Transcript of Proceedings


                              DEPARTMENT OF HEALTH9 EDUCATIONG AND WELFARE
























                                                            ACE -FEDERAL REPORTERS, INC.
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                                                                      415 Second Street, N.E.                               Telephone:
                                                                     Washington, D. C. 20002                        (Code 202) 547-6222

                                                                   NATIONWIDE COVERAGE






  CIAS
  @'-8132
                           DEPART@iril..'T Or IIEALTII, EDUCATION, AND WELI,'AP,-E

               2         HEALTII SER17ICES & I.iEl,4TAL IIEALTli AD@-IINISTRATION


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               6 RT@GIONAL lirDICAL PRO(-,PA@l SERVICE

               7 IZL-l@7IET,-l CO@lt-IITTEE

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              10                                Conference Room G-11
                                                Parklav7n Build, ng
                                                5600 Fishers Lane
                                                Rockville, "Iaryland
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                                                Tliursdav, 18 Januarv 1973
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                             Conference on the  above-entitled matter was

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                 reconvened at 8:30 a.pi., DR. ALEXANDER SCII@IIDT., University of
              15
                 Illinois, College of Pledicine, Chicago, Illinois, presiding
              16
                 Chairman.

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                                               C  0 N T E N   T S


                 2  Presentation hit:                                                     Page

                 3  MR. ROBERT E. TOO'L-'IEY - IIITEP@R-IOUIZTAIN                             3
                         ..Greenville Hospital System
                 4          Greenville, South Carolina

                 5  DR.  GLADYS Al@CPUl-I - MARYLAND                                         5G
                            Comprehensive Health Care System
                 6          Seattle', Washington

                 7  DR. IIILLIAI-I TIIIJPJ.IAN - NEW YORK IIETPO                             95
                            University of - Virc
                                                 .Tinia @ledical  Center
                 8          Charlottesville, Virginia

                 9  DR. JOSEPII IIESS - TENNESSEE I.IID-SOUTII                            114
                            Wayne State University
                10          Detroit,, I-licliigan

                11  DR. ALEXANDER    SCII@IIDT    ARIZONA
                12                     LOOD - SARP @,CO'IIIENDATION REPORT                162
                    MRS. IIARIA E.   r
                                               Alabaiiia, Illinois. Nortlilands
                13          Regional Piedical Program of Texas
                            El Paso,   Texas
                14
                    DR. EFFIE 0. ELLIS - SARP RFCO.@,11.IENDATION REPORT                  166
                15                            Arkansas, Iowa, Ohio Valley
                            Art'ierican -I-'-.e(lical Association
                16          Chicago, Illinois
                17  @IISS A"LIZABETII I,. KERR - SARP RECO@lfIEDIDATION RE-PORT           168
                                                   Florida, New Jersey, Tri-State
                18          University of Iowa
                            Iowa City, Iowa
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                                      P R.0 C E E D  I 14 C, S
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                2              DR. SCHMIDT:    If we can take our  seats,  I  think

                3  we should begin.
                4              Dr. Hess and Dr.   Kralewslzi are probably  still  in
                5  the cab.' There are  a couple  of  little  housekeeping  details
                6  we can take care of before we  get  on  into  our  agenda.  Let's
                7  see.  Where  is  Mr. Toomey?  Is he here?
                8              VOICE:   He was here earlier.
                9              VOICE:   Lot of peo le were  on  the  stairs-up  and
                                                   p

               I 0 down.
                               DR.  SCIIMIDT:  We-thought the order of the morning

                   would be Interrqountain, 1-taryland,, New York Metro,, Tennessee
               1 2
               13  Mid-South and Arizona, putting Intermountain    first.  It's

                   the one that has some visuals.
               1 4
                              .1 remind you of the-rating sheets    that  we  should
               15
               16  be filling out, the-big sheets.  And# lastly,    it's been.brought
                   to the attention of staff that  some  of  the  Review  Committee
               17
                   members really don't want their book sent to them, this book.
               18
               1 9 So, we'll ask that those  o f you who do want the book, the
                   Review Committee book sent to  you,to  leave  a  piece-of  paper
               20
               21  on top with your name and say, "Send book," and-those who
                   don't want it, put a piece of paper  out  and  say,  "Don't  send
               2 2
                   it.11  Because we discovered that at least one Review Committee
               23
                   member would got it and thro@,i'it a@@iav and it's a lot of  work
               24
  ,ce- eal Reporteis, Inc. for the postmen and the staff to pack it up  and  so  on  if  it
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                                                                                 4


                  isn't being used.

                2               So we will begin with  Intermountain  in  a  moment.

               @3
                                You know that  the  Surgeon  General-has  determined

                4 that gum chewing is detrimental to health.  It gives you

                5 cancer of the teeth.

                6               (Laughter.)

                7               DR. TI]I]RtIAN: I might point  out  that's  a  defense

                8 mechanism    as   you light your cigarette.

                9               (Laughter.)

               10               MR. TOOTAEY:  The first thing, we  have flip charts

               11 and  I have several transparencies.

               12               The Intermountain WIP encompasses, as far as

               13 population is concerned, a total of 1,850,000 people.  It
               14 overlaps with two other %@lPs:  Colorado, Wyoming, and Mountain

               15 States.

               16               The population of Utah is 60 percent urban, 20

               17 percent rural.    The four @lountain States, 59 and 41.
               18               The American Iiidiin population is only one   percent

               19 in Utah  and  two ocrcent in the  I-lountain States and the numbers,

               20 the percentage  of blacks in the area is very small.

               21               I think the next slide is a

               22               VOICE:  Could we have the lights, please.
               23               MR. TOO,?,IEY:  This slide is designed to show the

                                                  1
               24 original       area which oxtendc- d all the Cray  across  Nevada,

  ce -ef"l Repoiters,  Inc.
               25 pass Reno and into Montanat Idaho, I-lyoming
                                                                  Colorado, as well







                                                                                5


                  as Utah.

                               The CIIP agencies are not just the dots  but  they
               2
                  are the dots'with the lines around  them. There  is  a  CIIP
               3
                  agency here, here and here.  There  are developing  CIIP agencies
               4
               5  in other places but there are none  other than  over  into  the

                  Colorado area.
               6
                               No%.i,, very interestingly, the Intermountain RMP
               7
                  had its own turf problem because oil its  overlap  with  the

                  Colorado, Wyoming RMPs and  the Mountain States RMP.
               9
                               The.turf'problem, in fact, was resolved qeoqraphica 1
               10
                  by  redefining                'is now rep
               11              .1 the area and tli         resents the area
               12 1covered by Intermountain IITIP which really carved a  good  bit
                  of the Nevada and Idaho section out of the Intermountain IU-T
               13

                  and some of the Colorado.
               14
                               But I think the administrative decisions are the
               15
               16 ones that are interesting  because  the  three  coordinators
               17 met together, they discussed their problems,, the problems
                  of the overlap, the problems  that had arisen  in  terms  of
               18
               19 programs that had been established in the area and who should
                  sponsor the programs.
               20
                               They decided that they would create an organiz  ation
               21
                  which would  be made up of the three coordinators three staff
               22
                  members from each of their @?IP agencies and three board members
               23

                  or three RAG members.
               24
  ce -Federal Reporteis, lrc.  The RAC, members %.iould T,,eet only %.,,hen the meeting
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                                                                             6

                 was in the -- Well, let me back up and say,  they  agreed  to

               2 meet in every other month and in the area of each  of  the

               3 RIIP s
               4              So one meeting would be in the Colorado,  Wyoming
               5 RNIP and the other one in the Intermountain, and another  one
               6 in the Mountain States and they would be  in  sequence  every

               7 two months.
               8              When they met, the RAG member from that particular

               9 RMP area would attend the meeting.
              10              in addition to creating this organization --  and
              11 incidentally, the votes, the,only voting members viere the
              121three coordinators -- but in addition to the organization
                 that they developed themselves, made up  basically  of  seven
              1 3
              14 people who would meet to resolve whatever problems had arisen,
              15 each of the coordinators was a member of the RAG,  ex  officio

                 member of the RAG of the other two areas.
              1 6
              17              At the time they met, if there were  problems
              18 that arose that they didn't think  they  could  realistically
              19 resolve themselves, or if the vote was a  two-to-one  vote
              20 in other words, unless i@ was unanimous -- and if  the  others
              21 wanted to appeal,,-the person wanted to appealt there  was
                 an appeal mechanism established.
              22
                              And I think what I'm saying is there was a  turf
              23
                 problem.  There apparently was some jealousy, some difficulties
              24
  %Cllotat Repotters,  Inc. and they created "- in the resolution of this  problem,  they
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                  first of all created an organization themselves which would

