*LOOT







                             TRANSCRIPT OF                PROCEEDINGS


                              DZLVAR'IIL',PNT OF '.IEAUTA j,ZUCATION AND WELFAFX



                                  DI-VISION CF REGIONAL i'@ICAL PliOGrtMS



                                          AD HOC MIEW CO,%24ITTEE

















                                                              Fc,,ck-ville, "I',Iaryland
                                                              i,lay 24, 1974













                                    HOOVER REPORTING COMPANY, INC.
                                                  E)fflcial Reportcrs
                                                 Washington, D. C.
                                                    546-6666






   arc                         DEPARTMENT OF HDAtiTH, EDUCATIO%T AND WELFARE




                                  DIVISION  OF REGIONAL MEDICAL PROGRAMS


                                        AD HOC REVIEW  COMt4ITTEE






                                                      Conference Room   G-H
                                                      P. @ k-iiiw@. '-  -t
                                                       ar    n  ullding
                                                      5600 Fishers Lane
                                                      Rockville,   Maryland 20852

                                                      Friday,  Ma 24    1974
                                                                y

                               The meeting convened at 9:45 oleLock,   a.m.,

                    Dr. Herbert B. PahL. -Acting Director, Division of Regional

                    Medical Programs  presiding.

                    PRESENT:


                               Mr. Peterson, Chief, P&E

                               Dr. Winston  Miller,  Minneapolis,  Minnesota

                               Mrs. Jesse Salazar, Albuquerque,, New Mexico

                               Dr. Leonard  Scherliso  Baltimore,  Maryland

                               Mr. Joseph  de  LaPuente

                               Dr. Paul Teschan, Nashvilleo Tennessee

                               Sister Ann Josephine,  Notre  Dame,  Indiana

                               Mr. Kenneth Barrows, West  Des  Moineso  Iowa

                               Dr. Joseph Hess; Detroit, Michigan

                               Dr. -Albert Heustis,, Three Rivers,  Michigan




                              Dr. John Hirschboeck, Milwaukee, Wisconsin
                              Mr. Robert Toomey2 Gteenvilleo South Carolina
                              Dr. William Vaun, Long Branch, New Jersey
                              Mrs. Florence Wyckoff, Watsonville, California
                              Mrs.  Silsbee Acting Chief,, O&D

                              Mr. Chamblisso Acting Deputy Director
                                   Herbert Pahl, Acting Director, DRMP

                              Mr.  Francis Nash, Eastern Operations

                              Mr.  Richard Russell, Western Operations

                              Mr.  Michael Posta@ Mideontinent

                              Mr. lee  Van Winkle, South Central

                              And others






                                           C 0 N T E N T  S

                    Reports by:                                            @e

                              Mr. T4e Van Winkle
                              (South Central-)                              7

                              Mr. Michael Posta
                              (Mideontinent)

                           -.-.,,Mr, Richard Russell
                              (Western Operations)                        23

                                 -Fr -'- i'-
                                    ane s Nash
                              (Eastern Operations)                        25

                    Discussion re equity of treatment by  two
                    s ubc oraai t tee s                                   36

                                                                          41
                              Criteria


                              Oklahoma                                    43

                              Bi-State                                    45

                              Louisiana                                   47

                    Discussion re policy matters                          56

                    Recommendations to Council                            .60

                              Motion                                      6i


                              Recommendation amended                      71

                              Vote                                        77

                    Adjourned                                             8i






                                             P R 0 C E E D I N G S


                                 DR. PAHL:   I would like to call this session of the

                      meeting to order.

                                 There may be one or two of the committee still

                      getting a cup of coffee, but I understand some people had to

                      depart.  I believe we still have a reasonable amount of.acti-

                           before we can conclude the overall  meeting.  But  before  w(,,,,

                      go on further, I am sure all of you have probably noticed thal;

                      Mrs. Silsbee has been able to join us this morning, and I hop(-

                      that we don't have any more relapses which we had the other

                      day.

                                 Glad to have you back, Judy,

                                 I guess probably one of the   biggest disappointment

                      in her Life was to  miss  the  other  day.  We  will  be busy


                      briefing her as to what is going on.

                                 The purpose of this meeting really    is   to have one o,'

                      the panels inform the other what the actions      were.. very

                      briefly.  And  any  really  important  points  that  may be   pertinent

                      to that action, each  panel  has  had  certainly  a  few very  excit@-n

                      moments and some very difficult moments and I believe that

                      this information should be shared with the group as a whoLe.

                      because we are taking the full committee's recommendation

                      to the Council and also we hope to have  all  of  you  back  for  ttie

                      July review and you should all hear at this time what the

                      actions were.





                               It is difficult'to do this, as you   know  from  past

                     experience, because having not shared   In the full length

                     discussion aficl read the applications, you may feel that some oC

                     the actions are overly  harsh  from  what your  present  informa-

                     tion is. But that information may  be  outdated  by  18  months

                     or two years or so.  So what I woulcl like to urge  us  all  to

                     do Is not try to reopen all of the sessions which   we have

                     just,gone'through, but use this as an information   session.  Anil

                     I propose to do this in the following fashion, and thetis

                     to, firsts take Mr. Chambliss' group of applications and have

                     the two desk chiefs run down alphabetically the ones that

                     they were responsible for, and give you the highlight and any

                     point whbh they  feel  you  should  know.

                               Now, because we  are  still  on the confidentiality of

                     information and conflict of Interest, I   should say  that  when

                     your own conflict of interest region comes  up,  we  would  like

                     to have you out of the room,

                               These will be very short  presentations;  that  is,  a

                     few minutes on each. Because we have  53  and  we  are  heading

                    ,for getting out this morning.  So really don't wander down the

                     hall and Start that long distance telephone call. It will almost

                     be an in and out.

                               On the other hand, I believe that Perhaps one or two

                     points may require more than that few minutes) because there arE

                     some serious considerations that have come to my attention,, ani






                     I believe you will perhaps want more than just a sentence or

                     two.  So that. you will be better prepared to understand the

                     applications as they come before you in July.
                              The other matter is,.t least Dr. Tesc'han, maybe  some

                     others, have some points you would like to raise for group

                     consideration possibly formal recommendation for policy issues

                     for t,he Council and other matters. So as soon as we finish-

                     thisp we will be willing to entertain any kind of further

                     discussion on points to the staff or points to the Council

                     that you wish to make.

                              Now, if that is a satisfactory agenda, 1 am sure we

                     can proceed rather quickly, and I would like, first of all,, to

                     askvyhether that fits In with the way you feet we might best

                     convey a large volume of information over two days.

                              -ALL right, first I would like to ask, Bob,, let's

                     take yours f irst.

                              Do you have any general comment you want to make

                     for the group about the total set of applicat ions, and then  we

                     will go right into them?

                              MR. CHAMBLISS:  Yes. I might say as a  matter of

                     general information that panel A handled the applications  from

                     the South Central and Midcontinent areas.  We handled a total

                     f 28 applications and the total request  from those applica-
                     0

                     tions amounted to $65.5 million.

                              The overall actions recommended from this  panel,,





                    total $50 millions $50,273o9l3.

                              We are going to ask, then, for  the respective branch

                    chiefs of the South Central and Midcontinent Branches  to  give

                    just a brief summary of the individual actions taken by this

                    panel.

                            --,--Leeo will you proceed.

                              MR. VAN WINKLE:  I don't propose to get into the

                    specific rationale behind this-ancl how they arrived at these

                    decisions but basically I  am just going to give you  what  the

                    decision of the panel was.

                              On Alabama, they considered--

                              DR. PAHL: Give time for people to go In  and  out  of


                    the room,


                              MR VAN WINKLE:  There is no one from Alabama,

                              DR. PAHL:  Just in general.  Okay,

                              NR. VAN WINKLE: In Alabama,, they considered  this

                    to be an above average region and they recommended  funding  at

                    the level of $2,028,1389.

                              There were no specific recommendations other  than

                    that,

                              Florida, no one here from there either, is  there?

                              This was considered to be a superior region  and  was

                    recommended at a funding level of $2.7 millions

                              Georgia, another region that was considered to  be

                    superior, was recommended at a funding level of $3,,629,757.





                               On Georgiat they don't propose to come in in JQly

                     at all, This Is their total  request.

                               Illinois was considered to be an above-average region

                     was recommended for funding at $2,816,935.

                               Indiana was considered to be an average region, was

                     recommended for funding at $1,121,159.

                               Memphis was considered to  be an above average region,,

                     was recommended for funding at $2,600,000.

                               Michigan     I believe we have some people from

                     Michigan?

                               MR. CHAMBLISS. Yeso we do.

                               DR, HESS:.B-ut I have no conflict of interest.

                               DR. HEUSTIS:  I come from Michigan     I have no con-

                     flict of interest.  Do you want  me out?

                               DR. PAHL:  Please, if  you will,
                               (At this point, Drs. Hess and  Heustis withdrew

                         from  the room.)

                               MR. VAN WINKLE:  Michigan was considered to be an

                     average region, was recommended for funding at the level

                     of $2,5 million.'

                               DR. - PAHL: Let the record show Dr. Heustis and Dr.

                     Hess have both left the room.  Thank you.
                               (At this point, Drs. Hess and Heustis returned to

                         the  room.)

                               MR. VAN WINKLE:  Mississippi was considered to be a





                     superior region, was recommended for funding at the level of

                     $2.2 million.

                                North Carolina, considered to be a superior

                     region, recommended for  funding at the  level  of  $2,375,522.

                                NorthLancls

                                    this poin4 Dr.'Miller i4ithdrew from the room.)

                                MR. VAN WINKLE:  Dr. Miller has left the room.

                                Northlancls was considered to be a below average

                     region.  This largety'ha,d to do  with  staffing  difficulties.

                     Was recommended for funding at the level of $1.7 million,

                                (At this point, Dr. Miller returned  to  the  room.)

                                MR. VAN WINKLE: Ohio Valley  was  considered  to  be

                     an average region,  recommended for funding to the level of

                     $2o3O5o636.

                              ."South Carolina was considered to be   an average region,

                     was recommended for funding at the level of $2,2 million,

                                Tennessee Midsouth.


                                DR. PAHL:  Dr. Teschan.

                                (At this point, Dr. Teschan withdrew from the room.)

                                MR. VAN WINKLE:  Was considered to be an average

                     region,,kas recommended for funding at the level of

                     $2,133o972.

                                (At this point, Dr. Teschan returned to the room.)

                                MR, VAN WINKLE: Dr,  John  Hirschboeck  is  leaving.

                                (At this points Dr. Hirschboeck y,ithd.rev,,-from
                     the   room.)




                               MR. VAN WINKLE: Wisconsin was considered  to  be  an

                    average regions was recommended,for funding at  the  level  of

                    $2 million.

                              Now,, there was one common thread I think that   went
                    through all of these funding recommendations in terms    of some
                    reductions, is the fact that'irrespective  of  the  superiority
                    or excellence of the region, in many instances there was a

                    question whether the amount of work cut out  could  be  accom-
                    plished in the amount Left. I think that was probably one

                    common theme that went through that,

                              DR. SCH-ERLIS:  Sum total.

                              MR. VAN WINKLE:  $32o3ll,370.

                              That is all of these.

                              DR. PAHL:  Thank you very much, Lee.

                              Are there any comments or  discussions of these

                   applications?


                              Yes.

                              DR& SCHERLIS: This will come upo I am  sureo  as  we

                   discuss   other sections but looking at the target figure of
                   some 35-plus against the recommendation of $32,3 million,

                   does that mean-we will have at the most $3 million for the Jul@

                   request?

                              I know it will add up in the  different.groupso  but
                   is this the sort of calculation we will have to  make  in  terms

                   of what will be available in July?





                              DR. PHA L:  Ye s,, I w I I Igo into that at the end of

                    the full recitation here,

                              DR. SCH@RLIS:, Fine. Thank you,

                              MR. VAN WINKLE:  I -coulcl mention that the total May

                   -request that was being considered here came to $410159,,472..

                              .MR-S. WYCKOFF:  For this group?

                              MR. VAN WINKLE:  For this particular group,

                              DR. PAHL:  All right, thank youo Lee.

                              Mike, would you please take your group of regions.

                              NR. POSTA:  Just as a beginning, the 14 regions

                    from the Midcontineht Operations areas@ requested in their May
                    I application $24,436,527. Of this $24 million in request,
                   $17,,962,,843 was recommended for approval.

