one hundred pages.   It does

                         certainly   make  provisions'for  a   transition   period,   and   we   full'
                     20

                         anticipate  that   the   local   regional   medical   nrocra..@-   together 1

                         .iitli these Cli'P agencies and   experimental. !,-rplth   s
                     2
                         SYSL@ems,  and 1,Iill-Burton organizations will be         given the proper
                     23 li
                         opportunity to becomc incorporated into the proposed orcianiza
                     4

                         tioris.
                     25


                                                                                   -ainl,,,, in an\     war
                                                               c -@d      no@  c

                                                                                             tho@,e of    7ou
                           to i@,@rpc-tiia4L--c@
                       2

                                                                         ---ion closc-1,    @i..Il certainl@,
                                         bee-                    le c7,-

                           anp-eciate,  tl"-.
                       4

                                                .ye have  cc)-,Dies    t,,c  floor   bill   we   will   try

                       6   to  -,et   them   out to you,              i do believe that it will be
                           faily  close   tc)   what   may   be   Passed.   And   of   course,   the   time
                       7
                           table for enactment of legislation is unknown for good and

                           SU'Lficicnt reasons.

                         11             But it                be Passed later this fall.
                       10
                                        l'IR. 1311,P,@tDWS: You ha%,,e just c,,iven me a note     sayincT the

                           suTrj.@,a.ry of     ",,Dii'L is attac;ied to t-@e   Council agenda.
                       12

                                                                           c- i -n, sta@:)led.
                                              -3      It  s
                       13

                                        DR.   PPIIL: Oh, I    thou,--t  it @@l,as a  seperate hand-out.,
                       14
                       5   I see it.      It's  @-.ie  next  to  t' e last item.      There is a @@Tatio.-ia-@

                           Council for              Pol.icv                                       c do not

                           know at this time what relationshi,.') such council will have
                       17

                         i with this council, or        to the    ol--@er legislatively mandated

                           councils, of the constituent           procrra,7,s.

                                              OCDE'@   1-ilould it h)2 a--D--onriate for me to s,@ak

                           to         3. -    a-.ion at thi s
                       21

                                              P,,.",,L: Yes, I bcli-e%,o it    ould  be  a  goc,,C,  im-@@.
                       22
                                              0 r) F",L I  r c- v 3- C.,@ ., l' n c@ Pubel's summary yesterdE,.,,.,

                           and in think-@@lc,-  bout tie matter overnight, while I have not
                       241
                             t  lia.c7, an opportunity to read -t"-'ie sur,-,rary fully it is here.


                                                                              that Ili? '1620@,,,       @!e !-aware
                                              a
                                                                                                                    d

                                                                                              has played in tile
                                                    to i@,no.-cc-
                               a s c r     seems
                                                    ronment in recent y@@                             d lil'-Ic-. to
                                              crivi
                                                                                                       session,      thei
                               rc ad         s council and to those r)@                -it at t@
                               open s@i.,,sion a letter from c-natot @l.agnusen who is chairman
                        5   i
                            I  of tile -F@@.)coTrmitt---ce on Labor, llc-al,.th, education and @,7-alfare,
                        6

                               addressed to
                        7                        Senator 1,-c-nned@,7.
                                            And I am quoting.   Dear Senator Kenned@y.   It has
                            i  been reported to me that th,@ proposed legislative revision of
                               t,,ie   Pul)lic   health   Service   Act   in    ef@'ect    eliminates    the    Reuion,-:,.-i
                        10
                                         Programs.      And      w                                             tha
                                                                 oulc?@ ,Iivert the aopropriation                   t has
                               been   used   -,'or      purposes,  to local I,,lanning agencies,  as
                        12  ii
                            11
                                                 the present pro7 osz,,I.
                                            Planning agencies          would then be expected to develop
                        14
                               services    in  --he same rtanner       that I-Id@iP has been doing in recent
                        15
                               y,,2ars.   I am somewhat conc3rned whotner planning agencies are

                               -he al,3                         to    be    eng
                               4@    .-Propriate bodies                       age(i in the &cvelooment of
                        17

                               services.
                        18  I
                                             From my               ncc- with           -@,7ashincTton-Alaska          Regiora

                               'ledical rrograT.
                                                      it     seems to  Tqo  that  tile   dc-vc-lo-,.)i-,an,@-   of   services
                            ii-in this domplicated undertaking                               tl-i@-@ si-lills of  -,,)e@rsons

                                                 4
                               c. 1 Y, -,p @-; r i c, n c c d@n         o."'  c@@r:a,  and contract -)iannincT
                               )ends  almost     entirely on the determination of health care

                               needs
                        24
                                             By an agenc,",             @;taf,,-         can at-@cm@. t to i,,iatcli


                                    a]  Ocinand for @,erv

                                         It    scarrs that few if    z4,, i,, 1 1i-i n i.-i g :i c@ n c,sL,7@Ve
                      3
                           a br(-     @,@7,cctriiiii cj--@                                              -ence   i
                      4
                                         for thc,, actual cr,-lati,@.            services.          r  does
                      5  il
                           it see                                                                      r,
                                   m Practical for the F)IaiinincT agencies            to do so,  s4  ce
                      6
                           it   would   create    an unnecessarily      lar  c- and   cum!.)c-.rs        rganiza-
                      7

                           tion.

                                         I would think that a plann-iig board should be caoable
                         11 of   expressing   the   communities   will   an(,   the   board    of    a    develop@;
                      10
                                                             able of mal-,itig sound tac,
                         !I rient agency should be cap                                        t           C. g-
                                                                                              inical     -u

                           ments about the best way          to develop scrv)-ces at

                           level to meet the needs outlined             by the -r)lannir,.c,   raqc-ncy.
                      13
                                         These are two distinct         a c t v i L-. is @,,,h i c-, r@- v. r e t@f, e

                           involvement   of   boards   and   staff   with   tl-ioir    efforts    and    different

                           skills.     This  is  the  v,,ay  the  successful  r@@ip  sued  as   the   ',i',
                      16
                           RT,IP are now @@,orking.      I  am  concerned  that   if   we   atteml-)L-   to  thrt)rv
                      17
                           both activities into the                 @tructur@o,   one   of    the    activities!'
                      18

                                               d it may
                           @4ill suffer, an                 vc-,r@l  well  be  the   quality   of   the   service.,
                      19
                           developed in the function.

                                          he me cl    I s cli oo 1  facult@!,     the     medical     specialists
                      21@
                           the    medical     admin'    ators                         :irc               inter-
                      22
                           ested in -the way  care        is   delivered   at    the    patient    level
                      23
                         I withdraw   or   not    be                     if   both   functions   are    assiq-rc-,
                      24
                           to a'planning agency.
                      25


                                                                                                                                                             for        a
                                                                                                  carc-
                                                                  p r!
                                                          7@,

                                                                                                                              ai,
                                          n, @3   c-) n  a  1hr@             i.,-, 'Li r a ii c,-@

                                                                                 the  talents  o@
                                     4                    has                                                                                          t

                                                                                                                                                  cl, C- s
                                                                      of  those  MO                               :D
                                     5                                                        St  a!-',

                                                                                                                                                        oi:        all
                                     6                          Z;if2:,Ir       record        for        c-,ai-ii",Ig the  coo@r@ra.t@-"-on

                                                                                                    iT-,,rcvina         the         ci,,Iality         a.nd          access4L 4-
                                     7    of  the  delivery  syt(-    and

                                                                                                                            ',iea
                                     8    of  care  is  unequaled                       amoncT      the      ru!D!,Lc              lth  service    Act  pro

                                                            It  does  not  -,eem  reascna                                                                            17
                                     9    drams.                                                               ble  to  assume  tlat  the  ca,-)a!Di',L-
                                     10 1 il ities          R@IP          organizations          are          developing           are           trans--Ferrable           to
                                     1 1  other           organizations,           especially           -,,,:here            the            -ieiq            organizations

                                     12   have  few  of  the                 ta'L--nt                                                                --ssors

                                                                                                                                            org@krii
                                     13                         Certainly            I            recoan.-"Lza            ali-1                         zai@-ions
                                     14   lil-,c-  olann4..ng  aaenci es  and  ol--@                                                                    vc-.       not  ',-@-,en
                                     15   uniformly                  successful                   tliroucThout          nation.            But      anv           lack  o@  f

                                     16                                   e  attribut@olc  to  laci                           of  consistent  leaders--iTD
                                          success           is    mor

                                     17   direction  at  the  fc:O'c-.,:ral                                  t,ian  it  is                    fault        of         the

                                     18 1 anDroach.

                                     19                         And  undoubtedly  arc                            doing       to       need       to       make       SOMP-

                                     20   effort         sometime         in          ,-.he          develo,@-,-.en@- of          healtl-i          care           resources.

                                                            y                                       a s          c, d  t o  a c,, c- n c i. e s        c)      c- y iD c r

                                            n(a
                                     -2
                                                         @-@@a@ht       r@d to                               on-,,    strt@,'I(7tlien-@d  ir,  sr-)Iille

                                          0
                                     24

                                                                But  in  ii-@                                       r o                             nt  the   bes-


                              means of increasing                  (juali-ty and accc,@,@7,i-L)-i@lity o@L ccire  for!

                           2  the average  ci.@-3'.zcnl.

                                                                                             t'ic-
                           3                  In                                                                egisla-tion

                           4  will be able to rct,                     both the  ccnsur@ier ond proviOer

                                                                   i@ak   the   health   sy!7,teri   .,-or,-,   -r-   o;Dcrly.
                              relationships needeu.                       e

                           6  There should be some             wav      the new legislation can           i7i  @ir-e    the

                           7  cont-,i-nuation     of     healt'i     sc-rvice,3,     development      agencies      si7@,il-ar

                           8  to ,ir
                                   i@-     in     structure     and     experience-,     thereby     not     dissipate     the

                           9  national resources that we have Cic@veloped.
                                              It might well be advantageous  if                  the new i-ec7islatl-4-o-i'

                              were to establish a formal mechanism to assure that t@-)e  -efL@o:-ts

                           it,, of the planning agencic---,  -Lnd ti-i@           r-..'.!P arc.,coordinatc-(I,  i.@
                            11 that P,,"--P's  are in fact Oevel6ping delivery s-,r
                                                                                                   Zstems to       7-@e-t

                           14 the    healtli    needs    identified    by     t@le-     -)lann,-nq                and suc-'

                           15 mechanisms       could       certainly       bebe        established without      sr--ro,-,@,ing

                           16 the present programs.

                           7                  Creating      entirely      new      bureaucratic       structures       in

                           13 future,  and in the process,  using what would re-main                                   nave

                              achieved    for    existing    I@.IP    systems,     such     as     the     I-lashiiigton-

                              e@iias,,-.a    program    have    been     highly     successful.     Thank     you     for

                              your c,,c)nsiderat-i on.

                                                                          C.       -(7,iiusen.

                                                      I V70ii)-d          to   @.,i.iggest  thvt.  it   is   the   :-@@-nse
                           23
                              of this      Council thE,,t llr,, l@204  as             Ili-,-iLv!z l@icard it
                           24
                                       dequa-te as it is now drafted.   In that it  fails to rc@!cog-!
                           2,5 is i n,,-i


                            niz@  sufficiently  ti-L@-,-      0

                         1  d    1. 0T-i n  t  c@ c) 2:

                                                                                           liiiii@-(.@d  to
                                         7      f f 0 I.-
                      3                   ,,,n  d

                                                                    --iiii  a  s+,at@A                to  bc!
                                                   h i c

                                                                 of  th@,   'Local  lic,@Iltli  s@.rviCc  area
                      5                     ir,  the  c,,-., c c

                            wi--thi,-i  a  state  @,vhic-,    @jc)v@,-rno.L-
                      6

                      7

                                                                                       75,000  a  yraar  t,,,,
                      8                       @,d                   -ils

                      p                                        is  gros
                            y -a:r-           r  a  T) r o -, @, c @ -,
                                     mit        fc)                      sly  in,nC@-cuate  in  our  c-x@er-

                                         a             v           ot     tc -a c,"               or

                            ay)i-)Jicaticns.    ',herorLt) 3-- c- ',Ioul(:'   li'll-,e  to        a

                      12            these  ].4Lresi

                                                                                                                   4
                                                                 i a -L-                in  acio,@:)tixig
                      .3

                                                             4                                               inanci.
                            a-,-  sirtilar  legislat4              eF-,c'i
                                                                                c       @tatut,@,,    ai
                      4
                      15    al  support           to           -1@ainta4@nahealth

                                     on        a         s'-,ats-%qi6e or  i-ndc,,-,De.-i,@lent  (:c;i-,,missj-c)n
                      17  11 i.n a  p-Labli---Iy                      P@rd devoted                      to
                      18    work,   and  be  it  furl.-l.,,i,-a--         that t.,-Ie corrnent.:@-@ T-)rece-od.i-ng
                      19    this resolution,  cind             @-esc)lu@-@ion  itself  I)e  trE,,-ismitted  to
                      @o  1 the               of the           IntcrctE",.- a,-,d Fo.-eign Con@merce
                            Tpit4-Ce, and  the  Sc!nr,,t@-,          atid Pi:@l;)lic            cc)mm-
                      21                                                                             ittee  @o-

                          @"thcir consj.(ic--.,@-ati-on.

                                          DP. PP@TIL:            ,,,-@U "@r.  Ocrden.  'k r,.,ioti-on has
                      23
                                                                                    0  U-"4 on.    is t'@
                            m@,d@,.@, to he,@i,,a

                                                        4
                            a sc-@i-bnO, to
                      25


                                                  c- o r,d         i e     s- c- u sc n

                                    DR                  0(7,(I(-,n, would you rr@ael thal- r-c:-

                                please.

                   5                     O(':D-N: Bc- it resolved that t'-,.c Conciress in
                   6 ii ador)'-ing IIR 16204  or similar legislation qi                 a-"e  the
                             L                                              ve each s@-

                   7    statutory  and  financial  support  to  maintain   a   separate   h@-alt'-

                   3    systems development agency on a state-,,,iide basis or

                   9    confession appointed in a publicly n-ccoun-L-ablE@; i,7ay a.,id         e

                   10   exclusively to such %qorl,,.

                                    And  be  it  further  resolved  that  -L"I,,e  comments  pre-

                        cc-ed-',-,-.g this resolution, and thc-,  resolution  itself  be  tr@-ns-

                        mitt-c-d to the members of         IJOUSC- Tntersta%@.e and Forc-liarA CC-.-

                        mierce Committee, and the Senate Labor and Pi-,blic li7e]-fa,--e

                     'I Committee for their consi(-,,cration.

                                    DR. PAIIL: Discussion?  Dr. Schreiner?

                                    D    S C 11 PE I'-"@ l@ IZ: Y r@, s .I just wanted to ask a quc-s@-i-c-.

                   18   You  would  favor the dissolution of the regional process?

                                    l@4R. OGDEN: Yps, I are. T,@ecause I think this piece  of

                        legislation is directed to@,7ard the state-@@ide activitv.  1

                                                                                  Droarans  flo--
                         "cognize that many of our regici-.,al and r.@-ted4-

                              state boundaries L@ut           @r-- to have @in incapsulatc@e,

                        )rogram which is state !)oui,-ir3ary oriented, it seems       to me

                        that we can accomodate to that through our ekisting RJIIP'S.

                                    DR. WAL@ILIOCK: Your point was a specific  statement  b-z
                   25


                                                                         a t                      -i r i- i.,@  o f  1      z@,a
                                                     01"DE":  Yes,

                                L j-n

                                                                            ca,--4   c,,ala:r          Of   legislation
                                               D R    Y'    0 C.,,'
                         4
                                'Because    the  Pi',P  as vie have b@-en  !co':-,ing a4-  them             doesn't over-
                         5
                         6      flo-,,7 into other stated-,  Dan(! -@c)

                                                     OGDEDT.:  That's  cc-r--cct.
                         7

                                                                                       T    n
                            I                  DR.                                aS             rstand it           I     was
                                told       them could be no       larger  than           this room,  or they  coulC, be.
                         9  II
                                the       whole United States.            T,-. E, ts   h   at Called a re,;,i.cnal area.
                         10
                                co          are seeing sor,,l@-' of  L-hes             Pines, this is  sor,-,.@-.  of the

                                                               t--tj-nc, to       ;..i:-,d   a].'   Cay   @,,c-sterday,    an@
                                things that I @,;as PuJ
                         12

                         13
                                               I  did.,-i't get i-ip                          c.-   a   sit,@st   of    pancr.

                                               MR.  OGDEI-,':  Cf'  course,  'It,,e Iiave so,--,e      sta-L-es,  for
                         16     example,  California,  where we iave one-  -TZ@'ID                  for the -,...?hole    s t a
                                For the  state of New Yo--].r,                         at  lc-z,-@,st four.

                         18                    DR.                  Four,                ritht.
                                               I-!R.  OGDEN:  -P)Lncl under this ne@,@,, r)i,@ce  of  legislation,
                         19

                                J-1                T,;ILP I
                                '-.iese  four F-
                         20                            s would b;ncome  one.

                                                      "i,"i'21.a','MOCI'@:  Yc-s.
                         21
                                                                                        -all-,,       Dmetninq     I      have
                                                                            n        nL-
                           2
                                suggested      to this  Cou.,)c--'Ll
                         23  11

                                               DR. T7AIl@
                                                           LIOCK                              n on
                                                                                       :a e  c,       it longer than I
                         24

                                1-i ave .
                         25


                                                               u r -t

                                      DR.

                                                                                                   ra

                         vote  on it until               l@   a               0 c, C- to   Dead    ti-,e
                     4

                         !-,u-mz,-rv of  tlii ,@2,  I i c'-                 ',.a,   t  ',a-! a chance
                     5

                         to   do    yo@-.

                                      T   oa'): e  a c t i o n c n   c E,. l@ @a basic        an,,Dreliension@
                     7

                         that   a   r.)lz,.nn4
                                         -nci   auency   is   not   +---,,Pica!-,   a     ConsL-ituteca

                         to represent th-- orbvi-(fc-r-,, or to                 service        activi+,-i@ti.!

                         I  thin',"  it  is  a  -\7e--ry  real  con,@n-rn,  but   i   s',,iar=-
                     10

                                           P@TTL:  I am sure others                 ave  no+.-   has.   e
                                                                              -:D  s  "I

                         opr3ortiini  v also to read this,       anr.               !cunc4l's          Sensei
                     12

                         17o w 1   d        -t 4                                1   r    -r,       ha
                                      r c r         or. th -L S

                                                                                         -orn
                        "had   n r-) -n t-, o
                                         L. @.L                     n,7 L,-                     inc; c-f -re--
                     14

                        !'break.

                                      I  believe I ,.:ould like to                 @,usuail- step of

                     17  asking x-7hatl-.er an@,r          of the r.@          necatise  I   know   that
                        Ilse-veral people are here from       P-'-'.Pls and al@so -@r. Sparkman,  \.,,ho
                        ..is the Chairman of the Steering                                ',national
                     19
                        ,Coordinators, r-,igl-it .,7ish  to  add  a  cor-@,lc-nt  at  this  Doint  in
                        Ilthe proccedinus, and if -ict,                         ano@Lher o,:)nor'L-.unity
                     21
                        li@during the formal public session @or               cc.-@.@@-ts, on    this
                     22 I;
                        ii.point.

                                      Dr. -@,-,ark.-nati, wcjul@     car:2 to -.a",.e s,):ne cor,,@Tr.@-rits ati
                     24
                        ithis YDoint?      On the topic u,-iifer cons,-,@---ration?
                     2,I)


                                                                                     for tlii,,
                                         D'@

                                                                                               on the
                                         D P,.                 tl,t.Lnkin(., of cor,

                                                                        i-i c c C) f            s c o   a   ns,
                           if IOU                C- @-,D,Dj.Cf    U

                                         PT@. ,-'P 71, T                                            -c    the
                                                                             you.          @rc-cia4t-

                      6    chance of                  before you again.          And r,@        nting th-
                                                                                            prose

                      7    Coordinators,  cii-ici i    sup,-,o.-c'L--., motion as read by llr. Ogden.
                      8    I thin)-, the two important factors in the bill as I understand                       i
                      9    it -- I, too, h@i@ie not               the entire bill,  although I have

                           seen   the   summary   that   has    been    distributed    to    you.
                                         And T have lool@-led with              care on 13995 which         is

                                                                         -i@3 not  be
                                                    -v@Thich I -L.Ilink hL           en  m(,-.)Cified  -,Tcry
                      12   it',-, -,rodecesso,,

                      I    but       iini-, there   are t,/jo -i-T,@I)ortcii),t factors.
                      14 ii              one is t,-ic                    of existing      stat6-v7ic'@,-3 O.L
                      15   regional PIIP'E-, into smaller area-%iid-a regional Pledical ProgranLs,

                      16   I than!, the  subdivision into multiple smaller areas                   is a,,Dproprj..-

                           ate for rlanning   as has been do-7ionstrated by the act4-.-on                 of
                         ithose   C.TIPB    or    area-wide    agencies    which    can    identify    health

                      19
                           problems in their areas and deal with them.
                      20                 But   +--his      I think,  a totally inappropriate way

                      2i   from   rc-gio.-io.1 @-'@odical Prograris  to  fLinc,;:  ,@n since on a state@

                           wide   ]:)asis we can       acquire staff z4,-'Id .1                   and a brcad-,.-.1,
                      23   of   (iif'o-ront   kinds   of   di5cipl.ines    and    deal w      )roblc%-rp@s which
                      24   v@e clc)  on  a                I)cisis with the                @-;Socia-Lion,  the
                      25   volunta@,, health association, health dcpartr,.-@rts, and otherwise


                                                                          rs
                         II deil with health as si
                                        i think it     oulci         virtually J-@-rmd.nat,@ an

                                                                     liar ,,iith.   P,,nd as a matter
                               in t",,.c@ arcf-a:--, %.Inch

                          of fact, 4-i-i       blue                   -@L@ C.)n(.; o.L@ @@-h@, --@@i:)nrts on
                          @-7ashi..,-igton   ..-!"-h mat-t"cr@,, @,.,hi.cli I       se-i@; of @,,,ou  are
                          familiar with, last               rcl?ortsd tliit         @ill    as    written
                      6

                          would be the last rites               P-,I'@P
                      7                                   f or'
                      8                                                              at any health
                                        I think this in effect        is -rLic,    ,-;-l
                      9  11 resource development activity '@-i.nd of things r,,,'iP                doing,
                      10  look  to  me  to   be   added   as   an   afterthought   and   in   a   totally
                      11 !I inadequate manner.   I would like to mention just a couple 0

                      12  other things, Ilerb, if i eight.

                                        DP,. PAHL: Please.
                      13

                                        DR. SPARK@,,@-,'.'.,: Relative to the or.,L,-,ntat@-c)n      have
                      15 Ilto regional medical program I know that -oine of you have
                          served on regional advisory groups, or ati.ior co:T,,irtittees               or
                          in ther'ways -!lave  been  involved  with  the  rec@ic.)nz@.'L  i@.@.@--@clical

                      18 lpro@lrams.   I   reccanize   that   some   of   the   others   of   you    have

                      19  some are new.

                      20                Sor@,ie of your Predecessors have had the o,,).,t),@--tunlty

                          having to     site visits to regional medical proc,,rams, aiif,, those

                                                                                        -i v(@,,:@  helpful
                      2   I have talked to liiv! indicated that this                    L
                          experience in understanding what P,'.IID's do.   I r             co,7niza that
                      23 ii
                         tiyou all carefully'  read the written material we Sil'-Mit to You,
                      2,1@
                         '@-,,:Iie applications for pro-rams or projects.


                                                                                                t i                        r,@ v -L
                                                                        '@'o You for !:h,@

                                                                                                             (@Ui      4-.
                                                                        that -thn-
                               a 1,  o
                               tli,-2  st(-,ry tha-  I                              iavr@  an   o.l,)i@,ort-upity    to    und,-3r-

                                                                                                               t,    or    had
                                  -,nd    f you    were actually had had                    on-sitc@,,     vi-s-

                          5        littlk@    Moore    co@,-ta--t
                                                       %,7 you have  an orientation  session for Dr.  Pahl
                                                  kno

                               and his  staff the  details of which  I                    Or)n't    kno-,,,,,.    But    since
                          7  1
                               I   have   thoughl--   about   than   I   I:)L@latedl,!    rc.@cocTnizc--cl    that    as,    a

                                                                                                                       n
                               grou,),  the  coorc-ii-ators of il,,Pls hEvc done                    i I)oc)-   lob     i          i
                          9

                                                                                                E-, f un
                               expressing to what              th            the                           -,,on.

                                               7@,,nd I h@,vc. %,@ri.tten  to Dr.  Pahl         as]-,ing   %,,,,h,-th--r there    i

                                                       -iE@t      id                                           -,lines  f
                                                                u                    us  from commurilc,,,
                          .2   are  stren-ths  ti
                               with you,  and I         h E@    not    had    an    opportunity    to    have    a     res,,-)onse@

                               to him (.;n this,                        lir,i  to  follo'.1y, u,-) on        unl@,,-@'s   vlnu

                               want to speak to           it at thc-@ moment.
                          15

                                                                                         4
                          16                   DR.   Pi'k!,L:   I         ve not,      i--.,glit at this  time,  I-)ut we
                          17   will be  discussing this with  some C)4-' -r                                 individually

                               and with th--- Steering Committee.

                                               DP,.                  As  an example,  I don't             )@now        whether
                          19
                                         mbers of the National. Advisory Council i:-cceivecithis which
                               all me

                               is  a report of a                       ac,@couT-.,t@,@oil-';_ty rCT-)ort that was  submit-'--,-
                          21
                               that was  released about E7, i,.,,onL@-ii  EcTo.             'L,V'Iij.ch   is   -this   a   familiar

                             iidocumen@- to you?
                          23
                                               14R.  BAUI-1:  Tt's b,,-.,en mailed.
                          25                   DP,.  SPAI@,Y,@'-IAN:  I'lo!i@7  many   of   @ou   had   a   chance   to   see   it?


                                                 It
                                    DP,. PA.

                                                                                             4-
                    2

                                                @-7c-11 at t@ic- time of our I,,)hon,-., call it

                        E,-"-Iould hav,-@ I-,f,-@n re@--@l"v@---d bv you.

                    5                    OGDE,',I'4. I did i). o4L-- receive

                    6               DR. SPAPKllAN: l@ot verv    many.

                    7               DR. PAIIL:      shall  make  other   copies   available   to

                    8   you.

                                         SPAP.J.'@i",@.11: 'v-@ell, this is of no value in r-@easurinc
                    9

                    10  individual 21-@iP's.   But it  is  a  r.,teasure  of  the  aggregate  Impact

                        of Pd@.!P's  -n  helping  to  train  health  professionals  and  actuall,,-,

                    12  servina neoole.      ZrLd in implementing    community activities,

                                                                                      of it   i4-
                        and  while I iqouldn't ex,@Dect you to read c-,-v,@-ry  @,i o r cl.
                    13

                        is reasonable -well done.
                    14

                    15              And it is the    kind  of  thing  that  I  would  hope   you

                        had  had  a  chance  to  look  at.  In  order   to   better   understand

                    17  what  we  are  trying  to  do.  I  would  like  to,  @-heri,  after  I  have

                    18  had a chance to talk to Dr. Pahl, follow-up with Plays  in

                    19i which we may communicate with you.

                                                     4
                                    T,7ithout burdc- Lng you.
                    201                                          I know that you all have
                      1 more than   enough to read.  -A.he @;econd item I would like to
                    21

                        retention briefly is the goal of -the @Tati,onal Advisory Council

                         nd  I  am  pleased  that  in  the  motion  that  llr  Ogden  that   was
                    2s  a

                      !I seconded tiiat you all looking at the policies of PIIP that %,,ou
                    24

                        all, I think, then beginning to take steps to provide the


                  I  leadership that the I atic).nal Advisory Cou-,icil has ,)rovider,  For

                  2  Pl@,P in tile past.
                  3             I recognize that in your left two meetincTg in tli--
                  4         s year th4-ngs have bec@ii T:)r-t-I @@ll. upset, first as
                     previ.ou
                  5  a result of the        (,IlLit directed by the administration, and
                  6  then the rather abruT3t release of impounded funds so you were

                     kind o.L overwhelmed with applications.
                  7
                  8             But I would like to remind yoii that you are a very
                  9  respected  group, on     health care !scene.  You represent
                  10 a  group  of distinguished and dedicated people and that your
                  11 word relative to regional medical  programs  partlin  health  care,
                     is important an            h a tyo         take tire to d  3 v@r  1
                  12                 d I tliiiil@      t should
                     to consider health )olicy from the stand     oint of t
                .13                                             p          he   National

                  14 Advisory Council.
                                Arid I hOD6 that you will have time to do this. At
                  15
                  16 your last rieetinq, as an example, two resolutions came to
                      ou from the National Pc-view Committee,  and  one  f  them  recent
                  17 y                                                  0
                  18 mended that CTIP's turn to i@!,IP's when appropriate for  technical
                  19 and professional assistance regarding health care changes.
                  20            And the second one encouraged ',Dd@IP's and Clip's at
                  21 the state and local levels to work together closely to eXp      ore
                     ways in which better @)rograms would be carried on rega d ess
                  22
                  23 of the exact lanauage   that is in the legislation.  These, I
                     thought--, were both good ideas.
                  24
                                Mr. Rubel spoke against both, and after what I though
                  25


                                                             tion    in @l discussion   by    you,    both    of
                        I   was    verv    brief    connide.-a
                        2   til-cm were rejected.   On       June   2 0 , i.m,,@;;clj.ately   after   the    meeting

                                                                                                      4
                        3   I wrote to ll,lr.  Ptibc-1 and said i @,jas d'i,qap          nted in       s    dis
                                                                                     [)Ol
                        4   approval   of   them,    and    it seems to me          3   is    i.nconsistent    with.
                            his    previous    statement    relative    to    on..,-@@Din    positive     relations,
                        5

                        6   between PJIP and CIIP.
                                         V.Ihich I wholeheartedly          support.    And    I    said    that    1
                        7
                            I hope that there       will   be    some    tangible    evidence    from    him
                        8
                            on    action    relative    to    this    positive    relationship.    Ile     hasn't
                        9
                        10  responded   to   me,   nor   have   I   seen   any   evidence    of    this    action  1

                        11  on his   part.
                        12               To   -,ul)Dort what he said at the meeting last
                                                            regarding this,   Pt the I,,Iasliington-
                        3   Let me add an anecdote
                            Alaska    area    we    have    two    particular    grants    where    have t
                        14
                        15  forces    looking    at    these    kinds    of     alternative     arrangements       I
                        16  between   RMP   and   CIIP   with   the   best   people   we   can   find   in   both
                        17  RivIP   and   CHP   and   other   health   care   activities   in   1.)otli   states.
                        18               kleeting   and    trying    to    shed    their    vested    interests
                        19  as   much   As   possible   to   se--   what   kind    of    program should       @mergei
                        20  and  lastly,    that    in    Alaska,    our    coordinator,     who is how   a   v-3rVi
                            ab                                                   week that     sh-
                              10   young lady announced -.to me last
                                                                                                     i was about@
                        21
                            to get married to the director of the Anchora c-                   CIIP    agenc
                                                                                                           y-
                        22
                        23               I said I was all for this kind of exploration,                    but
                            it seemed to          thi@ @,las carrying it A little to far.
                        24
                        25               Thank you, very much.


                                        AIIL: Thank you         much, Dr. Sparlcmari.    1,7c-
                                   1) R. P

                       viill have a formal open session  a  little  J'-@,-tcr,  and  others
                  3    Presf--nt should :Lc--l Lrc@- '4-,o comment u on    matters tl-i-at

                  4    were discussed anci   Dr. Sparkman, should you wish to make

                  5    additional comments.
                  6                But .qe shall table the   motion  until.  the  Council  hasil

                  7    had the or,)portunitv to review thc.,z summary.

                  8                DR. JIY@IEIIAY: At some time in the   agenda-,  I  would

                  9    like to resoond to Dr. S$-)cirl,@manis comments   about the

                  10   ations of the Council relative to the resolutions.

                  11               DR. PAi'IL:  Perhaps  this  might  be  an  appropriate  time@I

                  12 1 tlien, Dr.  Janeway.    Our agBndE;-, is fl-(@--xible thick; corn ncT,

                       and perhaps this would be a good time.
                  14               DR. J7,NEIIAY:   I would like   Dr.. Sparl@man,   I would
                  15   not  like  the  impression  to  go  unanswered,  that  the   Council

                  16   did not  deliberate  appropriately  upon  the   substance   of   the

                  17   resolution brought bv the Technical review Committee.  In

                  18   particularly that the    wording of it is such th,-t,t it implies

                  19   a necessary conflict between CHP and P.DIP.