               2  handle the problem of including an appeal mechanism and,

                  secondly, they changed the boundaries of the area.
               3

                              So I think their resolution of  their  turf  problem
               4
               5  I've only been involved in one other -- but this seems to be
                  a very suitable resolution and it seems to be working.
               6
               7              There's no doubt that one of  the  key  elements
                  in the development of these Regional  Medical  Programs  has
               8
               9  to be in the area of'the goals that are established, the objec-
               10 tives that are established and the priorities and the activities
               11 that are established in order to carry these out.
               12             Notr,, these are some of the things that I'm  taking
                  advantage of; the fact that using this mechanism to respond
               13
               14 to some of the things that I have as part of  my  own  prosenta-
                  tioh, but I would tell you that one of the main difficulties
               15
               16 that I've seen with the IIUIP has been the fact that  they  have
               17 defined four goals and there are no  other  really  adequate
               18 objectives or priorities  that have been established.
               19             Now,,"the goals they've established,  of  course
               20 they do conform as goals to the major thrust  of  the  RMPS:
                  To improve accessibily, easing and  simplifying  entry  into
               21
                  the health care system for all consumers; to increase availabili+@-
               22
               23 by providing needed services in urban and rural areas with
               24 emphasis on'minorities and other underlserved persons; to
  @ce*ral Repofters, Inc. improve the quality, assuring that the most appropriate medical
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               I  services and related health care are furnished; andt finally,
               2 to increase the comprehensiveness, providing a full range of

                                   ention of disease  and injury, health
               3 services for prev

               4 maintenance and rehabilitation.
               5              In the  section  entitled "Process" in  our  review
               6  criteria, there is a  section  that's entitled "Goals, Objectives

               7  and Priorities."
               8              Their RAG does meet and they do go over the
               9  priorities for the programs that  have  been  established.  So

              10  they do establish them.
              11              But to the best of my knowledge and I did attempt
              12  to probe in this area, they have not  gone  beyond  spelling
              13  out these qoals in terms of the further refinements and

              14  developments of their program.

                              VOICE: @Could we have the lights,, please.
              15
                              MR. TOOMEY: IIhile I am here, I  might  as  well
              16
                  just take up the  funding  situation.  Their 06 1year fundingf
              17
              18  their award war, for 13 months which came to 2,915,000.  @lhen
              19  you annualize it or put it in the framework  of  the  twelve
              20  'months, their award for their sixth year was 2,690,"OOOI  and
              21  then-they had a plus of the emergency medical.services funding.
                              Their 07 year request is for  3,896,000  which  is
              22
                  approximately a million two above their  OG  year's  funding
              23
                              DR. TIIUTUl@'@l:  Bob, are you.going to speak to
              24

    Fedefal R,.,Pofters, Inc.
              25 their increase in staff later?






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                             MR. TOOMEY:  Yes, sir.  I'm looking for the

               2 asterisk.  Can you see it?

               3             MRS. SILSBEJ,:  Here.
               4             MR. TOOMEY:  Right.  Their operational projects,
               5  two and a half million dollars including one million one
               6  seventy-two for the continuation of their 14 on-going projects
               7  and a million three for new projects.
               8             However, we will come back to this, so@I'll leave
               9  this slide up for this so you can see it.
              10             Mr. Chairman, in 1972, the Intermountain R-kiP
              11  Is this working?  Can you hear me?  Okay-,'--@Internountain WIP
              12  had been visited on April 17 for an orientation program and a
              13 RAG meeting' and.July 12th to 15 for technical consultation
              14 and another RAG meeting.  on July 20   to meet with the
              15 Mountain States, the Colorado, I%Tyoming and the Intermountain
              16 P14P as regards the turf problem, the boundary problems.  Been
              17 visited in August     that was April, twice in July, August 25
              18 and 31, for a review verification, management,, assessment
              19 visit.    October"', for a kidney consultation, technical
              20 'consultation as regards the kidneys,  October 12thi later in
              211 October,, another technical consultation and a RAG meeting'.
              22 November 9 for a RAG staff retreat and November 19 -- No, and
                  again in November -- No. I'm sorry.  November 9 to 10, I think,
              23
              24 was the RAG meeting,, the last meeting.

  AC   ral Reporters,  Inc.
              25              Because these meetings  were I think relatively







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                I  important and they certainly, as I have read the material,

                2 were productive, it became rather obvious  the  areas  in  which

                3 problems existed in the Intermountain MIP.

                4              There was a concern as to  the  program  direction.

                5 That is, the extent to which it was  moving  away  from  the

                6 categorical program and into areas  which  were  in  conformance
                7 with the Regional Medical  Program.  And,  frankly,  over  this

                8 period of time,  it was obvious.the  project  would  develop

                9 and it was moving into these new areas.

               10              For instances they were developing relations with

               11 the CHP B Agencies in Pocatello, Idaho, Billings, Montana
               12 las well as within Salt Lake City itself.
               13              They.stimulated grant applications.  They were
               14 involved in the stimulation  of grant applications  for  IlMos,
               15 family health centers and proposals  for  migrant  health  work,
               16 migrant health care  for the migrant workers,-  developing  the
               17 health information testing center, program on diabetes..
               18 quality assurance,, emergency nurse training  and  areas  of

               1 9consumer education.
               20              So that I think in terms of the concerii  that  was
               21 expressed over the Deriod of the entire  year  as  regards  the
               22 major thrust and the movement  away  from  the  categorical.
               23 concerns, that this was very evident  that  they  were  working

               24 in the proper direction,

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               251             The second concern that was  expressed  by  the






                                I    visitors  had  to-do  with  the  existence  of  clearly  defined

                                2   goals,  objectives  and  priorities,  and  I  mentioned  that  as  I

                                3   spoke  and  showed  you  on  the  screen  the  goals.

                                4                            I  don't  believe  that  either  the  refinement  of

                                5  the  objectives'nor  the  development  of  priorities  is  at  the

                                6  Point  in  which  we  can  say  they  literally  have  achieved  their

                                7  needs.

                                8                            Another          aspect  of  the  development  of  goals  and

                                9  development              of  objectives  and  priorities,  has  to  do  with  the

                            10     fact  that  their  concerns  are  widespread  geographically,.

                            11     embracing  different  areas  and  different  sections  of  the  three
                            12 Istates  and  as  well  as  not  having  a  very  homogenous  culture
                            13     tu  work  with,  they  have  the  geography  and  they  have  the

                            14     different  states  and  they  have  the  different  concerns  in  the

                            15     different  states,  so  that  the  refinement  of  their  goals  into

                            16     areas  or  into  into  objectives  and  priorities'   can't  be  done

                                   on  a  single  and  a  unitary  basis.
                            17

                            18                             I  think  they  have  to  be  concerned  about  the                                            needs

                            19     that  exist           in  the  periphery  and  outside  the  state  of  Utah.

                                   And  what  I'm  saying  is  tha-E'there  are  different  needs-at
                            20

                                   different  places  and  there  are  different  priorities  in  different
                            21  1

                            22     areas  of  the  section                    they  serve  and  that  this  has  to  be  de-

                                   entralized  rather  than  centralized.
                            23     c
                            241                            The  third  area  of  great  concern  was  the  grantee-RIIP
                epoitefs,    Inc.  relationship    problem.                         And  the  problem  simply  is  this  and  it's
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               I  real  simple:  that  the present.coordinator does not have a
               2  desirable   relationship with the president of the University
               3  of Utah and his assistant, Dr. Emery and Dr. King.
               4              Second, the spelling out  of  the  responsibilities
               5  of the Regional Advisory Grouo and the grantee  in  which  there
               6  was responsibility for the activities of the R-NIP  assigned
               7  to the grantee -- but there was authority to  get  the  work
               81 done assigned to the RAG -- created a problem  in  the  eyes
               9  of the people at the University of Utah because  they  did  not
              10  feel that they should split the authority and the
              11  responsibility.  And the University wanted, in fact, to be
              12  totally and completely responsible and@to  have  the  authority
              13  for running-the intermountain PIIP.
              14              They could not see giving up  any  authority  to
                  the Regional Advisory Group, and of  course,  the  authority
              15
              16  of the Regional Advisory Group is spelled out in a  I-lemorandum

                  of Policy of  the  @IPS.
              17
                              Now, this  situation has not been resolved.   The
              18
                  University of  Utah  has indicated that rather than giving
              19
              .20 as much authority as our policy indicates  that  the-RAG  should
              21  have., the University of Utah said that they would give  up  the