                              First region in this group Is Arkansas.

                            .DR.TESCHAN:  Would you get  a little closer to the

                   mike,


                              MR. POSTA:  Okay.

                              Arkansaso reviewers felt this region was an average

                   one.  They were concerned with the lc6s of Dr. Silverblatt,,

                   a top-notch coordinator; because of this they did not feel tha;
                   the full amount of $1,830,000 request should be approved.

                              As a result, their recommended figure was $1.5 mil-

                   lion.


                              Bi-state, St. Louis,, reviewers considered Bi-state ti)

                   be average to below average.  The request of $1,128,ooo.,





                                                                         J. r_


                    roughly, was cut to $800oooo.

                              This Is approximately $7LOO00 below the projected

                    12-month funding level,'

                              Poor leadership, particularly with reference to the

                    RAG involvement, was noted.  Theyhave never received triennial

                    ttabus  Their track record was considered below average.

                              Colorado-Wyoming?  Colorado-Wyoming was considered

                    above average to-superior.  Thetarget figure of $1.5 million

                    was recommended, which was about $280,000 less than was re-

                    quested.

                              Intermountain?  No problems.

                              This region was considered above average.  One

                    reviewer in individual grade sheets considered It superior.

                    They commented on the good staff.  However, the application was

                    most ambiguous,  The region was considered to be overly funded

                    by some of the reviewers, Including staff.

                              The panel recommended-that $2 million of the $3.85

                    lion request should.be approved and this compares to $3.6 mil-

                    lion target for this region.

                              Iowa.
                              (At this pointsmr. Barrows withdrew from the room.)'
                              MR. lOSTA:  Iowa is considered above average to

                    superior.  The request was approved in the total amount reques.-l-
                    eci of $1,061,349, which is about 80 percent of the target

                    figure.





                                (At this point, Mi; Barrows returned to  the  room.)

                                MR. POSTA:  @,nsas.  Kansas was considered average

                     to above  average, approved $i,633,380, which is $100@000

                     less than requested.

                                This region had requested about   78 percent of  the.

                     target  figure.

                                Louisiana?  This reglon.-was considered  be-low average.
                     This never has achieved triennial status, It has    always

                     come in for an annual  type of an application,.

                     Leadership is still in  question.  The coordinators   on a haLf-'r.-

                     time basis.  Howevero   the request of $985,?12 was approve  as
                     requested,, which is 77 percent of the targeted figure.

                               -Missouri.  This region was considered average region.

                     The reviewers felt that the region has improved significantly

                     over the last several years.   As many of you are aware, this,.

                     particular region put an awful lot of emphasislon computer

                     and hardware in the past.  They have completely gotten away

                     from this particular thrust and are getting into outreach

                     programming.  The MS needs and requests in thisparticular

                     application should be reexamined by the health service agency
                     staff.  The reviewers felt that the program staff was too high.

                         that the application was considered  to  be  too  ambitious.

                               The reviewers approved the targeted figure which was
                               3
                        2-9

                               Approximately $715,,OOO was trimmed  from  the  budget






                    request.

                              Nebraska? This renion has  never  ach@ecl  triennial

                    status and as many of you will recall, their funding  was  cut

                    back aft-er the divorce from South Dakota several years ago.

                              The reviewers felt that the Nebraska's  application wa.,

                    the best they have seen to dater They  note  considerable  im-

                    provement.  And recommended a new funding level.--@n-.the amount o.

                    $912)000, which, in essences was $50,,OOO below the  requested

                    amount@ but over the target figure.

                              DR. PAHL-.  Before we leavepmike, was that considered

                    an above average or superior?  General rating?

                              MR. POSTA:  I can't be sure.

                              DR. PAHL:  Okay.

                              MR. POSTA:  This region was reviewed by Mr. Thompson

                    and he commented on theapplication, but I don't  recall  seeing

                    his notes or his grade sheet.


                              New Mexico.

                              (At this point, Mrs.  Salazar  withdr.ew from the

                         room.)

                              MR. POSTA:  Considered an average region by the

                    reviewers, there was some concern about Dr. Gay,  their  excel-

                    Lent coordinator,, leaving. However, the panel felt  that  the

                    region was still in good hands with Dr, Walsh's takeover,

                              This region will not be coming in for July  I  funds.

                              The target figure of $1,644,754  was  approved  which




                   was approximately $I.L million under what was requested,

                              Two particular projects were noted.  The health edu-

                   cation for the public wasoonsiderbd overly ambitious as far as

                   Its funding request was' concerned, and it was suggested that

                   an out-of-state group visit this partic ular project, give an

                   unbiased report, submit  it back to the coordinator for possibl(

                   rebudoeting.to other areas.

                              Also the EMS@project-is considered to be well In exCES

                   of double  the amount of the current application.

                              Most of the cuts were In those two areas.

                              (A tthis point, Mrs. Salazar returned to the  room.)

                              MR, POSTA: North Dakota, this region  Is  considered

                   below average.  However, the reviewers noted that this has beer

                   the lowest funded region of the  53.

                             'The target figure of $582,517 was approved or recom-

                   mended for funding, which is about $180,000  less than was  re-

                   quested.

                              Oklahom. Oklahom was  considered  average  to  below

                   average region. It never has  achieved  triennial  status.  The
                   target figure of $1,062,237 was approved;  $320,000 was

                   trimmed from the request,

                              The reviewers felt that a new thrust in dealing with

                   hospitals through regional development area districts was a

                   significant improvement over the old thrust, which  dealt  with

                   continuing education programming.





                              South Dakota,  South Dakota was givenan outstanding

                    review.  The reviewers felt this region-r-as you recall earlier,

                    I had mentioned the divorce with Nebraska?  Both regions,

                    Nebraska and South Dakota, have definitely improved.  Maybe

                    the divorce was great.  Anyway it was given an outstanding

                    review.


                             The application was approved in  the amount requested

                    of $729,417, which is over the targeted figure.

                             The target figure in this particular region was
                    $57ltO95.

                             Texas.  This region took the longest of any in our

                    paneL,, well over an hour.  It was sort of a unique request.

                    They did request 98 percent of the targeted figure and had

                    stated in the application that they would not be coming In

                    with a July application assuming this particular application

                    was approved,

                             The application was for $2,333,53L.

                             The're@L.'-problem as the reviewr saw it was that

                    approximately $L.5,million of the request was in the form of

                    an open ended contract calling for five programmatic areaE! from

                    which requests for proposals would be submitted to the various

                    consumer and provider organizations within the state4  We

                    were apprised at the last minute that about 62 applications

                    had been received, responding to those requests for proposals,

                    In the amount of $6.2 million.  And the RAG had requested the




                   review committee to allow @hem approximately $1,4 million..
                   $1.6 million considering about $200,000 of the request was in

                   the form of a developmental component to give them approval

                   to check on June 28th at the RAG meetinoo and to submit to the

                   regional medical program form 15's which are your summary

                   sheets, form 16 your budget sheets. So  that they could begin

                   those contracts promptly and get a full L2 month project

                   period behind them.

                             Considerable debate took place and it was decided

                   that the review committee could not in all due conscience

                   approve an open ended application of this sort.  They wound up

                   by approving $1.1 million at this time which would take care

                   of the continuation activities and thefrogram staff, and had

                   recommended that this be brought to the attention of the CouncJl

                   that meets in June with the proviso that after the RAG reviews

                   their 62 or more contract proposals and submits the L5'sancl
                   16's intoDRMP by July 10th,, that this body, the Review CommittEe,,

                   would be able to review them so that funding could begin immedj-

                   ately after this next review body would meet.  So that they

                   would not have to ro again to the August review.

                             DR. PAHL:  Thank you very much, Mike.

                             Sister Ann.

                             SISTER JOSEPHINE:  I am sorry, I am so used to responc-

                   ing to Intermountain, I did not move to Indiana,

                            .(Laughter)




                              DR. P-AHL:  We are.glad to have you with us# Sister.
                              (Laughter)

                              Is there any general discussion on the applications

                    that Mikp- has gone over?

                              DR. HESS:  I would Just comment that listening to whgl

                    Little qualitative comments we had, that I would guess that, irl

                    generalo your group used the rating system a Little bit

                    more liberally than ours did.

                              It Is hard to tell, but I would just raise that

                    comment*  Maybe as you hear the other halfp you might keep

                    that in mind.

                              I think one of the important things we ought to do

                    now is to look at the matter of consistency of rating and con-

                    sistency of fLindino, decisions between the two subcommittees.

                             DR, PAHL:  Dr, Scherlis.

                             DR. SCHERLIS:  I think in all fairness to our group..
                    we want to be considered extralibera'l or noncredible., we have

                    never been accused of that,

                             Our group never reached decision as to average or

                    superior.

                             I was wondering how you all arrived at those,  I

                    thinkyou got a flavor from what we said,then decided we reaLI7

                    meant they were superior*  We did not as a group really say

                    these things.

                             MR. VAN WINKLE:  I took these off the rating.





                              DR. SCHERLIS:  Got it  off the review rating?

                              MR. VAN-WINKLE:  That's right, not as the groups

                              DR. SCHERLIS:  Final block.

                              DR. PAHL:  This represents staff,  analysis of the

                    rating group results.

                              DR. TESCIIAN:' The question concerning the Texas

                    discussion which I thought was extremely interesting,  I  note

                    from the sheet here th@ey- are triennial status.

                              I was wondering whether that set of provisos  for

                    review here of the 15's and 16's was in accord  with  triennial

                    management policy? I would gather that that  has  been  decided

                    lnthe first group, so it is just for information as to whe-

                    ther or not that essentially takes from a  triennial  approved

                    region decision up to this group?

                              It Is a policy question.

                              DR. PAHL: Yes. I think it had to do  with  the  mag-

                    nitude of the funding. I wasn't in on  the  entire  discussion.

                    Pe@haps somebody can elaborate. But'I think  the  problem  here

                    wasnot-- the question was not to remove flexibility from a

                    region,, but it was such a -- I don't remember the exact amount

                   but it was such a large amount that I gather the  panel  didn't

                    really feel that it could handle the decision making  with  the

                    informationthat was at hand.


                              Judy, do you have something to contribute?

                              MRS. SILSBEE: I have a  question.  I  was  wondering





                    if the same consideration had been given to the Georgia appli-

                    cation which was somewhat similar?


                              DR. PAHL:  Perhaps that can be answered here.

                              Lee, has the same consideration been given @to-,@the

                    Georgia application?

                              I&R. VAN WINKLE: We didn't have the same difficulties

                    with Georgia.  The Texas application did not have sites.  It

                    @d@id not have project directors. It did -riot @have budgets.

                    The Georgia application was full blown.

                              MRS. SILSBEE:  Except it is still under review which

                    is the only difference.

                              The principle is the same, Leeo in both those appli-

                    cations.

                              MR. VAN WINKLE:  It did not come out, Judy., in the

                    discussion,


                              DR. TESCHAN:  I would respond to that by sayl ng

                    your answer, Lee, is entirely satisfactory to me.

                              DR. PAHL:  Yeso Dr. Miller.

                              DR. MILLER:  It might be brought out again that we hgd

                    rather extensive discussions about this issue$ and in several

                    RMP's -- not Georgials as I recall either,  Maybe we didn't

                    pick it up - the principle of whether a region under the

                    present system would be allowed to have the equivalent of a

                    developmental funds slush fund, fund of money awarded to them

                    without us knowing what they were going to use It for exactly.





                                                                                L

                                I think although we didn't  ever  pass  a  motion to that

                     ef fect, there was general agreement in our group that we    could

                     not authorize a bloc of grant components in this review.


                     process,

                                We have trouble defining some   of these as  to whether

                     they were block grant components or not.  Some    of them  come

                     awf ul,ly. close in.- other ways.  But anyway this was  the  issue

                     that we grappled with  and Texas was  the  outstanding  and  the

                     most extreme example.

                                DR. PAH L: Perhaps Dr. Heustis.

                                DR. HEUSTIS:  I would ask Dr,  Miller  if  you  would

                     be willing to correct the record for his words and delete

                     that little -- few adjectives he used after the word
                     "developmental grant"'?  It bothers me.

                                @I wouldn't want to even say the word.

                                (Laughter)

                                DR* . MILLER:  Yes, I am happy to do that.