                  20               The concern of   the Council, or    at least the sense      i

                  21   of it as 1 recall it, was that there was        some  concern   over
                  0&2  the Planning   in control function being amalgamated into the
                  @23  same agency.   The iii-Lo'Licati6ft is there, we felt, and I think,
                  24   quite correctly that the advisory council for rJ,P -- it would

                  25   be inadvisable for this Council to be making             dictatorial


                      statement from an adversary Positior@L           to t        O'Ll r,

                                                            control.
                   2  of  Ein agercy over           havc-.@ no

                                                                    that  thcre  was
                                -@@nd I  ould liop- to r,,"ia@,sure you
                   3                  w
                   4  adequate discussion, at  least in the mincls of the pe6,nlO who

                              nd this table.
                   5  are arou
                   6            DR. PAIIL: Than]-, you. Is there further discussion

                   7  on this point?
                   8            If not,  I would like to return to my brief report
                   q  to you.  There are several points and items of business we
                   10 should consider this morning.  First, I would like to, with
                   11 the indulgence of the Council iii--P@iber-.3 who were here yesterday
                   12 to repeat very briefly for the   benefit of those who were not
                      here y6sterddv, our current status with respect to two ap  .-a-
                   13
                   14 tiofts that the Council ,lead considered last time.
                                Let me take this opportunity to    do this,  because  we@,
                   16 have representatives from both  of  those  regions  here  this     i
                   17 morning, and they will be  speaking  with  us,  very  shortly.
                   19 And in order to provide the proper    background and undetztandir.,7,
                   19 1 believe it is necessary for me to repeat these remarks of

                   2o@ yesterdAv.
                   21,          As you w;"Il recall, at out last council meeting,
                        o of the tdcor-r@iencaations rTiade @@@ith regard to sliec- aonli.c4:i
                   22
                   ?.3 tions   the Applications from             and nassdu--S,:,'@'foll-,
                            f the fbllo,.vi             that is, trial funds should no4--
                   24 %%Ye re o           ng nature-.
                      be awarded for those particular apl@).ications  and  also  that  the
                    I                                                                    i
   @ :              I
     I          I  .i @


                       tvyc) programs i.i-i         ,;houl.d !)c. terminated in an  ord,,L-rly

                    2

                                                                        O@  by the    r,.lctor
                                   Tho --ccornraenclati,oris @,,Ic@,re accc,,

                       and we were on our         to                    @'@e in good faith
                    4

                       when it was called    to  our attention thal@@ ar.Tain, as  a  result

                    6  I am afraid, of a dismal ignorance of the        law, that @,,e  were

                       not able, as a  matter  of  fact,  to  implement  what  had  been  th--@t
                    7

                       Council recommendation.

                    9              71,nd the second part of  that,   the   orderly   termination

                       of the two programs, that is, we      had only the opporttinitv to
                    10

                       implement  the  first  part@of  the  recommendations  and  threat  is
                    11

                       not to Provide funds for those sl-@r-%dific apl)l.icEi4-ion-,  that  were
                    12

                       re'vie,v?ed at that time.
                    13

                                   In fact that  ,vas the case.  No awards were r-ade at
                    14
                     "the  June Council to either the Nassau-Su@-folk or the
                    15
                     !I programs.             we were in error in believing th-@@,     @,our
                    G

                       recommendation could be implemented and when we        were advised
                    17

                       of t:,ai@- error by our off:Lce of general   counsel,       ir,,i-Tradiatelyi
                    13

                       got  in  touch  with  the  reaions,  and  pointed  out  that  there  had'
                    19

                       been an error, on our part, and that what       we @.7ishe@, 4t--,-) do was
                    20
                       inform them     i  they (.].i.d havc- a riaht, and @@c- ho,,-)-- -L-,Il=v
                    21

                        -zercise -t            to rn-submit- applications for
                    22 11
                       by the  revie@-i Comm itt c- @7@st rda.,,,  and by this Cc)uicil.
                    23

                                  The reason that that action was risen was that         the.
                    24

                                                                              @%le reviewed
                       appl4 cations in question, the          cations t@ial-
                    25
                                                                                               i
                                                                                               I

                     I
                     I


                        in both the June
                                                      -and @ipf)' ic,!atioi-is under
                                            Council

                                                       @7 are sup..
                   2    a,r-     Council   techriiczil.'          T31ement,.-, to @-xirtinri @)@rcint.-,.
                   3                The I)u(Iget p,@,r.4Lod for all. re(-.,ional medical i
                                                                                         .?rograms@

                   4    extends from February 1, 1974, tliroiich       June 30, 1975, and
                   5    those ai:)Dlications revic@vc-;cl at the last Council meeting, as         ii
                                                     you todav technically are  sul)i)lc-rk@@ents],
                   6    well as the ones before

                        to exis4L-.ind aiiard@,.
                   7
                                                                                                  t
                   8                Therefore  it  is  not  appropriate  for   the   Council   to
                   9    make  a   recommendation   beyond   funding   for   the   specific   applica-
                   I    tions in question*       Having    g          r  that  psy   holoc'   1
                   0                                       otten ove              c     Iica
                        hurdle  and  shocked  everyone  we  as   a   headquarters   staff,   toget,ie
                   12 i@ with  the  staffs  of  the  tN.7o  regi@s  in  question  try  to   work
                   I    effectively within the time constraints that @,7c-re on all of
                   3

                   14,  us.
                   15               And  we  extended  the  deadline  from,.  July  1  to  July 9

                   16   to those   two specific regions to amend, to,revise and to
                   17 '!i' amplify  those  applicationc>.  And  our   staff   met   with   the   staff
                   18   of the two regions and you may imagine that there were both
                   19@@ several  trips  involved,  and  many  telephone   calls,   and   as   a
                        result  of  this  we  believe  that  the  regions   in   question   under-i
                   20
                        stand  fullv   the   concerns   that the  review   committee   and   the

                        Council had    ana had   spoken   to those  concerns  in  the   ai)plicatioi-i
                   22
                                    Also   we have Made two, made know to these re           ions
                                                                                          9

                        the fact that    during  the  open  session   both   the   review   committee
                   2,4
                        and'the Council there was the opportunity to speak            on   behalf


                              FL, matte--s.
                       ot the
                   2                             (,Tc@,-.,t to @T'On session, this r,,,criing,

                                                                                   'I -eqions.@
                                            r,,,en-t@; from r c.@,, i, c-@ s :-, iof bot'
                   3            have                             i t o. t i
                       Now, apart Ercm that r-,i@,tter I        ii-ioicate to tile co-@-@,ncil
                   4
                       you will recall at the  June  meeting  you  aT-,proved  88  rii-Ilion
                   5

                       dollars recommended for approval.

                                           ions of  dollars.  @-le  actually  made  ao:atds  of
                   7
                       a4 millions of dollars,     and  the  reason  we  did  not  implement
                   8
                       fully your recommendations was because it was felt to          '@-e better
                   9
                       management  to  reserve  the  different,  four   ,nillion   dollars,
                   10

                       to that we would have a total of 28 millions        of  dollars   for
                   11
                       support of the recommendations at, this                 because we had
                   12

                                                              -).)roxi-,7,at!l-,ly 43 r@,il'Lion
                   13  anticipated at that          to !,. ave a@ I

                       dollars in recrtiests.
                   14

                                  And we  felt  we  needed  the  28  million  in  order  to
                   15
                       rrovide   appropriate   implementation   of   the   recommendations front
                   16

                       thit Council.  As  a  result  of  the@@  actions  just  taken  thatI
                   17
                   18  recited  with  @laryland,  and  liassau-Suffolk,  those  two   an-olica-I

                       tions have increased the requested figure so that the          review
                   19

                       committee yesterddv had in the 53 applications before           itf
                   20

                       a total request of 46 million dollars.
                   21

                                  Our -L-c,@i-al dollars that are available  for  supi@dr*.  of
                   22
                       Re ional  radical Pro@rains   included not oiil,,! tile 28  riillion
                         9
                   23
                     Idollars,,but  some   unexnended   balances   of   approximAtely   one andit
                   24
                       a half to  no  more  than  two  million  dollars,  from  prior  L-udq--t
                   25


                       p--riods.

                   2               co +,-iat the total -moni(-@,s that   !,ia,),c, cin- ,qe wil'
                                                                                   a

                   3   know exa(--tlv as we            the  rc-,)ort  and  expenditures  forms

                       tl                                                                 this
                   4                     total amount that       will

                   5   Council         ig -for sul@),-@ort of P..ogional l,ledic@;; rograms   will

                   6   be  approximately  29.5  million  dollars,  to   30   million   dollars.

                   7               The committee acted yesterday in out closed session.

                   8   So we will be going over the specific recommendations. @,7e

                   9   have a point, however, ,,jhich does require  your  conside-ra4@-  ion  .

                   10  And as I  discuss  what  the  point  is,  I  would  like  to  pass  this

                   11  statement out to you.

                   12              And indicate to  you  @7hEit  our  problem  is;  under  the

                   1,3 court order which %,was signed ario, - I.ius the litigation is enc',Le-md,

                   14  five millions o-' dollars  @,,7@re  given  to  the  defendants,  if  You

                       will,  for  purposes  other  than  the  direct  support   Of   regional
                   15

                   1 C> medical programs.

                   17              This @,;as the negotiation that oc,,curred durii.g the

                   1   settlement,  and  those  purposes   were   described   very   completely

                       by lilr. Ptibel. Now,  the  condition  in  the  court  orcc-r  is  that

                   20  if
                          .@Ir. Rubel and ,3taff are unable to Obligate the five million

                       dollars withit-) 90 days, 90  days  from  the  si(7,ninv  of  the  final

                       cou@@t order,       -e.,raininc
                                                       funds of that five million then
                   @22

                       reverts to th,'@, @.@uoi.)ort of the regional medical ptoqtar.1s.
                   23
                   24              Ttius, i@.a may be faced in late Octol-,bt with the nossi@.-.
                       ity of distributing a very     small  or  medium  size;   or   although

                       unlikely a large size sum to the regional medical programs.


                     Up

                     ),)e             ars rc-r@-,@ainj-n(j, bccau,,s-,-. t
                  2
                  3  c7roa-'-- interest o,-i '-he ,,art of the administration to ui-i   7a

                     t h oE---    c--@7fc@cl-ivcly for the y@urposes they   u@
                  4

                   1 the negot.@.   i-ons.
                  5
                  6             But  we  do  not  wish  to   call   this   Council   back   should
                  7  it be required for us to distribute the small sum.   Thus,
                  8  we have drafted a statement which perhaps I can explain to
                     rather than co over the formalities, which would,  I th,'-n'r,
                  9
                  10 accorodate the situation very well.
                  11            And   not   require   vour   further   attention   on   ma@-ters
                  12 which I believe are not o'i' sufficient importance to have anot.!-,n]
                  13 meet;-ng.  TIhat we will propose to do with the close -t--o 30
                     million dollars that     have avai.l@41..)le, is    this
                  14
                                             ce t of your redony             for  eac,@l
                  15 firs  pay up to 100 per  n                  iandations

                     of the PPLV-a@h.
                  17            Should there still be funds  available  to  us  after
                  18 v7e have awarded 100 percent levels of your recommendations
                  19 todav, we would then return to your recom  nded levels
                     at the Jun-- council meeting.   Because I just indicated  to  .rou
                  20
                  21 that although you reco,,-.Yrtencled that we sur)TDort proqra:-,s --t a
                     total level o--F gq T-,illiol-l, we reduced that --o 84 Milli-or@, so
                  .2
                     we would then take any remaining funds and pay appropriate
                  23
                  24 amounts, up to the June council   recommended levels.
                                in the event, and these are a lot of if's, but  I.-n4LS
                  25


                                                                                                 @rc,
                                                                                                     S t  4@
                       1 14 S the @i@ty this pro-ram iT,,ust            things.   Should    -t',,c

                       2            .@S      1 aY)l             from    jac-it    iic,7 have. avail,,"  1.
                              moni-     ava--

                       3
                          to  us     or .,@liat may become  available  to  us  in  Oc-tol@-)c-r,  zi.s  -a

                       4 !result     of the   s
                                              ituaticn   I   have   just   indicated    to    ycil   (--h
                       5  five  million   dollars,   we   would   then   proposed   to   mak@,11.@   distti-i
                                                                                                                i
                       6  bution by formula,  and the formula is given at the bottom

                       7  of  this  page,  and   it   @.,ould   merely   state   that   we   v7ould   take
                       8  the actual award that @,ic made,  from this Auaust council reetih@g,

                       9  and the actual award made following the June council meeting,

                       10 and find out what percent of those tt,,7o            at7ards are of t

                       11 awards made at the June and Augu

                       12               And   apply   that   parCentact@   to    whatever    remaining    fund'",

                       1  we have.      lmd   6
                       3                      istr4-bute    those fiLnds to each region. T@"a 'feel

                          thr-it,this   is  e u-
                       14                     q itable and in Icc-a-,oiricT with your recommendations
                                                                                na
                     '15  of the June and August council            meel--ings/h@ve    been unusual,  in        1

                       l@6
                         ithat    All    programs,    basically    hi:lv@    been    reviewed,     simultaneously

                       17 rather than at q-aarterl           ario68 6@4 the vear.
                                                         y p

                       18               Secondly, the competition, the            applications     have      come
                       ig in  under a competitive system, whereas              during   the   earlier    lz>art,l

                     @@20 of  1  74   we   were                        ion.on   a    formula    bAsis,      ch  1,

                              p                     -endings of rc-,
                       21@ lper @atua.ted rank st,

                              1 is at the last       t,,.,o council    meetings    this    one    and    the
                       2 lfce
                       23 IcOuncil meeting,  are our best indication              of the latest c6ns@ider-

                          ation of Merit of each region.
                       24
                       2                Th6tefore   the   formula   that   we   have   d--Vired    we    believed


                 1  to be fair.
                                                         I hivc- made it clear,
                                t  @3 c C) @@'T"
                 3         uld 3    to - 'have. c@i the ra. @li.scu.(3sion or --iidorsenien
                    -ind I v7o
                 4  or, if ou %should, like to consider it later, discussion or
                    endorsement of -either this Proposal or a modification because
                 5
                 6                             ds we still may be faced with a
                  lonce this council meeting en

                 7  distribution of funds.
                 8           And I do not have  that authority unless we reconvene;,.
                 9  At some future date, so I would like to open it now for c7enera@
                    discussion or clarification if I have not made it clear.
                              DR. @-771,11',IOCI,': That's only a minor sum of money, youi
                 -2 say about four million dollars. Or a million and a half
                    is that correct? First you will take the sunt we allocated for!@
                 13
                    eighty eighty million dollars,
                             DR. PAIIL: Well, let me tr  first I will use the @Lun6.s
                 15                                   y
                 1  that were available to us to pay up to lor) percent of %.,,hat

                 17 we recommend today.

                 18
                              DR. PAIIL: The funds remaining I will then return
                 19
                    your June council recommendations and pay up to 100 percent   I

                     f those r c
                    o         e omr@.endations. If funds still remain, either what
                    .@;e have currently available, to us this su.-ri,3niar, or any that
                 22
                    may become available to us in October, I would then employ
                    the formula that. I have given %,7)iicii would represent a nerdeftta
                 24
                    determined for each region based oh the June and August Counc
                 25


                                    'c-tual           lo ti-iz.,,t rec,,.i.on, Iiich N@iill be at t!
                    3   100          Junc, and  t,,ugi.,ilst Cotincil recommended 3.--vels and  apply

                    4   th@- L-  vil-iatevcr I)ala,@ca reir,@i,-is.
                    5                               T @,7ou.Icl lilze to move that that be ell-

                    6   dorsed  or  approved  that
                               r

                                    I-IR. OGDE,4-. Can I ask a question.>
                    7

                    8               DR. PAHL:  Yes.
                    9               1,1@R. OGDEN: I am unclear    as to,wi-tat this five million
                    10  iwould be  used for andthe manner in       which that will be done.
                                    DR. PAIIL-. I can speak- more full  to the second part
                                                                           y

                        ltl-ic-n to  the  first  point.
                    12

                                    11R. OGDEI@: I think it is     the first p
                    13                                                           oint that 1 am
                    14  lmore. interested in.
                    15              DR. PAHL: I can get @rc)u material for the first point
                    6   17L--t me speak to the second point, however, @Ir. Ogden4  The
                    17  negotiations on the settlement or- this litigation have been
                    18  conducted primarily on behalf of the defendants by#, of course,l
                    I   our office of caneral counsel and the person of lir.  r,,ubel.

                                                                                  enqes tha
                    20@
                                    And to the purposes,,     needs, and chall                t  ,,illi
                            represented by hl-%rj.l-l(-T                    dollars Available
                    21  b--                            five  -millions of

                                                                                           r
                        to  the administration thus have been our          most and unde      his
                    22
                        @diredt personal consideration.
                    23
                    24              I-lo handed to us, yesterday, a rather lengthy statement

                           'c'   fran
                        v7li  vi    kly I had not seen until yesterday, because it is a


                             sc-,i-;arate activity '@,7i.t,in tl-%i!-@ bill..     c; o th a t t       s       c,,,i n

                             d   i@, rcfe-r         to        @ai-.,@             that I have,                  h
                       2

                                                                                                         e  we
                             4- oget lir.  r\ul-,cl to speak -L(-) it i,iore directly,             c@
                       3
                                       do not have inz"O.-rtation be@rond                  he distributed
                       4

                         i!       @,sterday.
                       5
                                           'iliow, the manner in which           @@a  money  e,,'ill  ".)a  snent
                       6
                             I understand is fully through contract process. @-nd the purpo-@@-,l
                       7
                             generally   designed   to    look    to,,,7ard    the    new    legislation    an    to

                             have    organized,    defined,    cleared,     and     publish     t.-,ose     kinds

                             of    studies    which    are    concerned    with     health     plannin     m6thod-
                       10                                                                            9
                             oligies,    evaluation    studies,     and     to     development     of     manuals
                       11

                                                                                                                      s
                             And procedures which will be of assistance to the orc6nizatiol@
                       12
                             which   we   expect   to    be    developin    and    supporting    as    a    result
                                                                         9
                       13
                             of t,.@proposed legislation.
                       14
                                           I   am   not   sure   that   that   says   much   nbre   or   even   as
                       15
                       16    well   as   4hat   he   said   yesterday,   but   I    cannot    ami)li'Lv    @-hat.

                                           DR.  SCI.Ir@,I,:7ER:  It's kind of anticipatory                as    I
                       17

                       18

                                           DR. PAIIL:  It's kind of anticipatory                   let'r@ go off
                       19

                             the  record for a moment          please.
                       20

                                                               f the record
                       21

                                           DR. PAI!I,- 1-7e   can      baclc on    the rec
                                                                    7o                       orc4.   auain.   I   wo

                             be          if @lir.          q,@re here today,       to   try   and   get   him   to
                       23
                             CoTr@,@ @-@id sT)eall to this p@)4-iit . It is kind of ir,7L,,Dorant         but   it
                       24
                       @25   has      n quit6     peripheral    to    m@!    activities.    Unless    t'@'lere    is


                           c- o n i r   e

                                            iT
                   2

                                                               sibi.litv of  thi.s Council to
                        think it 4-s  the st...itu,.torv rE,.@,pori
                   3
                        ap                enditure                         this  is  five-,  million
                   4      prove the   exp            f or IZI,IP money and

                        dollars oLc PIli@ moncv.    And I  i---rik unless  we  ii-ql.,)rove the manner
                   5
                   6    and purpose of Mr.     rubel's expenditures the money may not

                        be appropriately spent.
                   7
                                    DR. PAIIL: Yes,  well  that  does  bear  on  home  tlie  rnonevi
                   8
                        is  spent.  It  is  the  responsibility  of   this   Council   to   approval

                   10   all grant funds.
                                    @%IR. OGDE',N: Unless we say to @Ir. Pubel's resolution

                                                                                                  ate
                   12   that  you  have  the  authority  to  expehd  that  money   and   we   delcg
                        to you th-- ti(,,ht to -pend it  in  the  manner  it  which  you  sl@-@nd.il

                        it, ho@,7 you choose to pond i.t,  and  then  I  question  o7l.-iothc-r  her
                   14
                        is spending it under authority.
                   15

                                    MR. IIIRITO-. Isr, It  this  the  result  of  the  court  order,

                   17   Bob, rather   than
                   18               PIR. PAHL:  It's the result of the court order but
                        I am  in a  very poor   position to take issue with       flr. Ocrden.
                   19

                                    IIR. IIIROTO: Okay.
                   20
                                    DR. PATTL: l@,?hcit I would  say,  is  that  it  is  mv  under-
                   21
                           nding  that  an  expenditurb  of  grant  funds   must   tom,--   be-fore,
                        c>
                   22
                                 ecotpmended for approval by,this council, but          contract
                   23   an    e I

                                         0
                       I        and I d n.1t kno%q %that       iihc-tlier it is cLif,-L@orn or a,.
                   24
                       Ifra@n),@ly  but certainly   to tlio- best  of  mv   knowledge   no contracts


                                                               t@-,at
                          funds are requ2-r,--,(@l to CO-1"1"3
                                                                                          I)y tlii
                                                        come before oi, be
                          ditures are rcqu4-rc-(l to

                          council.

                                                      havc@,. not           so that as loria as
                    4

                                                                                                      c @A
                    5     five million doll,@:      is a%-,7a.ded in contract I believe techt
                    6     it must not come before, but I believe it wou'Ld Le %Raise for
                    7     You to have a better understanding.
                                       PJIR. OGDT'@l: ;,7as it dc;sic,,na@t,@din the court orO,--r

                    9     as contract funds?
                    10                 DR. PAIL: I turn to my            quasi-lawvcrs.
                    11                 IIR. GARDELL:  I'm both have a little information. I
                          think  one of the things the cou-t order did                  to release
                    12                                    L.
                          im                                       then        allocated to us
                    13           ded funds and --ho8e      f uii (a:L-,
                            L)oun
                    14    the amendment to the court otd;-nr takes                      million Color
                    '15   of the released i.m,@ounded funds to up,, @,,-idm,-tkes it av-@ilzibILe
                    16    to           -n contracts that ITRP, and tiiat'@s             really it is
                    17    c,,o, then,  @@;d have five million l@-cs to allocate to our
                    18                 @IR. OGDEN:   if that is the case        and it goes in thdt!

                    19    route, then my question is out of order.

                    20                 I,.IR. GARDELL: Yes
                    21                      PAIIL. Is it act   ually spelled b        as contract?
                                       DR.                                        U k:
                    22                  R.  C'@All,      hat'F, right. They don't have to  e
                                                D"LL: T                                                  I
                          made as contracts.  They        are not mad,@3 availa.bl@-- to us to ELl Ol".,-
                    23

                          to  our  P..j'4'Ps
                    ,,4
                    25                 IIR. OGDEN: Okay.


                                   DP,, Pi@T@li,:

                                       C- Y T  17 1)    ')-I't th
                                   D 1-@,

                   3   T)ract      eas ib IL,", ay of     ng cax,e 0
                   4    @--;ally would be m-.@,aniiigle@,  Have ci c,:),., n c,-      for  that!
                       purpose.    I don't really        any reason for s--endinc,,  an%7  timei

                   6   on

                   7               I move  the  motion-.
                   8               DR. PAIIL: All in favor of the ropos9nd resolution?
                   9   Relative to the formula for distributing
                   10                            We didn't get a second-.
                   11              I,IRS. IIORGAN: Yes we did.   I s@:Bcondcd it.
                                                                             @d And secbneed.1
                   12              DR. PAIIL: I'm sorry, it'i").as  --)een

                   13  All in favor, please say aye.

                                   VOICES: Aye.
                   14

                   15              DR.  PAIIL:  Opposed.

                   16              (1:@lo r---snonte)

                   17              DR. PAI',L: Themotion is carried.
                                   I-!R. OGDnll: As a matter of editorial cor,.r,..ent, should
                   18

                   19  the bottom line read -- Juii--@
                   20              11R. GARDELL: The words will be dated in @@iucTust. r.Pheyl
                       will be 6-ffcctive September 1. You're !)eina terribly t---dhnicall@.
                   21
                                   DP,,. PPITIL: All right. 'I'@ow @@ha@@@ ,a%"e gotten that,
                   2,2
                       I next wanted to move over to the arthritis,         @ut I see that

                             D    Gramlich and Mr. @-r)ear just,     ft @ll          so, fir t
                   2,, both, r.                                    I e,:   a roor.4          s
                                  ju t like to ha      -le        s                     n
                       1 wo'uld    s              ve  tl  minute  of        last reeti      coi-i-I
                   25


                                 -)el-i-@-ve tlic,,7 are att,,@cht2,,i if you have nct

                     had an oppor,tuni-tv.to read             -)s   could dc@fr-@r

                     action  on  -2 M
                 4

                                           These 1-iialien't beer, mailed out.  I

                 6   no  reason not  to suggest a motion that they be approved..

                 7                           Second the
                 8              DR. PAJIL: The motion has been Face to accept the

                 9   minutes as submitted.  Any discussion?

                 10             (-,,'4,o response.)
                 11             Dr. PATIL: All in favor Of the motion?

                 12             VOICES: Aye.

                 13             DR. PUIL:  Opposed?

                                ('@lo resi)ons-z
                 14
                 15             DR. PAIIL: The motion is carrie,-d.

                                MRS. 14ORGP.N':          0-F
                 16                          As a matter     -act, it would be illegal

                     and  still is part of the minutes.
                 17

                 18             DR. PAIIL: lle walk a tight ro:.?e here. 1-7e will be,
                                                                                brinc'j
                 19  in ]ust  a t6t6-nt, having a report from '.Ir. Ilatt Spear to

                 20  you up  to date on the  status o,-P t l@-I --arthritis program.  As
                 21  You will --ecAll, at the  last council -,-,e--ting,   I belie e

                    -we@@e just about  getti  tDyou .It t-.is -)oint
                                           nq
                 22
                 Z3                 SPJV,P@rl: rine.
                                DP,. PzjiL-. T@-' that is s,,-cfj.c@ent.  As you recall at
                 24
                     the.last Council r-,-@etiiig you did 1-is-.an to a presentation '@-y
                 25


                   I 11 both Dr.                  llr.        relative to thc- T)ilot @art

                   2    prograTri.
                   3                     t...- acti,,,Ii-ti.c.@;, coiisidcrEi-ticil,@l:.,:; and formal

                   4    rc-cor-,rt,@,ndat@ of the ad hoc                        Committee;
                   5    subsequent       -'.qat time,      have made a@,iarOs and I @@o-L,10,

                                                                                            of
                   6    like to call on- ','Ir. S-Dear to describe the current status
                   7    the I?rogram, and our activities since the last Council

                   8    rqeeting.

                   9

                   12

                   13

                   16

                   17

                   19

                   20

                   21

                   22

                   25


                                                    It %@7i        jiIL73t a!7, convenient

                                                                   s  on  the   same   startin7   Poin@@.
                      2  just  recapitulate @,o c-%lc@r@7onE.,   1

                                             l@474-          prizite for ?,.',,IP an all()cc-.t4@- c) n c- a r -
                      3      rf c@li-vc-(l in      an al)i-)ro
                         marl@c,-.@l: and a half million     dollars for     the  d--velopnieftt  of   a
                      4

                         ")ilot      -hritis  c@nter.
                      5
                      6               @'Then the request for al?pli.cations went out we receiv"@c          .

                        1ap           ns from 43
                              .plicatio             regions, totalling almost 16 million
                      7
                      8  dollars.     So  it  was   a   highly   competitive   situation   in   the   te-
                         view.   Policies   were   established   which   took   out   of   the   turiningfl

                      10 thos,-- kinds of activities which did hot seem to be directly

                         did not so--m to dir6ctly.bear on patient services and the

                                               4 ngS
                      12 d--vc-loDr.--nt of th-L      for  )atientc,   and   the   extension   of   care

                      13 to pat-.c-lits.
                      14              In  tl-i  outcor.,ie,  then,  as  recommended  by  tl,ls   ad   hoc
                      15 arthritis    review committee  and  the  Counc'xl  at  it".-.  last  session
                      1;3 l@ 31   of   the P-,'4P annlications for pilot arthritis funds were

       7
                                  d                                                    ur,
                      17 alDprovc      The  approval  exceeded  the  earmarked  f   Cs   by   some

                         small amount.

                      19              I  shouldn't  say  small  amount,   that's   editorial.   By        1
                      20 an  amount  of  almost  a  half  a  million  dollars.  l@7ith,  the  appro,

                      @2, fval c-ic t,,ie Council    funded,    0 r El l@)
                                                                      proved,  t  nded   to   approve     i

                        !the allocation o'L          fund to    all  of the pro(rams ti'lit co,.,i  fall
                      2
                                  the earmarked amounts Available to three,         program.
                      23
                                      P.nct       is  27  of  those  approved  prbgramst   and   the
                      24
                         re-rla5-@,iinq four @..jho were  approved,  but  for  which  there  were  not!
                      2.5
                                                                                                          i
                                                                                                          I
                        ,I
          0             II
      @  I              I                                                                                 i
                        ii
                        @i                                                                                I"
                        i
                        4
                                                                                                          i


                                                                :a,il-I c)r4

                                            clif7c-cti.c,,iarl, -funds up to
                   2  or uti'l@,

                   4                         letters to this effect that a re-,,,t'-on

                   5  is or is  not an,,Dro%,ed for c7%ar,-qarked funds or is or is not

                   6  approved   for the Ltilization of discretionary funds      I..as issuel@,

                             e 29.  The letter also requested that each of       the reg4o-.-,
                   7  on Jun

                   8  receiving approvals for pilot arthritis activity resno.-.@id in

                   9  writing as to  its  acceptance  of  the  award,  where  an  award  is

                   10 involved and or in all cases the conditions of the a.,,,,ardl

                   11 which was the s@L.,atem,--2nt embodied-in the approvals as to   the

                   12 kinds of activities that should be undertaken.

                   13            P@nd -he      +-8 of the funds that could     e ex-.oended

                   14 for those  activit-'-c-,s.  "L'o@ay have acceptances /'-l of    thos-=,

                   15 P@IP's and we are waiting for an additional ten.  To round          t

                   16 uT).  Eight of those have been contacted as.of      @esterday,   arid

                   17 they  ar- -,,7orkinc; as ra-,)idly  as thev can to get their ciccept-

                   18 anc@s in.