                  grantee position.
              22
                              And I believe, to the best of my  knowledge,  t  at
              23
                  this it still-weighinq and that there has been no decision
              24
  ce   I Reporters,  Inc. reached as to whether the University will,  in  fact,  continue
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                Ias the grantee or whether a nonprofit organization will

                 take place,
                2
                3            DR. SCIIMIDT:  Could I ask a question at this
                4point.  What is John Dixon saying?  Because some of the
                5participants in that dispute are leaving, Tom  King  is  going
                6to Columbia as Professor of Surgery. Pred  Emery  is  stepping
                7down as president. John Dixon is obviously a  stayer,  so  what

                 does John say about that?
                8
                9            MR. TOO@IEY:  Well, John had more to say about  the
              10 relationships that existed between the Dean's office  and  the
              11 President's office cind!Mr..Tl,,iglund than he did about the
                 situation as regards the two organizations.
              12
                             -Most of our conversation had to do with the
              1 3
              14 personality problem as Dr. Dixon was there.  I  don't  believe,
                 I don't remember that he had anything to say about the
              15

                 grantee relationship.
              16
              17             DR. MARGULIES:  I've had a letter from the
              18 Dean in which lie described to me, about as well as I've  heard
              19 it expressed, what the relationship ought to be, very strongly
                 in support of our understanding of the role of the-Regional
              20
              21 Advisory Group.  So that I don't think there's any rea
                 question about him accepting our policy and, in fact, believing
              22
              23 it.
              24             The difficulty  i.s'pr-etty    centered within  the
  ce   I Repoiters,  Inc. university administration and, particularly, the two individuals
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                1  both of whom are leaving by July 1 at latest.

                2               tiR. TOO@'-,IEY:  I think it will be resolved.  I  think

                3 that's,   well, kind of an obvious statement.

                4               Dr. Dixon seems  to  be  such  a  reasonable  person
                5  and he seemed to have an understanding of the problems that
                6  did exist between the university and the IMIP, that I think
                7  with the departure of  the  two  that  you  mentioned,  Dr.,King  and

                8  Dr. Emery, that many of the problems will be resolved.
                                The personal problem of the selectio    n of  a  coordi-
                9
               10 nator,, I think that-I -- I might as well mention      that   now.
               11               Dr.  Satovick  was  the  coordinator.  Ile  resigned
               12@and became  a  part-time  coordinator  from  March  to  August  of
               13 i72.  In August 01    172, he left and Mr. Richard Haglund

               14  became the coordinator.
                                Mr.  Hagl.und's  relationship  with  the  university
               15
               16  were not kind.  They were not good, and it has created a
               17  kind of a continuing  problem  and  it  gets  involved  with  the
               18  relationship between the university and  the  IIU.IP  in  that  the
               19  president, Dr. Emery and Dr. King, felt that before they
                   left office, that they w@nted to  be  able  to  be  in  a  position
               20
               21  to select the next coordinator, and they did not want to
               22  select lir. Iiagluncl, apparently.
                                And, really, it's a   further  dimension  of  what  is
               23
               24  both an organizational proble-,ii and a personal problem.
  l,eleal Reportets,  Inc.      In terms of replacing Mr.  ll,aglund,,  the  university,
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                 or the RAG, established a Search Committee, and  the  Search

               2 Committee had several names suggested to it.  They interviewed
               3 several people and they did not interview Mr. Haglund  at  the

               4 time.
               5             At this point, they could not come to  a  decision
               6 as to whom should be selected as the coordinator and,
                                            1
               7 consequently, they moved back and said, "If we're having
               8 these difficulties, then we'd better do  something  different
               9 than just interviewing peo'le.11
                                           p
              10             So they made an effort to develop a kind  of  a
              11 profile, if you will, of the person that  they  wanted.  They
              121spent a lot of time working on the profile and  the  criteria.
                             And when we were there in December, they  had  not
              13
              14 initiated any further interviews. Frankly,  both  myself  and
              15 1 think for the site visitors, we didn't know whether  or  not
              16 the RAG was attempting to stall until Dr. Emery and  Dr.  King
                 had left their positions at the University of Utah, or whether
              17
                 they seriously were just having difficulties  in  developin
              18                                                           9
                 the criteria and looking for the people that  were  wanted,
              19
                 that they would like to have as the coordinator, or whether it
              20
              21 lwas a little bit of both and a concern  with  possibilities of
                 keeping tir. Haglund on as the coordinator.
              22
              23             Because if the issue had come prior to  Dr.  Emery

                 and Dr. King leaving and Mr. Ilac
              24                                 Tlund had been the  selection
  l,e*tal Repoftets, Inc.
              25 of the RAG,, I think we would have had a rather    it would have





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                I precipitated kind of  another  major  problem,  and,it  was  my
                2  feeling that they were going to wait.
                3              Now, I understand from   1-tary Murphy that they  have
                4  begun to interview people and they   may attempt to make the

                5  decision before too long.
                6              I covered the turf problem and the tri-coordinatorl.@
                7  agreement and the acceptance of this.
                8              IPI.-IP, because of its vast geographic area, the
                9  several.states that it has to cover, has a problem in
                10 developing its  subreqionalization,  its  extension  into  the
                11 other areas, and the Regional Advisory Group and the coordinator
                12 Irealize that the full success of the program is dependent upon
                13 providing services and being  concerned  about  the  needs  of
                14 all of the region and not just Salt Lake City.
                15             They  have-taken  action.  They're  working   with
                16 CHP and health service  educational  activity  centers  and  other
                   areas, and I think, they recognize that the area is too large
                17
                18 to be operated centrally and  the  site  visitors  encouraged  the
                   IPI@IP to open regional offices in the other major  areas  of  the
                19
                20 region and to be staffed on a full-time basis.
                21             There has been a concern early, early on about
                22 the effectiveness of the Regional Advisory Group and its
    c-I
                23 method of operation.  At the present time, the RAG does
                   represent,))oth qeograT-.,hically'and in terms of minority interest,
                24

  Ace - ederal Reporters,  Inc.
                25 consumers and providers.; it has I  think  a  very  good  mix.






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                I Fourteen percent of the Regional Advisory  Group  represents

                2 minorities.
                3             Their attendance is really great.  Seventy-five

                4percent of the Regional Advisory Group members attend all

                5the four or five meetings per year that  are  held.  They  take
                61 a more active role in the total program.@'In terms of the
                7participation in all of the activities, they are  part  of  the
                8Program Development Committee.  They sit on the Technical
                9Review Groups, and I would'say that it's a very active role

              10 that they play now.
              11              Their Executive Committee  meets  regularly.  As
              12 a matter of fact,, the RAG members chair the  Technical  Review
              13 Comrnittees.--The'-Technical Review Committees are health
              14 manpower, consumer education, health care systems, provider
              15 education and the RAG members are chairmen of  each  of  these.
              16              RAG members are involved in both program

                 development  and in the evaluation and review.
              17

                              Ono other word about the extension  of  services
              18
              19 to the periphery-ancl the generation of ideas from the
                 periphery back into-the IJINIP, there is no systematic assessment
              -20
                lof the needs of the region.  Ap
              21                                 parently, planning has not been
              22 done effectively to get to the heeds of the area.
                              I think one of the pluses, if you will, as  I  saw
              23
              2  it, was with the chaiirj          Satovick to @Ir. Haglund with
                4                       e from Dr.
   laral Reportefs,  Inc.
  .ce            the-numbers of studies that were  made and to be ready for the
              25






                                                                              18

               I  site visitors, I was impressed'by the way  that  Mr.  Haglund

               2 handled  this situation.
               3              He had his organization ready  when  the  surveys

                  and the audits and the site visits were  done.  He  did  take
               4
               5  action to restructure the organization to meet the need.-that'.-
               6  had been spelled or had been indicated by the various visits.
                              Ile had worked in the development of the relationships
               7
               8  w.ith other organizations. The staff had  worked  toward  the
               9  development of new projects.  They were concerned when we were
              10  there with the development of a  decentralized  structure  to
              11  better serve the areas outside of Salt Lake, and they expressed
              121a concern for services to the periphery.
              13              They had pretty well minimized the turf problem
              14 and I would  say their relationships, other than  at the top.-
              15 level with the medical school, were quite good,   their working
              16 relationships below  the level of the President  and the Dean

                  at that time.
              17
              18              For the program that they offer, they have   55
              19  budgeted positions; 51 were filled.  There were either    three

                  or four that were unfilled at the time.
              20
              21              Their projects that they had  sponsored  and  which
              22  were sunDorted by IR-MP funds called for 114 positions.  Actually
                  that would be 82 full-time equivalents.  And, Billf I'm
              23
              24, really -- except for the

  %ce   I Repotters,  Inc.
              25              Their request for funding was  3,896,692  in  their






                                                                                  19

                I  seventh year; @,125,000 in the,eight-and nine year.