                                DR. PAHL: -All right, that constitutes the findings

                     of panel A.  I would like to ask Mr. Peterson if he would

                     care to Introduce, mke any general comments concerning panel B@

                     And then proceed along the same lines with the Individual

                     applications.

                                MR. PETERSON:  Panel B was transcontinental in scope

                     having looked at 25 regions handled by the Eastern and Western
                     Desks.  As  its  chairman  I  was-very  pleasantly  surprised,





                    perhaps not the word but by the serious  self-disciplined

                    way in which this groupoperated in the face of  the  same con-

                    straints that I am sure panel B was under except for lack of

                    information time, and what have you.

                              I think it will be clear as'you hear from Dick and

                    Frank, but the panel judgments and actions were more nearly

                    critical than otherwise.

                             We  did re-review our actions this morning on some

                    sort of overall comparative basis, but only in three cases

                    were some minor    10 percent changes made in the recommencla-

                    tions that previously had been taken by the panel in the two

                    prior days.

                             Since we are probably going to be  breaking  and

                    everybody is going to be running off, I would also like to

                    take this opportunity now, rather than trying,ti"seize it

                    later on, to say one other thing.  I think at a time when the

                    federal government and Public Service Is held in generally

                    lower esteem than it has for along,-long time,  The credibility

                    of this government and the public's faith in it would be far

                    greater if they could see the kinds of actions that are

                    taken by groups Like this to seb,:,the, submergec'part of the

                    iceburg,, not that tip that attracts the headlines. For that

                    reason I would like to say thanks to panel B and all of the

                    groups,, both personally and professionally,

                             DR. PAHL:  Thank you, Pete.





                              Dick, why don't we take your applications first?

                              MR. RUSSELL:  All right.

                              DR. PAHL:  And proceed along as we had before.

                              MR. RUSSELL:  I will go alphabetically.

                              Arizona  was considered a below average program;
                    funding  recommendation is $860,000, which is approximately

                    64 percent of its request.

                              The  reasons for this action, one is that the program

                    is not,in  conformance with the RMP grantee Regional Advisory

                    Group policy.

                              Two, the program is under an extreme influence,

                    perhaps"control-or a key representative of the grantee.

                              The third area is the questionable effectiveness

                    of the coordinator.

                              White  there are some indicationschanges are being

                    brought about in the prooram, this is attributed primarily

                    to the deputy of the program who has brought about some change,,;

                    however,, with the history of this program, the group came up

                    with this recommendation.


                              California.

                              (At this point, Mrs. Wyckoff withdrew from the room'.)

                              MR. RUSSELL:  Let the record show Mrs. Wyckoff

                    excused herself.

                              In the initial review which was yesterday, Califonir;t

                    was rated as an above-average-regiont and it was recommended




                    that It be funded in the amount requested, $8,L7Oo374.

                               MR. PETERSON:  Are you going to indicate--

                               MR. RUSSELL:  I am getting into the records Pete@

                    the grou.,o did reconsider the action in California this morning,

                    and inview of the rating and the needs of California, the

                    group decided to reduce the amount recommended for California

                    to $7,353,000, which was a 10 percent reduction in the amount

                    requested.


                               The third program is Hawaii

                               (At this point, Mrs. Wyckoff returned to the room.

                               MR. RUSSELL:     and Hawaii was considered an average

                    rating.  This Is primarily due to the recent change of coordina-

                    tors who has done a tremendous job in a reasonably short periol

                    of time.


                               It was recommended,, however, that Hawaii be funded

                    at $1.1-million.

                               Mountain States Regional Medical Program) which covert,

                    Idaho, Montana, Wyoming and Nebraska, was considered to be an

                    above average to superior region.  There was some concern

                    perhaps that the budget was inf lated.  And the panel recom-

                    mended a reduced level of $2,150,000.  And there was Indication

                    staff should get additional information on the budget which

                    we feel very  comfortable in doing.  I know we can get this

                    before Council.

                               The Oregon Regional-Medical Program was rated as   a




                   superior region* Recommendation was In the amount  requested

                   $11201;357.
                              The Wi3.shington-.Alaska program was rated as a superio
                                                    quested, $2pO77,311-
                    region with recommendation as re
                              And I believe that is all six of them.
                             ,.DR. SCHERLIS:  Do you have a total on that?
                              MR. RUSSELL:  No, I am sorry@ I do not.
                              DR. PAHL:  Frank@ would you please then take the
                    regions that you have and describe them briefly to use

                              MR. NASH:  All right.
                              Albany -- can you hear mep Pete?  Albany was viewed
                                                               mmended funding leve
                    as a superior region in  all respects; reco

                    was $Lo66,ooo.
                               Central New York was an average region; recommenda-

                     tion for fundinc, was $615,000.
                               Connecticut, below average to poor, funding  level

                     recommended @@510,000.
                               Greater Delaware VaLley, rated as above average
                     region, and recommended funding level was $2.3 million.
                               Lakes area was rated as below average  to  average
                     program; recommended funding level was $1 million.
                               That figure- was arrived at by taking the  current
                      level and deducting the cost in the application of all pro-
                      jects that had been funded for at Least three years, plus one-
                     half the cost of projects requesting two years sqpport,@which





                    they had several.

                              Maine, this was the superior region in all respects;

                    recommended funding level here was $1.7 million, $1,760,000.

                              DR. SCHERLIS:  Hold it.

                              MR. NASH-@'.'. Yes. Let the record show Dr. Scherlib


                    excused himself.

                              (At this point, Dr. Scherlis withdrew from the

                         room.)

                              DR. PAHL:  Frank,, that changed.

                              MR. NASH:  Yes.  This,, the recommendation by the

                    panel yesterday for Maine was $1.6 million.  This was reconsicl-

                    ered in our meeting this morning and final recommendation was

                    for $1,760,000, which Is about 90 percent of their targeted

                    figure, and this is the only application we expect to get froa

                    Maine.


                              Maryland, recommendation for Maryland was for termina.

                    tion of the program.  This was based primarily on the four

                    Items; one was lack of direction by the RegionaLAdvisory Group.

                    Two was inspective coordinator.  Three, disinterested or

                    self-serving grantee.  And four, end product of supported

                    activities in the past period would be useless.

                              I am sure you will want some discussion on that.
  c@ LI
                              DR. PAHL:  I think this is one of the points why we

                    did want to have the total group involved because this obviou.91,

                    Is a very serious recommendation.  And I certainly would





                     entertain any discussion by the committee even though a number

                     of you have not been involved in'the detaiLs,, but to raise any

                     questions of those who were involved In this  or  for  further

                     clarification before this recommendation is passed on as a

                     committee recommendation to the National Advisory Council.

                               ALL right, If not, Frank, will you proceed with the

                     other applications.

                               MR. MASH:  Metro, D.C., this  was considered  to  be

                     average to above average region.

                               (At this point Dr. Scherlis returned to the room.)

                               MR. NASH:  I think the panel noted improvement  in  thii

                     region over the past years.

                               Funding level recommended, $1.1 million.

                                                 anyone      -from Nassau-Suffolk'?
                               Nassau-Suffolk            here


                               ,Thiso the recommendation for this program  was  for

                     termination, and due to some problems with the  Regional  Advisor@

                     Groupp their lack of direction and leadership, the fact they

                     have had three coordinators within the past year or two, there

                     was great concern over the Leadership.  Capacity  of  the  present

                     coordinator, problems between RAG  and  grantee  organization,

                     again this was a recommendation for  termination.  They  may  want

                     to discuss this.


                               DR. HESS:  An important factor, there Is another

                     very Important factor too that was botnentioned; that iso the

                     Lack of a capable staff on board which to my mind  is  a  very






                    central concern.


                               MR. NASH:  Thank you.

                               DR. HESS:  The unlikelihood they can recruit capable

                    staff and  do anything in the time available.

                               DR. PAHL:  Thank you.

                               Mrs. Wyckoff.

                               MRS. WYCKOFF:  I would Like  to ask about both of thes(

                    that are recommended to be phased out.  I would like to ask

                    about both of these that are recommended to  be  phased  out.

                               Wouldyou say that the principal reason Lay  with  the

                    traumatic effect of the cutback on'their  programyor  was  it

                    due to something internal that couldn't be corrected regardless

                    of what happened?

                               DR. FAHt':  There are a number of people In the

                    room who I believe  might contribute to that.  But  Dr.  Heustis

                    .had his hand up first.

                               Does that pertain to responding to  Mrs.  Wyckoff?

                               DR. HEUSTIS: I think I can  do  this,  The  procedure

                    in these areas was of long standing and  failure  to  respond

                    over a considerable period of Years with diligent staff effort

                    and previous recommendations ofthe Advisory Council, this

                   vias taken careful considerate, deliberate way with  full  Qnder-

                    standing that staff and Council were reasonable  people  and  if

                    they accepted the recommendations they would make such arrange-

                    ments for an orderly termination of the program as in their





                    judgment was best.
                             DR. PAHL: Pardon me, before  we  proceed  further,  I
                    think the chair has erred in not asking Dr. Scherlis  to  remain
                    out of the room probably during this discussion,end I  have  a
                    feeling it may go on for just a few minutes.
                             Don't wander away too far, pleaseo Dr. Schertis.

                             Sorry, that was our error*
                              (At this point Dr, Scherlis withdrew from  the  room.)
                             MR. BARROWS:   Our arrival at this decision occurred
                    with great deal of anguish and  discussion.  We  were  influenced
                    by another very Important consider ation, the  upcoming  course
                    of planning. It was pretty well concluded that  the  new  pro-
                    gram., whatever it is.. would be better off to start from scratct
                    than to have this ineffective building block to work on.
                              DR. PAHL:  We certainly appreciate having that com-

                    ment.

                              I believe there are some others who may wish to
                    comment on this.  For examples Mrs. Silsbee or Mr. Nash and

                    others who have been involved.
                              Judy, would you care  to make any comments?
                              Does staff have any  comments to add to this discussl()r

                    at this point?

                              Mrs. Salazar.
                              MRS. SALAZAR:   I have a question Dr. Pahl.  What is
                    the timeframe  In which-these two rerylons are tobe  terminated?





                               What type of on-going funds and what amount would

                    they have  for. appropriate termination?

                               DR. PAHL: I can't answer  that  qLestion,  because

                    I haven't  been in on these discussions unfortunately.

                               Dr. Heustis.


                               DR. HEUSTIS:  The committee left  the  timeframe--

                    really, we thought it ought  to be done as soon as it could be

                    done in orderly fashion and  left the specific  timeframe  up

                    to staff and Council.

                               DR. PAHL:  Dr. Teschan.

                               DR. TESCHAN:  Yes, and we also  said probably  the

                    present budget would have sufficient funds to assure an

                    orderly phaseout and.if not,, the recommendation includes

                    language) as I recall It, to ask Council to  afford the region

                    sufficient funds for an orderly phaseout.

                               MR. PETERSON:  Yes,, the words early and orderly

                    are part of the recommendation without being specific in

                    terms of 30 days or 90 days.

                               DR. HEUSTIS:  We felt so strongly about this, we wante

                    to be careful and not water it clowniilth the full understanding

                    that we were dealing with reasonable people as far as the

                    staff and the Council were concernecio and they would take the

                    orderly process.

                               DR. PAHL:  Tharkyou.

                               Is thexefur.ther discussion on this application?





                                                                          A.

                                  ot,, Frank will return to the rest of the applica-
                              If n


                    tions,


                              MR. NASH:  Okay.

                               (,At this point, Dr. Scherlis returned to the room.)

                              MR. NASH:  New Jersey, this program was considered

                    to be superior in all aspects. The funding Level originally

                    recommended yesterday was for $2.9 million. Now, that brief'.-,,

                    meetinv this morningp the recommendation was changed# the

                    final recommendation being $3,190,000.

                              Ney York Metro, this was considered to be an average

                    proaram with funding recommendation of $2.5 million.  Also
                       4D

                    going with that is recommendation to Council that if dollars

                    areavailable, New York Metro be given a high priority to receiVE

                    additional funds.

                              -This was an application for over $7 million and about

                    half ofthe activities were proposed for two-year support.

                              Northern New England, this was considered to be an

                    average program; recommended they have a funding level of

                    $700,000.  And that the region be given advice to terminate

                    support of their data collecting activities there.