                   @19           As vou can imagine,, going from a request of sixteen

                   20 million to'somethinu in  the  order  of  less  than  five  r,@illions

                   21 i!i some drastic cut,-, .,;erc rade, and some restructuring of
                     il.,I.7ithin the ar)TDro%ral@-, 1,Deen necessary, and those ch--naes are
                   22

                      LI@ ing negotiated.
                   23

                                                                                    -wo  of
                                   t appears
                                 I            at tl-ii s  ent, that onlii one or
                   24
                   5 ithe 31 approved reaions may turn down the funds.  One        aiDparentI.@;
                   2
                     I
                     I
                     I
                     ii


                                    difFicilltY  in deciding what the,           h
                      is having some                                       n

                  2   be LiseCl or Pot.
                  3            *,low, t',c,,    coll;@,@littee and the Coiari--il  both
                  4   -two  @@@her actions, both  at   the   same   time,   they   recommend
                  5   the  @-)e some centralized fol.lo%q-up from the Division
                  6   Regional l.Ladical Proarams.   The major part.i of that I think,
                  7   the most important as@oect-is a desire that there be A method
                                             dinating like kinds of proarar".s that
                  8   and an approach to coor
                  9   nevertheless are dispersed the 31 T.U@T's.
                  10           T.,,Ie are also in the advice letter of June 29 asr@ed
                  11  tile Pd@IP's to give it some thought, and to give us the @,:ido:,r
                      of their c-.Y.P,@rience and thoughts Ilowever, they did no'r- have
                  12
                      the full information nc@-c"ted b-,i then to g,.@vc, a proper
                  13

                  14  in Our estimation
                  15            T--nd we are Dresently preparin  a letter to follows,.
                                                              9
                  16  that up and give them more concrete information such as @..ho
                  17  are the ball ii avers, who got     awards   and for %@!hA4.- ks
                  18  of i?urposes and what are the nature of the programs that
                  -19 have been approved for 4Lunding-
                  20            And just in conclusion, to these remarks, let me
                      read you     draft D@lrt of the letter that purports to
                                               The ein@)@asis of th       e    lot
                      the a-,)T,,roved progral-s.                e  approv   d   pi
                  2

                                                  4:
                  23  programs is the c,@-.tcnsioft oi, present kno%qledge in arthritis
                  24  diagnosis, treatment and care to coordinated services which
                  25  demonstrated improved patient aces8 to care,, and extension ol


                                                hrou(ii           uti,ii.za+@-io,,i
                       @rc)fc-s!7@ional -@ervic 3 t

                                                                        i-@isourc s.
                   2   :af?lslcnal personnel, ancl,
                                             clinics @@,ill be established in rcO@ical    I
                   3
                                      Aity  hospitals, and other community health
                   4     iter,,;, COTPIT'IU

                                                                                       h
                                -s.  Educational   programs  in  hospitals  and  tliroug

                                                                            the arthritic
                   6   visiting multi-disciplinary teams will increase
                                                                     private  physicians
                   7   handling capabilitie,.3  of I-lospital-s and
                   8   and will equip larger nu7ibers of medical     and health Personnel,,
                   9   as sup-port services in hospital clinics     and -- increased
                       patient care wil.1 be increased through     the  development   of
                   10

                   11  patient training activities.
                                  Semina s and workshops will be conducted at manv         i
                   2                     r
                       sites -.'"-or improved utilization  of  coi,%muhity  resources  -for
                   13

                       a                 -S, In
                        tthritis  servic        c uding home care, quidai-ic6-       s"r
                   15  lence.     Ekistinq health department personnel and facilities,,
                   16  and health groups, such    a E, the visiting liu,-rse-s Assodi.ation
                   i7  local councils on atfing, and operating community health trai
                   18  programs are cooperating and demonstrations  of appr 'V@
                   19  arthritis health care deliveries.  Several mode
                                                                            st   studies

                   20  to develop criteria for qualitiative care through provided
                                                                   ed; and industr-,.7
                       performance standards are b,ing conduct
                   21

                       surve,,.r is planned in c)nc,, region.
                                  @md   an                      educational program will
                   23
                       be developed in-coi-,c@-rt with  better organized occu    c-iti.o al
                   24                                                                n
                       health services.  Another region will. investigate      the utilize,"-
                   25


                     I                                     ationt restorati            dUC4-'
                        of solar work.-,.'-io,)s to ,;u,,),:)ort T.)         on to  nro     21

                   2    activities.
                   3                 iiur@,ber@o-@ T)r,--gram.,3 are focusing on t-.e -,rcblems
                   4    of low income qroupst    rural groups, and others are       focusing
                   5    on the development of    care deliveries in economic di8advanta.cn--z
                   6    inner-city residents.    Pt-@diatric arthritis services          be
                   7    developed in a variety of-settirigs, and one prograq is demon-@@
                   8    strating improved services to the geriatric po ulati6h.
                                                                            p
                   9               Localities which presently have little or no       rh6u-,Ia-
                  lo@   tological  resources are being supported by the initiation or
                        the expansion of medical, new     medical institution  -66-each4-ng

                  12    cat3abilitxes.
                  13               Across the country, chapters of the art-ri@-is
                  14    foundation ate   providing program coordination to  - @@Ublicat4-c,,
                  15    and increased numbers of volunteer @ workers       in    supportive
                  16    services.  And increased agent referrals  to       local    setvi6es

                  17  and resources.
                  18               That completes my report, Dr. Pahl, U.-,,less      there

                  19    are questions.
                  20               DR. PAIIL: Thank you   very much, I,,Iatt. Dr. !Tabr@r?
                  21               DR.IIM3ER: 1,That is, where is  that  program  iqith  the

                        geriatric  services,>
                  22
                                   --'IR. SPEAR: In .@lichigan. Uhivekritv of ,ichi an.
                                                                                    9
                  23
                                   DR.PAHL: Thank you, I.,att.  Dr. crarlili(-,.ile
                  24
                                   DR. GT.WILICIT         ndicat6d to you,
                                                   As I i                     I
                  25
                        to you  for not havi,,ia been able to get with you a             bit


                     this mornina due to the road construction which (lelaved

                     gr@tti-ng here.
                  21

                                  wondered, lio,.,7evcr, if you 'lave a statement to
                  3

                     make generally or  I ti-i-,'.rik to aOd and the information
                  4

                     I did pass to you  I thought I %,?ould like to make an
                  5
                     and statement to council, rather than a formal resolution.
                  6
                     But perhaps you would like  to make some comments, as a result:
                  7

                                I would have,a great deal, Dr. Pahl, except to say
                  8

                     that this is a great example of the flexibility of the P@'-n
                  9
                     process, in the administrative organization  that  is  able  to
                10

                     acce                                          1
                         pt the task, early on, accomplish   it rap'dly,- and a,-)paren-l-,-

                     bring it to reasponabl@r successful solution.
                12
                13             Matt's  renort is superb and I have  nothing  to  add

                14

                               DR.  PAIIL: Thank you. Let me just take  one  or  two
                15
                16   minutes, and  indicate to you.  I,,7e are  attemptinai should

                     there be further funding coming to us this year    than anything
                  7

                     we have spoken about to date, or will there be special Arthritil
                18

                     funds made available to this program we would attempt to enqata
                19
                20   in those Activities which the committee recommended    to  you,
                     and you endorsee that is to pro@,7i-'-- centralized audio-Vi-c-ualI
                21

                     re-sources, the development of cnrtain training films, va.@.c-o-
                22

                     tabas and so forth.
                23
                               But this requ4res a reasonable investment, inO,  %,7e
                24
                     do n6t have the dollars at the moment.  I,-7e do intend a.
                25


                                                to pull 4-oq,2t'lior          nc,        d
                  I   Spear indicated to try                      the exist-
                  2   activities into a cohesive program through the qood offices

                      of
                          ir.   Spear.
                  3
                  4               And beyond minimal funds needed for some confl4-ctiv--
                  5   meetings,   and so forth, I believe we can accomplish that.
                  6   So  we  do  hope to be able to report bacl,, to you at some futurel
                      time  that   the program  is  not  an  assemblage  of  disjointed
                  7
                  8   pro]ects but   does represent a total national program.
                                  TIow, facing us yesterday  and  today  there  are  a
                  9
                 10   limited number of arthritis applications      in the itly 1 Pl,!P
                      applications.  I  believe  five  regions  saw  fit  to   include
                 11
                      arthritis requests in the current  applications.  @,-7:,iich  is  to
                 12
                      say that most regions clearly understood that the pilot
                 13
                      arthritis program was related to the fiscal 74 -@Pundin
                 14                                                              cj an,.
                 '15  the activities of the  specially  established  ad  hoc  arthril-@7-s
                 16   review committee wnich met for one time and was disbanded.
                 17               Thus, we have a situation in Kenichi administratively
                 18   and indicate to those regions that basically their applications
                 19   h                                         although I think    in
                 20   some cases there have been honest misunderstandings,       so  that
                      perhaps this news would not be taken lightly4
                 21

                                  I feel that, however, it is important to reo en
                 22
                      with you  very briefly  the  fact  that  we  believe  the  oilot
                 23
                      arthritis cen4-er program was established and is no longer
                 24
                      open.  That  is,  regions  should  not  b6-'permitted  to  spend
                 25,


                            iv a-,,a.ilal)le funds or whatever Funds core to
                     currant
                 2   in th@          the clistri!Duti-,:)ns     been d,-!7,cussi.n@,,
                 3   this rorninq to Su,),-)Oft additional activities.
                 4             ',.e are trying to build a national cohesive proarar.-,
                 5   and as a result of that I have prepared a statement whic@
                 6   I would like to read to you, and if you feel you need to study
                 7   it we can distribute it.  The timing is perfect, Xen, thank

                 8   you.
                 9             But I believe it would  provide you with the sense
                10   of what I believe is necessary in order to be fair to all-
                     regional medical programs and to try to build    coh(--siVe 'r)ro-i!
                12   gram .'Lrom those activities that,-@iere reviewed and approved
                                             'MOWN alim-ii
                     by the Technical Boar  of ';-Ikpbr S.
                13
                               T e stat--r@n          ould      therefore, for vca
                14
                     to read to you and ask  for vour endorsement is tIlc
                15
                16 l@the underlying authority for the 1974 initiative in arthri4--,',si.

                17   was   ii  4-
                          p  ot- in scoQe and intent.  rmd heterogeneous activ.-'@-L."-@-
                18   beyond this level would not be appropriate employment of

                19   current grant funds.
                20             The full d@,veloi?z,,ient -gnd delivery of servides for
                     arthritis is an enormous undertaking, -Lind requires a cor,-,@-i-@-,u4-nc
                21
                     well o--qanized attack such as could be initiated un6-or,
                22
                     pending legislation.
                23 1
                               Thus, -,,7hile Co,-,,-ici2. is fully aware of the
                24
                     needs in the arthritis ficl6,, it dN-las not cdn!-,id@-r
                25


                      for arthritis, other than    for approvals and recor@-ffnend,-tt,-'.C)r,,.',
                      made at the June council -@@eeting to be ai')I?ro,@ri@,,@-e in
                  2
                      present environ,-,,i,@nt,.
                  3
                                 end the allocation or expenditure by indi@.",,-Iual
                  4
                      regional medical programs of funds for arthritis in   -clition
                  5
                      to approvals provided   at  the  June  13-14,  1974  Council  meeting'
                  6                                                                        t
                      are not approved.  The Council will entertain approval of
                  7
                  8   additional thrusts in arthritis in the event of appropriate
                      authority and new grant or other funds become available to
                  9

                      the   M4P's.
                  10

                                 Dr. Gramlich?
                  11
                                 DR. G@'U-ILICII: I heard thc--refore-in the  p6riodizatio,41
                  12
                         cess at the June meeting there were four applications
                      pro
                     1' that were approved by not funded. Those were outside the
                  14 II
                     Iscope of this
                  15
                                 DR.PAIIL: Those four are outside and'they have been       I
                  16
                      given specific permission following that Council disc s.@.ioh
                  17
                     ito utilite  their  funds  to  support.  Because  those  aT)nli&ati6nq'
                  18
                      went to and through the review process by the arthritis  review
                  19
                  20  committee.
                                 this pertains only to those activities that were
                  21
                     .not reviewed by that special arthritis review group.
                  22
                                 DR. CP@-ILICH:Oka@l.

                                 DR. PAIIL: Because regions  are  permitted  to  rebudget.,@
                  24
                      and anybody can rebudget into arthritis intli6- coming year.
                  25


                                                                       an
                     I don't know how we can @,stal-)Ii.,,h a national        WC%

                2    basically leave it open ended.
                3              The applications in arthritis that  have coTre be f ore
                                                               rthritis panel, and
                4    you today have not been reviewed by the a
                5    cannot be because we have no possibility, have  no possibility
                6    of calling them together again.
                               1-i'hat we are saying, therefore, is that your June
                7
                     actions, including the form which we did not have funds to
                     pay,  but were given permission by that closes th  arthritis
                     program effort unless s ecial arthritis funds were made avail-i
                10                          p
                it   able to us, or unless additional PJIP fundsi and then it would,
                12   come back to this Council in full measure.
                               That is the statement, the intent of the statements
                13
                               DR. GPJJ4LICII-. It seems reasonable and perfectly
                14
                15   clean to-me.  I move that it is adopted.  Unless Council

                16   wishes
                17             DR. ;.it'UII.IOCK: Second it.
                18             DR. PAIIL-. It's been moved and so6onded6  is there

                     a discussion
                19
                               DR. J@NEWAY: Isn't the intent of that  also to exclii(-'@'--
                20
                     those grants which on technical grounds were disapproved?      i
                21

                               DP,. PZJIL: Yes.
                22
                               DR. JXIEI-IAY: Ithink this will    clear in the sc-ns-@@,
                23

                     of it
                24
                               DR. PAIII,-. This then will be incorporated.  This
                25


                                                             cti-vities in the J
                  I11 says tha                   tivity     a
                              t only cipproved ac

                  2
                      S   Of r,.c-etin(7,s can utilize I-'-'iP funds, d,@sa,,-)pravr-,-;d c t ii e,-
                  3                             activities cannot  be sta @.c-('@,with
                      cannot utilize theTL-,,, an_
                  4   currently             or ex ected to be available   of the
                                                 p

                  5   a c 4L--lons we taken to  date,  this  morning.
                  6              DR. 1"01"lAP.OFF: Do you )-,novi off hand those five regions

                  7   that we can consider that  in  making  funding?

                  8              DRt PAHL: The specific four regions?  1.1r. SpeAr?

                  9              LIR. SPEAR: Florida, @,@emphis, L%Iississip i, and Tri-
                                                                         p

                  10  State.

                  11             DR. FLOOD: Tri-State brought up
                  12             DP,. PPHT: There is a motion on  the floor and sedond,--d

                  13  All in favor of tJie motion, please say aye.

                  14             VOICES: Aye.

                  15             DR. PAHL: All opposed?

                  16             (No response.)
                  17             DR. PAHL: !,lotion carried.  That concludes the forr,,.ai@

                  18  business,  except for, I think the very important public
                  19  session, and I would like to ask Council whether you would
                  20  like a brief break and then bring some   coffee back to the

                  2,                                                      ntati es
                      table and have your open meeting with the    repte@s

                  "12
                      or -...lheth--r you would   to continue oh;  and then have a

                  @23 break.

                  24             DR. l@ltLLIKEN: Coffee now.
                  25             DR. PAHL: All right.  I think   that is fair to  our


                   I  visitors too.

                   2              '@@ny Oon' k@- trk, to reconvene in, oli, ten c.-

                   3  minutes, as soon as-@17e can    bring some coffee or douqlinuts

                   4  back to the table.  And then we will be refreshed for hearing

                   5  from our guests.

                   6              (I,.ihereupon, a short recess was taken.)

                   7              D @T),. PAIIL: I.,lay we -come to ceder please? Now that we

                   8  have had  a  chance  to  get  some  refreshment,  I  would  think  we

                   9  are in better position to consider the remarks of our guests.

                  10  I would like to welcome both Mr. Bacon and Mr. Sargeant from

                  11  the I-,Iaryland PP4P.

                  12              !iirs. L,'AcCarthy, Dr. Scherl, Mr. Prasadl from "4assai-l-  i

                  13  Suffolk  @,-IP,  and  of  course,  Dr.  Sparkman  has  alread  snok6h
                                                                                 y

                     [with us this morning.
                  14

                  15              If there are  other  guests,  I  do  not  have  their  namesi,

                  16  here.  @qe  would  certainly  invite  you  to  participate  in  the   open

                         sion.    I have been asked because of          r  commitments   to
                  17  ses                                            othe

                  18  if we could call on Mr. Sargeant, from the,       Maryland  PLIP   first,'

                  19  and I would do so now.

                  20              And I would  ask  to  have  you  identify  yourself;   if

                  21  you will, for  the  record.  And  give  us  vour  statement,  or  su,,,)-@

                     init  a  stater.-ant  and  then  following  an  discussion  will   you
                                                                  y
                  22
                  23  please -- we'll   hear also from Mr. Bacon.       If you care  to  sp6a""I
                  24  and then if that is satisfactory, we will come to Dr. Scher!,

                      and others from the liassau-Suffolk R@IP.
                  25


                                IIP,. SARGEMIT: Thank you      I do have a 12:00    aopoin@--
                      ent in Baltir,,,or@, an,@,@. '--hat is what you get    vou try    0
                  2
                  3 ,5chedule things so tight.
                  4             I am a member of the Executive CorLmittee of @.ie Regiona
                  5  @idvisory GrouD and the I'@aryland 1-@legional -@lledical Program.  Like
                          I am a volunteer and give my  time  for  --  towards  ,-.0pefull'.,
                  6
                     operating  an:  efficient   and.effective   regional   medical   programme
                  7
                  8              I do have a statement which has been      aistri'--Uted   to
                  9  @ou but in  the  interest  of  your  time,  I  am  going  to  sLLnmariz-
                  10 it if I can.  IIhen wb,,.received the hews referred to earlier
                  11 this morning in -!Ilaryland  we did discuss it at 8orc length,
                  12 jancl felt it -important that perhaps people coming fro--i all     over
                     lithe country are not ascdgnizant of the ctv of Ball-.4--ore       and   i
                  13                                                                  r
                  14 ;the state of Maryland, as    they might be,   and  we  felt  it   would
                  15 be  irinortatt  that  you  understand  our  case,  And  bur   philosophies
                  16 and  therefore that is Part of the reason that I           h  re  today.
                                                                             am  e

                                 The Gentleman from VA is ptobablv close to        "@-aryland
                  17
                  18 iso understands the geographic situation perhaps better than
                     imbst of you  and  I  am  sure  Dr.  Schreiner  does,  from  Washington. i
                  19
                       aryland has a fairly large  population  but  our  Regional  l@-le  icali
                  20
                  2@i 1POptlation only  serves  about  three  million  of  that  p6..rulatiorl
                           is mad-- un of 2.7 million, in 14,,iryland.
                  22
                  23@            And 300,000  in  York,  Pennsylvania.  I-.  thirl-,  it  was
                     'r f@erre-d to earlier this mornina,  that. reqional medical nrograT:i@
                  24
                       o cross state boundaries and ours indeed does.           As    all   of
                  25


                  I  the Regional Programs we have been involved in changing   prio@--
                  2  ities, and a change in the effectiveness of funding, ai-ici :7,o

                  3  fort!-i.
                  4             So   have been  somewhat perplexed at times, and
                  5  somewhat harried at times  in order to get in our applications
                  6  for money.  And 1 am sure  that you have experienced .@ie same-

                  7  Situition that we have.
                  8             Now, of the throe million people that we serve in
                  9  the Maryland Regional @-ledical Program approximately two
                  10 million of that total is included in the metropolitan Baltimors
                  11                         he five standing counties as well as
                     area,  That comprises t
                  12 Baltimore city itself   which is a separate and distinct politir--
                  13 subdivision,, not part of a county.
                                And in western 4'-Iar land there are approxir@atel',7
                  14                              y
                  15 300,000.   These figures  are on the stateme
                                                                  nt which was
                  16 given to you, I am rounding it off; on the   Eastern Sliore of
                  17 1-1@aryl.and, which 1 quebs is referred to as Chesapeake country.,,
                @.18 there are approximately 250,000, And in the southern part

                  19 of Maryland is 115,000.
                  20            Then we have an additional 300,000    in York, Pennsy
                  21 vania.  Interestingly enoughi.,of the population, and that is
                     two Million in the Baltimore area, 75.6 percent of that pop-
                  22        are
                     ulation/in the low income area, in fact, 25.6 percent of the
                  23
                  24 people in metropolitan Baltirctre city alone are Medicaid
                  25 recipients.


                                     In fact,  54  aercent  of  all  the  people  in  the  state@i

                   2     of Maryland, the entire     population of  .','aryland  who  are  inedi-!

                   3     caid recipients reside     in  Baltimore city.  lIence., I think        i

                   4     what I an. tr ing to point out to you is that many of our
                                       y

                   5     obligations have been centered on Baltimore city, o7hich has            1,

                   6     been om the  driticisms that      we have had.

                   7                 And we have tried    to expand our    services in areas     I

                   8     outside Baltimore but primarily-the greater part of           our eff   r

                   9     and concentration has been toward improving  methods           of the   i

                   10    people in Baltimore city to receive medical dare.  And so,

                   11    while it may seem out of proportion to the members,of the

                   12    group,  And  the  members  of  the  technical   advisory   grouol   indeed

                                n't when you look upon the geographic and the econ
                   13    it has                                                            oini c

                   14    distribution that exists in the state of Maryland.

                   15               Now, we have adopted many approaches in         our  effort@,,

                   16    to submit  grant applications. 1-7e have --     amongst those 3@ncludc-1,

                                  of planning, for Health I.',Iaintenance Organizations
                   17    support

                   i8    we have  been  a  great  deal  of  atieht  education   in   hyper-tensib7-

                   14    for the  low-income black families, PArticularly in Baltimore

                         city.
                   20

                   21               We have pioneered in the areas of home health care
                   22    services-  to neighborhood corporations and       we  have  also   Assistc

                         in the training of pediatric nurse practitioners who to8av              I
                   23
                         in Maryland  Are serving not 6nlv Baltimore dity; but they
                   24

                         are,servinq in the rural poverty      areas as well.
                   25


                                                                                          -tant
                  1                I would 14ke to   7'0 in tout some of the very

                                                                                         -Le
                            c
                  2    e-ffe t@- of the P@,',') h as li,-.d on activities i,n title, lieal. id
                  3    in the state of 11"4,irylaiid.  In Baltimore -- I c-:im sure
                  4    those  of  you  associated  with  medical  schools  in  the   @7ity.
                  5    There  is  always  great  rivalry  between   the   medical   schools,
                  6    who is going to be the first with what.
                  7                In  Baltimore  when  we  developed  our   mechanism   for
                  8    let  me  get  the  correct   title   here.   lidney   Transplantation
                  9    Program.  Ile  were  funding  part  of  this  several   years   ago.
                       we were able to bring together the state's two medical sdh@Oll,,
                  10

                       the state  Ilealth  Department,  la  l@idn--y  foundation,  and  two
                  11
                  12   or three of the communit@7 hospitals which had       their own  pro-

                       grams,, to bring them together.
                  13

                                   So now we have one unit working      in   a   cooperative
                  14
                       manner to   accomplish the objectives that      four or five units
                  15

                       were  working  towards  before.  Ile  think  that  this  is  a   very
                  16 1
                       positive accor                                d
                  17                  ,Iplishment that  has  been  ma  e  in  the  city  of

                  18   Baltimore,  particularly  when  as  I  said  earlier,  there   have   al-
                  19   ways been rivalry.
                  20               And  I  see  some  smiles  on  some  Doctors  faces  her
                  21   Ile also bacY, in 19G9 asked for and received a grant of 8115;000
                     il't6unJed off for a three vear closed      chest     cardio-ptlitonarv
                  22 11
                       resuccitatioh training proaram.  And       this has been ta'p-.en  over I
                  23
                       since that tire by the ileart Association of @-iaryland who        has  i;
                  24
                       trained some 13,000 individuals in the life saving         technique.


                                                            iria  them  in  connection  with
                       m a r -Lals into Dutch.  And is us

                  2    its patient education )rogrL-,-ns in   Europe.

                                  So, a(Ilain', we think  that  this  is  a  very  important
                  4    for us    @.-,Iow, these three  things  that  I  have  just   mentioned
                  5    to you.  ile feel they demonstrate     the  vital  role  that   the
                  6    ',,Iaryland Pegional %'iedical Program has played in the  devblopr,-@.,it
                  7    of  new  and  effective  methods  of  providing   critically   needed
                  8          es where f@              reviously existed.
                       servic            -w if any p
                  9               You  have  before  you  today,  or  you  will  have   before!
                  10 i:l you   today two projects which applied  for  in  our  Jull,  al3plicat'ici

                       two of them applied directly to the 1--estern part
                                                                               of   Nlaryland.

                  12   lkrriere three hundred thousand of our   population   reside.    They

                       are part of   the   second   application oroaram.
                  13
                                  They   involve   health   education in one   case,   h6alt,
                  14
                  15 1 education  for teachers and Professionals in school system,
                  16   a ]olnt effort to  educate  the  teachers  so  that  we  can  cormunidra,
                  17 i this information to the students, and the school svstem in

                  18   liestern Maryland, which is part of the Appalachia          Poverty

                  @191 Region. area.
                  20 i            Over on the Bastdrn    shore we   have,  which  is  25o#,Ooo

                       population,  we are funding a     clinical   cancer program       a
                  21
                       hospital  di charge planningo:ogram and      c6htinti      du   at'onal
                                   s                                         n      c    I

                                         al, in Tiv  t County.      7i!l th 6e  f the
                       program   in gener            ar                    r   0        se  areI
                  23
                  24   now   being continued under private enterprise      and private   fun  in
                                  York, Pennsylvania which we serve,       with  a   population
                  25

                                                                                              i
                                                                                              i
                                                                                              I
                                                                                              i


                    1 with  a  population  of  300,000,  approximately         (-T'vO@n
                  2   continuous attention to this c-,'roa.
                                @e have an acute intermediate  nd long term scol
                                                                  a
                  3
                             ogram begun  in 1969 .iitli a grant  of  $561,000.  '."his
                  4   care pr
                                      pe ial hospital unit for    the  total  care  and
                  5   established a s  c
                                                         ince the termination of the
                      rehab of stroke T)atients.   And s                                   t
                  6

                      funding for that program
                  7                               in 1972, the entire program has     bee@
                      continued and today is    serving an areas with    a   population
                  8

                      of 300,000.
                  9
                 10              lie are very proud of these accomplishments T ich
                      we t'@'link are positive things which perhaps in  the  rush  of  all!,
                 11
                      the other applications and information coining to you may be
                 12
                 13   overlooked
                                 I would just like to make one li?.St comment,  o
                 14
                 15   point out  that each of the eight projects     that we have pro-
                 16   posed for  funding which will be before you today, at least,         i
                      we anticipate is aimed at achieving a specific ob4-ctive spelle
                 17
                      out in the latest, I said latest interpretation because as I
                 18
                      have indicated 6arlier, there have been      continuous changes
                 19
                      of Federal guidelines, and that is developed cooperative             1
                 20
                 21   relationships in the improvement of care in unoer-@erved        at--asi
                                 Developing   innovative    approaches to meclica'L care.
                 22
                      All  of  these  projects  received  full  review by the T.Br-,hnical
                 23
                      Review Committee or our Regional Iiedical -3rocl!ram ID,
                 24                                                             t-h
                      regional advisorv group  and  by  the  ,,aryland  CoTnpr--hdnsive
                 25


                                                                                     5 5

                      Health- Plan agency.

                  2              I thanlt vcu very i-,uch for @7our time.   I  have  been

                  3   as brief a!7, I cotilcl--.  do have --orr,,Dlet-c details on the

                  4   material that has already been distributed. I am glad to        ansi-7er

                  5   your questions.

                  6              DR. PAHL: Thank You very much, Mr. Sargeant.         Dr.

                  7   Gramlich?

                  8              DR. GRAI-ILICII: Mr. Sargeant, I am  sure  we  all  very

                  9   much  appreciate  your  lucid  comprehensive  remarks.  May  I   ask

                  10  your occupation?
                                                                                        0,
                  11             MR. SARGEAITT: I happen to be the Executive Direct t

                  12  of the State lledical Society,

                  13             DR. GRAI-ILICI@I: For the state of IIaryland?

                                 MR. SARGEA,4T: Yc-s.
                  14

                  15             DR. PAHL: Dr. I-lammock?

                  16             DR. XIAIU40CK: I,,That did you say about  the  medical

                  17  schools competing together.  14hat?

                  18             !LIIR. SARGEANT: We did get them into & kidney transpla

                  19  program.   It has been very  effective  and  we  have  very  &6  ive

                  20  recruitment for kidnel transplantation that are

                  21             DR.            But that is  the  only  program  they  met

                      'together on.
                  22

                                 MR. SARG'-rAITT: They have gottc-n  to  ether  in  many
                  23                                                  9

                      others.   The university medical service program      is@working
                  24
                  25  very-closely with them, as  is  the  I%Iedical  Society.  ille@have

                      a close relationship that we try to bring them       together.   Try


                                                                      think  -om-
                 1   to get them to see each other's vie%i points. 141,@
                 2   petition is good.  li@ov7ever, we 6on't think that is entirely1

                 3   bad.
                 4             DR. P.,MIL: Is there any other discussion or contents.
                     Thank you very mueh, L',Ir. Sargea          @iou ma
                 5                                  nt.  1-7e ho,       e you-
                 6   appointment in Baltimore without bre'aking the speed limits.
                 7             Mr. Bacon, do you have anything to add?
                 8             MR. BACOi4: '@io, in view.of the time pressures, Dr.
                 9   Pahl, it has been a pleasure to be invited.  And if there
                 10  are questions I would stay around.  But I also want to get
                 11  !-It. Sargeant back to his meeting.  So I won't interfere w@ithil

                 12  that.

                 13            DR. PAIIL: Yest Dr. Janeway.
                               DP,. JA'.IIEI,,IAY: Could I ask one question of Mr. SarqecAn
                 14
                 15  When you say you got them together,  does that mean  n t e
                 16  kidney transplantation and dialysis@  are being done in oniyl
                 17  one of the universities?
                 18            MR. SARGEIU4T: we have in !,Iaryland, perhaps, a unique
                 19  situation.  Two years ago the state legislature passed a
                 20  statute which set up a I-laryland Kidney Commission.  That
                     14arylAnd KidneV Commission has jurisdiction working with the
                 21
                 2A  CIIBA to designate only cc@irtain areas for kidney transplants

                     and dialysis.
                 23
                               In answer directly to your question, no. That do@sli
                 24
                     not mean that there is only one university in Baltimore  oin(i
                 25


                                            would have to be some interchange
                I     that.  Obviously %@'herc

                2     back and forth.
                                                                                b c- 1
                3              -here ar& manv dialysis centers. But  I  think  I
                4     to my understanding there are onlv two units, two transplanta-

                5     tion units in the City.
                6              DR. PAIIL: Thank you very much.  @7e certainly under-@
                                   ash off to Another appointment perhaps we may
                7     stand as you d
                8     now turn out attention to    I believe Dr. Larry Sthett,
                9     from NassAt-Suffolk has a statement, And Dr. 8cherr, if  you
                10    will identify yourself for the record we will be pleased to

                11    hear f rorq you.
                12              DR. SCHEPP: Dr. Pahl, members of the Council, t.Im
                13    Dr. Lawrence Scherrt Chdrman of the Nassau-Suffoll-I regional
                14    advisory group. @d I am a member of  the  area's  r,6oi641
                15    community.  I appreciate the fact that I can appear  0 ore    I

                16    you.
                17              The purpose of my visit here is, to express  the
                18    strong support of the regional advisory group for our  program
                -19   and to answer any questions that)pu may  have.  I,,e recognize
                20    very well the critiques  of this Council and the organizational

                21    of.. our PAG group.
                22              And actually to that end I visited the di 18ion
                      of the regional medical program with another member of @.G
                23
                24    to speak -with the staff#, to work but means to put into effecl@-
                25    what  was necessarily to present this grant before  6


                                                                            man
                   I  Yesterday I unfortunately could not be here, but         y   of
                   2  you did hear our coordinator, lir. Prasad qo over the contents@

                   3  of our program.
                   4             You also  have a prepared statement from me and I
                   5  will not go over that again.  The content of the program and
                   6  any questions referrable to that I will explain -- tliev are

                   7  explained in that statement.
                   8             I just would like   to clarify one  or  two  poitts,
                   9  that are not in that statement itself.  To begin with, our
                   10 region, Long Island, the two counties as in Maryland has a
                   11 competable population  of  2.6  million  people.  The  distribution
                   12 of the population is in  a  rather  h6tero  geneous  fashion.
                                 Half being  in  an  established  suburban  community
                   13                                                                r

                   14 the other in; a rural cor,,.muhit@7 fast becoming a  suburban
                   15 community.  Secondly  there  is  a  rather   unique   geoqraphi
                                                                                    c

                   16 position of our region.  It is penni
                                                              iisular in  origin,  and

                   17 finds itself admirably to regionalizatibn.

                   18            And it is that end that we have     developed our Pro,-
                   19 gram.    it is a community based regional medical program  1,7hic.'I@
                   20 has been in actual operation for the past four '. years  and
                                                                                        cyi
                   21 ..as been recognized by the community as an appropriate agen.

                                      -ntation of certain health programs.
                   22 for the 4-mplem@
                                 ITO",L earlier this year,, till-- Regional Advi rv  Grou@'
                   23                                                           so
                   24 through it's   committee had established the goals and
                   25  of ambulatory care.     The actual development  of  delivery  -.3er@


                                                       reventive  care
                     vi.ces and diagnostic servicaf7, of                and this
                     fortunately  conformed to our areas, th@- goals anO
                 3   of TTassau-Suffol)-, Coiil)rc-liens4-vE,, ilcalth Pla,,iiing Council and
                 4   'Was actually the start of-good effective coon---ration beti.,,een

                 5   the two agencies.
                 6            @oiq, the grant before you is reall%7  a  revitalized
                               i.4                                L
                 7   approach for our liassau-Suffolk regional medical program.
                 8   I-le are oroud of the stated objective and the methods of achi---v-

                 9   ing these objectives.
                 10            To go into details it does have fourteen  dir6-ctiA4
                 11  ambulatorycare projects..  It has two emergency services project

                     which are in essence ambulatory qare
                 12                                        I.Drojects.  @.nd it has
                 13  two renal programs which have arhbulatoty care components to

                 14  them.
                '15            Thereby meeting our goals and nriotities. l@o@,q, some
                 16  of the programs, despite the current limitation on RI.",Ps futur6
                 17  course do requite two years for realistic completion.      Our@
                 18  grant contains provision for this as well as t.rie means  for

                 19  continuing staff support.
                 20            That is, not only for the monitoring those particular
                 21  programs that are carried forward, but  for  monitoring  what
                 22  has cone@on before, what is going oft this year in the brbqramg
                     that have been started in previous years.    ;',-id W6 believe
                 23
                     that is-a rathet vital and imp
                                                    ortant role.
                 2-1
                                 Just three other very brief items.  on-- is the
                 2z


                     -lP sta
                 1   P     ff. The advisory group believes that our newly
                 2   staff under the direction of tir." ilrasad has the strcncjth and
                          sdom and tl-ie@Ic-adershi.p to heir) us carry this I)rogr,-im.
                 3   the @,@ii
                 4   Through to it's successful complc-tion.
                 5            The grant before you will,, I think, not only reflects
                 6   their dedication, but I think it reflects their expertise in i,
                 7   their field,, and I point out again, that their technical
                 8   competence and their cooperation with regard to our area-wide
                 9   comprehensive health planning council.
                 10           Cocondly the PAG itself has corrected some of its -7
                 11 most of its  prior organizational difficulties.  That is,
                 12  the separation of t@-functi6ns of the grantee organization-
                 13  from the regional advisory group itself.  The by-l.aiqs have
                 14  been revised And completely conform, now, to PI-IP directives.
                 15           And I think they have sustained a continuing int---reOt
                 16  by the way, in it's,objectives by this representative communi@N,
                 17  group.  And we believe that it is a major and a viable organiza.
                 18  tion to serve the health needs, on Long island.
                 19           Secondly, a word abouf.@the grantee organizations.
                 20  OUr grantee organiztion is independently incorporated specie   c
                     ly to deal with P.J.IP functions.  I would just likd to point
                 21
                     out that in a recent fiscal audit, covering three  to five
                 22
                     months on a rather intensive basis  really on a ddil y basis,  ii
                 23
                     the grantee organization was commended for its' expert handlii Ii(
                 24

                     of the fiscal matters.
                 25


                   1              This, I understand, is unusual to have a comr,,,--nci.,.--.,
                   2   on --,-I exit conference. Finall,,Y, in c"oTin(T, I viould just
                   3   like to reaffirm my.-supoort of our program     in the support C,

                             gional advisory group.
                   4   the re
                   5              Ile believe that the program is well designed and
                       it  is well coordinated to meet the needs of the people of            i
                   6
                       Long Island.  Ile have asked  for an amount which exceeds slic7l,-,,t.11
                   7
                   8   two million dollars for this next period.  we do ask And  o
                       request and do request that you favorably consider this, and
                   9

                  10   thank@ y-ou very much.