                2              The recommendation from  the  site  visitors  was  that

                3 triennial was recommended  with  a  funding  level  of  $3,000,000

                4 for each operational year, 07, 08and 09 and this amount

                5 would include a developmental component.
                6              I-le felt the funding for the 08 year should be
                7 contingent upon the appointment of a full-time coordinator
                8 and the resolution of the PL@IP grantee relationship policy

                9 problem.
               10              DR. SCIftlIDT:  Yes, I'll accept that  as  a  motion.

                  Mrs. Flood
               12              MRS. FLOOD:-  I had been assigned to attend this
               1311ast site visit but was unable to because of     a family
                  emergency, so my review   is strictly from the  material.
               14

                               I have some  expression of concern  that  of  the  24
               15
               16 projects requested for   the coming year, ten  of  which  are  new
               17 projects and 14 are continuation projects, 18 are still.based
                   n the University of Utah with only six projects based out of
               18
               19 the university setting.  This presents some sort of problem
                  for me to believe that the university and its leadership in
               20
               21 RMP is really looking  at  the  regionalization  of  the  program.
               22              1 realize we're not  supposed  to  look  at  specifics,
               23 but I do have one question  to  address  possibly  to  Mrs.  Murphy.
               241             They listed in the' current fun-,--ling period that

        at Repoitcrs,  Inc.
               25 Ithey're in now a termination of  the  emergency  medical  program,,






                                                                                20

                  Project Number   40; yet not for the coming year but for the
               2 following year, Year 08,  they  again  request  additional  funds

                  for the same project.
               3
               4              The current award in  that project which was 174,000
                  then, they come back in year 08 and ask for   184,000  more  with
               5
               6 no funding in the immediate next year or Year 07.
                              Can you offer me any explanation on that?
               7
               8              MRS. SILSBEE:   Excuse me. That's  a  fluke  in  the
                  printout.  That money was  dropped in at the end  of  the  fiscal
               9
               10 year, this last fiscal year.  The 225,000 or something is
               ii carried over. 'The period of time is too short, and under
               121the ground rules, that was something  like  an  18-month  award.
               13 So that accounts for that-hiatus
               14             MRS. FLOOD:  Okay.  Thank  you  for  the  explanation

                  and the clarification there.
               15
                              And the other concern is that the new projects
               16
               17 being instituted do not seem to  reflect a real  look  at  their
               18 goals and objectives. And other than  that,  I  guess  I  really
               19 don't have a great deal to offer of additional comments to
                  Mr. Toomey's presentation.
               20
               21             DR. SCHMIDT: Would you  be  willing  to  second  the

                  motion that we have?
               22
                              MRS. FLOOD:  Yes, I would.
               23
                              DR. SCHMIDT:  All,right.  So at least for purposes
               24
  tce*,at Repofters,  Inc. of discussion then. Okay. We'll have to be  getting  a  little
               25






                                                                                21

               I  feedback.  We'll  have to cut dozen on one of them t'nore.

               2               All right.  Well, thank.you.  Then the floor is
               3  ouen for discussion. Bill,  do  you  want  to  follow  anything

               4  up?
               5               DR. LUGINBUIIL:  In view of the uncertainties about
               6  this program, the fact that there's not a permanent
               7  coordinator and that there is a fragile relationship with
               8  the grantee which may or may not be changed, did you consider
               g:mal@ing this award a one-year award  and  getting  some  of  these

               10 matters worked out?
               11              I'm struck that there are some fairly serious

               12 problems here, at least potential problems.
               13              I'm also concerned that the level of funding as
               14 already awarded is really very high when you consider the
                  population. I think it  works  out  something  like  two  dollars
               15
               16 per head in that  Intermountain  area.  I  think  yesterday  we
                  gave t'07enty-seven cents to Louisiana.   That is a rather
               17
               18 horrendous differential  considering  that  there  are  serious
               19 problems apparently, or at least potential problems in this

                  region.
               20
               21              MR. TOOMEY:  I think there was a positive feeling
               22 after we got through talking with Dr. Dixon about the
               23 resolution of the coordinator problem and the relationship of
                  Ithe coordinator with t.,Ie riedical-school. And to answer  you,,
               241
  ,ce- eal Reporters, Ific. ii-le did not seriou -sly consider reducing it from the triennium
               25





                                                                                      22


                   status.
                2                DR.,SCIII.IIDT: You covered that  in  a  v7ay  by  making
                3  08  an  09  contingent  on  the  appointment  of  a  coordinator.  The
                4  program does have a lot of people and it's a solid program
                5  and  this  is  it's,  what,  second  triennium  that  it's  starting
                6  and it was one of  the  programs  that  got  off  to  a  quick  start
                7  and was one  of  the  first  few  made  operational  and  it's  always
                8  kind of been ahead  of  the  pack,  at  least  in  terms  of  numbers
                9  of projects and money and  so  on,  and  the  Review  CorLmiittee  has
                10 had many  discussions  about  what  has  been  termed  in  the  past
                11 the cost  of  emptiness  or  the  cost  of  mountains  and  distance
                12 land that sort of thing  which  has  been  one  of  the  factors  in
                   formulae that people have proposed.
                13
                                 MR. TOOIIEY:  I'd also told Dr. Luqinbuhl that,".
                14
                   you know, he's absolutely correct in what he says about
                15
                16 Louisiana. But  I  think,  if  you  remember,  we  agreed  that  the
                17 problem was not  at  this  level  in  terms  of  granting  funds  to
                18 Louisiana, but it was at the Louisiana level in terms of
                19 developing   a program  which  would  provide  more  funds  to  them.
                                 I don't think that they were reduced to that millior
                20
                211dollars.  I  think  that,  on  the  contrary,   they're   encouraged
                   to move  ahead  more  rapidly  with  their  programs  so  that  they
                22
                23 would be in a position to request.more funds.
                24               Now let rii-2 also say -one other thing in term, s  of
  lce*tai Repofters,  Inc.
                25 'Mrs.  Flood's  review,  I  personally  expressed  concern   about   a






                                                                            23

               1 number of their projects. For.instance, they  have  a  hospital

               2 administrators educational project. It's my  own  opinion  that

               3 that is the responsibility of the hospital administrators
               4 organizations that were and are involved in enhancing the
               5 capabilities of administrative people. And I  don't  know  that

               6 it's the IJU4Ps responsibility.'

               7             There's another one that had to do with  the  matter
               8 of safety, electrical safety, electrical hazards in the hospital.
               9 I feel that this is an administrative responsibility  for  each
              10Iof the institutions to be concerned about, the safety  of  their
              11 patients within their institution, and there is some justifica-
              12,ltion in terms of economies and the safety and well-being of
              13 all of the people in the entire area to be sure that the

              14 institution is safe.
              15             But I think this is-a project.  There's  also a
              16 veryo very major amount of money being allocated to  the  health
              17 information testing center and I think they  say  that t e
              18 break even point is at 20,000 Visits, and I  think  in the
              19 first few months"-- I donft remember.  Mrs. Flood, they had

              20 something like
              21             MRS. FLOOD:  Seven hundred and fifty.
              22             MR. TOOI.IEY: Seven hundred and fifty visits to  the

              23 health information testing center.
                             DR. LUk'2Il.l7BUIIL: It that on multipliasic screening?
              24
  ice -*,at Reporters,  Inc.
                             MRS. FLOOD:  @lultiphasic screening.
              25






                                                                              24

                              MR. TOO@IEY:  I might say I went through it

               2 earli.er,and I went through the healt h information testing

               3 center and I,want(-d to see if and Mrs. Murphy had suggested

               4 it would be desirable.