                              Puerto Rico was considered to be an above average

                    program, recommendation for their funding level was $695,862.

                              Rochester, Rochester was judged to be a superior

                    program with funding recommended of $3,061,471.

                              DR. HESS:  Explain that.  That is mainly for staff,




                    They have $1 million for projects coming in.. that accounts

                    for 'Low figure,

                               MR. NASH:  This.was  really all they asked for, this

                    particular application, because they  only  asked  for  staff

                    support and  continuation of ongoing activities.     Their July

                    application  will be considerably in excess of that.

                               Susquehana Valley seems to be a.lbelow-average region

                    As a matter  of fact, I believe the panel  had  some  serious

                    reservations  even as to the viability of this program.

                    Recommendation here was for $400,,000.

                               This primarily to support staff and very small amount

                    for  projects.

                               Tri-state,, this was considered to be a below average

                    to average retion.  The panel had many questions I believe

                    which we were unable to resolve.

                               The panel highly recommended a site visit be made to

                    this region prior to Council meeting.

                               The recommendation for fund'ing was $800,000.  And I am

                    assuming it was the Intent of the panel that should the site

                    visit get some of these other questions resolved then that

                    figure could be raised prior to  recommendation  of  Council.

                               Is that correct?

                               Virginia was considered to be an  average  region.

                    Funding level recommended was $1 million.  And with advice to

                    us that we express concern to the regions particularly over





                     their ability to fill the-many vacancies that they listed in

                     their program staff budget.

                               West Virginia was considered to be  a superior

                     program. The recommended fundina level was exactly what  they

                     requested in this first application, $663,132.  This is  basic.,l

                     ly a-program staff support plus two small projects.

                               The region will be coming in in July with a much

                     larger application.

                               Western PennsyLvania, this was considered to be an

                     average program. The recommended fuM ing  level  for  Western
                     P6nnsylvania was for $1.2 million, plus $170,285  to  support

                     the Mahoning Shenango HEC project in Ohio.

                               DR. PAHL: Is there any further question  or  clarifi.

                     cation on these?


                               Dr. Teschan.

                               DR. TESCHAN:  I would like to refer again to the

                     Arizona application and to ask If the reporter clarify -- as  I

                     recall, In our panel, Arizona was thecnly program which at  thE

                     time of the processing had not completed its  review  process

                     certifications and'I believe our recommendation  started  out

                     to be that there be no further allocation unless that process

                     were completed.

                               During the discussion, however, we found that  indee@

                     that project was well under way, that some of the influences
                     that would be inappropriate under the August 1972 policy  were,





                    as a matter of fact, being rectified.  And  the  question  I  have

                    is whether your notes and recollection  is  that  the  recommenda-

                    tion of panel B was some how contingent on the completion

                    after process that was already underway.

                               The question I am simply sort of raising is the issue

                    of approving funding for a region that  has  not  been  certified,

                               Do you recall that,_Dick.?  W,here.are we in that?

                               MR. RUSSELL:  I don't recall it  that  specifically.

                               I will ask Mrs. Sadin if she will comment on this

                    discussion yesterday.

                               MRS. SADIN:  No, I think what we said was their

                    RAG was going to meet  and at the next RAG meeting,  they  were

                    going to consider the  revision, already looked  at  the  revision

                    of bylaws.  They  needed 30 days before they consider this

                    would take place.   It has not taken place, but they said it

                    will,

                               DR. TESCHAN: I think it is almost a truism.  I

                    don't think there Is any Issue here particularly,, but I

                    gather it is understood or we should understand and make clear-

                    ly a matter of record that review  process  certification  will

                    be essential for Arizona before dollars  will  flow.  In  other

                   words, it seems to me that is a basic assumption under which th@

                    regions need to operate.

                               DR. PAHL:  That would be a recommendation to the


                    Council, then the Council condition on the grant award.





                              Underthe court order  staff may not,impose restric-

                   tions., but we may obviously-carry out any Council conditions or.

                   grant awards and this recommendation would be taken to the

                   Council,  That is my understanding*

                              DR. TESCHAN:  But the application, ins truction for

                   the current cycle says clearly all applicable policies will

                   continue to apply except those specific interdictions which

                   had been  specifically rescinded.

                              DR. PAHL:  That is correct.

                              DR. TESCHAN:  I have no evidence August 1972 policy


                   does not apply.

                              DR. PAHL:  Yes, Dr. Heustis.

                              DR. HEUSTIS:  I think it might be in order to clarif@

                   what we did this morning and to -iaake  perhaps panel A under-

                   stand the three rather modest changes that were made.

                              Staff over the evening took the material which we had

                   prepared yesterday and organized it with all of the superior

                   projects together and above average, thenfigured out some

                   percentages.  And so we tried to take a look at the numbers we

                   had come up with on,an Ibdividual basis yesterday and to see

                   whether in fact we had treated them In context with what we

                   thought the process and merit indicated.

                              That was the reason for the relatively minor changes

                   that were  made this morning.  I think it was a good device

                   and helped some of us to see things all in perspective.





                              DR. PAHL:  Thantc you very much.

                              Are there other comments from  anyone  concerning  the

                    activities or conclusions reached by either of the panels?

                              Dr. Hess.


                              DR. HESS: Yes, I would like to have  us  spend  a  few

                    moments  on what  I  @ould consider one of the major,items of

                    business for us to attend to this morni ng and that is the equit5

                    of treatment by these two subcommittees.

                              I am particularly concerned about those with  whom  we

                    have dealt harshly and on the other end of the  scale.  I  would

                    like to just raise one question about one region that  may  have

                    been treated by  panel  Amore generously than would have happen@d

                    had they beenieviewed by panel B.

                              Because'I think this is something we have to be

                    very much concerned about when we break down  into.putlic  sQb-

                    committees this way, that the decisions that come out  are  not


                    too much  afunction of which group reviewed a particular regioi.

                              Now, perhaps let's take them one at a time  and  let's

                    take the easiest first.  That is, I would like to raise a ques-

                    tion about intermountain and its level of funding,which, as

                    I understand, is $2 million. It was rated as  an  above  average

                    to superior region, according to my notes.  They apparently

                    are fundinco their annualized rate, close to $2 million, and

                    they were granted $2 million.

                              Wellit is $L.8 I guess.





                               Ardthey are going to be comeing in with -- let's see--

                               MR. POSTA:  Between @400,000 and $500,000.

                               DR. HESS: $500,000  --  for  another  half  million  in

                     July,  that will have to be dealt with.

                               This region does overlap to somedegree with Mountain

                     States and does it overlap with Colorado-Wyoming at all?

                               SISTER JOSEPHINE: Yes.


                               MR. POSTA:  Yes, sir,

                               DR. HESS:  Okay.

                               Is there some way of knowing on a    sort of FTE concep@

                     how many people this region'serves?

                               MR. POSTA:  I believe Lee has got the population


                     charts back here.

                               MISS RESNICK:    It is complicated as Dr.   Hess   sug-

                     geb.ts.

                              .@IR  POSTA:  That is six states involved,right?

                               MISS RESNICK:  We know it covers all of Utehand

                     a portion --  small portion of  Colorado,,a  portion  of  Montana

                     which is part of the Mountain States--

                               MRS. WYCKOFF:  Ancl  Washington-Alaska  has  also  some

                     turf problems.'

                               DR. HESS:  With Intermountain?

                               MR. CHAMBLISS:  Yes, they are also a part of it.

                               MISS RESNICK:  But since I am not t@e reviewer and a s

                     wasn't called on to support the population distribution, I am





                    a little hesitant to quote'anumber of  figures.  I  don't  know

                    what went into their programs as they developed  their  estimate

                    of need.  And how they got together.

                              I think there is a three-region committee  that  Looks

                    at it from that point of views isn't it, Mike?

                              MR. POSTA: Yes. For your information, in  panel  A,

                    what did come up was the turf problem that we have had for  a

                    number of years with the three regions concerned, and on  May

                    gtho the coordinators of all three regions got  together  along

                    with their RAG chairman and went over everything that they

                    have in the hopper at the prbsent time, what they are  funding,,

                    together with the May I request@ together with the  request  for

                    the use of the $6.9 million that was restricted, and went

                    through aLlof the applications to be assured that one  region

                    knew what the other one was doing, and got  their  endorsement.

                              They approved everything in the application  with  the

                    exception of ten activities, and those ten activities could

                    not be funded until this group got together againand they

                    have two definitely scheduled meetings a month from now,

                    the first one, before actually funding consideration  would  be

                    given to any of the approvals that would come forth  from  Coun-


                    CiL.


                              I don't exactly understand--

                              DR. HESS: Maybe it is not an answerable question.

                              MISS RESNICK:  I have some better figures on the




                     population.  We estimated last spring that the Intermountain

                     program roughly was responsible for $1.9 million.  That took
                     into account Utah, a portion of Wyoming, a small  portion  of

                     No vaci aa piece' of Idaho, and a piece of Montana.

                               It is very rough.  We have a map that kind of

                     overlays and so on,

                               DR. HESS:  All right.  That sounds fairly reasonable.
                     And I don't have any real question about that, a out, that re-
                     gion,  I am satisfied.

                              DR. SCHERLIS:  May I interrupt for a moment?
                               I am trying to discern the relevancy of that issue.
                     Are pu suggesting we should give dollars per population  that
                     would make our task very easy?
                              DR.HES9:  No, that should not be the only basis, but
                     1-think"we do have to look at the amount of money going into a
                     region in relationship to not only the population but the
                     quality of the program, needs to people, the other  resources
                     'they have towork with, And all these factors ought to  enter
                     into our judgments about what is appropriate.  And that we
                     should not take a narrow vision and look at the quality of
                     the program.alone  as the sole criterion upon which to base

                     judgment.

                              So I am satisfied-- And I know that we have been look-
                     Ing at quality andwe have got your rating and all that kind of
                   thing, but I do think that we have to not be unaware of the





                    number of people to be served and the kind of problems that

                    exist in the region.

                              MRS. SALAZAR:   Dr. Hessp would you speak to the poirt

                    then of, in my view, certain element of inconsistency in the

                    elimination of two regions this morning?

                              These regions have people in them and they are   still

                    in existence.

                              DR, SCHERLIS:  Shall I  leave the room again?

                              Will you stop that for  a moment?

                              DR. PAHL:  Off the record.
                              (DiscQssion off the record.)

                              DR. HESS:  Okay, I think my concerns at  the high

                    level are satisfied.  Now I am concerned about some of the

                    actions or recommendations that our group made in relationship

                    to some of the-- wells Ithink we need to share this a litt'le

                    more in depth.

                              Also I think I would raise a question as to whether

                    some of the regions that group A reviewed,, if in fact we as a

                    group as a whole are going to follow that and support the

                    recommendations of panel A, whether or not similar recommenda-

                    tions ought not be made for one or two regions reviewed by pan(I

                    A.

                              I got the A and B mixed up, but maybe you can follow

                    the sense of what I am saying.

                              Too, based on-your discussions the two that I thought





                   ought to be looked at again in light of this factor are

                   Louisiana and Bi-state.  And questionmark Oklahoma.

                             Now, I think the most efficient way  to  do  this  is

                   to Look at the criteria  which group B used for making the

                   recommendations and ask  group A how those  criteria  apply  to

                   those regions in question*

                                  reason I single those outo number ones the regions

                   are still on annual --,tatus which means there is a rather long'

                   history of not performing very  well or they would be on


                   triennialtatus.


                             And number two, they were--well, again, as I listened,

                   I wondered if maybe we as a group were a little bit more

                   strict in our application of the rating criteria than group A.

                   And so therefore the rating of average or below average may not

                   mean the same for the two groups.

                             So could we just review   now the basis for our recom-

                   mendations on the two  regions were,  one,  the  unsatisfactory

                   nature of the current. leadership  program  staff   leadership;


                   number  two
                                the Leadership of the RAG and feeling of weakness

                   at that level; thirdlyo the status of the grantee; and fourth,,

                   the role of the grantee -- fourthly the nature of the program

                   specific projects which were put forward as representing the
                                                                             CD

                   implementation of a program concept.

                             DR. PAHL:  Before we proceed, Dr. Teschan has a

                   comment and question.