                                  DR.PA,IIL: Thank vou very much, Doctor. I am sure %,ou
                  11
                  12   would be very responsive    to any questions that may come up.
                       Is there a discussion question?  illr. l@ililliken?
                  13
                                  MP,. PIILLIKEil: T-?ith regard to past budgets  i  in  recar e@
                  14

                  15   to                                  p
                          the projects that you are    oro osing, or recommending, .;ithin
                  16   this, what has been built in    to see that those projects are
                  17   inter-related with other sources of funding.  And what is
                  18   the potential for their continuation in case the PIIP money is        1
                  "119 not available after this grant period.
                  20              DR. SCITERR: That  of course    has ali-.@Ays been a r..a3or
                   1   consideration of the Regional Advisory Proup.  Despite the
                  2
                       'SUPPOsed@la8t year of funding,    and  that   is to seek a N-7a*@ to
                  2
                   2
                       stimulate the project to ]:)-Z@,in @.,it)i.     encourage the  T)ro@ec,-r-

                        ffi 6 or other provider organizations to  ick up the Dtdora,-i
                  @24  0   c                                           P
                       provxd6-d it is demonstrated its worthiness.
                  25
                                  Now,  I  think  that  theroin  is  the strength of our     I


                                            that have started have been picked u!-,
                   program.  Those l@rograms
                                                    tions emergency services ).)Al
                        m@- csT.)r-ct by other organza
                2  in so
                                       1                     1 bv some institution,:-,
                3  county health O@par,,ti,,ents, renal programs
                                                      hopefully the institution
                4  and by community medicine,  and  by
                   by which that is developed, and so on.
                5
                                                     om the ver  beginning to
                              it is our  intention  fr         y
                6
                                       ogram as a stimulus to start developing
                    use the regional  pr
                7
                                                                      e permanent
                8   each programs, ultimately to be picked up on a nor

                9   basis by other means.
                              DR. PAHL: Thank you4 Is there further discussion
                10
                     f questions of Dr. Scherr?
                    0

                12            (-,io response.)
                              DR.PAIIL:Mr. Prasad, @-7ould you have anything to
                13
                4   add?
                15            MR. PPASAD: No. I spoke yesterday.
                16            DR. PAHL-. Would you use the micro-,)hone, please, if
                17  you care to make a comments
                              MR. PPASAD: 1.10. I Spoke yesterday before the Revie@"7
                18
                19  C6mmitteeo and most of the Council members who were present,
                    and I have no comments to make.  U.-iless you have some questions
                20

                    to ask.
                21
                              DP..P,,NIIL-.  you.  Miss McCarthy?
                22
                              Miss IICCARTIIY: I-lo. Thank you.
                23
                              DR. PAHL: Well, theft, if there is no further dis-
                24
                    cUssion on Nassau-Suffolk,  I  want to thank You for returning
                25


                                        submitting  your  stal  ment  through  Mr4   Prasad
                       here today, and

                       y,-,sterd--,y.
                                  Are ther-a any ri@-.mbers of the public who  wish   to

                       make A statement to   comment upon the proceedings so far?

                                  Does the Council have anything further to discuss

                       in the open session.  Dr. S-,arkman?

                                  DR. SPARKMAN: Can 1   make  one mote pblhti   HOrb?

                                  DR. PAHL; Yes.

                                  DR. SPARKI@IAN: I think  you  are  all  familiar  with

                       the National Association P14Pf which instituted the i,ai,:suit

                       which released  the  impounded  funds.  @vhen  this  was  set  up

                       it was our view that this would serve     not only this lawsuit

                        urpose, but  alto some organization    like  the  American   Public
                       p
                       Health Association and others    to  provide  staff  education   and i

                       training.
                     li           And in fact we do have such a meeting      Planned  in
                     -1
                   7
                       Denver for September 3rd, and 4th, I                 At which   I
                       think a very good program has been developed.  Iqhich sb        far.,

                       has been oversubscribed by the various RMPS.
                  20                                                   onto parts of MIP
                                  And which will.@ieal with the vari

                  21                    t  develoT3m@               n
                       programs.-projec             -nt.  llanageme t,  and  I  am  sure
                       ,.vill be of considerable  Part, and we see   that  as  the  logical i"

                       extens on of the National Association.

                  24
                                  Actually,  all  of  ou  are  invited  to  attend,  and
                                                     y

                       .le will see that information    is given to you about it.
                     I
                                                                                            I
                   . ii


  nl                           DR. PAI-TL:  Than!,, vc)u.  Dr. (,ramli.ch?

                 2             DR. GRAMLICE:  Would it be appropriate to ask Dr.

                 3   Sparkman to give us a one-minute explanation of  what  the

                 4   NPJ,!A is?

                 5             DR. SPARTUIAN: Yes. I had hoped  that  Dr.  Jack

                 6 I Enale  from the Lakbs Area PI,!P was going to }--e hero, since

                 7   he is the president of the board.

                               This is an organization Dr.  Giamlichi  set  up

                 9   aside from. the steering committee in the regular coordinating

                 10  with the coordinators committee, funded bv personal and6

                 .11 private sources quite aside from anv grant  funds and initiated

                 12 i@! originally around September of last year when  it  became

                     apparent that without the release of impounded  funds  the
                 13

                                               -)ad,.
                 14  P14P future looked pretty I

                 151           But it has continued with meetings of the board,

                 16 lil the board being made up of some representatives of the

                 17  coordinators, some have come from the steering committee.

                 18  W6 think there is a real need.for the kind of staff traitind   I

                     that such an organization can provide.
                 19

                 00 11         We hope that this is going to be th
                                                                   e  ultimate

                 21  future.  obviously we should be out of the legislative

                   i@ I rleani the leaal problem. As Dr. Pahl has  said  and  as vou
                 2 ii
                     know, this, I believe, has been handled andi &8  I  h6p6; done
                 23
                     with shortly.
                 @24

                               There has been question as to whether  PIIP crAnt
                 25


                                                                                  r, 5

  L2                  funds could be used  for  this  purpose.  So  far  they  have not

                      been used.  And I have spoken vigorouslv,to this point.  I

                      am told that legally it   may be appro ri.atb to use    grant

                  4   funds.

                  5              r-ut I think until @,7e are beyond the legal problem,

                  6   until we have clearly established that this is an educational

                  7   activities, that these should not be used.  So far they have

                  8   hot been used.

                  9              The membership is made up of a   xyide  Varietv  of
                  10  people  -- Pi-!P staff, advisory group people, other individuals

                  11  with  whom we  have  worked.  There  are  some  institutional

                  12  memberships, peo  le  like  medical  assocations,  hos  itals,
                                       p

                  13  volunteer orqahitations @,iho wish to  4oin  in  that  fashion.

                  14             DR. PAHL:  Dr. Hab6rP

                  15             Thank you, Dr. Sparkman.

                  16             DR. HABER: Dr. Sparkman,  I  hope  you  v7ill  indulge

                  17  me to  the extent that I will  probably  ask  you  about  matters

                  18  that  have concerned me deeply for a long -period of      time.

                  19  But it strikes me that with the    imminent  emergence  of  a

                  20  national  health  insurance'  strategy  certainly  the  brgahiza" I

                  21  tional and substantive efforts demonstrated by     RMP  have  a

                  2   role to play, particularly in the transitional     vear8.
                  23             July question goes to thig@point6  if  indeed    as

                      this booklet indicates there are  some  21  million  people
                  24
                      wine can begin to be beneficiaries of a .-national  medical
                  25


  n3                 programf what has been done to bring home to the people
                2    the clients, if you will    the benefits accruing to the

                3    program?
                4              It strikes me that I am unfamiliar     much of the
                5    effort has gone into the providers in terms of popularizing
                6    or informing.  I-!hat has been done or what could be done to
                7    bring this home to the people that are the potential natural

                8    beneficiaries?
                9              DR. SPARKTAN:  I think  not enough has been done,
                -10  Dr. Pabet   If I understand the  intent of vour question
                11   one of  the goblems that-I see as a coordinator of an PMP
                12   is that  it order to futction most effectively you do some
                13   very low-key way to bring people  together  and make as
                     relatively little evidence of  your  existence.
                14
                15             And I find that this is the  way  you can get d3.f-
                16   fer6nt groups together.  And sometimes they hatdlv recognize
                                                        is accompli. hi  this.
                17   that the regional medical program             s  ng
                18   But it order to demonstrate to Congress, the  public And
                19 1 others that you are accomplishing something,  this it not a
                20   very effective order of operation.
                21             And so we find ourselves caught between these two.
                     I think that in general regional medical programs have done
                22
                     a T--)oor 3ob of deirotstrating to beneficiaries that thev havei
                23
                     in fact- served  a useful purpose,  I find continually  as I
                24
                     move around our  txio-State region, @,7ashingtbn.ahd Alaska,
                25


                                                                                  (,7

  n4                  that there are unexpected  and  surprising  numbers  of  people

                      i..Tno nav        ched in some  way bv our  r gi@onal medic  1
                             e been tou                                          a

                   @l program who volunteer the fact that    their appreciation   and
                 3
                 4    their hope that something like this    will be continued because',
                 5    they have been unable to find any kind of assistance to
                 6    bring together activities  to  accomplish  needs,  to  respond

                      to needs that they have.
                 7
                                DR. HABER: I  would  hazard  a  guess  that  probably
                 8
                 9    90 to 95 per cent of the  beneficiaries,  while  they  may  be
                      aware of the local clinic  or  school  operation  or  outreach
                 10
                      operation, are not  aware  of  the  fact that this is  served  by
                      the regional  medical  T)rogramin  tqrms of  coordinating,  plan-
                 12
                      ning and executing of  it.
                 13

                                And that is  a critical step, it  seems  --  to  bring
                 14

                 15   that realization home.

                 16             DR. SPARKP.IPIT: I would agree.  And I would welcome

                 17   an@7"thoughts here any of the members of the National Advisorv,

                 18   Council have about this. I think  we  have  done  a  poor  job

                 19   in this respect.

                 20             DR. PAHL:  I think in view of the time I will closel
                 21   this open portion of the meeting and again thank our visitors

                    -and guests for appealing and    speaking with  the  Council  And
                 22
                      being available for discussion, and ask at this    time that alli
                 23

                      individuals in the room other than those .-.,ho are part of
                 24
                 25   our.council or Federal empl6vbes please leave at     this  time.


                                                                   and th
   n5             I              Let's take a ti,7o-minute stretch        en @,7e  v7ill

                  2   enter our  review of anplications.

                  3              (A short-.recess was taken.)

                  4              T)R. PA17L: ?,,@lay v7e come to order again, please?

                  5   Will Council come to order, T)lease. I  would  like  to  r6con-

                  6   vene the Council for now the closed session and the review

                  7   of individual applications and, just as  is  our  custom,  call

                  8   to your attention the statement on  conflict  of  interest  and

                  9   confidentiality       etings which you  will  find  imm6diatelv
                                      of   me

                  10  behind your agenda.

                  11             And I would like now to turn the meeting over to

                  12  Mrs. Silsbee who will guide us through,the at)nlications.
                  13  Most of you were here  vesterdav  and  hoard  the  discussion
                  14  We hope that  that  wasa mutually  rewarding  and  satisfying

                  15  experience.

                  16             Ihave heard some favorable t6mments(from the

                  17  Review Committee members.  And I certainly hooe that you fo nd
                  18  it 'of interest. Let me state @,.for the record that  this  was

                  '19 an unusual proceeding and that it was  through  a  comedy,  a
                  20  set of highly unusual circumstances, but  that  the  members  of
                  2'L the Couh6il were sitting as 6fficiA! visitors  and  not  in  any

                      way,  as  participants.
                  22
                                 And so your discussion,  review  And  recommendations
                  24  today are  now as Council members and may be in  sur-port  of
                      or quite divergent  from  whatever  discussion,  recommendations
                  25


  n6                 were made yesterday.

                                And with  those few comments, Judy, would you
                 2

                     please lead us through?
                 3

                 4              MRS. SILSBEE:   There are a  courle  of  background
                 5   items that I think  are  important  here.  The  committee  did
                 6   expre s after the meeting yesterday some concern about the
                     speed with which they had-to move,  but  they  never  had  a
                 7

                     choice.
                 8
                                They had the Council meeting  today.  And  'it  may
                 9

                     not have been Apparent to all,  but  at  the  gbt-toqeth6r  in
                 10

                 11  July the individual reviewers did talk with one another and,      i

                     in most cases, where they were  not  able  to,  the  tried  to
                 12                                                    y

                     communicate by phone.  So there was a good deal    more back-
                 13
                     ground in terms of their deliberations    than  appeared  in

                 i5  public in the record.
                 16             The other thing is that we put on your desks    this

                            9
                 17  mornin      I mean,  in front of you     this is supposed  to
                 18  be pink.  And this   is the Staff's -- yesterday as   the CoTnmit-'@

                 19  tee was deliberating we were trying to vrite these up so

                 20  that you would have something in front of vou.

                                This is the gist of the recommlet6ati6nt of the
                 21

                     c
                      ommitt66,  and  they  are  alphabetically  arranged.  Also,
                                                                 r               just

                     now we have -- I feel like, yes, Virqifiia;   there is a way of
                 23
                     doing this -  we did get the transcript for    Yesterday
                 24
                     mbrning's session back in time.
                 25


                                                                              7 0

                               This is the first    we have been asking for  this
  n7
                2    for some time, but it finally  came  abou   That is only
                                                             t

                     those regions that--were reviewed in  the morning.  The after-
                3
                     noon session is still being  typed.  So we have asked the
                4
                     Staff to take apart the  transcripts and give you the
                5
                     verbatim transcript of those regions that we now have   the
                6
                 .i                                                                 I
                     transcript available on.,
                7
                               l@lith that background, I think this morning we will

                     try to go alphabetically.

                               Dr. Schreiner?
                10
                               DR. SCHRPINER:  Before you do that, I would find     i
                11
                   1 it helpful in perspective to  know if vou added up all thebel
                12
                     what did it come to?
                13
                               MRS. SILSBEE:  A very good point.
                14
                               DR. PAHL:  l@lell, I have the figure.
                15
                16             MRS. MORGAN:  It was on the board.
                               MRS. SILSBEE:  I erased it from the board this
                17
                18   morning because it didn't seem to be a thing to be public

                     knowledge.
                19
                               DR. PAHL:  The figure is $26,5570154, which ist
                20
                     from a management point of view, a verv nice level.  But you
                21
                   1. should not be bound to it in either an upward or downward
                22
                     direction, particularly in view of the action you took this
                23
                     morning which gives us that kind of flexibility to manage
                2
                     our affairs.


                              DR. SCIJREINER: That,gives us a feel for where  we

                2   are.

                3             MRS. SILS.BFE:  i am asking Mrs. Leventhal to dis

                4   tribute the kind of running summary we keen that puts  toge-

                5   -ther as much information as you have at this point.  This is

                6   the summary data on the recommendations yesterday.

                7             DR. JANETIAY:  Mrs. Silsbee, can I make a  ratuitbus;
                                                                       9

                8   comment?

                9             MRS. SILSBET:  Yes, sir.

                10            DR. JANEIIAY: 1 think it is an extraordinary

                11  accomplishment to be able to get                           b
                                                     the transcripts on the ta 16

                12  this morning,  You must have had-people chained to the 1.7alls

                13  all night.  I don't know how that was done.

                14
                              MRS. SILSBEE.-  Well, this gentleman to my right
                -15 and his peers are the ones that are responsible for that.

                16  But also, a push  I think, from the Dit6ctor's @,off       p
                                                                       ice@hel edJ

                17            DR. PAHL:  We found that once the rumor that I
                18  relayed yesterday didn't materialize,there was a free eveninlai

                19  for everyone.

                20

                21

                22

                23


                                               ALABAI.!A
  n9
                               !-IRS. SILSBEE: O.K. Could we start  with  Alabama?
                 2
                 3   I think the best wdv to proceed today is to ask the  primary

                     reviewer to make
                                     whatever comments and  make  recommendations

                     and then if the secondary reviewer has anything different  I
                     ill ask for that.  But it may not be necessar  at this
                     w                                             y

                 7   point.

                               Alabama.  Mrs. Gordon?
                 8
                               MRS. GORDON:  1 was pleasantly surprised this
                 9
                 10 ii morning when I read the various and sundry things we  have
                 11  received, since I wasn't here Vestetdav. I agree  pritrarilv
                     with the comments made ye8terdavi  The onlv addition  that
                 12
                     I would have is that Alabama does have a couple of their
                 13
                     pro3ects that noarlv all of the monev is for equipment.
                 14

                     And that I do question.
                 15

                               That is 126 and 125.
                 16

                               MRS. SILSBEE:  Mr. Ogden, you were present yetter-
                 17
                 18  day.  Do you have an thing to add?
                                         y
                 @19           MR. OGDEN:  No.  I would agree with the  comments   i
                     that woke made yesterday, particularly those which   appear
                 20
                     in the transcript from Dr. @Taun. Project number 134  does
                 21
                 2   indeed appear to be the same project that appeared here in
                 2
                     the previous application and was rejected.
                 23
                               And it is unlikely -- I felt in reading the material
                 24
                     that was sent to me    that it could he completed in a
                 25


                                                                              7 3

                                                    d some of their  oth r projects
  nlO            I   reasonable neriod of time.  An                     e

                 2                              feasible within the periodof one
                     perhaps are  not  terribly

                 3   year.

                 4              The matter of the equipment doesn't bother me that

                 5   much.  And I would agree with the allocation made by the

                 6   Review Committee yesterday.

                 7              Mrs. Gordon, do'you have any other feeling on

                 @8  that?

                 9              MRS. GORDON:  No.  I would agree with the alloca-

                 10  tion

                 11             MRS. SILSBEE:  Could I have a motion, pl6ase?

                 12             MR. OGDEN:  If Mrs.  Gordon will move it, I will

                 13  second  'It.

                 14             MRS. GORDON:  All riaht.

                 15             MRS. SILSBEE:  The motion has been made And

                 16  seconded  that the Review Committee rtcommendAtion6f a
                 17  funding  level for the Alabama application for  $680,000 b
                                                                                e

                 18
                     approved.

                                DisdussiOh?

                 20                  response.)

                 2 1            MRS.  SILSBEE:
                                                Nll in favor?

                 22             @70ICES:  Aye.

                 23             MRS.  SILSBEE:  Opposed?

                                 No  response.)
                 24

                                MRS.  SILSBEE:  The motion is carried
                 25


                                                                              7 4

                                                ALPANY
   nll
                              MRS. SILSrrE:  The  next region is Albany.  Dr.
                  2
                     Watkins is the primary reviewer.
                  31
                  4            DR. WATKINS:  Albany has a history as  a  superior
                  5  region.  In the May funding which Council recommended in
                     Tune it almost got 100 per cent of the  request.  In  other
                  6
                     words, it was 1 million 66.hundred thousand  and  they  got
                  7
                     1 million 12 thousand.
                  8
                               They Are asking this time for 541,437.  Mr. Barrows!,
                  9
                     recommended 4870000.  Based on Albany's superiority and
                  10
                     community involvement, I make a motion that they get 487,000
                     which was recommended                    Review  Committee.
                                           .yesterday by  the
                  12

                               MRS. SILSBEE:  Dr.  Haber?
                  13
                               DR. HABER:  I have  nothing to add,  except  that
                  14
                     would ask Dr. Watkins if we  could amend his motion to make
                  15
                  16 it $500,000i $13,000 more than he has suggested.

                               MR. MILLIKEN:  For what reason?
                  17i
                  18           DR. HABER:  I think that these  projedts are well
                  19 conceived.  I think that the one I am particularly intere ted
                  20 in is the one commented on in terms of  evaluation  of  the
                     medidaid screening                            ere seemed  to
                                         program.  I think that th
                  21
                     be some disparity between some of the reviewers  about  what
                  22
                     the level of funding should be.
                  23
                               Since.b6th of them are a  little bit  below  what
                  24
                     they asked, I think we  can be slightly more  generous  and give@i
                  25


   12            1   then some more.

                 2             MRS. SILSBEE:  Does thatconstitute a second, Dr.

                 3   lTaber?

                 4             DR. HABER:  Yes, it does, if Dr. TTatkins will

                 5 i accept  it.

                 6             DR. IIATKTI\'S I accent it.

                 7 1           MRS. SILSBEE:  The motion  has been made and secon e
                 8   that the  Albany ap lication be approved at a $5OOtOOO level.
                                       p

                 9   Additional comments?

                 10            Dr. Milliken     t mean, air. !,Iilliken?

                 11            MR. MILLIKEN:    I am concerted about the precedent

                 12  for the future applications.

                 13            MRS. SILSBEE:   Could vou use a Microphone, pipAse,

                 14  sir?
                 15            MR. MILLIKEN:  I am a little concerned about the

                 16        edent of this amendment for consideration for the forth
                     prec
                 171 coming  applications.  I  think if v7e could use specifics the

                 18  Dr.'gAve in terms of a specifid projedt that the increase
                 491 be allocated specifically to  that for the reasons that he

                 2o  gave rather than -leaving it to the judgment of heaven, they

                 21  might spetd it on projects that this Council and the

                     Committee feel were not  viorth
                 22                                y.

                               And I notice a departure from out usual routine.
                 23
                     I am not  against it.  But I believe there ought to be more
                 24

                     specific  instructions.
                 25


                                                                                7 F

                                               Mrs. Morgan?
   nl3           1             MRS. SILSPRF:
                 2             MRS. MORGAN:    Can we give  srecifi-C  instructions

                 3   to the regions as to how  they  are to snend the money?

                                                                         d that the
                 4             MRS. SILSBEE:   T,,Te can stronalv recormmen

                 5   basis of the funding decision was based on that asnect*
                 6             DR. PAHL:  We cat qive advice, but we do not    really!

                     earmark it for one specific vroject.  And in that sense,
                 7

                     in adding additional funds we would just have to rely       n
                 8                                                          .  UPO
                 9   whether they chose to follow our advice or not.  So your

                 to  reasons should be very -well spelled out.

                 11            But we can't guarantee the results.  lie do our best!

                 12  to transmit that advice.

                 13            DR. GRAMLICH:  Dr. Pahl,   Mr.  Milliken't  remarks
                 14 'have crvstalizod a growing concern   that has wbrm.06 its  way

                 15  into my mind.  This sounds a little   bit like -- I  want  to

                 16  ap6logiz6 and make it very brief.

                 17            The mechanism that is used is illustrated by this
                 18  particular request, especially where yesterday you Will

                 19  recall that one reviewer said, let's  make  it  this  figure,
                 20  the second" reviewer said, let's make  that,  and  they  said,

                 21  well,, 16t,s just split it.

                               And I like the approach that Dr. Habet has suggested:
                 22
                     that they be mote srecific. And this poitts  uD  to  rnd  the
                 2.3@
                    @Urqoncy of the problem which is only existing in this;parti-
                 24
                     cular session, -because if this is the last session it will
                 25


                                                                              77

   nl4            1  never be up again.

                                                    ion in
                  2             But here is a situat       which the whole structure
                  3  is a reverse pyramid. The primary  reviewer,  who  is  the  onlv

                  4  one who has really had the time and the ability to go over
                  5  the grant request in detail is the one who  starts  at  the
                  6  bottom of the apex of the pyramid on  which  the  total  funding

                  7  process is accomplished.
                  8             The secondary reviewer savs, well,  yOtl  I  think
                  9  it is probably all ri ht, or  mavbe we ought to  do  this  or
                                           9
                  10 that.   But then the Review  Committee accepts that, and if
                  11 we accept ito in turn, the  Review  Committe6ls   recommendation
                  121.ex pro facto without any really  serious  consideration  we
                     are just compounding that pyramid, on which some vdty
                  13
                     important decisions at the regional level might well     take
                  14

                  15 place.

                  16            Sd my plea is simply that I  think  y6st6rday's

                  17 review session, which  wasinterbsting,  very  interesting, was

                  18            ni u          it was Presurdd timewise- and  may
                     probably u  a e in that
                  19 have reached  the tight decision     ntobibly in most instances

                  20 it d:bd.
                  21            But I would agree. I think  the  Council  should
                     subject that to air.,ole scrutiny before acc6Dtiho it.
                  @22
                  23            MRS. SILSBEE:  The notion has been made and
                  A  seconded that the Albany application be approved
                  24-@                                                  at   $500,000
                     with advice to the region about  the  one  project  involving
                  25


                                                                              7 8

  nl.S           1   the   State.

                 2              Is there further discussion?

                 3              (ITO.'response.)

                 4              MRS. SILSBEE:  All in favor?

                 5              VOICES:  Aye.

                 6              MRS. SILSBEE:  Opposed?

                 7              (ilo response.)

                 8              MRS. SILSBEE:  The motion is carried.

                 9              The next region to be reviewed is Arizona, and Mr.

                10   Firoto is  the primary reviewer.

                11              MR. HIROT6:  May t ask if the afternoon transcripts

                12   from yOsterdAy's session will be available later?

                13              MRS4 SILSBEE:  Yesi Mr. Hiroto, would you like to

                14   hold off?

                15              MR. HIROTO-.  Yes.

                16

                17

                18

                .19

                20

                21

                22 ii

                23

                24

                25


                                                                               79    i

   nl6           1                              ARKANSAS
                 2              MRS. SILSBFF,:  We will go to Arkansas.
                 3              I'm sorry, I can't remember which ones came tp,
                 4   so if you  all will point this out it would he  most helpful.
                 5              Dr. Komaroff is the primary revieuet of the

                 6   Arkansas application.
                 7              DR. KOMAROFF-.  The June Council rated this region
                 8   as average4  Its funding level on.the basis of the June
                 9   Council recommendation is  currently  1.425  million.  They  seek

                10   a supplement of S816,000,

                                The main 6oncetn of the June Council denteted
                12@  around the stability of the core'staff and the uncertainty

                     About a new coordinator to teplac6 Dr. Silverblddt.
                13
                     According to Mt. PostA and the Staff of DR!'@IP, that Di6biem  is
                14

                15   being resolved.
                16              virtually all the vacant staff  positions  have  been
                     filledi  And the current acting  coordinator  verv  likely  will
                is   become the p6rmaneht coordinator.  The proj6dt  roo6sals in
                                                                       p

                19   this supplement are somewhat disapo6intinq   to me.  And I
                20   think Dr. Carpehter's review yesterday  sumnaiii6s  my  imt)res-

                     sions.
                21
                                The application consists of a great variety of
                22
                23   unrelated pt6iedts.  Many  seem  designed  0  uith6r  the  goals
                     of a single institution within the region rather than to
                24
                     accomplish'regionalizatioh.  I agree with that.  Th6te    are


                                                                                 80

   nl7           1 I  two projects that I think the Council should be parti6ularlv

                 2    concerned about.
                 3              one is a.'very large project, the Arkansas digestive

                 4    disease center, which requests  $176,000.  It  is  actually  a

                 5    low priority project from the  RAG.  The  thing  that  concerns
                 6    me about this project is that they state their primary objec-
                 7    tive is to., quote, facilitate the  further  development  and
                 8    upgrading of the gastroenterology training program at     the

                 9    medical center.
                 10             And they wish to purchase $880,000 worth of  ecruit)-
                 11   ment. Additionally, they will  hold  a  weekly  conference  to

                 12   which practitioners from the community  would  be  invited,  as
                 13   I imagin6 they currently would be, and hold a few educational

                      sessions around the region.
                 14
                 15             But it is clear, and I  think  they  state  frankly,

                 16   that the purpose of this grant is  reallv  to  supplement  the

                 17   training proaram in gastroenterology at   the  medical  center.

                 18   Ahd-I think the Council ought to  express  some  tangible  6on-

                           about that,
                 -19  cern
                 20             The second project   that perplexed me is  a  project
                 21   to establish rape crisis center control program.     this  is
                   i. sponsored by,the National Orcranizati6n for relomon   NOW,,And
                 22
                      the State of Arkansas, and x..,ould enhance the abilitv of  A
                 23
                      woman who had been raped to seek ik@.ediate  guidance  as  to
                 24

                      what she should do medically and legally.
                 25


   nlB           1             I think there are similar prototype for-this
                                                                             kind

                 2   of a rape crisis center around the country,that apparently
                 3   are quite effective.  But the concern I have is whether @!P

                 4   funds under section 900 -of the law really allow for this
                 5   kind of a categorical activity to be  supported.
                 6             It is not noncategorical; it is categorical.  And
                 7   it does not fall, in my estimation, viithin-the language of

                 8   the law.

                 9             DR. PAHL: It is  also  discriminatory.
                10             MR. KOMAROFF: I suppose rape  can  be.    would, to
                11  make these recommendations tangible,  agree  with the level 0-4
                12   $4OOiOOO the Review Committee recommended yesterdayi@but
                13   with two restrictions:  one, that there be no dollars exbended
                14   for the rape project andi second, thatho more than S30 000
                15   be expended for the digestive disease  proposal.

                16             DR. TTTAMIOCK:  Which would be for 6ducation?

                17             DP.* KOMAROFF:  Yes.
                18             DR4 PAHL4.  Dr. Komaroff, I think we would feel

                19   comfortable with that recommendation at a program,

                20             MRS. SILSBEE4.  Dr. Janeway?
                21             DR. JANETIAY:  Dr. Komaroff and   have discussed
                2    this prior to the meeting.  I concur with the technical
                 2
                23   review and with Or. KomArbff's comments, and second the

                     proposal.
                24
                               MRS. SILSBTE:  A motion has  been made and seconded


                                                                           8 2

   nl9         I    that the Arkansas application be approved at a S400,000

               2    level, with the fol lot-!ing conditions:  that no dollars be
                 I
                    expended for the rape review project and that no more than
               3

               4    $30,000 be expended for the digestive diseases activity.

               5              DR. JANEWAY:  That is component 104.

               6              MRS. SILSBEE:  Component 104.
               7              Is there further-discussion?

               8              (No response.)
               9              MRS. SILSBEE:  All in fAv6r?

               10             VOICES:  Aye.

               11             MRS* SILSBEE:  Opposed?

               12             (No response.)
               13             MRS. SILSBEE:  That motion is carried.

               14

               15

               16

               17

               18

               19

               20

               21

               22

               23

               24

               25


                                                                                8 3

                                                 BI-STATE
  n2O            I

                 2              MRS. SILSBEE:    The next  application to  be  r6viewed,

                                                                           Milliken.   ii
                 3   is Bi-State.  The principal reviewer there    is @ir,

                 4              Mr. Milliken,   'Dr. Watkins was here yesterday And'   i

                 5   you  weren't.  I  don't  know whether that

                 6              MR.  MILLIKEN:   Iwill defer to him.

                 7              MRS. SILSBEE:  Dr. Watkins?
                 8              DR. WATKINS:  Yes.  The Bi-State request was for

                                               ended funding level  wag  for  8275,000.,
                 9   $472f458,  and the recomm
                 10  And I agree with the Review Committee.  I think that      this

                     Bi-State critique, the projects compared to:May-Jtne      were
                 11

                     sort of around the same level -  in other words, the      same
                 12
                     level of priorititation and so forth       except  that  since

                     time is running out it is possible that    they might have oAdd6li
                 14
                 15  a little to get the $472.
                                   what we are asking is that this be reduced    to A
                 16             So
                 17  more feasible figure for them at $275POOO.  There wag a

                 18  recommendation by two reviewers of 270 to 300 thousand.  And

                 19  I think one reviewer  even  suggested  335  thousand.  But  we

                 20  are suq4estihq that it be 275 thousand,
                 21             MRS. SILSBEE:  Mri Milliken?

                                MR. MILLIKEN: I would  like  to  in  general  agree
                 22
                     with that. Powever, in  looking  at  the  many  pr6l66ts  that
                 23
                     were recommended be dropped, there    was one, number 59,
                 24
                     evaluation And  placement  of  long-term  care  OAti6ht$.  I  don't
                 25


                                                                           84

  n2l               know.the qualitv of this program.
                2             However, generally there are two great needs in
                3   the country which @ould show a need for developing and

                4   continuing such projects.  One relates to cost containment
                51  for health care, and the other to get resources in  lace for
                                                                       p

                6   the impending national health insurance.

                              And based on this, and if this is    I would have
                7
                8   to rely on Staff -- if this is a program that can be a
                9   quality ptograri and make contributions to those two needso
                    I wou;-d recommend that we add $30,000 specifically
                10                                                     Earmarked 12

                11  for funding of number 59.
                12            MRS. MORGAN:  1 don't see where 59 was deleted,

                13  an  ay.
                      YW

                14            MR. HIROTO:  It wasn't.
                15            MRS. PORCAII:  We've got 57, 58, then we go to 60.

                161,@         MR. MILLIKEN:  Oh, really?  The list I have

                17  indicates;@,--

                18            DR. WATKINS:  Let me see if I can    the regional

                -19 office made comments on 60, 57, 59 And 64, which were
                20  favorable.  And it would be an additional $60,000.  The
                21 I; question is:  Ate we in agreement with this?  If you are

                    in agr  eme
                          e   nt I will acdthe $30,000.
                22

                              MR  MILLIKEN:  Right*
                23

                              MRS. SILSBEE:  O.K.  Mrs. Flood?
                24
                              MRS. FLOOD:  The Review Committed's comments that   t
                25


                                                                              8 5

  n22             I  are listed on the pink sheet says that brief mention is made

                  2                          as the new coordinator.  Fowevetil
                     of Dr. Velix's arrival

                                                              le  i  plans or the
                  3  little discussion was giv(n to his new ro    n
                  4  role he might play in  the development of this  application.
                  5            Being A  little bit familiar with the  past history

                  6                                  k,that the power that
                     of the Bi State program,,I thin                        a man
                  7  of Dr. Velix's personality and capability might have   in
                  8  making the program develop into something stronger even   in    I
                  9  this last phase is something we shouldn't overlook.
                  10           Now, I would agree that at first.glance some of
                     these projedts do hot appear to be of the most outstanding
                  12 quality. But I viould think that Dr. Pelix has the  6apabilit-vi@
                  13 of holding neutral ground in a particular area where there
                  14 is quite A bit of thiversity medical school dis ussi6h; and     I
                                                                      c

                  15
                     there is impingement on ti-Stato by the Illinois   RMP and
                  16 There has been inactivity at times by the  Mitsouri RM-P.