               5              I was very much impressed with the program.  But
               6  it's a question of whetherp.-in terms of cost benefit, that

               7  will be the benefits coming to the area in any kind of a

               8  relationship to the cost of the project.
               9              So that as you'look at the individual projects,,
              10  and I believe Dr. Scherlis was concerned about this
              11  yesterday, there are some I think that are questionable.
              12  There's absolutely no doubt in my mind that the reduction
              13  from their request to what  we proposed is minimal.  I mean
              14  I think  that  allowing for the increase from the two million
              15  six to $3,000,000 is more than'satisfactory.
              16              MRS. FLOOD:  I would just like to reinforce
              1 7 llr. Too,,ne@r's comments in the same line again. 'Along@with
              18  the electrical hazards and the administration management training
              19  programs, they have an infectious disease control program in
              20  hospitals and they are n@t feasibility development demonstra-

              2 1Ition-projects.
                              These are actually three-year projects proposed
              22
              23  for the maintenance of these Services.  The infectious disease
              241control   progra.m is onc of monitoring laboratory functions and
  .ce*,ai Repofters,  [tic.I
                 1
              25 culturing, and these are services that should be -- the






                                                                                 25

                I  responsibility should be assumed by the institutions providing
                2 health care and I do not  feel  that  they  are  a  responsibility

                3 of this Regional Medical Program.
                4              MR. TOOMEY: I  think  this  goes  back  to  looking
                5 not only at the development of the goals, but I think that it
                6 points up once again the need  for  them  to  get  more  concerned
                7 about what they have to do to achieve these goals and
                8 I think their projects have been developed out of context with
                9 the establishment of any objective.

                                                      -man.
                10             DR. SCIIMIDT:  Dr. Tliui
                               DR. TI@IUR!.,IAN:  I don't mean to dredge the values of
                12 Louisiana, but, Bob, you just s  aid that Louisiana heeded to
                13 develop a program that would-bring more money in.
                14             Ilri not sure,with the exception of the 500,,000,,
                15 and I think that's a  reasonable-figure  for  their  kidney  in
                16 this year, I'm not sure that  they  developed  a  program  that
                17 deserves support any more than Louisiana does.

                               There's already one po
                18                                     int two million in the multi-
                19 phasix screening "I and they're asking for almost 300,000 this
                  year.  And yet we know they're only running 750 patients.
                20
                21             Just on that basis alone, to go back to Bill
                  Luginbuhl's comparison with Louisiana, with all this talented
                22
                -23,staff and all the time that they have, I don't see that they've
                  got a proqram'tliat they've identified  that  is  that  worthy  of
                24-

  ,ce   I Reporters,  Inc.
                25 support versus the i-)rogr,-im that we saw at Louisiina.   That






                                                                             26


               I  would be my concern.
               2              Ede did the technical consultant  and  kidney
               3 do reasonably well as far as these 53  ABCX  projects  are

               4 concerne-.
               5              DR. HINMAN-.  Ile don't think so

                              DR. THUMIAN:  Thank you.
               6
                              DR. HINMAN:  @-unfortunately.  It's one of those
               7
               8 technical reviews that was prior to our orientation --
                              DR. SCHMIDT:  Do you want to grab a mike, please.
               9
              10              DR. HINMAN:   We have some concern  over  the
                 large kidney project that was submitted by the IW4P.  This
              11
              12 was a pulling together of nine components that have been in
              1 3existence for sortie time.into a comprehensive plan.
                              We have no hang up over the plan itself, but
              14
                 weire concerned about the method of  funding,  i.e.,  IRMP
              15
                 support.  This  was reviewed by technical reviewers prior to
              16
                 the time when ,,Ye had an opportunity to have indoctrinated
              17
              1 8them into  the concepts of decremental funding and that  PJIP
                 money should be gotten out fairly quicl<ly.
              19
              20              The problem is that, for  instance,  the.home
              21 Idialysis component has had six years of IU4PS support from
                 home dialysis training,  a total of $1,222,000 in the past.
              22
              23 It was known by that unit that it.was to have been self-support"r
              24 by June 30th,,
  le -10,,l Repo t ts,  Inc.
           r c                The home dialysis unit had also provided $44,000
              25






                                                                                 27

               I  towards the transplant startup-and it had also,    the transplant

                  unit had, 'received support f roni an organs @ procurement
               2
               3  contract for the past three years for a total of $194,796 and
               4  they knew they were supposed to  be  self-supporting  by  the

               5  end of three years.
                               Now, this nurse-dialysis training program that
               6
               7  they propose to make a  national resource has been discussed
               8  with no one outside of Salt Lal,:.e City. The  nurses  that  have
                  been trained to date have all been from IR14P and there has
              10  been no evidence that we could find that would suggest that

                  this indeed could become a national resource.
              121              They had made no move other than.to ask for money
                  to do so.  So that our  concern is not  with  the  coverage  that
              1 3
              14  they want to provide for patients, but  the  fact  they  have
                  had three to six years  support for most  of  the  components
              15
                  and have not utilized  third-party  reimbursement  that  have
              16
              17  made -- of course,  the application came in  before,IlRl,  so
                  they were unable to  adjust to that.
              18
              19               But vie have, and I think that  it was put  into
                  the books, a funding recommendat  ion for a  total of,.in the
              20
              21 107 year, $159,400 of M.IPS funding as opposed to the five
                  hundred and tiqent3r-r.-ive that they requested; and the subsequent
              22
                  years, a similar reduction.
              23

                                     01,4r
                               1-1@. TO .,Y: ri.ft@-four thousand the  second  year
              24
  le    I Repofters, Inc. and eighteen thousand the third year.
              25






                                                                              28

                I             DR. IIINIIAN. it's not that what they want to  do
                2 is not good. It's just that it doesn't  seem  appropriate  for

                3 us to pay f or.
                4             DR. I-IARCULIES:  I wonder, could I interject at
                5this point.  I think  that this discussion has become remarkably
                 important,, not just for IM4P, but the fact that  you're  going
                6
                7back and lookino at Louisiana and wondering about some issues,
                8             We agonize regularly in this  rogran about the
                                                           p

                9kind of disparities which you are addressing. -on what basis,
                10 aside from historical accidents, is one justified two dollars
                11 per head one place and twenty-seven cents  per  head  another?
                              Well, in the process of trying to find a resolution
                131of course, we've looked at all kinds of factors like cost
                 need and so on, but here you have a very good  example  of  an
                14

                 issue around which some discussion can flovi that  might  lead
                15

                 to some conclusions.
                16
                17            The argument in the case of Intermountain R@iP  is
                18 that covers a vast area.  It has essentially one medical
                191 school available-@in contrast with, say, Louisiana  which  has
                20 three, and as a consequence, we are saying, at leas-t implying
                 if not saying previously so clearly, that under these
                21                     . I
                 circumstances, a greater investment is  necessary  to  achieve
                22
                23 the purpose which is improving the health care  of  the  people

                 in that area.
                24

  .ice cral Repotters, liic.
                251           Now when you go beyond that issue, you are now doing






                                                                               29

               1  an examining to see in what way IPIIP is responding to these

               2 peculiar needs of the Intermountain area  and  find  activities

               3 clustered around the medical school concentrated around a

               4 series of activities whith  tend to whirl around  a  university

               5 health science center and  see in what way they are filling

               6 that vast space and those  scattered areas with the  funds  that

               7 are available, you do raise some very  serious  questions  about

               8 its fundint and its directions.

               9              In its defense, on the other hand,'as  Ma@ has
              10 pointed out,, it was not only an early program but  one which

                 was encouraged to move in the directions that it did elect.

              12 It was given great, great support in early days by review
              13 committee and council to establish a kind  of  direction  which

              14 it has established.
              15              And, yet, for a very long period  of time, we
              16 have been pointing to places like Nevada and   Utah and contiguous
              171states like Colorado and wondering how  effectively  this  money
                 which is  so much per head is being utilized to fill  tie  empty
              18
              19 spaces that they"are trying to approach.
              20              What Dr. IIinman has just described in the  kidney
              21 program is, if at least not characteristic, one of the
              22 issues which is involved in your deliberations.
              231             I,IR. TOOI,!L'Y:  There's one other thing.also,, Dr.
              24 14ar@Tulies atd-Dr. Schinidt, that seems to bear out the discussion
  ,e    I Reportefs,  Inc. yesterday particularly by Dr. Sclierlis as regardst on.tlie  one
              25i
                 I                     -






                                                                                30

                I  hand, you look at the program,,.and when you-look at the
                2 program  the RAG  is changed, the staff is quite excellent.
                3 iTliey have one major problem in the selection of an evaluation
                4 or in the area of planning and evaluation and the coordination
                5 of these activities.  And there's no doubt in my mind, as 1
                6 look at what came uD in terms of problems as regards the
                7 program  actions and activities to rectify those problerti.,3,
                8 that this IRMP is really an excellent organization at this