                              DR. TESCHAN: I want simply  to  amplify  or  Illustrate

                   those four points didn't come out   of the air.  The  first  three

                   will.be recognized by I hope everybody here  as  almost  a  direct

                   quote from page one of the August L972 policy as to what are tt.B

                   essential ingredients of an RMP.

                              You have got to have a coordinator  who  is  capable,

                   You  have_got to have a RAG that functions.  You  have  to  have

                   a grantee that will stay in  its  fiscal  administrative  box.  And

                   to that, then, the committee appropriately, in my view, added

                   the outputs in terms of dollars in and what then happens is

                   in the region in terms of project as staff activity result.

                              So this wasn't an arbitrary set-- it is simply

                   citing   the ground rules on which all regions need to  be  judged.

                              MR. BARROWS:  Plus the  consideration the  new  program

                   would be'better off without having this to--

                              DR. PAHL: Dr. Scherlis, I  believe,  has  a  comment,

                   before  we respond to what those points were in these cases.

                              DR. SCHERLIS: I admire the fact you  have  set  up  what

                   appear to  be rather rigid criteria. I think  it  is  the  interp-

                   retation of these.criteria of the individual proejcts that

                   obviously you have to fall down and have to fail.

                              Because as we are speaking for the coordinators who

                   are resigning, seeking other positions,  who  have  found  other

                   positions, I think a great deal of our  response  to  these  appli-

                   cations admittedly is-bblsed on rather soft sand, as far as




                    trying to be as rigid as we might be a year or two ago.  We
                    don't have the potential ability of saying,  well,  we  will  let

                    them oet started and site visit them.
                             We don't have the potential threats  in  terms  of  the

                    careful supervision,

                             'We lack the central staff, on and on add on.
                             -And a great deal of the determinations  here,  regard-
                    less of what we can hope or assume we use these criteria,
                    really become more qualitative and less  quantitative,  I  think
                    that goes without saying, just as some of the criteria used

                    are rather ephemeral in terms of utilizing them.
                               Let me speak to Oklahoma.  I think this is one of the

                    three since I was a reviewer.
                               DR. PAHL:  Why don't you proceed with Oklahoma, since

                    you were the reviewer?
                               DR. SCHERLIS:  Yes. I site visited Oklahoma, and
                    this is  a program that has changed very significantly since the

                    time  that I site visited it.
                             The rating of average minus is probably taken from
                    my formal reView,@:that I handed in and this was based in great
                    measure upon my recollection of the area as it was when I
                    was last there and what I could deduce from the document.
                               Remember that none of us at this time have the bene-
                    fit of.the very carefully documented pink sheets we used to
                    have which I found to be  extraordinarily  good.  And  we  don't





                    'have the evaluation of all the preceding letters, site visit,


                    documentation and so on.

                              There is little question in my mind  that  Oklahoma

                    has moved from what was essentially a post-graduate training

                    program, educational parade, through the states Into what I

                    think now is a very exciting potential network for better

                    medical care through the area.

                              They have a new coordinator,  The program that he has

                    designed here I would view as being something that could fit

                    Into whatever survives whether it  Is  regional  medical  program

                    or regional planning council, or comprehensive bulk Programs,, :)i

                    what have you; these we networks which I think will  lead  to

                    better care in Oklahoma.

                              I don't reach this decision lightly.   It was pretty

                    well forced on me after a very vehement, active   discussion,

                    and I,  for one, support the recommendation that has been


                    made.


                              The grading of average minus was from  my  original

                    sheet. In terms of the discussion that took  place  heret  I  was

                    impressed with the fact that this group  has  changed  directions

                    significantly, what I will think will be  very  helpful  whatever

                    form planning takes and whatever form  actual  application  takes

                    in this region as far as whatever survival will be of RNII.

                              I could detail the document.   I would say this,

                    was most impressed with the change, I had viewed if Oklahoma




                    had come in this way two years ago, it would be by now one

                    of the better states.

                              It is very heavily provider  oriented, but I

                    think one year to go, this would be a  more fruitful way of

                    moving than in another@clirection.

                              DE. P.AHL:  Thank you very much, Dr. Scherlis

                              Is there further discussion  concerning  the  Oklahoma

                    application from staff'or other committee mer&ers?

                              Dr. Hesso I think that is responsive.

                              DR. HESS: I am asking is there  reason  for  Optimism.

                    I think that is ppttina, it in a nutshell.

                              DR. SCHERLIS:  It has changed markedly.

                              DR, HESS: The only question I  would  ask,  you  don't fLa


                    to elaborate--

                              DR. PAHL:  These are  Very valid points.  This is the

                    purpose for this session.  It  is in order.

                              DR. SCHERLIS:  I was asked at the meeting how I reacii-

                    &d the conclusion and I wished that I had had your points

                    score to use. I said It was a guts reaction in a great degree,

                    and I think all of us eventually have to come to that honest


                    admission.

                              DR. PAHL:  If there is nothing further in Oklahoma, E

                    believe one of the other regions that could  bear  some  discus-


                    sion was Bi-state.


                              I am not sure whether the reviewers  of  Bi-state  are





                     here or not.


                               MR. POSTA:  No.

                               DR. PAHL:  Then, Mike, could you be responsive
                     to Dr.Hess' points and perhaps just clarify a little bit
                     further some of the thinking that went on with Bi-state.
                              'MR. POSTA:  Well,, I think in my earlier summtions,,
                     it was as succinctly.put, they did come in with_an.,,applic.ation
                     of $L,l million, and they were cut back to $800,000, which
                     is not only well below the targetted figure, but about
                     $71,000 below the projected 12-month funding level for this
                     region. And that was,, in my opinion, a punitive action.
                              Now, whether that action was as punitive as panel B
                     would have taken would be up-for debate.
                              DR. HESS:  The question I would raise is,, you know,
                     to try-to bring some consistency into how we deal with regions*
                     Is there astaff and a RAG that can effectively use that
                     $700,ooo-$8oo,000 next year?  And,, you know, have something
                     worthwhile to come out of it that justifies that amount of

                     money and justifies continuing that RMP?

                             MR. POSTA:  Well, Doctor, I think the main concern
                     again is the past track record of this regic4 which has not

                     been too good.

                             Now,, we do have reason to believe that Dr. Felix
                     will be coming onboard to serve as coordinator.  And I am sure
                     that many of us in the'room know Dr. Felix.  He does have a




                     terrific track record himself*  And will be and has been in-

                     volved  to a degree in the application which     was drawn up.  And

                     some of  the activities that he has go   t certainly the-- I shoult
                     relate staff feels that $800,000 is not an excessive       figure,

                                DR. HESS: Your basis for optimism is Dr. Felix?

                                MR. POSTA: At this time, yes, sir.

                                DR. HESS:  Something will depend upon which to

                     @be,se optimism. That is all I am looking for really.

                                DR. PAHL:  IL there any further discussion or comment

                     'by anyone on Bi-state?

                                If not,, let's turn our attention to Louisiana.  And

                     again, I am not certain who the reviewer on the committee was.

                                Is there-any comment from the committee on Louisiana,

                     or perhap4 Mikep we can turn back to you*

                                Go aheadp Mike.

                                MR.POSTA:  Louisiana did come in with an application
                     of $8oo--$985,000, which was 77 percent of its targeted

                     figure,

                                This is a private corporation that is the grantee.

                     They do have a terrific track record as far as expenditure of

                     funds, They have had very little unexpended balances,

                                The indirect cost rates have been extremely hill in

                     this particular region. It has been well managed. They do have

                     a couple of outside consultants who have stayed with the program

                     since it was terminated.




                                                                          14 0


                              Staff and the reviewers felt that this region accepte@

                    the termination orders or the phaseout-orders  very  strictly,

                    And when they said close down, that is exactly what they

                    decided 'to do, is to close down.

                              However$ in the State of Louisianao they have to

                    notify the Secretary of State within six months.of termination

                    to carry out that termination or -liquidation.

                              In the meantime we got a continuation   order to

                    continue as a result staff did carry on. They did  hire  a  few

                    more people. They brought back their  deputy  direct-or.  How-

                    ever, at this time the staff is limited in  scope.  They  have

                    hired four additional peopLd@ Dr, Sabatiero  the  coordinator,,

                    is back on board, about 50 percent of the time.  I  can  truth-

                    fully say, in visiting the region two months ago with Mrs,

                    Z,i2lav8ky, that the chairman of the Regional Advisory Group

                    and the chairman of the evaluation committee of  this  particu-

                    lar progra mare exceptional people. And  their  Regional  Advi-

                    sory Group does function quite actively and does not fund pro-

                    grams unless they are.@ exceptionally well monitored from  the

                    start. That is, they do not fund just to  be  spending  federal

                    money,

                              DR. HESS:  I guess my question the main thing I

                    would ask is are they doing appropriate things for  people  in

                    the region and is there good leadership there?

                              In other words, are things looking-- is there a





                     basis for optimism for next year?

                                MR. POSTA:  That-is speculative, Doctor.

                                Based on 50 percent of the coordinator's time , based

                     on the fact this is a  corporation  that  would  be  phased  out

                     on tim with no expectation that this corporation will

                     continue as a grantee, the,same as many     of our  say  universi-

                     ties will continue to function,ancl will    be able  to  monitor

                     toward the end, I think all of    this was  considered  when the

                     overall comments or grading to    this  region  was  below  averagee

                                DR. PAHL:  Thank you,   Mike.

                                Sister Ann.

                                SISTER JOSEPHINE:  Your last comment kind of preempts

                     what I am going to ask,

                                Over the years I have heard us from    time  to  time

                     concerned  and particularly 'indirect costs and    direct costs

                     alsog when a university is the grantee agency,      And  in  terms

                     of utilization  'ofi@dollarb',to'pr6vicle,services  and  development

                     of programs it   has been the  experience  of  this  program  that

                     where the grantee  agency  was  other  than  the  university  we

                     got more dollars down in,services and in programs,

                                Your last comment  was  a  little  disturbing  to  me,  I

                     wonder are we going to reflect  on  that  experience  and  do  you

                     think reflecting on it, itis doing  to  probably  'appear  in  the

                     new guiclelnes for whatever this new  model  is  that  Is  going  to

                     be developed?




                                                                           50

                              DR. PAHL:  I think.I can answer for Mr. Posta and say-

                              MR. POSTA:  I had' hoped you would.

                              (Laughter)

                              DR. PAHL:     a number of us are hopeful that the

                    experiences will be translated into action as we go  into  this

                    new phase,

                              Mr. Rubel, who isn't here this morning, I think would

                    say that in his various task forces that he has set up internal

                    ly to try to plan something concerning the organizational

                    framework and direction and policies, he has :-,included a num-

                    ber of people -- for instance,Mr. Peterson Is In charge of one

                    of the subcommittees working with Mr, Rubel in  designation  of

                    possible health service areas. And we have RMP  people  on  all

                    of these little subcommittees.

                             Unfortunately beyond the agency level I  aa  not  cer-

                    tain how 'much of what we talk about will survive,, but there is

                    a very real intent to try to take the best from both the

                    CHI' and RMP and learn from it.

                             I think then is some reason for optimism in this, but

                    when one comes to a specific point, such as the one you are

                    referring to, I don't have any first-hand information, Maybe

                    someone in the room knows, but we are concerned with maximum

                    impact,, with available dollarsp and utilization of skills and

                    techniques that have been developed.

                             I think in many cases the Congress is going to be




                                                                            51

                    more alert to this than possibly sow of the elements in the

                    administration.


                               SISTER JOSEPHINE:  I think I am a little sensitive

                    o-n @this pointx maybe oversensitive.

                               But I:'remer&er a number of years ago we were just

                    doin g a little study on one of the OEO programs and it took

                    $60,000 to get $1,000 down to the people.  It is disturbing.

                               DR. PAHL:  Yes.  Yeg. We are having a meeting at th(.,

                    other end of thehall oil arthritis  center  program  and  yesterday

                    afternoon that same discussion came up as we look at the

                    available dollars and what can be done to have an impacts and

                    then see the cost-benefit.  So that there are many groups

                    that are recognizing we have to reconsider this and I do hope

                    we benefit from it.


                              Bob.

                              NR. CHA@LISS:  Yes.     I thin@ Sister, and there is

                    some indication that there will bebenefits from    past experiences

                    in that in the new legislative prof,)oi5als,, the operating 9,genCiES

                    are shown to be nonprofit corporations,  that  deals.I  think  spe-

                    cifical ly with the question that you were  raising  about  the  in-

                    direct cost.