                                I would like to Iask if the
                  17                                        gentlemen might consider,,
                  18 in light of the  cut that was given at the itno Coundil; an.
                  19 Additi6hal $100,000 to fund the Bi State program at $375,000
                  20 rather than $275,000, with your specific recommendation of
                  21 that pr6je6t being included, that 59  but with no comment
                  221.,@e about the rest of this money     that it, $60,000 or

                  23 $70,,000.
                  24,           That might be of value to Dr. F6!ix to accomplish
                  25 something; coordination in another   area.


                                                                             P 6

  n23           1              MR. MILLIFFN: You feel that  he  needs  additional

                2    staff, do you?
                3              MRS. FLOOD:  FO,I don't think he needs necessarily

                4    additional staff.   I think he needs a little discretionary
                5    capability there,  to be responsive to these things  in  the
                           so
                6    r6qion/that he doesn't have the stigma of being r@elat6d  to

                7    the universities in that area.
                8              I think he needs a little more discretion  so  he
                9    can be more able than the previous coordinator to relate to

                10   needs,in that  region
                11             DR. WATKINS:  Well, if we were to review  and  we
                12   were to add, I  would suggest that it be based on what we
                13   just mentioned, the regional office comments. -And t ose

                                   an additional 60, not 100. So I  would  w  nt
                14   comments were                                          a
                15   to have a reason for adding to the 275,, end the reason would
                16 1 be .strongly in favor of the regional comments  which  were

                17   the projects just mentioned, 59, 64, 60 and  57.

                18             That was the group eliminated by  the  reviewers.
                19   That is a group that is worth 60,000.  So it would  give  me

                20   a better feeling if I said 60 rather than  100.
                21             MRS. FLOOD:  Well, I would accept the 60.
                               MR. MILLIKEN:  What bothers me "- I am hot aoainst
                22
                     adding Another 40-000. We have the money.  But  I  think  we
                23
                24   need a more tangible, specific advice for so doing, in line

                     with my earlier comment.
                25


                                                                                87

   n24                          1 think it puts  us in a vprv bad light to add

                     additional amounts  without  avery snecific  cause
                2

                3               DR. WATKINS:  Can we have Staff  comment on this?

                4               MRS. SILSBEE:  Mr. Posta?

                5               MR. POSTA:  I think the purpose Of  what Mrs. Flood-'ti

                6    picked up  in the green sheet was'primarily instigated by
                7    Staff.  It was something that was not said-rather than what
                8    was said.  Dr. Felix did come in and talk  to  Dr.  Pahl  and

                9    the   proper staff here at DRM-P.
                10              He did respond with a  three-pa4e  letter  stating   I

                11   some of his goAls, what he would like to do dtrihg the next
                12   year in the St. Louis area.  As we know, he does have a
                13   terrific  reputation.  And  to date -- he has  been  on  board
                14   since Jul !St  --  has  gotten together with 6xpotimental
                                y
                     health delivery service system there in  St.  Louis  as  Well

                16   as with ARCH program and the CITP agency.
                17              And one of his primary goals is to utilize the
                18   institutions already set up and yet At the same  imeto
                19   pursue some of his goals in primary  dare  and  in  manpower.
                -20  Now, the Other point that was mentioned  in  the  pink  sheet
                21   you have before you was the role that Dr. Felix h
                                                                        as  layed
                                                                            p

                     in establishih  And prepa
                @22                 9           ring this particular Application.

                23              And v7hen we asked him that, the answer  was  com-
                24   pl6tely h6gative:  He did hot have a role in pre_pArih4 this
                @@25, particular application.  So it is our strategy At least to


                                                                               88

  n25             1  present this to you with expectations that perhaps Dr.

                  2  Felix would have more latitude in getting into those areas

                  3  that he particular  has a special talent for.

                  4            MRS. SILSBEE:  But  for  Councills  consideration,

                  5  they have the application in front of  them.  This  is  sort

                  6  of the horns of a dilemma.  And in terms of the advice that

                  7  we would give to the region, as I heard the discussion,, is

                  8  thatcertain of your activities we think are first rate,

                  9  some of the others we don't think are good.  But we really

                  10 think that you ought to scrap the whole thing  and  look  at

                  11 your priorities all over again and put your faith in Dr.

                  12 Felix.

                               Now, this could be translated in some way or
                  13

                     another, but it does create a problem.
                  14

                  15           MR. HIROTO: Is  there  a  motion?

                  16           MRS. SILSBEE:  No,  there  isn't.

                  17           DR. WATKINS: V-7e move  $335,000.

                  18           MR. MILLIKEN:  I second it.

                  19           MRS. SILSBEE:  The motion has  been made And seconded

                     that the Bi-State application  be  approved at the  level  of
                  20

                     $335,0004
                  21

                               Is there further discussion?
                  22

                               (No response.)
                  23

                               MRS. SILSBEE:  in favor?
                  24@
                  25           VOICES:   Aye.


                                                                           89
                . I

   n26          1             MRS. SILSBFE:  Opposed?

                2             DR. JANEV7AY:  No.

                3.            MRS. SILSBEE:  Let the record show there was one

                4   in opposition.

                5             The motion is carri ed.

                6             MR. PIROTO:  Am I to leave?

                7             DR. JANETIAY: Yes.

                8

                9

                10

                12

                13

                14

                15

                16

                17

                19

                20

                21

                22

                23

                24

                25


                                                                                  90

  n27                                           CALIRORNIA

                 2              MRS. SILSBEE:   The next  application  to  be  reviewed

                 3  11 is  from  California.  And 'Mr. Firoto is out of  the  room.

                 4  ti! Dr. Janeway is primary reviewer.

                 5              DR. JANEWA-Y: As noted in  the  Ma-v-june  review,

                 6    the program was above average  and  continues,  in  my  opinion,

                 7    to be above average  to  superior.  The  May-June  request  was

                 8    on the order of $8,170,000, with  a  DRMP  funding  decision  of

                 9    almost 7  million  dollars   even somewhat below the

                 10   Committee   recommendations

                                The  current   request is for $5,592,000.  It is mv

                 12   opinion in  reviewing  this -- And I  concur  with  the  technical

                 13   review committee      that the  request  is  overl  ambitious
                                                                      y

                 14   for the time frame of accomplishment.  And the    amount  can

                 15   be effectively reduced  to  an amount of 3  million  dollars.

                 16 11            would  express  only  one  administrative  concern:

                 17   Although there  seems to be a  reasonably  good  relationship

                 18   between the @MP activity  and  the  various  CFP-agencies,  there

                 19   are some areas of  clearly  unresolved  conflict.  And  I  think

                 20   that with what I see as  somewhat  more  dispersion  of  activity

                 21   in this State  tending  to get back to the  way  it  was  before

                    ,;!,reorganization, that the coordinator  should  he  cautioned
                 22 if

                    i in this regard.
                 Z3
                                The   recommendation for funding is at  the  level  of
                 24

                      3 million dollars.  And  I  so move.
                 25


                                                                                   9 1

  n28                            MRS. SILSBEE:  Mr. Ogden?

                                 AIR. OGDET%T: I  disagIree with  Dr.  Janeway  on  the
                  2
                  3   level of  funding. -.And I would  like  to  spend  a  few  moments
                      on this  particular  application,  inasmuch  as  1  think  it  is
                  4

                      the largest before us today.
                  5
                                 Those of vou who were here yesterday and listened
                  6
                  7   to the  discussion  will  recognize  that  Dr.  Heuttig,  who  was
                      the primary reviewer yesterday, recommended      this  be   funded
                  8
                      in  full,  $5,592iOOO.  Dr.  flirschboeck,  who  was  the  secondary
                  9
                  10  reviewer, suggested it be reduced to 2 million dollars.
                                 After  considerable  discussion  among   the   eople
                  11                                                          p
                      around the  Review  Committee  table  about  the  projects  and a
                  12
                      group of other things,  the  final  decision  dame  down  to  a bit
                  13
                    1 of  dickering. Now,  at  the  risk  of  going  over  things  that
                  14
                  15  YOU   li_,iten6d to yesterday,, there was a show  of  hands  on  how
                  16  many   would prefer 3 million.

                  17             Dr. fleustis said, how about 4 or 5?

                                 Then Mrs. Silsbee said, well     the  motion  has  been

                  19  made at 2  million, how many in favor.      That was voted down.

                  20  That motion was defeated.
                  21             And  Mr. Barrows  said, well, then   I will  move  it  at
                    '-3 million.  And they finally got an acceptance at 3 million
                  221
                    1 without any discussion of whether these were valwble rr6jects,
                  23i
                  24  whether the RMP was being cut too far or patticularditdussion
                  25  with respect to the quality of the this program.


                                                                              92

   n29           1             Now, you  don't  have available to you, I don't  thinki,

                 21  the yellow printout  sheets  on this.  Do you have this in

                                     yo
                 3   your books?  If    u would look for a moment  with me at  the

                 4   yellow printout sheets on the California Regional Medical

                 5   Program, there are some things here  that I think are of

                 6   considerable interest to us.

                 7             MR. MILLIKEN: These  are  numbered.  which  one  do

                 8   you want to look at?

                 9             MR. OGDEN: Let's begin with  the  cover  sheet  for
                 10  just a moment. There are 83 projects here;  61  of  them  are

                 11  new, and 22 are requests for@continued support  --  1.3  million!

                 12  of continued support.

                 13            And if you look at  the next page, you will see that

                     program staff,  which  includes existing projects as  well  as
                 14

                 15  continued projects, is 1.6 million.  Now, if vou add un the     i

                 16  continued support and program staff, you are at 2.9 million,

                 17  which is the 3 million dollars that we ate talking about.

                 18            Admittedly program staff may  be  possibly  reduced   II

                 19  in the event they do nothing on new projects.  But the 3

                 20  million, I -suggest, may only continue the  projects  that  they!
                     have and cover Drograms.  That does not cover now projects.-
                 21

                     In looking across,, I see  that there may be some  cutback  on
                 22
                     program staff if there  are  no new projects.
                 23

                               DR. JANEWAY: May I make a point of clarification?
                 24

                     It was my impression, as I was primary  reviewer,  that  none
                 25


                                                                             9 3

  n3O           I   of this was for program staff.  That was all funded in    the

                2   May-June application.

                3              MRS. SILSBEE: Is that not  correct,  Mr.  Russell?

                4              MR  RUSSELL:  That is correct.
                5 11           DR. JAIIEWAY:  That 1.6 million has  already  been

                6   funded,-

                7              MR. OGDEN: All right. If you  come  down  to  the
                8   request for September of '74,to June of 175 which is in the
                9   third column, that is under the heading of five in here,,      1.

                10  you will begin to tee the programs that  thev  are  proposing

                11  are those to which they propose to add some additional

                12  funds.

                13             These include a series of kidney  programs,  some
                14I of which were funded at  very small amounts in the  Tulv  '74  I
                15  to June of 175 request  and for which they are now requesting

                16  additional funds.

                17             And when you come over, come several pages   along

                18  don't you have a printout, now beginning on page 7.you begin

                19  to pick up new projects which  they are talking about beginning

                20  with about 147T.  And you will find some that are added to.
                21  But beginning on page 8 they are all new Projects that,they
                    are talking about funding for the period  of  September  174 to
                22
                23  June of 175.
                               Now, I find some of these to be  of  considerable
                24
                    interest and also of value.  There are projects here concerning
                25


                                                                                94

   n3l               the health  care  network  in the Imperial Valley which involves

                 2
                     migrant workers.  There    is an American  Indian  clinic  aware-

                 3           oject here.
                     ness pr

                 4              There are upgrading  of  free  clinics,  ambulatory

                 5   care facilities --  a   whole series of things  that  I  feel

                     were simply  ignored  in  the discussions yesterday.  And  I

                 7   came  awav  from  yesterday's discussion  somewhat   dismayed with

                 8   the manner in which  the  California  application  was  handled.

                 9              I recognize that this is a big  program  and  it  is

                 10  an expensive program.  It is a lot of money.  But my reaction

                 11  to it is that the cut from  5.5  million,  nearly  5.6  million

                 12  to 3 million was done almost  on  a  bargaining  basis,  without

                 13  much consideration of the actuality of the needs of this

                 14  pro_gram,

                 15             And I think or feel that we  should  add  back  money

                 16  into this application.  I  haven't  totaled  up  the  requests

                 17  that appear on pages 8, 9 and 10 at all.  But I wou        sug-

                 18  gest,that if we added back upwards of a half million dollars,'

                 19  maybe-@-even a million, we would be finding money  well   spent

                 20  in a superior program that has always had exceptional mAnage-I

                 21  ment and has done a great deal of good  in  what  is  now  the

                 22  largest State in this nation.

                 23             MR. IIAIIMOCK:  You would take it back to 5 million?

                 24  Is that what you are saying?

                 25             MR. OGDEN: I would take it  back  at  least  to  4.


                                                                                9 5

   n32             I            DR. JANEWAY:  Let  me  respond  to  that.  PerhapsI
                   2 am speaking not as a member  of  the  National  Advisory  Council
                   3 and a little bit too  much  from  a  technical  standpoint.  But
                   4 if you are going to put 1.5  million  dollars  into  a  hyperten-
                     sion screening program in 10 months, you had better be
                   5
                     pretty well prepared as a physician population to have     some
                   6
                     reasonable idea as to what you are  going  to  do  with  the
                   7
                   8 people who you identify.
                                And that is where my comments  saying  that  they  arei
                   9
                     being overly ambitious:  If  there  are  indeed  23  unidentified
                   10
                     hypertensives in the United States, and probably more than
                   11
                     that, you can set up programs  wh@ch  build  up  people's  expec-
                   12
                   13 @@tatli6ns to a level which you cannot possibly  meet  within  the
                     limits of the delivery system  or  within  the  cost  barriers
                   14
                     that would be imposed by defining that population.
                   15
                                I think it is an admirable program.  And    I am  hot
                   16
                   17 making a comment there. I am just  saying  that  as  to  the
                   18 cjuality of it I think it  is  overambitious.  And  that  was my
                   ig iinterpretation of the technical  review  that  was  also  given.
                     I would agree that on the surface  there  would  appear  to  have
                   20
                   21 been some bargaining as to the  level of  funding,  at  the
                   22 -outset of which one would get the impression that  it  v7as  not
                     being done on the merits of the proposal.
                   23
                                But I thnk ultimately that it  was  and  that  the
                   24
                     technical expectation was the  one  that  cast  the  deciding
                   25


                                                                                96

  n33            I   factor.  And I would say   that I agree with your comments  to

                 2   a point,.but I certainly   agree with the  recommendations  of

                 3   the Review Committee.

                 4              That is just too much money. It  would  not  be  as

                 5   well spent in that as it would if   it were  distributed  dif-

                 6   ferently throughout the regions.

                 7              MRS. SILSBEE:  Dr. Gramlich?

                 8              DR. GRAMLICH: Dr. Janeway  raises  a  criticism  of

                 9   a million  dollars for a hypertension screening program.  And

                 10  I would observe that the  same  Review  Committee  recommended

                 11  a million dollars for a  hypertension  screening  program  and

                 12  treatment program in the State of Mississippi.
                 13             DR. JANEWAY:  They  cut is by  $840,000  specifically.!

                 14             DR. GRAR-ILICH: Yes, but from a 2  million  dollar

                 15  level, leavin   them with a million dollars.

                 16             DR. JANET-IAY:  The incidence of hypertension in

                 17  the State of Mississippi or  prevalence,  whatever  you  want    I

                 18  to use, based upon the  racial  distribution  and  the  characters

                 19  isties of people living in that area, I think you will find

                 20  a striking difference from California.

                 21             As I said, I don't want to get into being a
                 22  technical reviewer on this, but when you  have  a  very  high
                 23  percentage black population,and  in  the  entire  Southeastern
                 24  United States, if you look at the   prevalence of hypertension,i.
                     coronary, arterial disease      you are dealing with a different
                 25


                                                                               97

   n34            1   type of population and a different health care need.
                  2            MR. OGDEN:   Let me make one brief  comment here.
                  3   I think since the time we started the Regional Medical
                  4   Programs in 1966, we have witnessed in Pinerica-@@probably the
                      greatest migration of People in historv.  And I speak    about
                  5
                  6   the migration of the black peoples of this country from

                  7   the South to the North and-the West.
                  8             We may'not all be aware of  this,  but  as  recently
                  9   as probably 1946, right after the war, some  77  per  cent  of
                  10  the black population in this country lived in  the  South  and
                  11  was thought of As the rural Southern  problem.  Today  65  per
                  12  cent of the black people in  this country live  in  the  North
                  13  and the West and are really  thought of as An  urban  problem.
                                The black population in this nation has settled
                  14

                  15
                      in California, New York State, Michiqan, New Jersey.  And
                  16  I think we sometimes are not aware of these things that have
                  17  been affecting our regional medical programs.
                  18            And I would suggest that if hypertension exists
                  19  in Mississippi it also exists in California.  There is a
                  20  tremendous black population in California.  And it has been,
                  21  a very rapidlv growing population.
                  22            Dick, may 1 just comment, too,  then  I  will  close
                      this off:  Many of these projects,I asked you to look at on
                  23
                      pages 8 9 and 10 of this  computer  printout  are  not  hyper-
                  24         ol                                                       I
                  25  tension projects; these are projects spread among a   great


                                                                              9 8

   n35               many other things.
                  2            I plead no particular case for California.  I am

                  3  not from California.  But I simply feel that this is a pro-

                  4  gram that deserves better consideration than it received

                  5  yesterday.

                  6            MRS.  SILSBEE:  Dr.  Schreiner?

                  7            DR. SCHREINER: -I.just  @nt  to ooint out that both

                  8  the reviewers have made some excellent  specific points.  I
                  9  do think, however, we should put in perspective that.7 inillio
                  10 do-Ilars plus 3 or something over that is roughly 10  per  cent

                  11 of the entire nation's RMP funds.
                  12           .1 don'tthink we should view California as being     I

                  13 a deprived State.
                  14           MRS. SILSBEE:   Dr. Komaroff?
                  15           DR. KOMAROFF: Another was to  look  at  the  perspec-
                  16 tive is that California has 10 per cent of  the  population  of
                  17 the country.  And we had available About 64 per cent of
                  18      unds that were requested in this cvcle.  3 million;,,-
                     the f                                                     out

                     of a request of 5 is about 60  per  cent.

                  20           So an average   region ought to get around 3 million.i,
                  21 But I would think that  if  this region is, in fact, regarded
                  22 to be superior or above averaqe that -- jtst  that  is  another
                  23 context within which  one  might look at the 3 million.         I
                  24           MRS. SILSBEE:  Dr. Janeway has made a motion that
                  25 the application be approved at the 3 million dollar level.


                                                                                9 9
  n36            1   I didn't hear  a  second.

                 2              MR. IIMIMOCK:  I will second that  motion.

                 3              MRS. SILSBEE:  All right.  The motion has been

                 4   made and seconded that the California application  be  approved.;.

                 5   at the level of 3 million dollars.

                 6              Is there further discussion?

                 7              (No  response.)

                 8              MRS. SILSBEE:  All in favor say Aye?

                 9              VOICES:  @Aye.

                10              MRS. SILSBEE: Could you rut  your  hands  up,  please?i
                11   That is one, two, three, four, five, six, seven say aye.

                12              Nay> Seven.

                                MRS. MORGAN:  Maybe  we should set it  aside and go

                14  to

                .15             MRS. SILSBEE:  Dr. Wammock?

                16
                                DR. 1,7AMMOCK: You talk about the new projects  over
                17   here. I  have  just  been looking at that hypertension.  And

                     if you look at on page 9,1 thought I had it, California, it'
                19  -seems to have gotten away.  But it looks to   me that  there  arel
                20   lots of hypertension projects over here --   159C, 159Di 159B    'I

                21   159F  159G, community h pertension awareness project, 159H,
                                             Y.

                22  'high blood pressure control in  Berrett County,  159  --  there's!

                23  about 10 or 15 down there that   go right on to the hyperten-

                24  sion.

                25              So.I think there is a tremendous amount of money


                                                                             100

  n37            I11 being put in that program there.

                 2             MRS. SILSBEE:  Well, I think that was brought out

                 3ii a little earlier.

                 4             DR. TIA@IMOCK:  it was brought out a little earlier.

                 5   But this is in the nev7 projects in which they are reauestina

                 6   this.

                 7             MR. OGDEN:  Can-I-make a new motion that we put

                 8   California at 4 million dollars?

                 9             MRS. SILSBEE-:  Is there a second to that?

                 10            DR. ORAMLICH:  Second.

                 11            MRS. SILSBEE:  The motion has been made and seconded

                 12  that California application be approved at the level of 4

                 13  million dollars.

                 14            Is there further discussion?

                 15            MR. MILLIKEN:  I think 3 and A half.  Try 3 and a

                 16  half.

                 17            DR. JANEWAY:  How about 3 million 640?

                 18            MRS. SILSBEE:  I miaht add that the Council doesn't

                 @19 seem to be any more deliberate in its setting the fund levels

                 20  than the Committee seemed to be yesterday.

                 21            All in favor of the motion to approve the applica-

                 22  tion at 4 million raise their hands?  Four.

                 23            Opposed?  Eight, nine.

                 24            The motion is defeated.
                 25            MR. ODGEN:  Dick, you want to move it?


                                                                            1 01

   n38          1             DR. JANEWAY:  I move approval of the California

                2   application at $3,640,000.
                3             MRS. FL06D: I will second that motion.

                4             MRS. SILSBEE:  $3,640,000.  The notion has been

                5  -made and seconded that the California application be approved,@

                6   at the level of S3,640,000.

                7             MRS. GORDON:  I would like to ask for a short

                8   explanation of the magic mathematical formula used to arrive

                9   at that?

               10             DR. JANEWAY:  It is 65 per cent of 5.6 million.

               11             MRS. SILSBEE:  Does that answer vour question?

               12             Is there further discussion?

               13             (No response.)

               14             MRS. SILSBEE:  All in favor of the motion sav aye?

               @15            VOICES:  Aye.

               16             MRS. SILSBEE:  Opposed?

               17             (No response.)

               18             MRS. SILSBEE:  The motion is carried.

                              I-lould someone ask Mr. Firoto to come back?
               19

               20

               2 1

               22

               23

               24

               25


                                                                             10  2

   n39                                     CENTRAL rIEll YORK

                2              %,IRS. SILSBEE: The next application is Central

                3 11 New York, and Miss--Martinez is the primary reviewer.

                4              MISS IIARTINE7: The Committee recommended  a fundinc

                5    level of $450,000.  I was not auite so generous.  I  found

                6    that at least two sets of projects duplicated or extended

                7    each other in that they were two that were, number 77 and
                8    78 were really building of facilities, which  I  don't  think

                9    is feasible for one year projects.

                10             Two more were really sort  of  education  projects.

                11   The end result is that I ended up with a funding recommenda-   1.

                12   tion 'of 38.1,372.

                13             MRS. SILSBEE:   Dr. Schreiner?

                14            -DR. SCHREINER:  Yes.  I had perhaps the advantage
                15   of site visiting this area.  And there are a number of
                161  developments from the previous time.  I agree with miss

                17
                     Martinez on those two particular projects.

                18             I would also like to  point outi however,  that  in
                -19  the region's own priority list  they are in the low nriority
                20   groups  so that they have insight into the problem which she

                21   mentioned.
                               Ile helped them actually set up a  very  democratic
                22
                     method for determining the priorities in the various places.   1
                23
                24   And I think it has worked extremely  well  there.  There  are  i

                     a high number of inputs, and they have a verv go
                25                                                     od type  of


                                                                            10 3

                 1   rating system for establishing priorities.

                 2            Now, in previous sessions the kidney programs were  i

                 3   toned down because-'they did have some problems in getting

                 4   areawide agreement on  anumber of the projects. I  do  think

                 5   that they made a lot  of progress in that particular area

                 6        our  last  funding.
                     since

                 7            And the kidney projects  have been asked for at  a

                 8   level of 111,000.  The second area that I would give very

                 9   high priority to, and I can find in their priority list

                 10  reasonably highly rated as well, are those relating to  the

                 11  north country, which is an extremely desolate area.

                 12           Even though it is in New York State,  within  easy

                 13  driving distance of New York City, it has one of the  lowest

                 14  population densities in the United States. And there  are  a  i

                 15  number of very uniaue minority circumstances up there,

                 16  including an Indian reservation which never sighed a  treaty

                 17  with the United States and therefore doesn't come under  the

                 18  Bureau of Indian Affairs and it is entirely dependent  upon

                 19  this kind of activity.

                 20            I can identify-about another $135,,OOO worth of
                 21  projects relating to the north country area.  So I am afrai'd
                 22  that my recommendation would be a little bit higher.  if  I

                 23  assumed the program staff figure is correct -- and I  would

                 24  agree it is possible  it could be cut a little bit and put
                                          two
                 25  the emphasis in these/areas     I could come up with a fiaurei


                                                                           ^4

  n4l             1 of $562,000.

                2             So then I am a little far away from Miss Martinez.
                3 ii          MRS. SILSBEE:  Well, I don't have a motion.

                4             DR. SCHREINER:  I would like, obviously, to move

                5   the higher figure and she would like to move the lower figure.

                6             MRS. SILSBEE:  We've got three figures before us

                7   now.

                8             MR. OGDEN:  What are those, please?

                9             MRS. SILSBEE:  But we don't have amotion.

                10I           DR. SCHREINER:  I would like to move 562.

                11            MISS MARTINEZ:   5 6 2

                12            DR. SCHREINER:  Yes.

                13            MRS. SILSBEE:  lt562,000.  Is there a second?

                14            (No response.)

                15            MRS. SILSBEE:  Is there another motion?

                16            MISS MARTINEZ:  Yes.  I would like to make a motion

                17  for 382,000.

                18            MRS. SILSBEE:  383,000?

                19            MT-SS MARTINEZ:  82.

                20            MRS. SILSBEE:  382,000.  Is there a secon ?

                21            (No response.)

                22            MRS. SILSBEE:  Is there another motion?

                23            DR. KOMAROFF:  I move the Committee's recomm6nda-

                24  tion of S450,000.

                25            DR. JANEWAY:  Seconded.


                                                                             10 5

   n42           1             MRS. SILSBEE:  The motion has been made and seconded

                 2  that the Central New Yor@ application be approved at the

                 3   level of $450,000.-.

                 4             Is there further discussion?

                 5             (No response'.)

                 6             MRS. SILSBEE:  All in favor?

                 7             VOICES:  Aye.

                 8             MRS. SILSBEE:  Opposed?

                 9             (No response.)
                 lo            MPS. SILSBEE:  The motion is carried.

                 12

                 13

                 14

                 15

                 16

                 17

                 18

                 20

                 2 1

                 22

                 23

                 24

                 25


    n43          I                          COLORADO/WYOMING

                 2             MRS. SILSBEE:  The next region to be reviewed is

                 3 i Colorado/Tiyoming.  And let the record show that Dr. Gramlicl-.

                 4   is out of the room.

                 5             Miss f@lartinez?

                 6             MISS I-IARTINEZ:  I am waiting.

                 7             All right.  I believe the Committee's recommendation

                 8   was for $200,000.   Again I am a'little low in that I recom-

                 9   mend 146,959.  1 have a comment to make on one of the projects

                10   in particular -- well, two, all right.

                11             one, number 59, seems to me  to be Primarily An
                                                                     a
                12   education project.  And I was wondering %,,hether/Staff person

                13   could tell me if this was developed in cooperation with the

                14   educational commission of Colorado?

                15             MRS. SILSBEE:  Miss Murphy, did  you hear the aues

                16   tion?

                17             MRS. MURPHY:  Yes.  I have to check.it.

                18             MRS. SILSBEE:  Could you get over to the microphone,

                19
                     please?

                20             MRS. MURPHY:  I really know no more about the

                21   project than what is on page 15.

                22             MISS @IARTINEZ:  1,7ell, if it is the information that

                23   I read last night, then I just make the observation that the

                24   educational commission or agencies in the State were not
                25   consulted And that the project description was extremely


   n44           1   hazy in my mind.  So I have severe questions about that

                 2   one.

                               But the one that I really object to is  number  64,
                 3

                 4   which is entitled, health promotion service, primarily a

                 5   project to teach senior, Spanish-speaking senior  citizens,

                 6   sort of an education Droject. And at one  point  the  comment

                 7   is made that the money is 'going to be given to the public

                 8   health department to2hire nurses who will go out and  try  to

                 9   overcome social barriers.

                 10            That doesn't explain how it is going to be  done,

                 11  it doesn't explain who, you know, what criteria is  going  to

                 12  be used inthe selection of staff to do this. To  me,  this

                 13  is an example of a lot of poor planning that goes  into  pro-

                     jects which are supposed to reach minority people and don't.
                 14

                 15            In other words, it is an exmple of the use of  a

                 16  minority population for funding. And I would  suggest  that

                 17  either that project proposal be developed so that it is under

                 18  community control and hires community persons to do the out-

                     reach or that they be requested to not fund it.
                 19

                 20            MRS. SILSBEE:  Dr. Haber?

                 21            DR. HPJBER:  I have a serious question about project

                     number 61. Could Staff enlighten us about  what  is  intended
                 22

                     with the $17,000?  You cAn't buy bahd-aids for $17,000.
                 23
                               MRS. MURPHY: That proposal has been  called  into
                 24

                     EMS for consideration. We will not fund it until  it  qets
                 25


                                                                               10 8

    n45          I   approval.

                 2             DR. HABER:  Very well.

                 3             MRS. SILSBEE:  It has  not been referred  to  EMS.

                 4   That was one we wanted to get the Corinittee's views on,

                 5
                     because it doesn't conflict with the legislation.

                 6             DR. HABER: I would like to point  out  that  a  burn

                 7   center  is an extremely expensive  operation,  requiring  heavy

                 8   staffing by very skilled people.  And I think   that we  sadly

                 9
                     or badly need the development of such burn centers.  But

                10   unless this is some kind of exploratory project -- I canit

                11   tell here -- I would say that the scope appears  to  be  hope-
                12 'I lessly inadequate.

                13             The  demands  of these burn centers are  such  that

                14   you should deploy these with the greatest  precision  and  in.

                15   areas where they are likely to be well utilized, and concen-

                16
                     trate the rest on developing transportation svstems to aet

                17   people to where  the  burn centers  are.

                18
                               I don't know what  this,  but $17,000 seems to  be

                '19  so inadequate that it is  ludicrous,  I would think.

                20             MRS.  SILSBEE:  Mrs.  Morgan?

                21             MRS. MORGAN:   I don't believe Col orado has a  burn

                22  -center  or such at the present time.  They  have  applied  to

                23   the legislature and were turned down last spring for money

                24   to build a burn center.

                25             This $17,000,  I believe, mainly is to take a nurse


    n46          I   who has been working in, quote, unquote, what they call

                 2   their burn center where they treat   their burn patients

                     which is a $12,
                 3                   000., add to it travel about the State, and

                 4   I think really  to urge passage of a legislature bill where

                 5   it will be taken care of by the State at'the Colorado

                 6   General.

                 7              DR. EABER:  Well,.if it is preparatory or edtca-

                 8   tional

                 9              MRS. MORGAN:  I think it is really a study to get

                10   information to develop one.

                11              DR. HABER:  T@7ell, O.K.  Under those circumstances

                12   T  will  be mollified..

                13              MRS. SILSBEE:  I haven't had a motion on Colorado/

                14   Wyoming.
                15              MISS MARTINEZ:  Yes.  I would to make a motion that!

                16   we fund at the level of 146,959.

                17              MRS. SILSBEE:  Is there a second?

                18              DR. KOMAROFF:  Second.

                @19             MRS. SILSBEE:  A motion has been made and seconded

                20   that  the Colorado/v7yoming application be approved at the

                21   level  of $146,959.

                22              DR. KOM@ROFF:  Including that caveat that she

                23   mentioned  about theSpanish-speAking

                24              MRS. SILSBEE:  That is project 54.

                25              MISS MARTINEZ:  Yes, either it be developed with


                     the safeguards I mentioned or that it not be done.
  n47            I
                 2             @IRS. SILSBFE:  All right.  Is there         d4-scus-

                 3   sion?
                 4             DR. JANEWAY:  Does that mean, Miss !ilart4--ez., that
                 5   if it is developed in a manner satisfactory to Staff and @-'P
                 6   that the allocation is increased by @65,000?

                               DR. KOMAROFF:  or $41,000.
                 7
                 8             DR. JANEWAY: $41,000, whatever it is, so it would

                 9   come out 187,000.
               10              MISS MARTINEZ.  Yes, I would be willing to go along

               11    with that idea.
               12              MRS. SILSBEE:  That requires a motion, @.en(iment.
               13              MISS 14ARTI17EZ: I would like to make a r-@.o.--4Lon to

               J.4   that effect.
               '15             MRS. SILSBEE:  Vle.still have one on the -floor nov7.

               16              MISS PIARTIITEZ: I see.

               17              MRS. SILSBEE:  The motion was not t at.
               18              MISS MARTINE?,:  Can I withdraw the original motion?

               19              MRS. SILSBEE:  Yes.

               20              Does the  second o7ant to withdraw?

               21              DR. KO@IAROFF:  Yes.
               22              MRS. SILSBEE-  All riaht.  Start again.
               2.3             MISS MARTINEZ:  All right.  I move that Colorado/
               24    Wyoming be funded at the level 146,959 and -- how should I
               25    put.it -- which would include the elimination of nroj6ct


                    number 64, unless that project can be developed to include
                  2 a community control policv board and outreach  workers  who
                  3 are from and sensitive to the needs of the particular nonu-
                  4 lation being served and that if such conditions are met

                    that the funding level be increased
                  51
                  6            MRS. SILSBEE:  No, you have to go the other  wav

                  7 to get a motion like that.-

                  8            MISS MARTINEZ:  $41,000.
                  9            DR. YOMAROFF:  187, 188, but restrict the $41,000

                  10 unless they do it right.
                  11           MISS MARTINEZ:  O.K4  Does it come out exactly

                  12 187?