                9 point with some problems.
               10             On the other hand, when you look at the projects,
                  the projects are a carry-over from the past.  They are
               12 centralized at the university.  They really do -- while     they
               13 tend toward the qoals that have been established, they   are not
                   n fact fully cohsonant,with what you  can  almost  perceive  Is
               14 i

               15 the needs of the areas.
                              They are things that  have  been  developed  because
               16
                  of somebody's personal  interest, and where I (ive the program
               17
                  probably a ratin  of an  A in terms of what they  did  in  order
               18
                  to overcome and  offset their problems, I would  barely give
               19
               20 them a C in terms of the projects  that  have  been  established
                 Ito carry this out.
               21
               22             DR. SCIltlIDT:  This is a very difficult thing.
                  Sometimes I make a mistake in that I read everything that
               23
                  comes into my -off ice nrettv-miich, and one of the tliin(jr, I
                4
  Icelb,al Reportets,  Inc.
               2 5recently red f rom- RI.",P that came to my office was an ol.)Vj-ous





                                                                             31

                 concern about the involvement of hospitals in JU4P. And  this

                 was felt important enough whether it was political or not.
               2

                 It was felt important enough to do a staff survey on the
               3
               41involverqent of hospitals in M.IP.  And there was some agonizing
               5 over the fact that hospitals are not as involved in RIlPs

                 as they should be.
               6
               7             And if you really look at how hospitals can be,
                 tied int o MlPs, you do get into things like training programs
               8
               9 for administrators, helping hospitals who would not have  the
                IsoT)histication in electronic engineering to pick up the
              10
                 subtle threats to life posed by equipment that nobody in  the
              11

                 hospital understands.
              12
                             These sorts-bf things, you can, in other words,
              13 if you put your mind to it, at least find some rationale  for
              14

                 projects.
              15
                             I ,igree with Dt','IIargulies that this is an
              16
                 important discussion and I all-7ay-9 have a growing sense of
              17
                 unease when the Louisianas are brought into a discussion like
              18

                 this.
              19
              20             The Oxford English Dictionary defines the word
                 "mediocre" as average, and the big problem of a democracy,
              21
                 the greatest threat of any democracy is that, carried through,
              22
              23 it inevitably leads to mediocrity.
                             if you bring up the Louisianas and start averaging,
              24
  @Cle'al Reporteis, Inc. you're going to get do%.7n to a million dollars. You're   going
              25






                                                                            32

               I  to get down to some mean, to some average, and if there  are

               2 50 regions, that's a fifty million dollar  program.  If  it's

               3 a two million dollar average, then it's i hundred million

               4 dollar program.  And there is an  element: of  ridiculousness

                 to that.
               5
               6             Noii,, I'm not arguing for supporting a program
                                            1
               7 becuase it's got a lot of money in it now.  I'm arguing

                 a ainst backing off a good program.
               8  9
               9            @I recently poured tremendous resources  into  one
              10 department because I know it was a minor department.  I
              11 happened to recruit superb opthalmologists, and I poured
              12 resources into opthalmol'ogy., much to the dismay of some
              13 others, but that is some place where this  particular  school

                 can make a difference because of the neople that's there and
              14

                 so on.  And I think that we're putting money into places where
              15

                 it will make a difference and I really do worry about the
              16
              17 ultimate direction of the program and so on when we make too
              18 much of the money differences.
              19             The review committee, by and'large,  through  the
              20 years has strongly resisted Capi4-ation formulas and-this sort
                 of thing and, personally I believe rightfully  so,  and  I've
              211                        It

                 obviously stimulated some comments,
              22

                             Dr. Thurman.
              23
              24             DR. TIIUP\!.!-@.'I:  I-Tell, one would not to interfere

  ,:e  I Reportets,  Inc.
                 with that beautiful monologue, but let me point but that if you
              25






                                                                                    3 3

                I pour money down a  rat  liolE,,  it.doesn't  improve  it  by  pouring

                  I
                2  more  money  down  it  necessarily.  And  nobody  here,  so  far,
                3  has said they have a c                                   hat'
                                           .Tood program, llr. Chairman.  T      s  the

                4  problem,, and that's what we're speaking to.
                5                I have  no  disagreement  with  the  triennial  status
                61becailse this is  a  groun  of  individuals  who  have  proved  their
                7'orqanizational capability @ut they have not prov       ed their
                8  thought  capability  by  this  demonstration  of  projects   that

                9 we are looking at this morning.
                10               And I think  that  I'm  not  comparing  per  capita
                11 and I would agree one  hundred  percent  witJi  that  part  of  what
                121YOu said.  That would be a.mistake.  What I'm looking at is
                131the amount of money that they have now, what they're asking

                   fort and how they would plan to use that money.
                1 4
                                 This has notliing to do with what  1-ir.  Toomey  said
                15
                161about their capabilities or with what you said about their
                17 overall approach. But  I  do  say  that  for  all  that  talent,,
               .18 sitting behind those desks, largely in Salt Lake       City, that
                19 they have not demonstrated to us a program capacility that
                   goes along  with  their  overall  capability,  and  that's  all  I'm
                20

                   saying,
                2 1
                22               And I would wash out the Louisiana and everything
                23 else cluicl-,ly because I agree a  hundred  percent  with  what  you
                  Isaid.
                24
  @ceeat Reporters,  Inc.I
                25               DR. SCIII.IIDT:  Dr. T.uginbuhl.






                                                                                34


                               DR. LU(,INBUJIL:  I certainly am not arguing in

               2  any sense for capitation.  I agree that the program should
               3 be funded in a large measure based    on their capability  and

                  performance.
               4
               5               1  am hard pressed for  looking over the documents,
               6  though, to arrive -,it the conclusion that this is a particularly
               7  capable program. I think in the past,  they  seem  to  have  done
               8  pretty well at a time that the competition was rather
               9  different and the goals were  rather  different.  But  it  looks
               10 to me as though they have  not kept up with change, that they're
               11 still a program that is doing things that they started four
                  and five years ago.  It's largely based in Salt Lake City.
               12
               13              1 think there are major problems about the
               14 leadership of the program when you have an acting director wliols
               15 in conflict with the grantee that isn't  resolved,  and  I  don't
                  agree that this  program at this stage deserves a three-year
               16
               17 green light.  I  think this program has major problems to
               18 solve.  I thin),-, it needs to shift its direction.
               19              I think that it should have its funding  cut  to  a
               20 level and it should be looked at again in one year  'to  see  if
               211indeed they haven't solved the problems they faced.  I'd
               22 like to see some performance.
                               DR. SCIi-@.IIDT:  Could you defint "shift'its direction".
               23
               24              DR. LU(-@ll-lj7,IJIIL: I-lell, as a start,, I'd like to see
  @ce- ederal Reporters,  Inc. ltl-iorl,get more projects outside of Salt Lake, out elsewhere  in
               251





                                                                              35


                  the region which they've been advised to do before.     It.looks
               2 to me as though the projects are still dealing with    categorical
               3 problems,that they're not making a broad attack on the overall
               41problems of health care delivery.
               5             .,For example, a project in multiphasic screening,

               6  1 don't really regard as an innovative project  in  health  care

               7  delivery, in spending over a million dollars  to  screen  750

               8  people.  It's not a very cost effective program.
               9              DR. tiARGULIES: I think this  is  worth  pursuing.

              10  I hope that Mac was not reflecting what he thought I was

              11  implying because I certainlylliave no interest  whatsoever  in

              12  a capitation approach.

              13'             What I aim saying is that there should be a
              14  disparity based upon quality and perhaps  some  other  factors
              15  but the disparity should produce some result, and  if  it  is
              16  going to be more money in a region, there should be some
              17  evidence that for moneyt you're getting  more  results,  -It's

              18  that simple.
              19              If you look at the size of  this  staff  relative to
              20  other programs, it's a huge staff, and then take  a  look  at
              21 Ithe indirect costs for this particular program, I don't know
              22  if they're before you or not, but if they're  not,  you  would
              23  have a reminder of it, you have to ask yourself, "If this
              24  the best way in which this money can be spent for the-people

       al Peporters,  Inc.
              25  who live in the Internountain Regional  Medical  Program  area?"






                                                                              36

                              And if not, then you have to -- there comes a time

               2 when you begin to at least discuss this as a principle, whether

               3 you want to act on it now or not,

               4              MISS AIIDERSON:  Mr. Chairman, I was wondering if

               5  the site visi tors found our what happened to the projects

               6  that were discontinued.  Did they have continued funding,

               7  or what

               8              MR. TOOMEY: I don't  remember  specifically,  ISut

               9  their record of continuation of funding is pretty good.