                              There will be a new set of grantee types under the

                    new legislation, that is as it is now Proposed.

                              DR. PAHL: To return to the  business  at  hand,  I  would

                    like to ask if there is any further discussion on any of the




                                                                          52

                    findings recommendations) on the applications because if

                    not,' then the chair Wtll understand that the findings and recon

                    mendations which have been  made and discussed here are those


                    which are adopted by  the committee and will be passed on to th@

                    NationaL Advisory Council.

                              Mrs, Silsbee.'

                              MRS. SILSBEE.:  Dr. PahL, I would like to suggest

                    that the gist of.this discussion that has  taken place in  terms

                    of the bounce between 'the two, be sort of a preamble to the

                    Council,, which will have an opportunity to look at all of the

                    actions again,'that this might very well be kind of a caveat

                    that the committee gives to the Council in looking at the incli-


                    vidual actions.


                              DR. PAHL: Yes. I think as  is  customary,  staff  does

                    try to reflect as well a3 we understand what we hear for the

                    Council, so that they can act in an intelligent fashion  on  the

                    various recommendations. And we are sensitive  to  the  problems

                    that you labor under in two separate'groups,

                              We had no choice but we will try to reflect the

                    various interpretations and shades and interplay of feelings

                   .not only by the sheets but by all the record that is here In,

                    the staff in the room.  So I think you should be assured of th3,t

                              Dr, Miller.

                              DR. MILLER:  Could you give us an overall s     ry

                    picture of what we have done noiv?




                                                                            53


                               How much did we approve and--

                               DR. PAH L: I am de lighted to do that.

                               DR. MILLER:  How does it look in terms  of  the  July

                     process?

                               DR. PHL:  Yes, I am delighted to  do that.  Because br

                     coincidence, it makes calculation which I had  made back in

                     March appear very brilliant, when really it was just sheer

                     coincidence.

                               The total figure that apparently the tvo panels

                     have  approved with the various modifications this morning

                     comes out to be a'recommendation of '@'85,047,297 for June Coun-

                     cil awards. If Council goes along  with  all  committee  recom-

                     mendations,

                               This is from an anticipated amount available for bot-1

                     June and August awards of $114 Million -- letls just leave it

                     at $114 million, because you will recall  from  the  discussion

                     I had the other day, because of the unsettled state of the
                     litigation, we are still talking about between $109 million

                     and *LI4 million.

                               If, however, -vie-do have the $114 million  available

                     for support of RMP regular type programs, the recommendations'

                     $85 million asa result of this committee meeting would represeil

                     using 74-lt2 percent of the total available funds.

                               This is very encouraging.  Because back in March we

                     had to establish an allocation mode between the June and




                                                                               511

                     August Councils and we  had  arbitrarily  at  that  time  set  aside

                     75 percents precisely, for,June and 25 percent for August.

                     And at that time we didn't know-- we hadn't even issued the

                     instructions for regions to prepare applications.  And we also

                     didn't know within $30  million  how  much  would  be  available  to

                     use

                                So as I say@ It is sheer acc   iclent and not clue to  som@

                     Texas instrument   that was hidden away somewhere.

                                So basically you  have  approved  75  percent  of  probably

                     what would be the dollars available to us.

                                If the Litigation does award $5    million to the Depart-

                     ment for some of-its other purposes, which are certainly

                     directly connected  with  the  forthcoming  phase,  this  would  still

                     bring us within about 79 percent; your recommendations would

                     be about 79 percent of the total funds available.

                                So that come your  July  meeting  and  the  August  Council

                     we are right on target with  about  the  proper  ration  if  you  go

                     back to MY 75/25 percent.

                                Dr. Scherlis.


                                DR. SCHERLIS: . @,ny of these projects will st.@r

                     as of a certain date,  but  obviously  won't  reach  full  staff  or

                     full operation for a significant period of time after that.

                                What happens to those funds which are left either at

                     a local level or at a national  level  as  of  July  1975,  give  or

                     take whatever period of tine the extensions are?




                                                                          55

                              DR. PAHI,:  The only strict requirement which the

                    Administration has placed on this is that RMP's may not in-

                    cur obligations beyond June 30, 1975. -Thus contracts can't-@be

                    written beyond that length of tineand there comes a moni-

                    toring and surveillance issue at hand, which Is the same one

                    that an  program faceq@which we faced last year as prouram is
                           y

                    scheduled to terminate and how do you handle on-going   activitiE!.,

                              We are.'actively involved, as I think I mentioned  yes-

                    terday,, in trying to get the Administration to put forth what

                    a federal responsibility is.

                              I don't believe we have the exact answer, but in

                    general, over the coming months, all.'Of us who are involved in

                    headquarters operations truly believe that there will be

                    mechanisms developed and guidelines developed that  moneys  would

                    be able to be spent for the purposes Intended and ther(- will  be

                    continuation of monitoring and surveillance.

                              We certainly don't wish to see contracts  entered  into

                    and then June 30, L975, everything terminated again.  And we

                    are trying to plan since we have a whole year ahead,  the  answer

                    isn't here, but that is the clear intent and interest.

                              Now,, with the business of applications aside, I

                    believe,, I know Dr. Tesdhan has one or two points which he

                    would like to bring to the conunittee's attention and perhaps

                    there are other matters of business before we adjourn.

                              Mr. @,rrow s.




                                                                           56

                              MR. BARRO,,IS: I just wanted to take one  moment  to

                    say on behalf of my fellow reviewers how much we admire    the

                    strength and dedication t hat.staff has exhibited during this

                    extremely trying time.

                              You have got.a great bunch of  people  here,  compe-

                    tent   They are straight arrows and whom you can believe.

                    We hope you can keep your team together.

                              (Applause)

                              DR. P.AHL:  Well, on behalf of the staffp it is a  plea-

                    sure to hear it,  I already know it, but I do thank you very


                    much.

                              There is nothing we can do without the staff that we

                    have. They have been extremely  loyal  under  circumstances  which

                    you recognize as difficult and which indeed has been the case.

                    So thank you very much.

                              That is one of the rewards for being one of the

                    faceless,nameless bureaucrats, able to accept that  on  behalf  of

                    the  staff.

                              Dr. Teschano would you like to bring up the points wti@

                    you mentioned to me before the meeting for committee discussior?

                              DR. TESCHAN:  Sure.

                              Ken Barrows has just preempted point one.

                              I look at Ken for having said it the way  it  needed  tc


                    be said.


                              The matters that I think we might consider  as  a  grouf




                                                                           57

                    are som recommendations   to Council, generally three.  One,

                    we have already dealt with I  thinks and might go without sayin),,

                    but I hope that Dick and others who were preparing these  thing:,,

                    might also focus again  on the point that we do need  to  reiter-

                    ate that we would recommend strono,,Iy to Council the whole  facts

                    In the matter of those policies that your RIUIT has used throu-@t

                    the years and I refer specifically to the  August  30th  issuance

                    of Council for 1972, that they be very sure that as a matter

                    of fact each region is@in compliance with that policy before

                    funds are allocated. That is to say,  that  that  can  accommodate

                    a firm contingency.

                              I think that is not only correct from everything

                    I have said, but it is also a fairness and human -- Its'

                    essential intrinsic Integrity in the program be maintained

                    so that all of the regions are  dealt with thesame way.

                              I am very sensitive to Dr. Hess' concerns on that

                    and I think we did a good job.  I was satisfied and learned a

                    lot in Listening to how we dealt with that particular issue.

                              This is raised much in that same viewpoint,

                              Nowo the other two things I happened  to  have  written

                    out I am going  to leave copies with Herb here in just  a  minute

                    and they are issues that also came up in our discussions in bond

                    panels undoubtedly but I want to put the following little

                    comnient; that is, while I am sensitive and meet at every hand

                    in all of the discussions I have the kind of  thing  Dr.  Scherli3






                    pointed out we just seem to have this year lefto Lord knows

                    the coordinators have been fac-ed with that in their regions

                    and in discussions with one with  the other.  But the critical


                    issue is I think we have to look  at the context of the era


                    In which we live and not simply be caught in what appears to

                    be the near-term progr4mmic potential or efforts.

                              We are bold on every side that RMP Is going to finisi

                    so our job-here is to give I't a decent burial and to utiLize

                  i funds as well as we can, and allow slippages because Lord

                    knows there are slippages.


                              I would take the -other view that we are. not dealinc7


                    with the next year,  We are dealingin history up to this

                    timef and we are dealing with many years to come in which this

                    particular year is one of several turning points,

                              I don't think th@ is a one turning point; I think it

                    Is one of several turning points.  Therefore, I feel if we

                    are going to conduct our business responsively, we need to

                    conduct it with a clear recognition that what we do now and the

                    Integrity with which we do it must necessarily influence to an

                    unknown, but to som degree what happens hereafter.

                              So that when we have considered some of the regions

                    and when we sounded a little bit pedantic, perhaps, in citino,

                    the August 1972 policy, that you have got to have these ele-

                    ments and there has to be regional support within the region

                    and a good imaoe in a region for a region to warrant continual o
                                  C>




                                                                            59

                     et cetera.  We have done that with the notion that I  f the

                     RMP in a region is going to be useful for something hereafter,

                     then it needs to have that quality of image or quality of

                     function in a re@ion that is going to be worth something to

                     build around as the follow-on versions following RMP, et

                     cetera.

                               It is terribly important.that the issues and profes-
                     sionalism @nd quality which are so clear In  the  superior  region

                     application particularly, be the hallmark in contrast  to  all  th

                     other alternatives of which there are plenty.

                               So it is reL> Ily on that basis that I feel the

                     Council now has a particularly vital turn In the  road,  a  fork

                     in the road to confront. Either the Council can  take  w@  t  to

                     me seems to be a defeatist attitude in saying, well, we are

                     only here to occupy space and to while away the  hours,  or  the

                     Council can contribute in some small measure to tidying up the

                     situation. And in strengthening the  regions  for  the  transition

                     period.

                               Therefore, it is with that in mind that there are

                     two statements in perhaps somewhat-- wells there  are  two  state-

                     ments that in my view this group might consider for recom-

                     niendation to the Council for a formal policy statement  to  the

                     region.  In other words,, it is not just a recommendation  to  the

                     Council, but recommendation Council take these  and  issue  them

                     as guidance policy to. the regions in the country for their




                                                                              60

                     implementation and guidance,,  it  is a two-step operation..

                               First of these has   to do with getting ready for the

                     next phase.  -And a statement which says that might.read some-

                     thing like this:

                                "In view of legislative developments now underway fox

                          further evolution of RMP, in association with the CHP and

                          HILL-Burton programs, in the interests of national health

                          planning, Council  'encourages RMP's to  develop or-aniza--

                          tional readiness,  structural changes,   and any remaining

                          regional relationships which'ar-e appropriate to lead,

                          participate in and accommodate the anticipated new opera-

                          ting structures  and  requirements.  The  purpose  of  this

                          orientation is to preserve for the new formats within

                          the states and regions the   capabilities and voluntary

                          cooperative  relationships  which  the-RMP  experience  has

                          created."

                               That sounds a little   platitude  an  altruistic,  but

                    I think if we have organizational structural arrangements in

                    a regions that  defeats  the  region's  capabilities  in  getting

                    readyo being an appropriate participant in the new development,

                    that those  organizational changes should be made.
                                   C>

                               The second recommendation for Council policy and the

                    request to HEA, as I understand, might read Like this -- and

                    it has really to do with CHP's -- it might read like this:

                               '@lhiLe recognizing legislative mandate and DRMP




                                                                          6

                         regulations regarding Rle-CHP relationships, Council

                         requests that the national CHP Leadership  transmit  to

                         areaiilde CHP (b) agencies nationally the mandate for

                         fully reciprocal relationships with  RMP'S,  especially

                         in calling upon RMP assistance for professional and

                         technical input into ongoing CHP plans development;

                         and in the interests of fairness and  full  reciprocity

                         Council furthermore agrees and instructs ad hoc RMP

                         review committee and staff to set aside any  influence  of

                         negative CHP comments upon an RMP application  unless  the

                         commenting CHP(B) agency has provided the RMP with,,  one,

                         the criteria and a description of the (b)  agency  review-

                                                                    e (b) agency
                         and-cornment process, and two, a List of th

                         objectives and priorities upon which at least a part of
                         the RMP response should be focused,"

                              DR. PAHL:  -ALL right, thank you*

                              DR. TESCHAN:  I would like to move the acceptance of

                    these, or for any purpose.