                  13           MR. HIROTO:  188.

                               MISS MARTIITEZ: All right. Let's try  this  once
                  14
                  15 aga3.n. I move that Coldrad6/Wvoming be funded  at  188,182

                  16 with the condition that project 64 is to be developed to

                  17 include a community policy board and community outreach
                  18 workers sensitive to the population in question,  and  that

                  19 if such conditions are not met that the funding level be

                  20 reduced to 146,959.
                  211          MRS. SILSBEE:  You have heard the motion.  Is there

                   !'a second?
                  22
                  23j          DR. @IAIIMOCK:  Second.
                  24           MRS. SILSBEE:: Any further discussion?
                  25           (No response.)


                                                                            112

  a49                         MRS. SILSBEE:  All in favor?

               2  l@          VOICES:  Ave.
   0
               3              MRS. SILSBEE:  Opposed?

               4              DR. J@'\TEWAY:  I'llo.

               5
                              MRS. MORGAN:  No.

               6              MRS. SILSBEE:  Let's see.  Let's have the ayes

               7    raise their hands.

               8              O.K.  Let's have the nays raise their hands.

               9              The ayes have it.  The motion is carried.

               10             Dr. janeway?

               11             DR. JANEWAY: It seems to me  that  there  must  bea

               12   reasonable balance between fulfilling all the  responsibilities

               13   and carrying out the policies and statutes of  the RP-!P versus

               14 II the selective identification  of  Particular  Projects.  The

               15
                    technical review has been done.

               16             And there are only two Council Tier-hers who  have

               17   had the opportunity even to read the forms 15.  I would just

               18   hope that we don't gitt-like the fellow who went down  into

               19   the swamp and he saw an alligator down there, and  he  beat

               20   that alligator over the head and he killed them.

               21 'I          And he just kept running into more alligators and

               22   'killing alligators and forgot after he was down there with

               23 ii all those alligators around that somebody sent him down to

               24   clean out the swamp.

               25             DR. WMTIIOCK4  Common, Sam Ervin.


                                                                                 1 1 3

  n5O                           MR. PIILLIKEN: You mean he is  up  to  his  elbows  in

                 2     alligators?
                 3              MRS. MORCAtl:  fle's not quite that far.
                 4              DR. JANEWAY:  I have to   abridge the storv a little

                 5     bit.
                 6              MRS. FLOOD:  As a matter of comment        and  again,
                 7     as Dr. Janeway occasionally,says, gratuitously -- I do think
                 8     though that we have some responsibility.  if the technical
                 9     reviewers or the Re ional Advisory Group itself does not
                                          9
                 10 @i take into consideration the problems of dealing with minority!
                       groups and using terminology such as overcome cultural
                 12    barriers rather than to address cultural barriers in a
                 13    manner that can be adapted to the health delivery system.
                 14               And we do face  the  responsibility  of  questioning
                 15    the development of individual projects when they    are serving;
                 16    a population that many times is not articulate in expressing

                 17    it
                        s own needs.
                 18               DR. JANEWAY:  I don't disagree with that one bit..

                 19               MRS. SILSBEE:   Thank you.
                 20               The transcript  for Arizona has  arrived,  and  have
                 21    you had  a chance to look  at it, Mr. Hiroto, or would you
                 22    rather  go ahead?  'Vie can come back later?
                 23               MR. HIROTO:  All right.  I will   take Conn6cticut.
                 24               MRS. SILSBEE:  Yot'll take Connectidut.  Do you

                 25    have  that one.!


                                                                             A

   n5l                        MR. HIROTO:  No.

                2             MRS. SILSBEE:  We have to hold for just a few

                3   minutes while there is a switch    the changing of the guard

                4   here.

                5             (Whereuvon, at 12:30, a luncheon recess was taken

                6   until 1:00 p.m.)

                7

                8

                9

                10

                12

                13

                14

                15

                16

                17

                18

                19

                20

                21

                22

                23

                24
   is           25


                                                                            11 5

                                        AFTERN00141 SESSIO@4
                2             MS. SILSBEE:  The meetina @.:ill come to order.
                3     In the break that-we have had, I've had about three or four
                  I'
                4     requests of individuals in regions who have to leave early
                      and I'm prepared to accomodate them as much as Possible, but@
                      we're going to have to move alone.  1,'Ir. Hiroto.
                6
                7              MR. HIROTO:  Ms@ Chairman, would you entertain a
                8     motion that should the primary reviewer and the secondary
                9     reviewer have no Problems or difficulties with the result
                      of the Review Committee, that we vote in block on those and
                0
                11    go along the table and list those states that we feel securer
                      with and only review those or discuss those that some Deop ei
                12
                13    may have questions about.
                               MS. SILSBEE:  I will entertain the motion.
                14
                               MR. MILLIKEN:  Second.
                15
                16             DR. HABER:  One mechanism for accomplishing that
                17    might be if you were to read down the entire list of  remain-;
                18    ing proposals and ask if objection is raised on the Part of
                      primary or secondary reviewer with the committee's retommen-i
                19
                20    dation.  A negative answer would seem to indicate that it
                21    would then be part of a block to vote on.

                               MS. SILSBEE:  Riaht.
                22
                23              DR. TAIMIMOCK:  You said you would read down the

                24    list?
                25              DR. HABER:  Yes.  ',"here are several ways to


                                                                             11 6  1

                I     accomplish this, but the most cxdeditious would be for
                      Mrs. Silsbee to read down the list and if anyone feels
                2

                                   ft
                      that he doesn  q@ along with the committee's report,   he    1
                3

                      so states and it is then removed for@ individual considera-
                4

                      tion from the Block Vote.                                    i
                5
                6               MS. SILSBEE:  I think the record should show that
                      the entire council has before them the composite  recommends-'
                7
                      tions of the review committee showing the requested  level
                8
                9     and the committee approved recommendation.  I also  think
                10    that the record should show that this is in view of the
               .11    fact that you participated as observers in discussions  of

                      the committee's deliberations yesterday.
                12

                                I-IS. GORDOII:                              con-
                13                           Was there any problem with the

                      flict of interest?
                14
               .15              MS. SILSBEE: Not on block  action.  All  right,
                16    the motion has been made and seconded that we qo  throuqh
                17    this. I'll go down the list and if anyone has  any  ob]ec-
                18    tion to the committee recommendation, we will tbLke that
                19    particular application out for discussion, otherwise there
                20    will be a mo tion about the block action.  All in favor.

                                MS. SILSBEE:  opposed.
                21

                                Motion carried.
                22
                23              I will not only read the list, but I will read into i
                24    the record what the recommendation was as far as  the  funding

                      level.
                25


                                                                                   1 1 7

                   1               MS. SILSBEE:  Arizona - $150,000.
                   2               MR. IIIPOTO:  Object.
                   3               MS. SILSBEE:  Connecticut - $750,000.
                   4               DR. GRIVALICII:  Object.
                   5               MS. SILSBEE:  $600,000     Florida.
                                   Greater Delaware Valley     $684,512.
                   6

                                   Hawaii - $486,750.
                   7
                   8               Illinois    $750,000.
                   9               Indiana   $240,000.
                   10              Intermountain
                   11              DR. KOMAROFF:  Object.
                   12              MS. SILSBEE:  Iowa - $173,929
                   13                             Kansas - $363,545
                   14                             Lakes Area - $150FOOO
                                                  Louisiana
                   15
                   16              DR.   JANEWAY: Object.
                   17              MS.   SILSBEE: Maryland - $650,000.
                                   DR. 1,7AMMOCK.- I think we had better go over that.
                   18
                                   MS.  SILSBEE-. Memphis - $9501000
                   19
                                                  Metro-D.C. - $250,000
                   20
                   21                             Michigan     $500,000
                                                  Mississippi   - $2,000 000
                   22
                   23                             Missouri -   $540,000
                   24                             Mountain States - $300,000
                                                  Nassau/Suffolk
                   25


                 1              DR. KOIIAROFF: I think we had better discuss that.1

                 2              MS.  SILSBEE: Nebraska - $95,000

                 3                            New Jersey - $1,100,000

                 4                            New York Metro - $950,000

                 5                            North Carolina - $120,000

                 6                            Northern New England - $600,000

                 7                            Northlands - $300,000

                 8                            Oklahoma - $25OiOOO

                 9                            Oregon - $148,693

                 10                           Puerto Rico -  131,335

                 11                           Rochester - $1,000,000

                 12                           South Carolina

                 13             MRS.  GORDON: 'Objection.

                 14             MS.  SILSBEE: South Dakota - $88r850

                 15                           Susquehanna Valley - $500,000

                 16                           Tennessee/Mid-South - $570,000

                 17                           Tri-State - $610,000

                 18             MS.  SILSBEE: We'll come back to Texas.  Tri-State

                 19  $61 0,000. Virginia - $960,860.
                 20             MS. MARTINEZ:. Object.

                                I-IRS. FLOOD:  They have an arthritis program.  Tt-'s,
                 21
                 22  not essential, it's automatically taken care of.

                 23             MS. SILSBEE:  From the previous recommendation.

                 24             Washington/Alaska - $530,000

                 25             West Virginia - si,ooo,ooo


                                 MS. SILSBEE:  Western Pennsylvania     $450,000.

                                 DR.  HABER:  Objection.
                 2

                                 MS. SILSBEE:  Wisconsin    $200,000.
                 3

                      We'll review Arizona, Connectucut, Intermountain, Louislana,l,
                 4
                 5    Maryland, Nassau-Suffolk, South Carolina, Virginia, Western

                      Pennsvlvania with Texas.
                 6

                                 MRS. MORGAN:  I move that we accept the Review
                 7

                      Committee's recommendations for funding of the regions
                 8

                      not specified to be taken care of separately.
                 9

                 10              DR.  KOMAROFF:  Second4

                 11              MS. SILSBEE:  Is  there further discussion?

                 12             .(No response)

                 13              MS. SILSBEE:  All in favor.

                 14                             Opposed.

                 15              MS. SILSBEE:  Motion is carried.

                 16   I-le'll now go to Arizona.
                 17              MRS. KLEIN:  This is just a minor thing,   but we
                 18   has taken  some this morning and the way the motion   was
                      worded, all those other than the ones that were recentlv
                 '19
                 20   enumerated so I think    the motion should show, except for     I

                      those already discussed   and approved4
                 21

                                                I think that was the consensus
                                 MS. SILSBEE
                 22

                      of the discussion beforehand-.
                 23

                 24

                 25


                                                                            1 2 0

                 1                        ARIZONA

                 2             MS. SILS BEE:  Arizona - Dr. Gramlich.

                 3             DR. GU.I@ILICH:  As a matter of principle, Arizona

                 4   has had difficulty with the organization, the leadership and

                 5   had had some other difficulties that were technical with thei,

                 6   DRMP and counsel said to clear it up, so  Arizona  cleared

                     them up and the Technical-Review Committee  rewarded  this
                 7

                 8   function by cutting their  allocation---their  recommenda-

                 9   tion. The question is one of  principal.  Do  you  reward

                 10  virtue in a negative fashion or a positive fashion?

                 11  There's not much question about the technical capabilities

                 12  of the region to accomplish the project it  had  ordered.

                 13  That was a minor element, but the concern on the  part  of

                 14  the technical review committee was, if you  haven't  been goodl

                 15  up to now, that you've changed everything we said you should

                 16  do, so we're goina to reward you by cutting  your  grant.     i
                 17            MR. HIROTO:  I echo that.  I was going to  request

                 18  the'council to consider changing the amount of  the  award

                 -19 to $240,000-@ $240,718 because at least it meets the three

                 20  component projects in the upper three pro3ects that have the

                     highest oriority.
                 21

                               DR. GRP2-ILICH:  If that's a motion, I second it.
                 22
                 23            MS. SILSBEE:  The motion has been made and
                 24  seconded that the Arizona application be  approved  atthe
                     level of $240,7i8.  Is there further discussion?
                 25


                                                                              121

                  1             (No resnonse)
                  2             14S. SILSBEE:  All in favor.
                  3                            opposed.
                  4             MS. SILSBEE:   The motion is carried.

                  5

                  .6

                  7

                  8

                  9

                  10

                  11

                  12

                  13

                  14

                  15

                  16

                  17

                  18

                  '19

                  20

                  21

                  22

                  23

                  24

                  25


                                                                             12 2,

                                             CONNECTICUT
                 2              1114S. SILSBEE:  We will now go to Sonnecticut.

                 3    Mr. Iliroto.
                 4              MR. IIIROTO:  I can appreciate the problem that
                 5    probably we all face with Connecticut and that Connecticut's'!
                 6    program has continued as it was designed until just the last
                 7    10 months.  The technical reviewers, one recommended a
                 8    a level of $250,000; the other recommended a level of
                 9    $1,400,000, which reflects, I think, the difficulties we
                 10   all have in reviewing Connecticut.  Dr. Gramlich,-if you
                 11   have any comment that you would like to make.
                 12             DR. GRAMLICH:  Yes.  Aaain, these are general
                 13   comments and more philosophical then technical.  Here,
                 14   apparently and I don't know the region well at all.  I
                 15   may be in error, but it appears this is an RMP  set  up  with
                 16   a different kind of program from the pattern throughout the
                 17   rest of the States, throughout the rest of the nation and

                 18   therefore, our last Technical Review  Committee  said,  well,
                 19   since it doesn't conform, we shouldn't give them any money.
                 20   Now, maybe this is an entirely wrong interpretation.,  I
                 21   would appreciate staff input on the assessment of the
                      justification for dropping the funding because of the   fa  t
                 22                                                             c
                 23   of the different kind of program, one from the other.
                                MR. HIROTO: Dr. Gramlich, I  don't  think  that  is
                 24
                      a Primary  consideration. The problem seems to  be  that  all
                 25


                                                                              1 2 3

                      of the P14P funding or most of it has gone into the

                      institutional area, rather than into  other areas and
                2

                3     despite staff efforts to spread the  Drogram a little rore
                4     fully throughout the state and throughout other institutions,
                5     this was not accomplished. At the last  council  meetincrf

                      council agreed to reduce funding  dramatically  because  this
                6

                      was the only way that Connecticut would get  the  message,
                7

                      so to speak.  They have gotten the message  to a  degree  and

                      so the $750,000 level seemed reasonable to  rhe review
                9

                10    committee.

                                DR. GRA14LICH:  Rebuttal time.

                                MS. SISLBEE:   Dr. Gramlich4
                12

                                DR. GRAMLICH: To begin with  the  May  request  for
                13
                14    funding was not large. It was something in  the  order  of

                      $636,000 dollars.  The major request is-what we have in
                15

                16    front of us now. Therefore, since the  timing  again  with

                17    Connecticut, was differnt, we are penalizing  them even

                18    further by not killing their program by  refusing  to  accezt

                      their major funding request.
                19

                                MS. SILSBEE:  Dr.Janeway.
                20
                21              DR. JANEWAY:  It is my recollection; Dr. Gr&-,nli-ch

                      that one of the things that was taken into consideration @as
                22

                23    considerable amount of their funding was going through into

                24    1976.

                25              DR. GRAMLICII:  Correct.


                                                                           1 2  4

                 1             DR. JANEIIAY: And the way I recall the  technical

                 2   discussions, there was a general sense of that qroup  that

                 3                         und Projects through '76.
                     felt they should not f

                 4             MS. SILSBEE: There were  several  considerations,

                 5   Dr. Janeway in terms of the level.  one of them was the

                 6   two year funding request.  The other was a contract that

                 7   would have enabled the monitoring capacity to go beyond

                 8   June 30th, but in addition, there were the two  university

                 9   resources that were funded at a fairly s3zable amount,

                 10  Other portions of the program that would have been of  con-

                 11  cern was the third faculty. There were no  funds  requested

                 12  for that.  The Connecticut application in @lay, Dr. Gramlich
                 13  was requesting support for staff plus two months of  continual

                 14  tion projects.  This amplification asks for 10 to 22 months

                 15  for some activities and 10 months for others, so it is

                 16  complicated by that factor.

                 17            DR. GRIU4LICH:  Right, but neverthelsss, if you

                 18  take all the two year pro3ects and this iscrude  arithmetic  I

                 '19 but nevertheless if you take the two year pro]ects and  cut
                 20  each of them in half and award them one half of the two  year@

                 21  total, you're in effect awarding them for one  year.  They
                     still wind up with a figure $1,430,000. The way  I  visualized
                 22

                     this, it was incorrect, that since Connecticut dame in  for
                 23
                     a small grant request last May, if we cut them way down  thisi
                 24

                 25  time, we're in effect, killing their total program.


                                                                             1  2  5

                1               MR. IIIROTO:  There was something like $240,000
                2     more or less requested just for the monitoring bv Yale
                3     University of the-.second year program, so we might sub-
                4     tract further your total by that much.  I may be wrong.

                                DR. GRI@,LICH:  The principal involved is  o we
                5

                6     want to kill Connecticut or not.
                7               MS. SILSBEE:  There is no motion on tie floor.
                8               DR. GRAMLICH:  Since I have done most of th6
                9     screaming and hollering, 1 will therefore move that
                10    Connecticut.be awarded a grant in the amount of $1,435,800.
                11              MS. SILSBEE:  Is There a second?
                12              DR. HABER:  I will second it.
                13              MS. SILSBEE:  Dr. Gramlidh, what was  the  total?

                                DR. GRAMLICH:  $1,435,500.  This is arrived at
                14
                15    by very crude arithmetic, by taking each two  year  nro3ect
                16    and dividing it in half and totalling it with the  ones  of
                17    the one year projects.  It's the only way I could really

                18    fi,4ure it.
                19              Ms. SILSBEE: The motion has been made and seconded
                20    that the Connecticut application be approved at  the  level

                21    of $1,435,500.

                                MRS. GORDON:  I'm just wondering, there's really
                22
                23    no way probably that we have'of knowing whether dividing
                      the two year project in half leaves you a  viable  project.
                24
                25              MS. SILSBEE7:  I think in this particular instance,!


                                                                                12 6

                       we  have---

                                 MRS. GORDON:   --- it's not a matter of a new activi@L-y
                   2

                   3   so much.

                                 MS. SILSBEE:  I think we may need   some  help  here 1
                   4

                                                                               new
                   5   from Mr. Nash.  The two year Projects, are they a

                   6   or are they continuations?
                   7             MR. NASH: I  think  some  of  them-are  new.  The
                       onces, I think, that  concern  the  review  committee  the
                   8
                       four projects going to Yale and Yukon are for over $800,000
                   9

                       for the two year period.
                   10
                   11            MS. SILSBEE:  Mrs. Gordon, because   you were not
                   12  here yesterday, there was  considerable  discussion  with  the
                   13  committee and Dr. Pahl about the  two  year  request.  T  e
                   14  region recieved its money and has  the  ontion  of  putting
                   15  some money away for some activities, if   they  feel  they

                   16  shoudl go longer than two years, if they can work out    some
                   17  kind of a contractural arrangement, so this is just a    way off
                   18  arriving at a level and I don't think   that should be  a  major

                   19  worry for you.  The Regional Advisory   GrouD will  make  that

                   20  decision.   Mr. Milliken.

                                 MR.  MILLIKEN:  My   understand
                   21                                          inq is that  you  have--i
                       my understanding is that  Yale  was  just awarded one of the
                   22
                       few large cancer centers --- cancer  development  research.
                   23
                       Are they going to be able to spend all  of  this  with  the
                   24

                       limited staff they have there?
                   25


                 1             DR. GRA,14LICH:  The money that goes into the
                 2   Regional Medical Program aspect of this Program would
                 3   not --- this is their community outreach part of the
                 4   university budget.  They won't --- I don't think they will
                 5   have much of a problem spending money.
                               MS. SILSBEE:  Thev have had experience in this.
                 6
                     The motion has been made-and seconded that the Connecticut
                 7
                 8   application be approved at $1,430,500.  All in favor.  Could'i
                 9   I see a show of hands?  Five.  Opposed - the opposed have
                 10  it.  The motion is not carried.  I will entertain another

                 11  motion.

                              'MR. HIROTO:,  I move the review committee's
                 12
                 13  recommendation of $750,000 be.approved.

                               MS. SILSBEE:  Is there a second?
                 14

                 15            MR. OGDEN:  Second.
                 16            MS. SILSBEE:  The motion has been made and

                 17  seconded that the Connecticut application be approved
                 18  at the level of $750,000.  Is there further discussion?

                 19             (No response)

                 20            MS. SILSBEE   All in favor?

                 21                           opposed.

                                              The ayes have it.
                 22

                 23

                 24

                 25


                                                                                 1 2 8

                                            INTEP,P,IOUNTAIN

                                 MS. SILSBEE:  The next   application to  be  reviewed
                  2

                  3    is Intermountain and the record   shows that Mrs.  Klein  and

                  4    Dr. Gramlich are  out of the room.  Dr. Komaroff was the

                       reviewer.
                  5

                  6              DR. KO@,IAROFF:  Intermountain was rated by the

                       June Council as an above-average region.  They were awar
                  7                                                                ded

                  8    2.23 million dollars, as a result of last councils      session.i
                  9    They now request a supplement of $481,000 for 19 new     project@!,
                                                                                       I
                10     activities.  The last council expressed several concerns

                11     which appear --- most of which appear to have  been  resolved

                12     and let me surunarize them briefly.  There  has  always  been

                13     a turf problem with the  Intermountain  regions,  the  mountain

                       states and Colorado and  Wyoming  regions.  This  appears  to
                14

                15     have been resolved by some interlocking   membership  of  the

                16     advisory groups and frequent regular  meetings  of  the  membersi

                17     of the advisory group --- of the members of each of  the  threei,

                18     advi'sory groups as well as by some joint funding of projects

                19     which have a geographical overlap  with  these  three  RMP'S.

                20               A second concern has been  the  relationship  of  thisi

                21     RIIP its CHPH agency and apparently, according to the staff

                       review and the CTIP letters in the application,  there  is  now
                22

                       a serious  review by CHP under consideration by the RAG of
                23

                24     CHP.

                25               The third concern that  the  council  expressed  last


                                                                              2 9

                                                                oping and moni-Icr-
                1     time involved the role of the RAG in devel
                2     ing projects. The region has developed what  they  call  a
                3     drag advocate nrogram whereby individual members  of  the
                4'1   RAG are responsbile for shepherding a project proposal
                      through it's passage and subsequently  monitoring  that
                5
                      project after it has been funded. It seems  like  a  worth-
                6
                7     while idea. There was a.question of  conflict  of  interest
                8     in the establishment of a health  development  services
                      corporation.  Dr. Pahl mentioned yesterday  that  through
                9
                10    action by the State Attorney Gen6ral and  through  meetinas

                11    with the RMP staff members, this conflict of interest ates-
                12    tion has been resolved. There was  concern  that  council
                  I
                13    epxressed regardingthe university domination of past
                14    projects.  In this cycle, 18 of the 19 projects were
                15    sponsored by outside agencies which may have created a
                16    problem, but has solved at least the -concern  of  council
                17    -from the last time. The directorship of the  program  and

                18    the capabilities of the four staff are deemed to  be  good

                19    by those people who know the region best.  I  have  not
                20    visited there. The  project  proposal,  however  seemed  to
                21    me to be exceedingly non specific and hard  to  evaluate.
                22    They have some very uninspiring continuing  education  oro-
                23    jedts and they propose to develo-pe their own audio  visual
                      materials.  Many of them give the impression of duplicating
                24
                25    kinds of activities which have gone on in other regions with-


                      out giving evidence that  they plan to build on  the ex-@erienc;e

                      of others and I have the  uneasy feeling that they  may  be,
                 2
                      repeating the failures and not the  successes  of  other  such
                 3
                      attempts at @IP, but it's hard to.tell from these abstradts.l
                 4
                 .5             One proposal is to establish a workshop on drug
                      and alcohol abuse, and I just wonder why they haven't
                 6
                      applied through the institute for  drug  and  alcohol  abuse
                 7
                 8    or such an activity.  It  seems to me on the fringe of
                 9    P14P's funding mandate.  Several strong projects are
                 10   listed.  one of the most interesting involves a computerized,
                 11   agency referal for extended services  in  which  they  would
                 12   try to do a better job of  referring  patients  to  apparently
                 13   social service agencies. I would --- I'm  not  concerned  that
                 14   the projects are over inflated as has been described by the
                 15   past council and the  review  committee  yesterday.  In  fact,
                 16-  if anything, they appear to underestimate the cost and time
                 17   needed to accomplish local objectives, but I have a feeling
                 18   there is a lack of cohesion  about the whole package and I
                 19   take issue with the committee's decision  to  fund  them  at
                 20   virtually 100 percent of their request and would reduce
                      the request from---reduce the award from $450,000 to           i
                 21
                 22   $350,000, out of a total request of $480.  I would also
                      convey to them again, as council did   At its  last  meeting
                 23
                      that the  project --- the corp staff, not the project  staff
                 24
                      should include more minority representation  particularly
                 25


                                        LOUISIANA
                              MS. SILSBEE:  The next region to be reviewed is    1
                 2
                 31   Louisiana. Dr. Janeway.
                              DR. JAIIEWAY:  I.Im the secondary reviewer --- I'm thei
                 4
                 5    primary reviewer.  The reason why I wanted to take it out
                      ofthe block was partly to get some technical advice from
                 61
                 7    the staffon this.  I am concerned about the application

                 8    for $75,000.
                 9             MS. SILSBEE:  Bring Dr. Gramlich and Mrs. Klein

                 10   back in.
                 11            DR. JANEVIAY:  I'll hold my comment until Mrs.
                      Klein gets back.  She's a lawyer and she may be able to
                 12

                      help
                 13
                                (Dr. Gramlich and Mrs. Klein re-enter6d the
                 14
                 15             hearing room.)
                 16            MS. SILSBEE:  Is staff ready to listen to the
                 17   question Dr. Janeway has.  Can theycome up tDthe table,

                 18   please.
                 19             DR. JANEWAY:  My questions are technical and
                 20   relates to Project C-10-in the Louisiana application which
                      is entitled "Study of N. 0. Tax Supported Clinics Servincr  i
                 21
                      Title 19 Recipients."  It's the major request in the
                 22
                      Louisiana Application and I would like to know whether it
                 23
                      is appropriate'that RMP funds be used to evaluate the
                 24
                 25   activities.of the clinics supported by other tax funds.


                                                                             1 3 3

                 1   one wonders if that shouldn't be the function  of  either
                 2   the state, per se or the agency that provides medical
                 3   funding. It's just a question that I,  myself  am  unable
                 4   to answer it.  I don't have the knowledge.
                 5             MS. SILSBEE:  Mr. Sibloski, do you have any

                 6   comments?
                 7             MR. 8IBLOWSI:  Not really.  It's a hard one to

                 8   swallow.
                 9             DR. JAIIEWAY:  I brought it up BECAUSE Nobody in
                 10  Technical Review even mentioned it6
                 11            MRS. GORDON:  As secondary reviewek, we only figur@d
                 12  what they were trying to do was get an impartial judgement
                 13  on it and the other federal agencies  weren't  impartial.
                 14            DR. JANEWAY:  It might pay to have Blue Cross come

                 15  in and do it for them.
                 16            DR. GRA-MLICH:  My impression of the medic-aid

                 17  level is extremely low.
                 18            MR. SIBLOWSKI:  -I canot really respond4  I really
                 19  had some concernwhen I was talking to Dr. Savlier as to why
                 20  they decided to participate.  He was basically saying that
                     the RAP is in the only neutral position in the state to
                 21
                     attack it.  Everybody else seems to be involved and it's      i
                 22                                                                i
                     a non biased review assessment and if you look on Page 16,
                 23
                     the people all-involved in this- -are involved with the
                 24
                     consulting firm of Shindell and Associates.  The Louisiana
                 25


                                                                            1 3 4
                       Division of Administration and'Planning; the Division of
                                                                       ce; the
                                           ivision of Health Maintenan
                  i    Family Services; the D
                2 1
                                              division and it  seems  reading
                       Charity hospital systems
                3
                                                              bers  in many
                       in between the lines that many Board mem
                4
                  I                          non biased type of thing where the
                5      organizations, it isa
                6      RMP is entered in and is trying to fulfill a certain role.
                               DR. JANEWAY:  Let me ask*you --- try to explain to
                7
                8      me the comments-coming out of the HPC in Lafayette, Louisiana
                9      to which is attached, at least in my copy a memorandum, the
                       last paragraph which says,, "This study is intende  to in-
                10
                11     fluence the manner in which HEW funds out patient medical
                12     services in the state and may result in increased availability
                13     of these funds.  I'm only asking this question because I
                14     don't want the people in this 14ational Advisory Council to
                       be put in the position of approving something which is
                15
                16     against statutes.  I'm not trying to hurt the Louisiana

                17     RMP.
                18              MR. POSTA:  If I could make a brief comment.
                       This is not related directly to your question, which I
                19
                20     think is quite valid.  The last council, if you will
                       remember, one of the reviewers specifically  requested
                21
                       to get them more involved with the BEgional Medical
                22
                       Program, more involved with bringing the private institt-
                23
                24     tions in and the private sectors into the indigent clinic
                25     or the hospital system.  I'm not saying this was developed


                                                                                  1 3 5

                  I    totally as a result of that   recommendation, but to me it

                  2    sort of fits into that cline   of  the  Regional  Proqram---

                  3    Regional Medical Proaram  through some of    its new  leaders

                  4    who are making a conscientious effort to upgrade the care

                  5    of all thepeople.

                  6               DR. SCHREINER: My  comment  to  that  comment  is

                  7    the last time --- it's a  very  unique  system.  This  represents

                  8    an extremely high percentage  of  the  state  budget  going  into

                  9    the support of these hospitals which are really state
                 10    hospitals and I think it's very superficial to say the

                 11    private practioneers should  get  involved  at  the  expense

                 12    of the state hospitals.  If you have essentially a Govern-
                 13    ment hospital and the  physicians  there  are  on  salary,  there
                 14    is really no practical way those kind of physicians are goin
                 15    to get involved and this is what they have.  They have a

                 16    network hospital, and a very high percentage of the state

                 17    budget goes to it, a very high percentage.

                 18               MS. SILSBEE:  Dr. Pahl, I'm glad    to see vou  badk..

                 19               DR. PAHL:  I'm gearing up for Texas.

                 20               MS.SILSBEE:  Dr. Janeway has raised the question

                 21    with regard to the Louisiana application.  The project
                 22    C-10 which IMP funds are going to be used to evaluate the
                 23    medic-aid services for children-@-
                 24               MRS.-GORDON:  Tax supported clinic.
                 25               DR. JANEWAY:  Tax supported clinics for Title 19


                                                                              13 6
                                                                        ut,, at  least
                      recipients and they  are going.to contract this o
                      it says in the memo here they will contract it out to
                2

                      Shindell Associatds.
                3
                                MS. SILSBEE:  He is.questioning the legality.
                4
                                DR. JANEWAY: Far be it from me  to  question  the
                5
                      legality.  I'm questioning whether it is legal.  I want
                6
                      some technical input.
                7
                                MS. SILSBEE: That's a better way  to  put  it.  The
                8
                      legality of counsel taking action.
                9
                                DR. PAHL: As usual, I am  not  prepared,  certainly
                10
                      on the spur of the moment. I think what we  would  like  to
                11
                      have is your recommendation within,what the legalities are
                12
                13    and we can determine then  post  counsel and act  accordingly.
                      In other words, on a technical  matter like this, I'm  not
                14
                      really prepared to give you an  answer that has any  force
                15.
                      behlnd it. What I would prefer  to  do is find out  whether   1
                16
                      it is the consensus of this  committee that, if legal,  do
                17

                18    you recommend that we make the award which  would  include
                19    that or if not legal, do you recommend a funding  level  which!
                20    encompasses those dollars, but they could use  those  dollars 1
                21    for other purposes, so we need vour assent and we will

                      determine the legality.
                22
                23              DR. HABER:  I too was concerned about  this  project,
                      but in a direction somewhat different from Dr. Janeway.  I
                24
                      thou ht this was a particularly apt use of funds,, Regional
                25        9


                                                                               7

                      Medical Program and at a stage when winding down is in

                      process and when one would hope that  funds  appropriated
                2
                3     for the project w@uld be susceptible to a final verdict,
                4     I think that one of the Purposes of the Recrional Medical
                5     Program is the development of innovated projects and
                6     certainly the evaluation of ongoing  government  mechanisms.
                7     I agree with Dr. Schreiner assessment that- Louisiana  is

                      hard put in terms of development of medic-aid programs
                8
                9     and I think it would be very useful to get independent
                10    surveys. I think it is  appropriate.  I'm  not  qualified
                11    to judgethe legality-In terms of appropriateness, I think
                12    we ought to approve it though.
                13              MS. SILSBEE:  Is there a motion?
                14              DR. JANEWAY:  In light of the discussion,  I  move
                15    therefore that we accept the recommendation from the

                16    Technical Committee that louisiana be funded it  the  amount

                17    of $168,680 dollars, pending review bv the staff  on  the

                18    legality and appropriateness of C-10.

                19              MR. HIROTO:  Second.

                20              MS. SILSBEE:  Dr. Janeway, does that motion en-

                      compass, as a rule, if they could not spend money  on  that,
                21

                      that the region should have the money or have it taken a,,.,,av.
                22

                23              DR. JANEWAY:  No.

                24              MS. SILSBEE : Is there any discussion?

                25              (No response)


                I              MS. SILSBEE:'  The motion has been made and

                2    seconded that the Louisiana application be approved
                3    at the level of $i68,680 with the condition that the
                4    funding for the amount of money for Project C-10 be contin-
                5    gent on our staff review of the legality and appropriateness.