              10              DR. SCliMIDT: The site visit  report,  I  think.as

              11  I recall reading it over, said that out of  14  projects  that
              121were phased out, nine were picked up by other funding.
              13              DR. TIIUMIAN:  Right.

              14              MR. TOOMEY:  I would say once again, that if you

                  look at the component parts of the  organization  itself,  the
              15
              16  Regional Advisory Group has matured, and they are participating
              171and I think certainly that, from what I've seen, you could
              18 rate them at an excellent level.
              19              When-you look at the staff, its organization, the
              20  kind of peonle they've got, that's rated as excellent.

                              The one weakness at the moment is the  loss  of  a
              21
              22  chief of their evaluation section and no replacement there on
              23  a permanent full-time basis, but a temporary person or a
              24 !person who is 'f ull-ti-..'e, but temporarily in charge of the
       at Reporters,  Inc. evaluation section. This is good.
              25





                                                                               37

                1             They do need one change in that and I thin]-.  the
                2 Imanagement assessment people recommended that  evaluation  be
                31involved at the very beginning and that they monitor the

                4 programs as they go through. 'The-evalucition-people at the

                5 beginning could establish the objectives that should be

                6 evaluated.

                7             I don't want to go  through it, but I think in

                8 terms of the program, once again, it's excellent.

                              In terms of the projects that  are  being  carried
                9
              10  on, I think they're less  than  excellent.  Charlie  Hilsenroth
              11  reminded me that this has been rated as a  B-plus  agency,  and
              1211 think that you average out the excellence  of  the  staff  and
              13 the not quitt so excellent projects at  the  moment  and  that's

              14  about where we would come, I would presume,
              15              I think my own opinion is that really the
              16  development of the objectives and then development of projects
              17  to achieve these objectives is the direction  that  they  have

                  to take in order that the ir activities match their capabilitic,-
              18
                  because they are,an extremely capable organization as I see it.
              19

                              DR. SCIIMIDT:  John.
              20

                              DR. KP\ALEWSKI: A statement and then  a  couple  of
              21
              22  questions.  First of all, it seems to me, in  looking  at  this
              23  application versus some of the older ones, that they have made
                 isome chanqe@in'the3-r orientation and I think that they probably
              24,
  'Cle"l Repofters, Inc- do have the capability to carry out that change as they go alonq
              25





                                                                            3 8

               1             Much of this will depend on the new coordinator,
               2 however, and I wonder if the site team has some comments@about
               3 whether or not you think they're going to fill  this  spot
                 fairly soon, were you impressed with the  candidates  they're
               4
                 looking at, what are their capabilities?
               5
                             And then a second question, in terms  of  budgets
               6
               7 here, it appears that much of the difference  between  the
               8 budgets they're requesting and last year's budget is involved
               9 in things such as grants, et cetera, and I'm not sure I fully
              10 understand that. It appears that last  year,  it  didn't'cost
              11 them anything for rent.  This year it's going to cost them
              12 $1381000. These are differences that I can't  quite  see  how

                 they're put together'.
              1 3
              14             MR. TOOIIEY:  1,7ell, the rent issue, as far as the
              15 rental is concerned, they were using  facilities  provided
              16 by the University, and they were divided up into three or
              17 four different locations throughout the  university  setting.
                             They have felt that in order to pull the unit
              18
              19 together, that thev should find quarters where they  all  can
              20 @e together and there is-A research --,No. I want t.o  say
                 a research triangle     but there's a research park.  And they
              211
    C')       22 plan to rent quarters at that research park which is away
                 from the university but does bring all of their staff
              23
              24 together, and-tli,".tls v.7here the rental problem comes iij-).
  ,coal Reportefs,  Inc.     DR. SCIII-III)T:  Dr. James and then 16liss I-,err.
              25





                                                                                                   39


                                                       That will be the indirect cost.

                  2                                   just quickly
                  3                                      oh, yes, on the coordinator business.

                      Gc.;
                  4
                  5                                    The site visitors were        impressed
                                                      .@laglund, while he is not      an extrovert,,
                  6
                  -7. he                              :idous personality.   Ile seemed to have
                  8,                                      iIis   personality   was    perhaps    not
                  g                                   n terms of his abilities and his
                  10                                  es, we felt he had done well.
                                                           considered initially for the

                                                         He  was  at  the   time   we   were   there
                  12  '-POs
                  1 3                                 -_is an active applicant for the position.
                  14  He Cr                           seemed to be a number of -- some feelin@
                  15  tha-"--                            of carrying on this task.
                                                        Dixon's   feelings    from    the    medical
                  16
                                                        that the selection of Mr.          Ilacjlund
                  17  schoc
                  18  at t@i-'.                       '--her precipitate a problem between the

                      univ7@..'
                  19
                                                      '@--to me that they were on the horns of
                  20
                  21  a di-I                          e only way they could get off it would
                  22  be tc@                          -ect somebody else and Mary tells me
                  23  that                            ;ve recently in looking and they
                                                        somebody.   They expect to, and he will
                  24  shor
        ai Reportefs, Inc. be a                       llr. Ilaglund.
                  25





                                                                              4 0

                              Well, excuse me, she didn't say that, but the

               2  implications were that this was the action going  to  be  taken.

               3              DR. SCliMIDT:  Dr. James.

                              DR. JAI-IES:  I would like to approach this just from
               4
               5  another point of view.   Relative to the  excellent  way  that
               6  the information regarding the total program has been
               7  disseminated throughout the IR@IP in that there  apparently  has
               8  been knowledge gained by other agencies,  consumers  who  have
               9  benefited from the program, I wonder whether or  not  can  the
              10  site visit teari tell me the.impact of the total  program  as
                   t has related to the provision of services to the people in
                ithis large geographical area?
              12
                              I wonder, for instance, we get caught up here on
              13
                  all the technical gobbledegook regarding  a  new  coordinator
              14
              15  which can be taken care of at orie,level, but  then  the  impact
                  of the program in terms of just what are these projects dbinge
              16
              17  are they reallv reaching the people, are  they  servicing  the
                  people? And if not, if then  that  the  budget  considerations
              .18
                  are as we see them here, which may  look  excessive  as-compared
              19
              20  to Louisiana and/or Mississippi or wherever,  would  the  budget
              21  considerations not be concerned %-7ith whether or not the  14
              22  programs that are on-qoing, the new programs, are they reaching
              23  the people?  CanIthe site visitors tell me this?
              241             I-don't understand the conversation  up  to  this
  cele"l Reportefs,  Inc.
              25  point.  I thin!-. that I reallyv7aiit to knov7 @-ihat's happening to





                                                                             41

                I the Programs in meeting the needs of the people in the
                2 communities in the area in the region.
                3            MR. TOOMEY: I think I would answer that they have
                  added things that were not available previously and  to  the
                4
                5 extent that they have done this, they have met the  needs  of
                6 many of the people whose needs were not being met previously.
                7            Noxit it may not be all that you want, but it's a
                8 positive factor. For instance, they've  worked  very  closely

                                                   n
                9 ,Tith the Comprehensive Health Pla ning Agencies.  Now,  this
                10 is a move in the direction.' This is just not in  Salt  Lake
                11 but in helping in other areas, in  developing  Comprehensive
                12 Ilealth Planning Agencies and working with them,  cooperating
                13 with them and providing some funding to them.
                14           This is in Pocatello, Billings, Montana, as well
                15 as in Provo.  Their health learning centers in Pocatello, Idaho
                16 is providing additional manpower  and,  hopefully,  additional
                17 services to the people.
                              They have moved out into the migrant worker area
                18
                19 and they have r-loved into the Indian -- meeting some of the needs
                20 of the Indians.
                211           So I would say, overall, the answer was yes, that
                22 we were satisfied that they were moving in  that  direction.
                23            DR. JPI@IES: It apparently seems then, from  the
                   aterial tha@@-I have !i;canned,'tliat this lnIP has indeed
                24 m
  %cetefal Repotters,  Inc.
                25 involved other he'altli-related agencies and lent support to helpi






                                                                                  4 2

                1 them develop programs which,  in  fact,  does  get  down  to  the
                2 grassroots level of providing the services, is that not right?