                              DR. PAHL:  Thank you.

                              Perhaps the committee would like to discuss the

                    first of these in order, or have the first one reread.
                                                             7
                              What is the committee's     I am sorry in a  sense

                    that so many of our members had to depart, because  I  think

                    these issues are Important ones@ and I am also sorry Mr. Rubel

                    is not here for the closing session, because I believe that he




                                                                          62

                    would have been quite impressed to see the kind  of  activities

                    and discussions that have ensued over this  period.  And  also,

                    of course, with this theme which is something which we are

                    all,concerned with, the reciprocity of action.

                              But beyond that, what is your desire in this matter?

                              Ifoub you care to discuss these?

                              Dr. Scherlis, you look like you  are about to make  a

                    comment.

                              DR. SCHERLIS@: Sort of digesting what you said.

                              I agree completely with every word you said and woul..

                    be pleased to second.

                              My big concern is really what effect this would have

                              As all the people at this table have, I have been on

                    site visits  where you have contact with various (b) agencies

                    and (a)  agencies and I must confess that in terms  of  profes-

                    sionalism and  in term of objectives and goals, I  have  to  say

                    one can point  to rare instances, at least in the space that

                    I have been  able to visit@ where (b)'agencies or  (a)  agencies

                    have been relatively effective.

                              My big concern is really what will happen to  all  of

                    the workvihich RMP has accomplished?

                              I remember when RIvIP's first started) trying to

                    describe what,regional proper-7-venture-was.. These words  were

                    meaningless to me. I ',think in terms of  their  effectiveness,

                    the various projects that wecarried out only speak to  a  small




                                                                          63

                    part of the accomplishment.

                              I strono-ly support both statements.  I just question

                    what will happen to them.

                              Perhaps you can alert us to what  you view as the

                    probability as to what will emerge from CHP and RMP and

                    HILL-Burton at this time,


                              I am more impressed with both  the planning and  pro-

                    fessionalism and the discernment of need  by RMP as  compared

                    to the (b) agencies and (a) agencies even those communities

                    where they are supposedly relatively affected.

                              I think there is an obvious need for  these  groups

                    working together.

                              This Is a problem not only of logistics, but  day  to

                    day political strategy and this is where I have a real concern

                              I am more impressed with the  relatively  objectivity

                    of RMP's as compared to the relative lack of  objectivity  of

                    (a) and (b) agencies.

                              The sorts of letters that you read and request after

                    request from the regions in terms of the review process of (b)

                    agencies and (a) agencies we like that.  But  we  don't  like

                    this one, We like that one; that one is  just  great.  And  you

                    come -away with you just don't know what the basis for the

                    evaluations are and this is where I would strongly support bot'i

                    of your statements.

                              I would just -hope that they would do more than  just




                                                                           64

                    go to the Courcil.   I v!oulcl hope that whoever sets policy,

                    whoever that might beo whate ver dark room, that  somewhere  this

                    would glimmer in and possibly shed some light on  what  could  be


                    a very complicated process,

                              DR. PAHL:  Well, without responding completely

                    to your question, because a-ain I don't think that  I  can  speak

                    from a nonbiased point of view, I do believe  that.from  our  ob-

                    serve,tion of what it is we do in RMP, relative to what I  see

                    happening In CHP'S, I  'must say that as the program  director

                    here, I subscribe to  everything you have just said.

                              We are trying to work more  closely  in  headquarters

                    relationship. We have been interested in  trying  to,  as  you

                    know, strengthen the CHP individual  agencies,  planning  pro-

                    cesses.  I honestly don't know 6ut of my personal experience of

                    one-program that has actually tried to do  more  to  cooperate

                    with and support another program than RMP has through the years,

                    the comprehensive health planning effort,

                              And it is only recently that the headquarters staff


                    have been interactinc,- and that is as a result of this  fune-


                    tional reorganization that is going on.

                              I think the statement Is a very  good  statement.  I

                    would be pleased to give it maximum impact  within  the  agency

                    because I know there are many individuals who  feel  the  same

                    as you have expressed that there is an imbalance  here  in  the

                    way this is being discussed, looked at.  Ana to the extent tha;





                                                                           U:)


                    the Council would like to  adopt  this  as  a  recommendation,,

                    whether they would or not this is what we are trying to do

                    as staff.  But I think it could have some greater force if

                    it were a Council recoruwndation.

                              Perhaps I shouldn't say anything about the first one

                    since we haven't discussed that point.

                              So from staff point of view,, we would not be adverse

                    by any means to @aKing, such a reconnendat'i on to Coutici 1,  and

                    I believe a recommendation by them to the Administrator and he,@-

                    quarters staff, and perhaps higher  throuch  the  Department
                                                              C)

                    could, again, bring to the attention of peo  pLe the feeling and

                    sense not only of this group, but  of  the  entire  organization

                   @tiat is connected with the P14P program.

                              This has been said over and over   again.  This is ano@-

                    ther way of saying it. But it Is a good L--ime to  say  this

                    because it is important.  And I believe that it could have soya@)

                    impact and it should be said, because I think what is being

                    stated is true.  So ,nany times the RtIP's have tried to assist

                    and get the advice of the Local agencies and in fact    have

                    found that there is very little relative to the kind of streng-il,

                       and there are many 7ood reasons for this,  It is not demean-

                    ing the CHP (b) agencies by any means; there  are  a  good  many

                    reasons. But all of this should go  toward  providing  a  better

                    f ut ure f or a I I of us.

                               I thinkvie are looking to the future, not  trying  to




                                                                                  66

                      investigate what happened in the past,

                                 DR. SCHERLIS:  Point of'information.  -As you made
                      the motion, where did you wish this to be transmitted to

                      Council c;r to Council and to appropriate agencies?

                                 DR. PAHL:  It can be both.

                                 DR. SCIIERLIS:  It can be both?

                                 DR. TESCHAN:    I felt the first   step, formal Council

                      recommendation, that'then becomes instruction to staff to get

                      the message at the staff level here.  But I am more concerned--
                      well, equally concerned at this point that the regions have
                      strong Council backing and I recall clearly,when Council made
                      a statement, I don't think Council ever understood how

                      impressive that was to coordinators, regional advisory groups,

                      et  cetera,.
                                 This Council pronouncement of encouragement, et cete2-a

                      more or  less I expect from region to region, but generally had
                      a lot to do with how we shaped our sort of concept of how we

                      should be conducting business.

                                 So while intangible, I feel it has a terrifically

                      important potential impact and particularly now.
                                 So a strong move to Council, and If Council then
                      says it, it becomes encumbent on staff as executors to some
                      extent, on Council advice, that that would carry forward in

                      the further deliberations,

                                 DR. PAII L:  I presume this recommendation would be a




                                                                          67

                    recommendation by Council to the Assistant Secretary of

                    Health, because obviously our Council has no responsibility

                    over comprehensive health planning but through  the  Assistant

                    Secretary of Health.  A'nd there could be coordination of efforts

                    within the bureaucracy.:

                              Sister-Ann.

                              SISTER JOSEPHINE:  Yeso I too would like to support

                    this type of activity.  tind,, you @,@iow.,'I:n reflecting back  on

                    the program and in reflecting on something that came  to me

                    in a note from one of the members here, you  know.* the

                    Regional Medical Prouram has had something of a Year of Camelot;

                    you know, we return to Camelot.  And the knights retCirned

                    and the armies of the Middle East shing up     (laughter) --

                    but, you know, it is so gratifying to me to see we still dream

                    dreams and that the Innovative program, you know, still has


                    that spark.

                              I believe that we cantsay a thing too often, because

                    one day someone might just listen and hear it is what  we  are

                    saying.

                              I would think it is very important that  gets  wide-


                    circulation.


                              DR. PAHL:  Mrs. Wyckoff.

                              NRS. WYCKOFF:  I agree wholeheartedly with that

                    s tat e@,ne n t .


                              I hope something can be done so this conversation and




                                                                              68


                     this resolution we have will be passed along in such a

                     way@that it will not be lost    through the decentralization

                     process that seems to be contemplated.

                                I was very sad  to hear you all act as though you

                     were goino- to be gone  :very sood.
                                CD

                                DR. PAH L:  Not everyone, just--

                                ICS. WYCKOFF,:  It just means HEW regionalization,

                                             I
                     which is very different from our R14P re'giotialization.

                                I hope that'something can be put  in  the  mill  so  that

                     this will not be lost In the   dreadful shock of pulling the

                     center magic apart.

                                DR. PAHL:  I hope so.

                                I don't think this is the point, to get into that.

                     But itlis  quite possible that  under new legislation, be that

                     enactment  of extension  Legislation  for  the  individual  programs

                     or health  resources planninr-, legislation, unless there is quit3

                     a different environment  I  suspect  the  Department  will  probably

                     make the determination that this program should be clecentral-

                     ized in the regional offices and our    staff-fully understand

                     this. And this would mean basically very few individLats

                     would actually go to  regional  offices@  because  they  would  find

                     satisfying work locally which most  of  them  would  prefer  to  do,

                     so that would mean positions would go to regional offices.

                     Our staff would be reduced in members by that amo    unt and

                     functions would be shifted to regional office and the




                                                                          69

                    character of the program I would have Lo say I think would

                    probably suffer in the initial stages at least, because there

                    would be many new faces handling RMP responsibilities in the

                    regional offices.

                              IM. WYC KOFF   Will decisions be made at the region-

                    al level for many of these things we are now making?

                              DR. PAHL:  Yes, that is what, is contemplated.

                              @IRS. WYCKOFF:  That is the th'ing,

                              DR. PAHL:  We will have National Advisory Counc@ll,,

                    that will come back.

                              MRS. WYCKOFF:  If that is kept in the legislation.

                              DR. PAHL:  There are so many lf8.  But the armo'ur

                    is not completely rusty

                              Dr  Hess.

                              DR. HESS:  I fully support these two recommendations

                    in principle and would just like to suggest a possibility
                    of an amendment to each of them. The first one, as I thought
                    about that, I wondered if I were an RMP coordinator, how

                    would I respond to such a general directive when you don't

                    know what it is you should be shaping up for or moving toward.
                              And so the amendment would be that if Council apa-o'v@E
                    this, that it be part of Council and/or staff responsibility t)
                    keep the regions informed so that they will know, you know,
                    be in receipt of advice as to how best to prepare for this kin(I

                    of transition.




                                                                             70

                                No,vi . I know that is very hard to do and the time

                     and the nature of the advice  would be very  important  to  not

                     keep things in a turmoil on the  basis  of  changing  signals,

                     But,nevertheLess, just'to  say that without any further

                     guidanceas to what that means may not be as helpful as we woulJ

                     like to have it be.


                                So that if you can get the sense of that really

                     further specification  of that--

                                DR. P.AHL:.  appreciate that.

                                Actually I have a problem with perhaps   two words in

                     here, which I think bear directly on your point.

                                If I may read the statement again,  Paul,  and  then

                     Show what my concern is, because this is a   concexn  that  is

                     shared,by many of us in,headquarters  in  order  to  try  o  e

                     most helpful to the groups we are serving.


                                The statement reads:

                                III n view of legislative  developments  now  underway

                          for further evolution of RMP,  in  association  with  the


                          CHP and Ilill-Burton pro-rams, in the Interests of national

                          health planning Council encourages RMP's to develop

                          organizational readiness

                                And here is where I would like to delete "structural


                     changes,

                              and any remaining  regional  relationships  which  are

                          appropriate to lead, participate in and accommodate the

                          ,anticipated new operatinr, structures and  requirements.




                                                                                 7 L

                           The purpose of this orientation is to preserve for the

                           new formats within the states and regions the capabilities

                           and voluntary cooperative relationships which the Rle


                           experience has created.

                                 The reason that I personally, although we will       take

                      your recommendation to, what it is  you  wish  to  say  to  Council,

                      but the reason-I have problems with having the Council encoura,,,rE

                      the rerions to develop structural change,--, at  this  point  is  be-

                      cause that Is one of  the  primary  uncertainties  and  is  still  th

                      subject of debate.