                6              All in favor.

                7              Opposed.

                8              The motion is carried.

                9

                10

                11

                12

                13

                14

                15

                16

                17

                18

                19

                20

                21

                22

                23

                24

                25


                                               MARYLAND

                2               MS. SILSBEE: The next  application  to  review  is

                      Maryland.   Dr. Wammock, would you get the  micronhonebe@@or--
                3

                4     you  start?

                                DR. WAMTIOCK:  I think so.  I was the primarv ju--4ae

                6     in this case and at the May-June Council meeting, there

                7     was a request of $762,000-dollars and  this-was  denied  and

                8     then they put in a new request for $724,000 dollars and

                9     786 cents and at the meeting yesterday it was approved for

                10    $756,000 dollars. I need a little  bit  of  information  here.

                11    The total program staff.- C-0000 - is that $336,604 correct?:

                12              MS. SILSBEE:  Let me look at the   sheet?

                13              MRS. FLYNN:  That was May-Jtne.

                14              MS. SILSBEE:  Mr. Nash, could you come up to the

                15    table  please?

                16              MS. SILSBEE.-  Did you hear Dr. Wammock's question?.

                17              MR. NASH:  I did not.

                18              I-IS. SILSBEE: Dr. Wammock wants to know what about--

                19    was it  338---?

                20              DR. WAMMOCK:   $336,,467 was the original  Program

                21    staff --- total program staff. The original grant  in  Mav  and

                22    June, the request was  then $762 and the new one is for Prcc--r=--.

                23    Staff of $233,000 and  $724,000 for July. The  Program  StAf.@

                      of $233-000 with the approval yesterday of $350,000 ---  no,
                24
                25    $650,000---that's one-third for staff.


                  1             MS. SILSBEE:  Dr.  Wammock, ifyou will look at the

                  2   printout labeled 7-74i you will see  that  the  total  request

                  3   was $724,000, of which  the staff is$302,961.

                  4             DR. T@7AI-IMOCK:  That's right, the indirect column s@@

                      right-.
                  5

                  6             MS. SILSBEE:  There was no money provided for

                  7   staff because there was no money provided from the May

                  8   application, so-this is it.  The $650,000 as I understood

                  9   the committee recommendation yesterday  would  allow  for  the

                  10  staff, about half for staff and about half for the activities

                  11  that were proposed.  Is that right, Mr. Nash?

                                MR. NASH:  I thin,  one  of  the  recommendationswas
                  12

                  13  that $250,000 for staff and $400,000 for projects.

                  14            DR. WAMMOCK:  400 for projects and 250 for staff?

                  15            MR. NASH: Yes,sir.

                  16            MR. OGDEN:  I think we ought to be aware that a

                  17  great deal of the activities that may go  into  this  project.

                  is  is staff activities, so that you canot judge the total

                  19  request for a particular project as being the total cost

                  20  because some of that.act.ivity is being carried out by staff

                  21  people themselves.

                                DR. V7@LMOCK4  I recognize that.
                  22

                                MR. OGDEN:  So, I don't,believe the action   yester-
                  23
                  24  day of say $250'.-OOO for staff and $4,00,000 for programs  is
                  25  any sense out of line.


                                                                             I A

                                DR. IlAt-IPIOCK:  You don't think that's out of line?

                 2              MR. OGDEN:  No, I'don't.  I recommend that it be

                 3    accepted the way 'it was yesterday.

                 4              DR. VIM-L'40CK:  I just reopened it for the question

                 5    of clarification in my own mind as to which way this was

                 6    going because I wasn't quite sure.  I went through this thin..,

                 7    and looked at the various projects which I described and I

                 8    don't know whether they're goingtb be implemented or not.

                 9    Perhaps it may do some good and perhaps it may tot do any
                10    good.  I'll let the motion stand as it is as of yesterday,
                11    but I wanted to bring this up for clarififation in my own

                12    mind.  I make a motion.

                13             MR. OGDEN:  I'll second it4

                14             MS. SILSBEE:  The motion has been made and

                -15   seconded that the committee recommendation of $650,000
                16    stand.  Dr. Watkihs, did you have anything to add to that
                17    as secondary reviewer.7

                18             DR. WATKINS:  No comment.

                19             MS. SILSBEE:  The motion has been made and seconded

                20    that the Maryland application be approved atthe level of

                21    $650,000 dollars.  Is there any further discussion?

                22             (No response)

                23            Ms. SILSBER-"  All in favor?

                24                           Opposed.

                25                           The motion it carried.


                I                         NASSAU?SUFFOLK
                2              MS. SILSBEE:  The next region to review is

                3    Nassau/Suffolk and-the pririar@, reviewer is Mr. Milliken.

                4              MR. MILLIKEN:  Was this discussed yesterday?

                5              MS. SILSBEE:  Yes, sir.  Do -vou have a transcript

                6    on that?

                               MR. MILLIKEN:  Yes, I do.  With the information
                7

                     we had this morning, it would appear that we do have to
                8

                9    change our previous decision of no funding.  I have no

               10    evidence to find fault with or change the review committee

               11    recommendation of $900,000, although I personally question

                     if that much is necessary due to'the situation therein.
               12

                     Maybe the second reviewer has something to add.  I'll make
               13

               14    a motion later on.

               15              DR. GRAMLICH:  I find this interesting.  It

               16    appears we're reversing our position of June and July.

               17    They have made a strong appeal and I guess if council  has

               18    no ma.or objection to reinstating them, I would have  to
                          3

               19    support that decision.   So move.

               20              MS. SILSBEE:  Second.

                               MS. MO'.RGZL'q:  Second.
               21

               22              MR. OGDEN:  Could I ask the membe@s of council---

               23              MS. SILSBEE:  Mr. Ogden, could you use the

               24    microphone.

               25              MR. OGDEN:  Look At the page concerning Nassau/


                    Suffolk.  The program staffing here of $343,000 for what
                  2 they have proposed to be slightly over a $2 million dollar
                    program, now if wel@e limiting this to $900,000 dollars,
                  3
                  4 obviously we cannot let the entire $343,000 for the -program:.-.
                  5 stay, so I think there needs to be something said if we
                  6 accept the $900,000.  I didn't hear the review committee

                  7 yesterday.
                               MS. SILSBEE:  They made the point, Mr. Ogden, it
                  8
                    was not in the motion, but it was  in the advice to the
                  9

                  10  region.
                  11           MR. OGDEN:  That may be in the minutes.  Idon't have'

                  12 that in my notes.                 I
                  13           MS. SILSBEE : The pink slip says:  "Based on the
                  14 funding recommendations for the attending period, it was
                    further recommended that the Nassau/Suf-folk RMP be adjusk--ed,
                  15
                  16 Staffing request to be proportionate to the forthcoming

                  17 award.
                  18           DR. GRAMLICH:  In relationship to the presentation
                  19 this morning, I was a little at a loss and wondered if the
                  20 applicant was fully aware of the fact that this council felt
                  21 they should be in a phase out period

                  22           MS. SILSBEE:  Mrs. Floodi
                  23           MRS. FLOOD:  May I ask if staff has verified  that
                  24  Projects 021 and 022 of the E@IS projects are appropriate to

                  25  the allowable concepts of our funding.


                 1            MS. SILSBEE:  We have had a return from 11.1r.  Reardon
                 2  who is EMS Systems Chief and he doesn't see any problem with
                 3  regard to their Dor@ion of the legislation and we got a
                 4  telephone call this  morning from the part of HRA that is
                    administering the training part of EMS and they also do     not
                 5
                 6  see any problem or conflict.  That is not to sav they are
                    looking at it from any other standpoint but that.
                 7
                 8            MS. FLYNN:  Those two line items approximate
                 9  $400,000 dollars and even though we're recommending-from
                10  committee that their staff be  brought  into  line  by  readjust-
                11  ment according to the award, if they're  just  given  an  award
                12  without further recommendation, other than    staff  limitations,

                    it would appear that their only endeavor would be emeraenc
                13
                                                                                  y

                    medical services and emergency medical training.
                14
                15             MR. STOLOV: We have received  the  priority  level  on
                16  the projects and the equipment is  below  the  $900,000  dollars,
                17  however, the EMS training is above it,but again, 1 feel it        i
                18  is expensive, but it was their determination where to put
                19  the money once they get this $900,000.  They  may  not  put  it

                2o  all into that EMS training.      The Nassau County which  is  the

                21  more populated and richer county is way down at the bottom ofl

                22  'their priority list.
                23             MR. OGDEN:  Would you explain to me what this
                24  $355,000 is, how much of this would be funded out of the

                25  $900,000?


                  1            !4R. STOLOV:  I believe Dr. Pahl mentioned yesterda,.7

                  2 that we still have not developed policy regarding what hannens
                  3 in terms of independent P.,,NIP beyond June of '75, so we don

                  4 know liE',l wide if this is allowable under grants and  admiriistra-

                  5 tion practices, but I believe it would have  been  a  contract
                  6 in their own Nassau/Suffolk E--'P Inc to carry this out  in  this,

                  7 scope and amount.  When the-committee looked at this, it did

                  8 not consider this in their funding.level.  They left it out.

                  9            MS. SILSBEE:  The Chairman suggested the $2,000,000

                  10 request be cut down to $900,000 and that maybe  a  moot  issue    I

                  11 in terms of continuing the program or putting money aside.

                  12           DR. SCHREINER:  I was primary reviewer on the           i

                  13 last go round.

                               MS. SILSBEE:  Acdordina to the old assignment list,
                  141

                  15 Mr. Milliken, you had it last year also.

                  16           DR. SCHREINER:  I was hoping it   would be somebod,,i

                  17 !here.   I'm very impressed As Dr. Scherer happens to be an

                  18 old   friend of mine and I was wondering if this was in line

                  ig 'with his $900,000 speed.

                  20           DR. P2UIL: Mr. Milliken, right, I'm afraid  you're  it.

                  21           MS. IIORGAN: Mr. Milliken, you were it  last  time.

                  22          @MR. MILLIKEN:   I don't recall all the details.

                               MS. SILSBEE: In terms of  making  the  assignments,
                  23
                  24 I try to keep them as consistent as possible.

                  25           MR. MILLIKEN:  On the yellow sheet,   the second  yellow


                                                                             1 4 6

                 I  sheet, the second item CO-5,COG-5,  Grantee  Central  Service.  I

                 2  Could somebody explain what that is?
                 3            MS. SILSBE'E:  That is what we were just discussing.

                 4            MR. STOLOV:  it's an independent RMP, therefore

                 5  according to instructions, they should close by June  of  '7n

                 6  and they have to issue contracts to extend beyond that period   1;
                 7  and they felt it would be good use of Government money  if  theyl

                 8  continued to fund the grantee should over ride  contracts  be

                 9  issued.

                 10           DR. PAHL: I was about to make a  statement  on  that

                 11  when we got to Dri Schreiner's question.  We have a policy
                 12 lwhich comes out of the DHEW decisi!on not to permit staff or

                 13  an MIP to perpetuate itself beyond June '30 of '75.  To

                    merely state that all grantees, regardless of what they wish   to
                 14
                 15 do in terms of contract activities may hot engage in  that  kindi

                 16 of situation which would perpetuate the RMP or the  staff  bevon(i

                 17 June 30 of 175. They may contract with groups  to  carry  out

                 18 activities past June 30 of 175, bu not in such a  way  to

                 19 perpetuate themselves, so if Nassau/Suffolk, and I  don't know
                 20 Ithe details of this, if Nassau/Suffolk or some other RMP   has
                 21 funds in.it which, in effect, would continue to support staff   1.
                 22 @eyond that point in time, then I believe we would take

                 23      riate administrative action with our  office  of  manage-

                 24 nent because we re applying a uniform rule in accord with

                 25 Departmental policy. I hope I have  made  that  distinguishing


                                                                            1,17

                 1  line rather clear.
                 2            r@'iR. MILLIKE'11,7: I still go with the action of June
                 3  and the reTDort of the committee unless there is new informat4@cn
                 4  or evidence that shows reconsideration should be made.
                 5            MS. SILSBEE:  Would you state that motion again
                 6  and into the microphone so we can all hear it.
                 7            MR. MILLIKEN:  I'move the committee recommendation
                 8  of a phase-out award of $900,000 be awarded to this state.
                 9            MS. SILSBEE : A "phase out" award,, do you want

                 10 that stated in the motion?

                 11           MR. MILLIKEN:  Yes, I do.
                 12           MS. SILSBEE:  Is there @ second to that?
                 13           MR. K014AROPF:  Point of clarification. Would you

                 14 resolve your ambivalence.
                 15           MR. MILLIKEN:  I will remove from the motion the
                 16  "Phase out" words, but Iwould like staff to be instructed
                 17 to have them understand that this $9OOiOoo dollars is for the
                 18 purpose of helping conclude their efforts and not continue

                 19 the program as they proposed.
                              DR. PAHL:  I'm not sure I'm going to clarify this
                 20
                 21  situation at all.  I think we do understand that in all of

                 22  these recommendations, particularly where there has been some

                 23  drastic cuts from requested levels and I ,i sure more so in

                 24 the case of this region, that it will have a very serious
                 25  impact on their program development.  I think it would be


                  1  really in error for us to characterize this more than some

                  2  others that.f.@,,e have been concerned with here as phase  out

                  3  or terminated.  I think we really should onlv accept the

                  4  motion for a funding  level  recognizing  that  probably  what

                  5  you say will cause serious  dislocation  from  what  they  had

                  6  anticipated.

                  7             MS. SILSBEE:  VJould you restate your motion.

                  8             MR. MILLIKEN:  I move that council accept the

                  9  committee  recommendation to fund this agency at.$900,1000        i

                  10 dollars.

                  11            MS. SILSBEE:  Is there a second?

                  12            MRS. MORGAN:  Second.

                  13            MS. SILSBEE:  The motion has been made and seconded

                     that the  Nassau/8uffolk application be aDnroved at the level
                  14

                  15 of  $900,000.  Is there further discussion?

                  16            DR. TIILMMOCK:  I would like to ask a question about

                  17 32   family nurse practical and critical care nursing patient

                  18 family nurse, that comes to     $150,000.  ;,,,ill somebody explain'@,

                  19 that to me?

                  20            MR. STOLOV:  Your addition is correct on that.

                  21            MS. SILSBEE:  Ilhat do you want explained, Dr.

                  2  Wammock?'

                  23            DR. I-7MU4OCK: Are they going  to  train  practical

                  24 nurses   or what?

                  25            MS. SILBEE:  Ile don't know if thev're going to do


                  1  anything because they have had a request of $2 million.

                  2  Jerry, do you know the purpose?

                  3            MR. STOL-OV:  They are separate projects.  one is

                  4  the university base and the other is a community base.

                  5  one is nurse trained - nurse nractioner and the other

                  6  is more of a socio emotional thing to train nurses in

                  7  giving support to families who have critical illnesses.

                  8  They are different Drojects.

                  9            MS. SILSBEE:  The question is, where do they fall

                  10 on the priority list?

                  11           MR.  STOLOV:  I'll check that out on my paner

                  12 work.

                  13           DR. G@,ILICH:  May I ask a question?  It does not

                     relate to the subject at hand, but it does relate to the "Ilassau
                  14

                  15 question.  In one of the other regions, we find that the

                  16 regional advisory group apparently worked very well And  in

                  17 Nassau/Suffolk, they apparently did not.

                  18           MS. SILSBEE:  That has a long history.  -I think

                     they actually didn't have a combined board   There was a
                  19

                  20 combined grantee and we made them have a  different reaional
                                                                            1

                  21 advisory group and a different council.  Thre was some overia@

                     butthe combined grantee situation did not work out andt-hat was
                  22
                  23 was about a year aco September or so.  We had joint sta'L4-:i,"a

                  24 too, Dr. Gramlich.

                  25           MR. STOLOV:  I have on both proDects my paperwork.


                                                                             i5o

                 1  on both projects    family nurse oractioner v.,hich was $142,0001!

                 2  project, it ranks number 11, which the critical care nursina
                 3  project, Number 16.-'@ The dollars fall out,if they  stick  to

                 4  the original dollars submitted, $860,000  off  of  projects

                 5  1 through 10 and it stops at venereal disease.  These

                 6  are well below the level again.

                 7             MS. SILSBEE:  So,they would fall out.

                 8             MS. FLYNN: If I may just ask, does  Project  Number

                 9  29, fall out.

                 10            MR. STOLOV:  Project 29 does not fall out.

                 11            MS. SILSBEE:  That  project---

                 12            MS. FLYNN: They left their priority  and  sioendinq

                 13 dollars the same?

                               Ms.
                 14                SILSBEE :Yes.  There is a motion on the floor.

                 15            MR. STOLOV:  Mr. Ogden raised @h6 question, what wa

                 16 the title  of the project.

                 17            MS. FLYNN:  It's a computer analysis of whether

                 18 health educational materials have been  written by authors  in  i

                 19 a leval that is readable by the health  care consumer.  $36,000

                 20 dollars to have a computer analyze all  health education

                 21 materials so it will be at the 4th grade readina level.

                 22            MS. SILSBEE:  There's amotion on the -floor to the   i

                 23 effect that the Nassau/Suffolk applications be aporoved   at the;!

                 2-t level of $900,000 dollars.  Is  there  further  discussion?

                 25            (No response)


                                                                             151

                              I-IS. SILSBEE:  All in favor say "aye".

                2                            Opposed.

                3                            The motion is carried.

                4

                5

                6

                7

                8

                9

                10

                11

                12

                13

                14

                15

                16

                17

                18

                19

                20

                21

                22

                23

                24

                25


                                                                                      5 2

       14cLane      1              %IRS. SILSBI:'E:  l'Irs. Flood, we will convev    your

                    2   concern for this corolete documentation at what level health

                    3   education Traterial,-q,need to be prepared for consumabilit,@

                    4   capability.

                    5              As this discussion     went on before you finallv
                    6   acted, there was reluctance,      but in terms of the final      action@

                    7   '@iassau/Suffolk now has $90r),Or)O.    @@le viill be glad to work

                    8   with them further on this.

                    9

                    10

                    11

                    12

                    13

                    14

                    15

                    16

                    17

                    18

                    19

                    20

                    21

                    22

                    23

                    24

                    25


    rm2           1.                     SOUTI] CAROLINA
                  2                SILSBE@@,  The next application to be
                  3II reviewed is South Carolina, and Dr. liaber, you are the pririari

                  4 reviewer.
                  5           DR. IIABR@R: I must confess
                  6           MRS. SILSBEE:  Could you talk  into the microphone,  i

                  7 sir?
                              DR. HABER:  I must  confess to a larger  degree  of
                  8
                  9 confusion about this protocol  than I felt on  first  reading
                    it.  It seems to me that it is difficult to reconcile the
                  10
                  11 reviews that we had in June with those that are submitted  now.!
                  12 T wonder if staff could accomr@iodate me to the extent of d'IS-
                  13 cussing one of the major issues of the concerns that -.-7e had
                  14 at our last meeting about the involvement of the Govertor's
                    office in the -P-14P.  Could that be brieflv clarified now?
                  15
                  16          !.IRS. SILSBEE:  Mr. Van l,linkle?
                  17          MRS. MORGAN:  The Governor is  going to resign tonight,
                  18          MR. VAIL !II@@ll'ILE: Dr.. ;'4oslev has recently. sent us,
                  19 not a series, a whole bundle  of  correspondence,  memos.  He
                  20 has been in touch with these people.  I don't think  it  has
                  21 been resolved.  Negotiations are going on.   I am not sure
                    there is any resolution in terms of getting them to agree
                  n&2

                    to agree.
                  23
                               I,IRS. SILSBEE:  Tlould you spe@, into the i7.icrophone.
                  24
                  25           MR. VAIJ         The region originally responded


                                                                          1 5 4

     rmi         I   very vehemently because they felt that the representatives
                 2   of the Covernor's commission had been a part of the  --  both
                 3   the technical revie-@q and the regional advisory groun in
                 4   1,7hich the decision had been made, and there were none of
                 5   these difficulties raised, and they felt that the project
                     had had proper review, but we have been explained  bv  phone,
                 6
                 7   the council's condition took the consideration, but  still
                     felt there'had to be a resolution locally.  That has  not

                     yet occurred.
                 9
                 10           DR. IIABER: llell, that is unfortunate,  of  course.
                 11  Nonetheless I feel, and mv contention is that the funding
                 12  review that sorne of the reviewers have recommended for  this
                 13  is unduly harsh. I -feel that this has been a  good  oroqrami
                     In the face of adversity they have tried to keep it together.
                 14
                 15  They have replaced their losses with admirable fortitude.
                 16  T think that manv of the projects are  well  constructed  and
                 17  conceived.  It seems to me we are criticizing them, or at
                 18  least some of the reviewers are criticizing them, for a wide
                 9   variety, apparently, of disorganized projects, and yet in the
                 1
                 20  earlier criticism was that it tended   to be too  global  and
                 21  not specific enough, so we are getting them  both  ways,  and

                     .1 think this unfortunate.
                 22
                 23            Again, I feel that manlv,of the projects are
                     well constructed.  I feel that there is no point  in our
                 24
                     perpetuating our own indecision or worse, contrary  viei..,-@,,
                 25


                                                                           1 5 5

      rn4            towards them. I think thev have had the endorsement   on
                2                                            al review confere
                     pages 1,,34 and following the CliP @',IP annu
                3                            it seems to I)e indicated the ult;,rate.
                      think that they have;
                4    phase-out of this be modest extensions of some of these
                5    activities, and I would suggest that instead of the t)ronosed
                6    level  that they should be funded at  a level of a million
                7    dollars  for the supplemental request that they have come in,
                8    which is some $473,000 less than they have requested.

                9              '-,IRS. SILSBEE: Dr. Komaroff?
                10             DR. KOI-4AROFF:  I think a series of projects, 66

                11
                     projects which are described here, can both be vague in
                12   their individual description and disconnected, without  an%,
                13   kind of sense of cohesiveness, and I -- well, that in  fact is.
                14   my feeling about reading this ai),olicatidn.  '@ve have aregion
                15   that is a relatively small state  in terms of its T)opulation
                16   which is alreadv funded at a level of two million dollars,
                17   and I have kind of a gut feeling that their supplement ought
                18   to be closer to $400,000 recommended bv committee-than an

                '19
                     additional million dollars, bringing our level up to three

                20   million.
                21             DR. 'r"olIAR(.)FF: I will summarize. As an exar,@nle
                22   of m-v edginess, I will tell you @.7h-N,, I am edav.  Yesterdav
                23   there was a question as to whether  the '-RAG had set anv
                24   priorities among these 66 T)rojects.  1,7ow, in fact, there is
                25   a listing of priorities,, but you will notice that the rankings


                                                                                              156'
    rm                  of the projects within each groun is in exact ordinal
       D

                   2
                        sequence to the numbers of the project.  !,.@at I mean         is

                   3
                        these Drojects .7hich are rated one through 12 are projects

                   4    number  91, 2, 3, 4,   5,  6,  7,  etc.  You  have  the  feeling   that

                        unless  thev numbered   the  orojects  after   thev   set   priorities,

                   6
                        that   this priority rating is simoly a kind of          a  joke.   They,,

                   7    just   took blocks of projects in    sequence as they appeared

                   8    in their  numbering and gave them,     quotes, "prioritv       rating."

                   9    That mav  be unfair   to the region,    and  the  staff   knows   whetherl

                   10   this region numbers    its projects   after  thev  give  them   a

                   11   priority rating which would be quite unusual in mv experience

                   12
                        then I would be mollified.

                   13              I-IR. VA14 WI'LIKL
                                                  E*  I  don't  know  when  they   number   them.1

                                                                                        f
                        ly guess would be that    that  is  one  of  the  last  orders  o

                   15
                        business before they mail to us.  I haven't been down to

                   16
                                                                                  r regions
                        South Carolina in recent months.  Some of the othe                       i

                   17
                        when thev r)reoare those, they prepare them bv title only.

                   18
                                   I-IRS. SILSBEE:  Thev have their own     local    nurlbering

                   19
                        system, and then thev relate it to ours.
                   20              DR.  KOI-IAROFF:  It may be nothing, but I had a feeling

                   21   reading through this    that it was kind of poorly connected,.

                   22   over ambitious, in a    region  that  was  alreadv   quite   well

                   Z3   funded for its size,    and I would be reluctant to bring       their

                   24   level uo to three million.

                   Z5
                                   .4RS.   SILSBEE:  '7e don't have a motion on the floor.


                                                                               15 7

      rm6                      DR. l@OrIAROFF:  CouldI move five hundred thousand?

                 2             DR. T@IA!.,U-IOCN: I second that motion.

                 3             'i4RS. SILSBEE: The motion has been  made and

                 4   seconded that South Carolina application be   approved  at the

                 5   level of $500,000.

                 6             Is there  further discussion?

                 7             ('.,,To response.)

                 8             MRS. SILSBEE:  All in favor?

                 9             VOICES:  Aye.

                 10            MRS. SILSBEE:  Opposed?

                 11            (No response.)

                 12            MRS. SILSBEE:  The motion is carried.

                 13

                 14

                 15

                 16

                 11

                 18

                 19

                 20

                 2.1

                 22

                 23

                 24

                 25


     rm7         I                           TEXAS
                 2                            If we go alphabetically, we come
                              !IRS. SILSBEE:

                 3  to
                       Lexas.

                 4            MRS. FLOOD:  1,7e are going to Texas?
                 5            MRS. SILSBR.E:  llrs. Flood is going out of the room.
                 6            Has the Texas pink sheets, or  white,  been  distri-

                 7  buted?

                 8            MRS. MORCAN:  No.
                 9            MRS. SILSBEE:  Let's distribute then,.

                 10           Off the record.

                 11            (Discussion off the record.)

                 12           MRS. SILSBEE:  On the record.
                 13           You will recall that the Ilay application  from  the
                 14  Texas regional medical program included requests for funds
                 15  for a series of contacts of which the ideas were spelled out
                 16  in the May application, but the specifics regarding  who  was
                 17  going to carry it out and what institution and the-amount
                 18  for each contract was missing because that was going through
                 19  their local review process at the time that it was doing

                 20  through the national reviev7 -process.
                 21            Council considered this application and decided
                 22  that in general the goals and objectives of  the  region  and
                 23  the general management of the region seemed to be sufficient
                 24  to enable council to delegate to the review committee which
                 25  at that time had felt that it was going to meet  in  June  or


                                                                                  1 5 9

      rm8              July, to delegate to the  committee the authority to look at
                 2     the individual Project proposals and recommend whether that

                 3
                       money should be released  or not, so  in  effect  council  made
                 4     a recommendation of -- well, let's   see if I  can  find  it  now.
                 5     They recommended that the Texas application be funded at
                 6     the requested level of  two  million  three  hundred  and  thirty-
                 7     three, five hundred and fiftv-one, pending the satisfactory
                 8     review of the specific contract proposals bv the July       review
                 9     committee.  This was to enable Texas to go ahead because it
                 10    was a non-profit corporation that had wanted to do their
                 11    thing in the 12 months, and til6v didn't  want  to  slovi  them

                 12    down in that process.
                 13              The July committee was not able to meet, and they
                 14                 gust, which was yesterday, and the  discussed
                       had net in Au                                      y

                 15    the Application.

                 16
                                 .Now, Mrs. Illiorgan, I am going to let you pick  u-o

                 17
                       from there.

                 18
                                 MRS. MORGA-,i:   Our pink sheet  that  has  now  turned@
                 19    white, the application for funding for    the various contracts

                 20
                       of one million four  hundred  thousand  dollars  was  what  was
                 21    left over from  our  meeting  in  June.  The  review  committee
                 22    recommended the use of one million dollars.  The reviewers
                 23    were still apprehensive regarding the monitoring capabilities
                 24    we have had, and I don't believe the review committee had this
                 25    information, and this is that they are going to activate their,


                                                                          1 6 0

    rm9             review committee which will consist of on this, T)lus members

                  I from the  RA(',. The concern of the re%,i-e%.i committee was health
                    professionals reviewing these -,)rojects.  If you are familiar
                 3

                 4  with the Texas RAG, it is practically all health professionals.
                 5  About 95 percent of them are nhvslcians on the RAG, and these
                 6  physicians are going to be the ones, and this  is  from  the

                    material we have received,.who will be on the review committee.
                 7

                    There is no question in my mind but that there will be healt-hl@
                 8

                 9  professionals  reviewing  these  area contracts.  Thev  have

                 10 Sent in their form, which  is  a  six page form. It  has  to he
                 11 filled out monthly on the various   contracts and sent  in; will

                 12 be reviewed  by  their  committee.  Ihavein my mind  no doubt

                    that these will be reviewed bv health T)rofe8sionals),  and
                 13

                    I would like to move that the  level from June  meeting  of
                 14
                 15 one million four hundred thousand be returned to the Texas

                 16 RMP.

                 17            Mrs. SILSDr-_E:  Dr.Schreiner?

                 18            DR. SCHREI.IIER:  I am a little bit confused about

                 19 the back and forth thing and the old  grant.  If  vou  could

                 20 clarify that a little bit?  in other words, are you

                    didn't hear the discussion yesterday on this Darticularone.
                 21

                   "Are they-prooosing anv additional now money?
                 22

                               IIRS. SILSDT-7E:  -Io. T@,,Tell, they are. I was  going
                 23
                    to ask Mrs. Morgan if she would mind rewording her motion4
                 24
                    We gave them an award for two million three hundred whatever
                 25
   0


                                                                                    6 1

    rmlo              it was, and we restricted  1.4 million dollars pene@@ng the
                  2   satisfactory review, so  in  a  sense  they  can't  snend that

                  3
                      1.4 million.

                  4
                                 DR. SCIIPEIIIER:  It is called internment.

                  5              MRS. SILSBEE:  Internment for a reason.      The actioni

                  6   of the committee yesterday would release one million dollars

                  7   of that.   Another four hundred thousand  presumably  would

                  8   come back  here, and they would not be allowed to spend it.

                  9              MRS. ',IIORGIUI:  May I change my motion to state

                  10  that we released to Texas RMP one million four hundred

                  11  thousand dollars of impounded funds to them?

                  12             DR. PAHL:  We remove all restrictions.

                  13             MRS. MORGA,:i:  In other words, restrictions are

                  14  remved from Texas.

                  15             DR. '@lP@4-xIOCK:  The restricted funds is what you

                  16
                      meant, and not impounded.

                  17
                                 MRS. MORGAII:  Had this one million four hundred

                  18
                      thousand  dollars been released in June to Texas, they were

                  -19  not planning on coming in on this cycle four, any money at

                  20  all.

                  21
                                 DR. SCPR'-PI'zlv-R:  So this comes out of the 84, not

                  22 l,'o ut of the 20. Thatis what I wanted.

                  23             MRS. 11110'-RG@l:  It comes out of  that  money.

                  24             tiRS. SILSBEE:  The  money  that  has  alreadv been

                  25
                      awarded.


                                                                                                  1 6 2

        rml 1                           DR. SCIT.@, I@4ER:   I @.7ill second that motion.

                     2                  MRS. SILSBEE:   The motion has been made and seconded

                     3    that the    restrictions on the contract funds in the j@exas                      i

                     4     a@-iard be lifted.   Is there further discussion?

                     5                  MR. HIPOTO:   Quettion.

                     6                  J"IPS. SILSBEE:   All in     favor, aye.

                     7                  VOICES:   Ave.

                     8                  '@IRS. SILSBEE:   Opposed?

                     9                  (.No response.)

                     10                 @IRS. SILSBEE:     The motion is carried.

                     11

                     12

                     13

                     14

                     15

                     16

                     17

                     18

                     -19

                     20

                     21

                     22

                     23

                     24

                     25
   0


                                                                           1 -'j 3

                                              VIRGI@4IA
     rml2

                                               'last we go to Virginia, and Dr.
                 2             .IRS. SILSB]7@l-:

                 3   l,latkins.

                               DR. T,IATKILIS:  I @have no problem with Virginia.
                 4
                 5   This is Virginia, and T)r. Perez has changed the face of t'----
                     whole program.  Pliss Martinez had a question4
                 6

                               MRS. SILSBEE:  Miss .@lartinez?
                 7
                               IIISS MARTI',NTEZ:  In thinking over the project

                     descriptions, I notice that a great manv of   the iDro3ects
                 9
                     are really supportive or extending grants to CHP's for
                 10
                 11  planning, for the normal planning of CHP programs, which I

                     am not sure is terribly wise, even if it is legal. In anT.7
                 12
                     case, I think the committee recommended nine sixty-three?
                 13
                 14            MRS. MORGA:I: It is nine sixtv-t-hree eight six---.,.
                               MISS P4ARTIIIE"7j: And I would liPe to reduce that
                 15
                 16  sum somewhat to seven-oh-seven seven   fi'Lty-nine.   just
                 17  went through the projects, and eliminating things like nu:.-.her

                 18  48 which is a grant to a CIIP agency for a
                 19            MRS. SILSBEE: Miss Martinez, in terms of what @rou     1
                 20  are recomnendihq there, have you, are you aware, that a
                     message was sent back to the re ional medical programs
                 21                                  9
                     concerning the need to do "- or to get geared   up for healt',
                 22
                 23  resources planning and that this should be done in collabora+--ic

                     with the CHP agencies?
                 24

                               MISS '@'4ARTINEZ No.
                 25


        rml3     1              i@IIZS. SILS13FF,:  And this was a definite suggestion

                 2   that was given to the regional medical orogram back in
                                         I
                 3   or April, sometime   like  that.

                 4              !IISS @,IARTI@ll',Z:  All right. It doesn't seem to !-.e

                 5   that anv of their projects are terriblv innovative or

                 6   looking, but if that is with the @'.IP

                 7              '-IRS. SILSBEE-.  No.  If you don't thinkthe acti%,it'

                 8   themselves, that is fine, but as far as being legal, this is

                 9   something they  have  been  sort of urged to do.