                                 Organizational  readiness  capability,  closer   cementin@

                      of relationships in the  regions  is  all  to  the  good.  But  both

                      CHP leadership and we and  Dr.  Margolis  and  Dr.  Endicott  in  our

                      various capacities know, both privately in the      office   and-pub-

                      lady, have urged groups not to jump the gun into what-they

                      presume to be the proper organizational structure.

                                 So I have  a feelinT in reading these words about

                      organizational structural changes, this would encourage some

                      people to move perhaps faster than would be for their own

                      good,

                                 In terms of keeping regions  informed,  I  think  we  all

                      again, in  our separate  capacities,  and  with  what  knowledge  we
                                                                                    CD

                      have, are  trying to do this.  Some groups are moving ahead.

                                 For example, there has been a change of grantee in

                      Northern New England just recently,  but  it  is  not  as  a  result




                                                                         72

                    of the last few months' thinking.  They have been doing this

                    now  or a couple o  years and thinking about it.

                              It has had a lot of thought.

                              Others are trying to anticipate the exact outcom

                    of the legislation and are trying to be there when it happens,

                    and both Mr. Rubel and I and, as I say, our administrative

                    superiors indeed are cautious people against undue haste.

                    That@was my,only concerti, Paul, with your statement.  But I

                    don't want to impose my concern on what may be the committee's

                    wish to transmit.


                             .So I would like to have that point of view further

                    explored, if you will.

                             DR  TESCHAN:  I would like certainly to respond to

                    that.

                             Sometimes I think this kind of discussion, or at

                    least issue we are now talkintT about, is a liattle bit, oh, a

                    little -- It is distinctly unsubstantial.  It is ethereal.

                             First of all, practicalities are nobody is really

                    going to go to a lot of trouble in any RMP to make large

                    chanres into something they know not what.

                             There are., after all, some pretty practical figures

                    and they have a limited amount of staff time for such busy work.

                             Moreover,, I also think it is important for us to rem(@m

                    ber that instructions or encouragement or guidance coming down

                    from Council and staff.is also paralleled by a good deal of




                                                                           73

                    Information transfer between regions  through  the  coordinator

                    organizations in HS-1.  Moreover$ all the coordinators are

                    perfectly capable of reading the legislation and reading

                            --ts on the committee hearings, et cetera, and  so  are
                    the repoi

                    members of the P,-AG and some of them do.

                              So there are several routes.  I  6on't  think  either

                    having it the way It is or not having i-t the way it is is real-

                    ly going to-have any enormous Impact.

                              I sympathize with this and If you feel more com-

                    fortable and if the Counci I would then be able to be saved,

                    all kinds of minutes of backing and filling on such an unsub-

                    stantia.1 point, I would be perfectly happy with the notion for

                    making preparations for or sort of getting oriented toward,

                    rather,than to actually put on paper and get signe(l@ in some

                    crucial way a specific thing we know not what  at  the  present

                    time.

                              Critical issue, it is  almost code, it is hard for me

                    to say what needed to be said.

                              DR. PAHL:  Excellent  statemen4 really is.

                              DR. TESCHAN:  But what is meant by structural changes

                    specifically is the notion there are structures In some of the

                    regionso either the way staff-is put together or  the  way  RAG

                    is built, or the way the relationships  actually  work  between

                    them, or who the grantee is or how that whole business works,

                    under the August  1972 policy, which effectively for many of




                                                                              7zi

                     the prime movers of health affairs in states and regions vitia-c-

                     the'significance and possible impacts of RMII.

                                If RMP and @G finds that is the case, that particu-

                     lar corner of that statement was to open the possibility       that

                     if there are serious      if any part of that is a serious     ball

                    aid chain to the image and function of an rdIP in!i" a.region@ this

                     would be a good time to get that out and to get -it settled and

                     to move on its own merits, quite aside from what the fut,ure

                     might be.

                                DR. P-AHL:  Sure.

                               ..DR. TESCHAN:  It Is to encourage those changes,
                     tidy up.the  ship,  plug the leaks, get the thing ready for sea.

                     Because we are going to be  in  highe4  heavier  water  for  awhile

                     than we are right now.

                                'So I think we really ought to  get  underway  with  it.

                                DR. PAHL:  To be specific--

                                DR. SCHERLIS:  Ile would like to have his statement


                     launched,  I gather.

                                (Laughter)

                                DR. PAHL:  To be specific,, we have had a spate of

                     inquiries  in going into not-for-profit grante6 structures,

                     That is alL we have been tryino, to pull the bit of brake on for

                     their good as well as for what we believe to be sensible

                     reasons, but certainly not internal rearrangements, and the

                     kind of .structural changes you are talking about.




                                                                          75

                              DR. SCIIERLIS:  You would not be 9,dverse to removing

                    those administrative covers -- what are you talking  about?


                    What kind of structural


                              DR. PAHL:  We are heav ity involved with it,  more

                    people are involved.


                              It is their insistent demand we are here to serve.

                              DR. TESCHAN: My feeling on that, if In the region

                    thereis serious problem with a structural situation --

                              DR. PAHL:  Specific.

                              DR. TESCHAN:  -- let us,say, for example, a nonprofi;

                    corporation mode would be better for very good  independent

                    region reasons, then let's go now for a nonprofit-- for

                    its intrinsic merits in the region, not for something down the


                    road.


                              DR. PAHL:  That we are doing.  I think we have a sen3E

                    and I think it is a very excellent statement.

                              DR. TESCHAN:  We can take those words out if that


                    part of it is understood.

                              DR. PAHL:  Is there further discussion?


                              Dr. Hess.


                              DR. HESS:  Yes.  On the second statement, again I wa3

                    looking at the practical application of that, and if your

                    intent was that that would be applied in this next upcoming

                    two reviews,, that being the case, I don't know that there

                    would be information to be able to apply that criterion  to




                                                                         76

                    knowvhether or not each (b).agency had submitted its criteria

                    and priorities, and so on,-to the RMP'S. I don't see  how  that

                    is implementable durin(7 the next-- these immediate two

                    reviews @.n the next month or so.


                              DR. TESCHAN:  I don't think that should bother our

                    deliberations.  I think it is the resolve of our group and if

                    Council backs it, which is really the question, then I think

                    we can deal with CHP comments on somewhat more official grounds

                    within the RMP review process than we felt really comfortable Lr


                    doing up to now.

                              I have been concerned, but reassured by the last  two

                    days.  I was.concerned when I came here that we would be worry-

                    Ing.  We would be unduly influenced by insubstantial grounds fDi

                    negative comments from CHP.  We have not been so.

                              What this will do as I see it, the purpose is  really

                    not to Influence us so much if we already agreed to it, but

                    I would hope it would strengthen Herb's hands and that of

                    his staf  in conducting their business with  heir coun er-

                    parts in these new ad hoc subcommittees. And will  also  influ-

                    ence the regions in how they deal in the future, regions at th,s

                    point, seeing'the ascendancy of CHP, may be increasingly en-

                    dowed as to how to seek    I think this puts it on a simple

                    professional basis.

                              DR. HESS:  lly only concern is for these immediate

                    applications.






                               DE. TESCMN:  Wouldn't worry about it.

                               DR. HESS:     it-seems,to  me a little bit too tight

                    to apply.

                               MR. BARRCK@IS:  Without respect to the recommendations

                    the fact of the matter is our panels panel B, concluded that

                    all we can do would be to examine the RMP   s share in this re la -


                    tionship.

                               DR. PAHL:  Surely.

                               MR. BARRGIS:  They had done what they were supposed

                    to do.  We had no way of measuring the other-- I think that

                    Is a factor in the recommendation to the Council involved.


                               DR. PAHL:  Yes.  This picture certainly will be

                    presented  to them, so that they can view this In its proper

                    perspective.

                               DR. HEUSTIS:  I would like to call for question on

                    the motion, as editorially amended, without having you read it

                    again,

                               DR. PAHL.  Without reading, all those in favor of th(@

                    two motions, the first one as amended, please signify by

                    saying .11 aye,

                               DR. -PAHL: Opposed?

                               (No response.)

                               DR. PAHL:  Motion is carried andreconunendations will


                    be transmitted to Council.


                               DR. SCHERLIS:  May I state it be carried unanimously,




                                                                           78

                    just for matter of ree(@)rdi

                               DR. PAHL:  C,,trrieci unanimously,

                               You might be Interested in hearing the  arthritis  groll

                    status report.

                               I am happy to report they probably feel if  they  were

                    panel C, they have the@ tougher problem.  They are working

                    very hard. Dr, Roger l@son from Nebraska  is  serving  as  chair-
                    man of that Igroup.  Welhave a very fine ad hoc group with  43

                    applications requesting I believe it is$16 million with  $4.2  m.'.

                    lion earmarked for the support of these  pilot  arthritis  centers,

                               The group yesterday spent the better part of the  day

                    discussing -- this is a brand  new  conceptnot  only  program,

                    for us           1 new concept as to what are the elements whic-1
                            but branc

                    should,be in a center and how to give various weighting to

                    these elements.

                               (Discussion off the record.)

                               DR. PAHL: The arthritis panel  is  struggling  with
                                                                           CD

                    $16 million in requests, with $4 million  available  and  they

                    spent the better part of yesterday trying to develop the

                    element and Important features of centers.  And they scanned

                    throu.@h the applications in a descriptive fashion., one by  one,

                    and about last night the time that you broke up  I  believe  they

                    did also and came back to work at eight o'clock  this  morning  anc

                    are working today, possibly tonight, and possibly into tomorroi

                    morning.  Because they feel it is also important not just to




                                                                          79

                    spend ,)LI.2 million as you feel It is not just to distribute

                    funds, impounded funds, but to get something more out of
                                                                CD

                    this,, to get more than the s= of the parts.

                              I am very pleased to say they are very much aware of

                    it, and therefore I have a, request to make of our own staff to

                    stay around this afternoon and do their post-committee work

                    in the offices, because some of the people that you have seen
                                          I
                    departing in the-last 'half hour or so here are being requested

                    to go Into that room and tell that ad hoc Arthritis Committee

                    the capabilities of the region for managing what is a special

                    arthritis program.

                              So we are not trying to divorce this activity out of

                    the RMP activity.

                              I told Dr. 14ason we couldn't be holdinom the Arthriti
                    Committee a6 a better time for having a full su rvey of 53

                    regions with as much Information as we can accommodate right

                    now*


                              So I thought you would like that status report and

                    somhow those difficult decisions will be made.

                             Before closing, I would like to reiterate Mr. Barrow

                    comments from my own point of view, and I know from Bob's point

                    of view on our own staff efforts.

                             We have been carrying two activities of arthritis an([

                    R14P applications simultaneously.  You do recognize, because

                    you have been with us for a much longer period of times the




                                                                          80

                     kind of work and quality of work that has come out and you

                     have cluly acknowledged tha.t for-whici-i I am very appreciative.

                              The Arthritis Committee prior to the end of yes-

                     terday @,lso expressed itsappreciation for the quality of the

                     staff work, done by a group who I had never seen, who had

                     never seen arthritis application, had to read textbooks,

                     listen to experts,, do homework, and do staff work for that

                     committee.


                             .I think my very real personal impression ts I come

                     away from thes e two and three days of meetings is that I have

                     never been associated with a program that has risen really

                     to the need that they have, and done so in such a high qualit@

                     fashion.

                              Many of them have been holding two jobs over the mort

                     of May in older to get these materials for you, and so IT

                     personally thank them.  I know both Bob and Mr. Peterson,

                     chairing the other panel, do, and it is very nice to record tha

                     and I am sure the Council will appreciate all of the work.

                              But In addition to that,, I would also like to thank

                     you. It has been a very difficult job on your part to have

                     been away from the many changes that have taken place and then

                     to come back and with the kind of short time and the extremely

                     heavy work-load, to do the kind of decision making that you hava,

                              I think this morning's session has been  particularly

                     gratifying to me to be able to discuss some of these points,




                                                                         8i

                   and Issues, because -vie do feel a real respotisibi II ty not

                   for winding down a program, but for moving into the new phase

                   and maintaining the strength and improving it where we can*

                             So again we thank you very much and we will look

                   forward to seeing, hopefully, all of you in July, and wish you

                   well on your return trips.

                             @eting is adjourned.

                             Thank you,.

                             (Whereupon, at 12:00 o'clock, ribon, the meeting

                       was adjourned.