                 10             MISS  MARTINEZ:   All right.  Are vou satisfied?
                 11             DR. WATKINS:  Yes.   T.,Then we were on site, we were
                 12  very hard  on them, and  I  feel that Perez has done a good
                 13  in  changing  that  program.  He has changed the PAO, he has

                 14  increased the minority representation, minoritv input in L@.-e

                 15
                     urban areas., and I think I would like to see it remain as 4s
                 16             MISS MARTINEZ: Okay. I will reaffirm the
                 17  recommendation.

                 18             MRS. SILSBEE: Is there a second?

                 19             MRS. r-IORCAkl: I am seconding.
                 20             I-IRS. SILSBEE: The motion has been made and secon@-e@-

                                                                                  t 4
                 21 that the  committee recommendation on the Virginia anplica @cn

                 22 to approve the application at the level of $963,860 be annro,.,e@-,,

                 23 recommended.

                 24             Is there further discussion?

                 25             ('.,lo response.)


                                                                                                           6 5

        rml 4                            I-IRS. SILSBEE:   All in favor?

                                         %7,OICES:    Aye.
                      2
                      3                  MRS. SILS'BEE:       Ooposed?

                      4                   (@To response.)
                      5                  MRS. SILSBEE:        The motion is carried.

                      6

                      7

                      8

                      9

                      10

                      12

                      13

                      14

                      15

                      16

                      17

                      18

                      19

                      20

                      21

                      22

                      23

                      24

                      25


                                                                              1 6 6

      rml 5                                 1 @,' E S T E R',i PE41@SYLVANIA
                 2             ilps. SILSBEE:  Now we will go to Ilestern Pennsy

                 3   vania.
                 4             MISS !,IARTILNEZ:  In that Case I would like to do
                 5   the very same thing on @,lestern Pennsylvania because  the
                 6   number that I cameout with was about  a  hundred  thousand
                 7   dollars 16ss,  I had subtracted number 49 from that, so it

                     comes
                 8         outimore or less the same.
                               MRS. SILSBEE:  Would you move?     Would  ou Put the
                 9                                                      y

                 10 dollar in?
                 11            MISS ?.IARTINEZ:  Four hundred fifty thousand.
                 12            MRS. SILSBEE:  Is t here a second?

                 13            MR. IIIPOTO:  Second.
                 14            MRS. SILSBEE:  The motion has been made and
                 15  seconded that the Western Pennsylvania ao            be  approved
                                                               ,placation

                 16  at the level of $450,000.  Is  there  further  discussion?

                 17            MRS. MORGALL:  Question.

                 18            MRS. SILSBEE:  All in favor?

                 19            VOICES:  Aye.

                 20            MRS. SILSBEE:  -All opposed?

                 21             (No response.)

                               MRS. SILSBEE:  The motion is carried, and that
                 22
                 23  ends the review of the applications.

                 24

                 25


                                                                                1 6  7

                               DR. GR7U4LICTI:  Mav I Open ulo         mall sub
     rml6                                                    one more s         ject

                 2
                               DR. PAHL   T
                                          41@e have that as well as Mr. Ogden's

                 3
                    .resolution.

                 4
                               DR. GP-NILICII:  I mean relative to this project,

                 5   specifically Mississippi.

                 6             MRS. SILSBEE:  Yes, sir?

                 7             DR. GR7V-,ILICII: There is a verv strange request

                 8   and it is kind of -- the review committee didn't pay an

                 9   awful lot of attention to it, a two  million  dollar,  roughly

                 10  t@io million dollar request for hypertension screening and
                 11  treatment program including one million dollars for    salaries,i,
                 12  and included in that salary scale was  82  public  health  hursesi
                 13  who presumably are alreadv on deck, so that the @T funds
                 14  as far as I can determine  from the grant requests, be used
                 15  SirIT)ly to'supply what is now being spent by the state health
                 16  department.  Included also is $500,000 plus   or minus for
                 17  drugs for treatment of some possible 110000   hypertensives.     I
                 18  llow, the review committee's attitude is, it  is a poor  state   i

                 19
                     and they have got lots of blacks and they need  all  of  this,   i
                 20  but there was no particular attention  paid  to  the  construction
                 21  of the budget which included apparent substitution of PIIP
                 22  salaries  for what are now state health  department  salaries.

                 23  That is one item.
                 24             The other item is, if the treatment to  be  applied
                 25  to the suspect hypertensive or to discover  hypertensive  which'!,


                                                                                      1 6 8

       rm!7             is to be administered to the count,7 health officer in           each

                        county.  ,low, this Doses a problem      of nractice of medicine,

                    3
                        if you will, bN7 r,-4P funds.    If the  council  feels  this   is

                    4
                      I'appropriate, this    is fine.    All I want to do    is  bring  it
                    5
                        to the council's attention     to  make  sure  it  is   considered
                    6   appropriate.  This has to do with Mississippi only.

                    7
                                   MRS. SILSBEE:  I's there discussion on this T)Oint?
                    8              DR. KO!iA-ROFF:  Can staff enlighten us as to       whetheri
                    9   this will supplement the  resources of the state health
                  10    department, or merely supplant them?

                  1 1               4
                                   @'@.IRS. SILSBEE:  Mr. Van Winkle, there are two
                  12    issues here, in case you couldn'@ hear.
                      1
                  13               MR. VAN WINKLE:  I heard.  I was trying to hide.
                  14    My answer  is, no, I don't know.  I read the aoolic@-k--ion.

                  -15
                        Ile did ask that thev include the full, T,@,hen they sent in,

                        not the center form 15.  That is all vou @.7ould      have had.
                  17  1
                        I presume that Dr. Vaun looked at it, b.eina -Eie tDri--mar-v
                  18    reviewer.  He did not discuss that; however, as far as

                  19
                        practice of  medicine,  we  have  been  in  the  habit  of  doing  it

                  20
                        for years on demonstration projects.  I do know that they

                  21
                        proposed to take these over and continue it after this first

                  22    'year  funding.  The  government  has  put  already  a  line  out  of

                  23    its budget to  supnort  it,  but  I  do  not  know  if  these  nurses

                  24    are on bid, or if they intend to hire new ones.  I just don't

                  25    know.,


                                                                                   1 6 9

     rml 8
                                 !.IRS. SILSBI@: Dr. Komaroff?

                  2
                                 DR. XO"!A',P.OFF:  I  looked at  that   application

                  3
                      last night after  our discussion, and I had the impression

                  4
                      that it was an unusually well documented request, but probably
                  5   .-7.hat was going on was that IU@T money was offsetting certain
                  6   expenditures that were Dart of the state department of  ublic'!
                                                                                   p
                  7   health this year, but that   the quid pro cTuo  was  that  the
                  8   government was going to take over the support of the program
                  9   in future years,, and that that  seemed  to  me  a  reasonable
                 10   bargain; consider the  importance  of  this  problem  in  that

                      state medically.

                 12
                                 DR. OPLILICH:  I am satisfied.  Thank you.

                 13              DR. PAIIL: I have two items of business before

                 14   we  adjourn.

                 15

                 16

                 17

                 18

                 19

                 20

                 21

                 22

                 23

                 24

                 25


                                                                                                  1 7 0

                                                                   ction i,"-ici
                                                  is  that  tl-le  a                    i) c-, e n
                                     rnhe @irs4l-

                                                          t'-
                          ta,@en, @er-,i.@ions made 1) y  ,is Council result in         a total
                     2 1
                                   ded dollar    level    of @-27,154,37,"              @597,22@,
                          rpco=en                                               c    s
                     3
                          a@ove the total recor..i,@iende,-l to you Play the "';Icvicw  Committee
                     4
                                      40  of  @l-e  re-,ions you  concurred  %Keith  the   Con7,iL-
                                                                                                  -te-@  s

                     5
                          recommendations; five      rec-,ions had some amount added to the
                     6
                          corL,@iittee's recommendations, and in t%,o cases, your redor,-,nendati

                     7
                          @,cre to reduce the Co:,7,mittee"s recommendations.
                                      -.he sccond item of 1-usiness I @,.7ould li.e to come
                     9    baci: to, unless there is discussion on that -- 1.)r. l@omaro;-:f?

                     10
                                                p               that mean @,@e approve less
                                                @O@P:    @Does
                     11   money than   is  available to spend?  Ilow does that affect the
                          iDolic,,, ,.?e aT)oroved earlier today about prorating a kind of
                     12
                          an extra supplement after the fact.
                     13
                                      D'@l . Plk T TL: @,',Ie are in 3ust fine shape at these

                     14
                          levels.    ','e ended the -Cray verv                  7.1.,e  action  you
                     15   1-001- this morning   and the recommended dollar level is

                             nq to nerm
                     16   goi             i@ us to distribute all of our r,.onles in,-'
                     17               on @..hat 1-iapr,-ens over tlie. course of the L@all,
                          @-iill be able to - with the formal order that you endorsed,
                          be able to accommodate any chanae there.
                     19
                                       So, r-aftaqerially everything is o'@lay.
                     20
                                      i,r. jane,,.7aty?
                     21
                                            jl'7T7T,l
                                                          %,,a,@,  -,us    .,in-
                                                                   t chec'

                     22
                                            n. I TT        you --F                   so sure t-i-@s
                                                                          I am not

                     23   are in su--!@, good s ape.
                     24                                   @,7as checking mv o,,@-n  mat'@-@e-matics
                     25   I-ecause I thought we had added                      '@--ut it is such


                                                                              171

                    a small amount of differ      onl@T
                                            en,-P-i
                2  1
                                                          -forence,   @.7ill
                              DTZ. P,' TT L: if ticre is a dirL

                3
                    either take it out ?'5f 7--c,ith's salary, or give it to her.

                4             I-le have one of t@iese
                                                   fantastic data -matic
                5   aides on sale, or something, and there is volt--aae fluctuation
                    and during one of my afternoon telephone calls, I found
                6
                    Tdith sitting poking these keys.  At the same time, doing
                7
                    everything in lona hand because with voltage fluctuation
                8
                    you don't end with the same digits you should.  So,  I  think
                9   we better qo back to lead pencil and nar)er.
                10            I gather the correct fiaure is @,,17,349,054.

                11  Another one of the rumors.

                12            I have received information, also, again,  I  don't
                   lknoi-,7 whether it is a rumor or not,"-Iut presumably it has
                13 1
                   !'f.-,een announced out of the '-,7hite Fouc@e that, as .;,ou I:no7,,,,
                14
                15  will he announcement either at 01:00   and now some people
                    say 8:30 - and Congressman Ford is to undergo his i,-iaugerationj
                16
                    at 6:00 p.m. tomorrow.  I quess we will all learn as to
                17
                    go to airports whether this is rumor or          -Lhis was
                18  given to me as a  statement.

                19            'L"he other item of business
                    @n more firm ground ab out is to reconsider the resolution

                    --hat PI.-. Oqden introduced, and which we tabled until hopefully

                    you had an opportunity to look over.
                              -mbe summary material pertinent to  the  resolution.

                    'Ir. Ogden, I think i,,,c have distributed this to  each  person.
                24
                    Po-r!,,aps, vou i,,7ould like to make some comments.
                25            1,@,'R. OODEIT: I hopeIthat many of you have had an


                 3                                                                                1 7 2

                     1   opportunity to lool@ at the material 'i,earle(i "Su.=.arv of t-e
                         .national           Policy   Plannina   and   '?resources    De%,elopment
                     2

                         P@ct of 1074."

                                       r. J.-maro--Ff, @qho is  sitt4ncT  next   to   me   here,
                     4
                        ihas probably (Tone throu,7,li it     a   little   more   carefully   than
                     5
                         many  of  you  and  underlined  the  areas   and   I   will   call   on

                     6
                         him  just  in  a  few  moments  for   his   comments.   But,   in   doing

                     7   through this piece of legislation I found no-place where I

                     8   could find anything that fitted tile function of any existilicl

                         regional  medical  program,   save   per-al)s   some   of   the   progra,-is
                     9

                         which  are  in  fractions  of   states,   such   as   some   of   those
                    10
                         perhaps in the State of @.'ew York.

                                     If the Governor      of the   state  were   to   decide   the
                    12
                         health service area, -for       example,   .:as '-Iassau/su-'folk - per.-a-s!

                    13
                        I'l.'assau/Suffbil- R:@,P could become the health service syste-s
                    14   agency  in  that   particular   area.   --u@@,   this   particular   pi-c--e
                    15   of   legislation   while   it   seems   to   encompass Hill'Burton-al ost       I

                    16   completely    and  you  Still  find  that   comes   un on Pac,,e 5 on @-'.-e
                        I
                    17   description of the health resources -.Ikevelopment               the  onl,,7

                         place that I find -J@IP perhaps even suggested is            on  Page   6
                    18

                         under Area Health Services Develonment           Fund.
                    19
                    20           @@Tow,  remember  here  @@,,e  arc  talking  about   a   health
                         system  agency.   '7ow, health syste                               profit
                                                                   m auency   is a non-

                    21
                         private   operation on a local or area-,7ide         basis.   But,    t-4---

                    22  is  a  health  service  area  no7@ulat4-cn   of   less   than   half   a

                    23  million.  It  is  not  permitted.  It  can   be   up   to   about   t@,.,b
                    24  million,  as   I   recall   ilr.   Rubel's   corc-,ent   yesterday.   But, it
                         woulcl   encompass-the   health   service   area   would   encompass   an-,7
                    25


                                                                                          1 7 3

               4
                       standard m,-n@@--opolitan-statistical  area, %.7hiel-i is entirely

                   2
                      ,-.,itli a 1,Doundry - it can cTo over state lines, but there arc

                   3
                      I'-Iiterall-y, 1 understand,  100's of   S141SA s in the United
                                             -at ,-.,e are lool:in
                   4  lit'ta+-es. So, that  w'                   q at here is an area
                   5  li.ioalth services development fund which is going to be a
                   6               hing, and indeed we find that the arant that
                       ocalized t

                       can be made for the development within one of those on page
                   7
                       2 - no single crant or    contract may excee(I $75,000 be made
                   8
                       for more than   two years.
                   9
                                  It simply tal'r-ed about the area health services

                   10
                       development fund.     -.,is is whv I have proposed this resolution
                   11 lThat this piece of    legislation      it be suggested that this
                   12 Ibe amended to give    each state the statttorv and financial
                   13           to maintain a senarate health s-,-,7@-teis development
                       support

                       aaency on a  state-@.,-
                                            ,ic:c, '.@lasis. Do,   that at least @,,,e iav---    I
                   14
                   15  to,-ething si.-qiliar to the PT,'P's v7e  have today       can perform
                       a  state-iiide  mission  or   function.   And, indeed, @.@.c could
                   16
                      !even say, goinCT beyond state lines.  "ut, I suspect the
                   17
                      J'-incl of legislation T@ic are -,eeing coming up here is.going to
                   18
                       be limited to state !-.)oundries and national health insurance-.
                   19  -@nav indeed have in it have some sort of state-wide function

                   20  mechanism.
                   21              So,             this resolution and in it, the
                                       I propose
                       -second part of it I have said, "@-he comments that proceeded
                   22
                           rf--soltuion  and  the   resolution   itself be transmitted to    tliei
                   23
                       members of ti-c !'louse Interstate and-Foreign Cor@imerce Co,-Lriittee
                   24
                       -- and 1.)v that    meant to encompass the comments that I        made
                                                                                          ON
                   25
                       in the letter from    Senator i!aqnuson to Senator c"@ennedy,     which


                                                                                                   1 7 4
                 5

                         i read to you earlier and which should a7ir@ear in the transcrip
                     2   o-- the  inutes of this -,ice4-inc                   .7e vou that let,-er
                          L       l@                                  c,:-i n

                     3                                                                              cl:.
                         i -f you .ould 14-,!-e to   ,'erox it.   I          1 2@':, to  Iliave  it  ba

                     4    But,  I will I)c hcirpy to hand it to you.
                     5                1 do recommend that we do t-is.  I am quite
                     6   concerned  that  the  kind  of   legislation   '-a4L.   ..,e   see   coming
                         out simply does not recognize the place tat regional medica
                     7
                         proarams have come to serve on the Ar,,er4-ca.- scene.   And,
                     8
                         certainl  many of us who worked with this -Droaram since its
                                   y
                     9
                          nception eight years ago this Sprina feel that it has acccmpl.,-,
                     10  fat  more  than  it  has  been  given  credit   'o--   and   that   it   has
                     11  the potential to accomplish a great deal 4L-I-a-@- is qoi-ncTto
                     12  ]De necessary in order to mal:e nat-?onil                       legislation

                                                                         --c   v-r-,.r   complicated
                     13  function when it begins to deal with
                         undertaking of the Aeliverv of services an4- the deliverv of
                     14

                         care.
                     15
                                      And, it seems to me that unless          the    nroviders    of
                     16
                         this ration are given an opportunity to                   their   in    put
                     17
                         through something like irl@P, that the success            oi national
                     18
                         health insurance is jeopardized and I lo-ce that              we are going
                     19  to be able to have the continuation of so-:e'Lhinglike the

                     20  regional medical r@rbqrams.
                                           Pi-.iTL: Thank you,   very illucl-  .,.r. Oa-l,cn.
                     21
                                      -here @@7as a motion introduced        and seconded, I think
                     22
                             possibly..
                     23
                                      D R . I 1,T, I 0 C KSedond.
                     24
                                      DR. PLIAl'i'L: Thank @,,ou, Dr. !@@'a=cck.
                     25               I think there should be room j@cr discussion by


                                                                               1 7 5

          r

                    Council on this im@ortant topic.

                 2
                               Dr. i'lomarof.@'?
                 3                            Ps I loolr, through this, the Bill,
                 41 the thing  that concerns me is that all of the various
                    aaencies which would he created bv the Bill seem to relate
                 5
                    to planni-na and to the Tnonitorincr of facility expansion
                 6
                                              %-here is no sense or very
                    within   the region.  That 4-                         little
                 7
                    language that would relate  to   what you might:thihk of as
                 8
                    a perational arm  of  such  an  agenc.yor group  of  agencies
                 9  to actually do demonstration projects  in  health  services.
                10  And, the funds that are alluded to 314a and b funds, I
                11  believe, are by title 9,  Planning  Funds.  Not  operational

                12  funds.
                13              So, as I understand your motionibob -- I am
                   junclear about your first -- the first component of it.  Do
                14
                    you-mean that this operational agency would be independent
                15
                                       o.@o s E-, d i n
                16

                   I
                                           Yes, I do.

                17
                               D,R .0, '@,N R 0 F'@r     ally the null-. of the

                1 8
                    question.   l,'ho reports to who? I believe that there ought
                19  to be a separate and clearly defined and funded operational
                    arm tha-t__Inc)ks lik2 P-T,!P. i am bothered, though, at the
                20
                    prospect of havincT that agency wholly separate from the
                21
                    leadership, or @@@hatever, supervision of the rlanning agenc,-es.i
                22
                               DR.           I ,,:ill Vield to you.

                23
                               DR. J7k@,-,E',AY: 30 seconds?

                24
                               DP .           30  seconds of my time.

                25             DR. PAIIIL:  Dr. Janev@Tay.


                  7

                                                        would   sunport,   quite   frank-l@-,,
                     2  Peparation of          iDlanninq   function,    -particularly    t,-e

                     3
                        strategic PI-annina function, to use a managerial ter

                     4  is  implied  by  the  sur-,rLiarv  of  the   legislation   -   propose

                     5  legislation.
                                     I thin;,- that to have planning and control
                     6
                        I say operational control           the   implementation   mode    c-@
                     7
                        any kind of management function in           the   same   agencv   is co,,:r--,n=@
                     8
                        disaster   and,   Although,   I   would   aaree   with   you,   Tony, t.-at
                     9
                        there  ]-as  to   he   a   responsive   inter-rel-ationsl-4ip,   that

                     10
                        is so much to be -Tained by having the planning function
                        separate   from   the   implementation   function.   That,    I    %.:ould
                     12 certainly   be   prenared   to   support   a   resolution   of   this

                                                        T
                                     np,. YOIIz@.PCFF:       do you feel it ...,ould be
                     13
                        disaster.  Are %7ou thinl-.i-ncr    ';-)ac,@ to experience  bctl,7eei-
                     14
                        @l', P-and CLIP?
                     15
                                     DP,. J@A"7E7@ 7AY:   ',70. I am  thinking  in  terms  of  +--'@-e
                     16
                                                                                                    -is
                        -@.anageTlent  function   and   there   is   room   for   disagreement
                     17
                        but if you read @Inthonv'E                  Plannincr Control S,,,ste-s,
                     18
                        the Possibility       of the    planner-becoming    so    involveo.'in
                     19 plans that the implementation          L,,ecomes  impossible,   or   i-.at

                                               e
                     20 there  is   no   outsie,  regulation of it.       It puts too

                     21 power in one place.
                                     @TOT..7  there  are  aJmittccllv  some  ranaaers  -,@-ho
                     22
                        v7i-th that and   sal,, the  E,,lanning.control  oualit   to   he   in   e
                     23
                        same agency, If you set plahnina or isolate it you develop
                     24
                        think tanks that @l,on'@"-clrain any@,.here.
                     25              But, i4 vou put planning and         control in the same


                                                                               1 77

                            vou go to the opnosite extreme @,.,herp- you think h a
                 2
                   li@y creating an infinite nui-i,'@.)or of haystacks will give you
                 3
                   1 an infinite sun
                   j I              :)l,i of needles.
                 4              7. @n,,',ATZOT'F: It cuts   @@,,avs, '@-ut the for
                              lp
                 5 ltl.-e reason vou just cited, it seems to me that the providers
                   li@,-ould more likely be attracted to these I<inds of planning
                 6 1
                     agencies, and therefore,  the doing of reasonable planning.
                 7
                     If there were some - or more tangible operational components
                 8
                     that thev could be involved with.
                 9
                            I think one of the problems with C,-IP has been that

                10
                     the providers have found it unattractive because it was

                11
                     so abstract and so unrelated to subsequent tangible acco,-,.Plisl-,,
                12   ments and if there could be some uniting  of this operational    I
                13   arm and the planning arm, so that what the operational arm
                14   was doing didn't in fact th@--art the rational -plats of the
                15   region, then it would seem to me to make more sense.
                16             DR. JAI@El@TAY:  What I was trying tC indicate is
                     that I @%,ould hope that the planning function %,:ould not thwart
                17
                     the normal-operational arm.
                18
                               I-TR. O(',.DE,@',,:  I think that this, perhaps, could be.

                '19
                     corrected by having the development component also report
                20  to th             th planning and development acencv, which is
                21  assumed to exist under this piece of legislation.  It has
                   ii-to core into bein(7.  But the legislation just simoly doesn't
                22
                23   SIDell out sufficiently how that development is going to ta'j-,e
                     place, except for these very local agencies.  And, I would
                24
                     lilz-, to see draftcd into this piece- of legislation the
                25   provision that there be a separate health systems development


                                                                             17 8

                                     state health plannina development aqency
                2
                    structure.
                3
                             DI'. I',OP4AT',OFF:  But it would report to the state

                4
                  'health planning aaencv.  I ,,,,ould support that.
                5                O(,DEII: I don't see how it could do otherwise.
                6   I don't think it would report to a central body in Washington,
                7   D. C. It would have to be on a state level.
                8            DR.           I have been somewhat disturbed since
                    I have had the privilege and the opportunity to serve on
                9
                    this council, and in particularly in fact seeing the ministries
                10
                    fractured or other number of states or group, region - what
                11
                   Iever you want   try to plan a health program.  It seems to
                12 1me to be a rather difficult situation to put two or three
                   estates on the l,@lestern side or the Eastern side together to
                14  wed.them, in the @,,'Orth and South - to wed,them, in one

                15  program.
                16            I don't see how this is possible to develop any
                17  worthwhile health system care delivery, or whatever you want
                    to call it, unless you have it on a state-@,7ide basis and
                18
                    you have all the components of all the agencies that are involve
                19
                    in this kind of a system workinc, together.  Because if you

                20
                    are doing to put it in one community or another community$,
                21                                   it comes under one umbrella
                    or 15 different projects, unless
                22  they are going to be in difficulty.  I base this on what
                    little bit that I know about the ot)erati-on of the re iona
                23                                                       9
                    medical program, -and from the standpoint of a state-wide
                24
                    operation that something has come out of this.  But, If
                25


                                                                                     179

                 10
                      it gets dissolved -- and I haven't read this -- and if        I
                  2 1
                      read i@ I am quite sure I @..,ouldn't ]@no,..., %,:hat I %,.,as rea,@lina.
                  3                                       Iiird or     -fourth time
                      I may have to read   -,Lt @,ack the t
                  4   or ti-ie @Lifth time, and may not l,now what I %,@as reading.
                                    o,7n personal feeling is that I am probably      too
                  5
                  6   close to the  trees to see the forest., or the forest to       see
                      ,the trees.  or @..,hatever vou call  it.  Tores'L--trees,  trees-
                  7
                      forest.
                  8
                                  !TZ. OGDE.1,11:  @qoods.

                  9
                                 DR. Tll:-Iv.,U@-.1-OCK: I think that, as l@Ir. Ogden has
                  10  pointed out  and  someone  else,  that  people  don't  know  about
                  11  the aood that the -EZI,'P has done and I think it is pret y
                  12  hard to get across to people @.7hat P-"P is and I am sure
                      that there are a lot of -LDl-..vsicians that C,,o not understand
                  13

                                          ti
                          operation and  iie riDcranism of the         nro,-:ram. Some o--a
                  14
                      them feel that it has not been Worthwhile,       L-u4-
                  15   11                                                , I personally
                  16  foe! that it has been worth%.71iile and I think this resolution
                      here drawn un by 7'r.            I I..7ant to con(7Aratu'Late- him
                  17
                      for the foresight and    the merit and the courage and the
                  18
                      good common sense and    judament to draw this up and'I thin'r-@
                  '19 @-,,e need --o support this resolution and somehow or another

                  20  get it across.
                  21              JT!o-.", c@@-@ective it %,@ill !De as far as Congress is

                                   I @-o-.i'L- 1,@now.
                     I.Concernea
                  12
                                                                           n    rri  -Picati@n
                                      pi -I-Tl,: Is there further discus@io  or odi.L
                  23
                                                  I -v-oul,.l like to add some  languaae

                  24
                       that P.-Lai@-es it clear that this health svs,@-e-,tns development
                  25 1 actoncy will support demonstration healt'n services projects.


                                                                                  180

                                                                ices is written ir
                                I don't t.@'in!7 th
                                                 at health serv

                  2
                       am not sure it is c-,uite clear lilo,,.., this agency would be

                  3
                      different from the -Tanning aacncies that are    in the current
                  4   ,:, i              L-'                                             i
                      , 11, and secondly, I think we oucfht to state   that   this
                  5   separate agency would report to the state health planning
                  6   and development agency that . is described in the Bill.
                                DR. JAT.IEI-IAY: Would you read it to us?
                  7
                                                                  d  language7   I
                  8             DR. KO,.',IPROFF-.  Read the propose
                      haven't written it yet, but I will.
                  9
                                How would this be: "Resolved:  That the Congress
                  10
                      in adopting IT           similar legislat
                                      1620-@.'k or               ion give to each
                  11  state the statutory and  financial sur@port  to  maintain  a
                  12  separate health systems  development agency which suppor s
                  13  demonstration projec-Ls and health services.  This agency
                  14  would report to the state health plannini and development
                      agency, or similar independent       I am sorry    agency
                  15
                      and be devoted exclusively to sur--i,. ,,,crk.  '@nd be it-- further
                  16
                      resolved
                  17
                                 DR. IIIULT--IOCK:  Dr. Komaroff, I am sorrv, but you
                  18
                      are getting too wordy there. 1-ile are  going  to  get  lost
                  19
                      because I think the first sentence-@.;hat you say - the health
                  20                                     s 4-        basis --
                      sl,7steTis development agency on a  ate-i@7ide           and I
                  21  think health systems development agency is very comprehensive.@

                      TO  me it is.
                  22
                                 DR. HABER: !light I suggest Health system development
                  23
                  24  and'-demonstration agency.
                                 ',lip,. OGDEN: On a state-wide basis for  similar
                  25


                                                                                                                 18  1

              2
                                independent commissions in           a publicly accountable way

                         2
                                in reporting to the state health and development agency
                         3      and devoted    exclusively       to such work.

                                            DR    TIO"i@R(IFF:     All ri ht.
                         4                                                 9
                                            DR.   T,71@l@@"IOCK:  Iyield.
                         5
                                            DR.   PAITI,:   @lay   we have the      final wording before
                         6
                                we have the question?
                         7
                                            "iR.  OGDEF,,:   The way that           have     this      drafted

                         8
                                at the moment reads  "Resolved:  That the Congress in adopting
                         9      IIR 16204 or dnilarlegislation give to each state the statutor,,
                         0      and    financial    support    to    maintain    a     separate     health     systems
                         11     development and demonstration agency on a stato-wide
                         12     basis,  or similar independent             commission appointed in a
                                publicly accountable way,  reporting to the state hea t
                         13
                                a                 cl development agency and devoted exclusively
                  +INIA
                                to such   v,,ork,  and be it further,  Resolved:   That the
                         15
                                comments     preceding     this     resolution     and     the      resolution
                         16
                                itself be transmitted to the nembtrs of the House Interstate
                         17
                                and Foreign Commerce Committee and the Senate Labor

                         18
                                and    Public    @,.7elfare    Committee     for     their     consideration-.

                         19                  DR.  PAHL:   Thank you.
                         20                  DR. l-.7P@@l-',',IOCK:   Plr.  Ogden, for          clarification.
                                Accountable     way      and      reporting?
                         21
                                                    C(',DE@T:   I    am    sorry.    Appointed    in    a     publicly
                         22
                                accountable @qav.   That has to do with
                         23
                                                    T t',I:;V I ','I C, C K
                                              DR                   But   you    put    another    word    in    there.

                         24
                                               PIR. OGDEI,7:    1-7e inserted     the words  "re-porting to

                         25
                                the state health        and   planning agency."


             I- 3
                               This %.,as -ony's T)oint, that separate health

                 2
                     systems development has to report to somebody.  @-@'e are
                 3   going to have it report to  the state health planni-.a
                 4                           !,'couldn't that be under state, or not?

                                           T@7ell, I do
                                                      n't think-that this
                 5
                     damages the sense of that I am tryinrT to accomplish.
                 -6
                                    YLEI17:  l@'Ir. Chairman.
                 7
                               D-r\.. PAITI,:  Yes, 'Irs. Klein.
                 8
                                    KL@-I-  This reporting bothersme as to whether

                 9
                     j.-L. should be to the agenc,), or,as in Idaho, the planning

                 lo
                   lqrou,2s report to the Governor, who is responsible for admins-
                   itrai--ion of all programs.  T-,nd, that would keep it on the
                 12 Istate -- As-I understand it, the purpose of that insertion
                 13 lis to keep it on a state-wide basis, rather than re@orting
                     to any federal agency, for example. So, I would        i--O see
                 14
                     it made more general, rather than a specific title, !Decause
                 15
                                                                             4-
                     some states don't have that type of agency, or one ti-a@ is
                 16
                     titled that @.:ay.
                 17
                                              -.hey will have this Bill.

                 18
                                            Under this Bill  they       have to.
                 -19           DR.             -In the resolve, what do you mean
                 20  by, "in the comments pre ceding this resolution?"-
                                   OC@D@@l: This @@-as the letter from Senator
                 21

                     "agnuson.
                 22
                               D,?,. P7,-.7L: Ts', -.hnrc further discussion by Counsel?
                 23
                                             Cuettion.

                 24
                                   O(',DE.',:  T-'Iait just a moment.  On the riatler
                 25  of information.  Tonv and I have decided that this should be


                                                                             183

                     vii7crorti-nq to the state-@iide health coordinating council
                  2  -ilos@ are the people that have the 16 members.  T,,7e have

                     the wrong group to rcnort to.
                  4            Tqe are going to report to the state-i-7ide health

                  5  coordinating council.
                 @6            Is evcrvbodv terribly confused?  Can we vote on it?
                               DR. PA!,-'L:  l@iitli that change, namely, the state-i%,ide
                  7
                   ihedlth coordinating council.  With no further discussion, I
                  81
                     would ask the question - all in  avor ofthe resolution As
                  9
                     last amended, please say llaye.11
                  10           VOICES:  Aye.

                .11            DR. PAHL:  Onpbsed?

                  12           (,.To response.)

                                                   n      rr
                  13           DR. PAHL:  The rqotio  is ca  ied.
                                                 7@l m--@ - ownwimmaw
                  14           in closing, I would like to tl-iank Ilrs. Silsby
                     and the staff verv much for again going @hrough an unusually
                  15
                     difficult "Oeriod and specifically say that I am not quite
                  16
                  17 certain under what circumstances this council -- we may or
                     may not meet again.  !lb have not set a future meeting date.
                  18 I would, however, like to thank you individually and collective
                  19 as a council for your guidance and support throughout a
                  20 rather difficult period, and not this particular review
                  21 cycle.  Since we are uncertain what does face us, I want
                     -you to understand that terms of appointment continue until
                  22
                     such time as we inform you otherwise because of the passage
                  23
                     of legislation or other unforeseen circumstances.
                  24
                               But, I do look forward, as I know the Staff does

                  25
                     to working with vou again in some way as we enter  into


                                                                                  1 8 4

                     our neT.-i error.

                    2
                               Unless there are further comments, I then

                    3
                     adjourn this meetind.

                    4
                                Thank youi
                                (T           at 3:15 p.-                   s adjourned.),
                    5            @-7hereupon,           a., the mbeting wa

                    6

                    7

                    8

                    9

                    10

                    11

                    12

                    13

                    14

                    15

                    16

                    17

                    18

                    19

                    20

                    21

                    22

                    23

                    24

                    25