                                MR. TOOMEY:  Thatis true.
                3

                4               DR. JMIES:  So  what  we're  really  discussing  at
                5  this particular point then are probably the technical
                6  difficulties in  administrative  staffing  or  the  administrative
                7  level. Does this not seem to  be  where  we  are  at  this  point?
                8               MR. TOOMEY: I would  say  the  main  problem  --
                9               DR. JAMES: And what are  you  using  as  a  basis  to
              .1olevaluate this whole program.and to justify the budget staff
               11 requirements or program requirements?
               12               I would like a clarification on that, please.
               1 3              -DR. SCHMIDT: l@ell, I would try to sun-a-narize
               14  much of the  discussion by saying that  there  have  been  an
                   awful lot of activities in the Intermountain Regional Medical
               15
                   Program which have undeniably done well by the people and

                   for the people and  so on,
               17
                                The major concern is that they  have  a  set  of
               .18
                   goals.  They have not broken these down into objectives and
               19
                   related then to  the demonstrated needs in a satisfactory way.
               20
               21               The relationship of these projects to their
               22  objectives and relation to the  people  is  less  clear  than  one

                   would like.
               23
               24               There's concern that   the projects are in some
   0,3f Reporters,  Inc. instances very expensive and are not being phased  out  in  a
               25






                                                                                   4 3


                   decremental way satisfactorily.

                2               Elizabeth.
                3               @IISS KERR:  I think we've hit a key issue and

                4  1 think

                5               DR. SCIIIIIDT:  Do you want  to c
                                                                .Trab a mike.

                6               14ISS KERR:  Yes.  I say I   think iqelve hit a key
                7  issue here  and I sense we've sort of taken 180-degree turn.
                8               I would have difficulty in supporting @Ir. Toomey's
                9  rationalization that this corps staff was extremely good,
               10  and the program  in essence'this is what he said, was not very
               11  good.  Yet they would average    out at C-plus, and this is where
               12 11 run into a verv moralistic problem, as     far as I'm concerned

               13  in rating.
               14               Now, if they have an excellent staff of 50 some
               15  people that are  making  the  right  decisions,  then  the  program
               16  ought to be better.  And this is why I get confused.
               17               I thought you said the program was good.  I-agree
                   that  I  kept hearing that the  people  needs  were  being  met  and
               18
               19  that's   what we're' after.
               20               I-IR. TOO@IBY:  ilell, one of the problems  here,   in.
               21 lanswer to Dr. Thurman's earlier question,     is that I think
                   there are kind of two  kinds  of  staff,in  a  way  you're  talking
               22

                   about.
               23
               24               one is wlii--t@L-. we would ordinarily consider the core
  @cet'al Reporters,  Inc.
                   staff, the  leadership staff, and another great segment and then
               25 1






                                                                                 44

                I probably the majority of the  staff  is  project  staff.  So  they
                2 tie together people in the project, and a lot of the additional

                3 782, the 1066 monies would go to support people that are
                4 tied into these new projects that they're applying for.  So
                5 that  let'r, say that more than half of the staff is project

                6 related.
                7              I think that the general consensus has been  tha4L-.
                8 what we would consider the core:  staff  through  the  years,  has

                9 been 4ood.  I think that's fair.
               10              MISS I'ERR: Yes,,, but I still am concerned  if  they
               11 come up with a high rating because  of  this  strong  core.  staff
               12 and I'm not talking about this  particular  region  alone  --  but
               13 then sometimes we don't read it right, it seems to me, in their
               14 activities, in their performance and effectiveness,

                               DR. SCHIIIDT:  Joe.
               15
                               DR. IIESS:  I think over the years,this  has been
               16
               17 considered to be one of the  more  effective  MlPs.  And  I.Iiave
              .18 no doubt that much of what  they're  doing  is  indeed  affecting
               lglthe health of the neople.
               20              But there's another consideration which.hasn't
               21 been brought up here which I think we need  to  take  a  look  at
                  and that is the issue of the relative  need  of  this  region  in
               22          1
                  relationship to other regions.
               23
               24              I'(Ion"@- I,.@,@li-eve that the RTIP,uring public funds as
  'Ceo,al Repoftefs,  Inc. it is, should ap
               25                  p@ar maritocracy






                                                                            45

                              In other words, the merit and the capability
               2 of the program should be the only factor. The  need  of  the
               3  region should also be a modifying influence as  best  we-can

               4  determine vihat those needs are.
                              And along with some of the questions that Dr,
               5
               6 Luginbuhl was raising and some of the comparisons,  I  think
               7 we have to be concerned at this level about our consistency

               8 as we look at these various regions,
               9              Now, Louisiana has been raised as one example, and
              10  I would point out for our consideration what our deliberations
              11  were concerning Washington and Alaska yesterday.
              121             You look at the quality of that program as it was
              13  described for us. Their funding level for a  population  of
              14  3.7 million people, we recommended $2.3 million which comes
                  out to about sixty-two cents-per capita.   You look at the healt@
              15
              16  indices, the ones that we have in the report, in every respect,
                  considering heart, cancer, stroke and all other causes of
              17
                  mortality rates and considering that as the only  numerical
              18
              19  data that we have for comparisons, that the Intermountain
                          s better off in all of those categories, significantly,
              20  rec
                    .lion i
              21  than-the Washington-Alaska region.
                              So there are-other factors that are not as quintifia,
              22
              23  that we have to'take-into consideration.  But the point I'm
              24  trying to get'to is t;'@is: that as @.i,2 try to make reco,@iLmer,(-Iatic..t
  :kce- eral Reportets,  Inc. about the various'regions, that we ought to consider the needs,
              25






                                                                             4 6

               I the health needs of the regioi-i-as well as the capability of
               2 the staff and the recognition that if we overfund some regions,
               3 that is automatically going to have some repercussions on others

               4 in terms of their getting money.
               5              So, consequently,, I believe that this region#,
               6  even though it's had a good program and all those things, its.
               7  geographical problems, it's overfunded at the current and at the
               8  present time and that we ought to start a trend to cut this
               9  region back to what is more equitable in terms of where

              10  they stand in the national picture.
              11              DR. SCHIIIDT:  All right.  I'll use that to
              12              DR. HESS: If you're ready,, I'm prepared  to  make

              13 a recommendation.
              14              DR. SCII@IIDT:  All right.  We have a motion
              15  that's seconded on the floor for level funding for the
              16  second.triennium 'of $3 million, @,iith.two contingencies:  one
              17  that by the second year of the triennium, i.e., they get
             .181$3 million for the next year, they would  get  $3  million  for
              19 the 08 year providing a permanent coordinator  was  chosen  and
              20 they settled the issue with the grantee organization.
                                                             .T
              211             if you wish to make a substitute motion,, that

              22 would  be in order.
              23              DR. IIESS:  Yes. I would like to propose that
                  in place of the $3 million for this ne.,4'L-- @,e@cir, we recommend
              24
  le*,al Reporters,  Inc.
              25 2.5  which  is below their current year funding and that for the





                                                                             47

                 year after that, that it be 2.3 with  an  indication  thatlwe
               2 think that this trend ought to be reversed  and  there  ought
               3 to be a levelling off at a lower level.  And then it's up to
               4 the  ingenuity of this staff to make the best use of  the  funds
               5 which they have to meet the health needs of  the  people  in

                 this   region.
               6
               7              DR. SCII!IIDT: All right. If you're  talking  about

                 a triennium
               8
               9              DR. BRI14DLEY: Third year.
              10              DR. SCHMIDT: -- what sorts  of things would  be
              11 falling in year three?
                              DR. HESS:  Well, I would say if the third year'
              13 were also at-2.3, taking into account inflation  as  long  as
              14 there would still  be a relative cutback-in the  third  year.

                              DR. LUGlN]3tJllL:  Second.
              15
                              DR. SCHMIDT:  All right.  There is A substitute
              16
                 motion   then. it is seconded. It would be  2.5,  2.3t  2.30
              17
              18              Dr. Luginbuhl.
                              DR. LUGINBUTIL: I just want to point  out  some
              19
              20 interesting features in @e budget in the 07 year.     If I  read
                 correctly, therels.included $300,000 for developmental component
              21 1
                 $300,000 for nultiphasic screening, probably half a million
              22
              23 dollars going into the renal program, and these  are  all  items
              24 that I would question,  And if you look at the projects,, the
  @ce*fal Repofters,  Inc. new -projects and vou split out the renal project,  the  ones
              251






                                                                               4 8

                  that appear to be the -nost innovative  are  all  subcontracts
               2  and the projects that are being continued are rather categorical.
                              And I wonder what the staff is going  to  do  if.tlie
               3
               4  categorical projects are phased out  since  the  new  projects
               5  are subcontracts?
                              It seems to me if you cut  this  program  back,  that
               6
                  there is plenty  of room for some readjustment  and   redirection
               7
               8  and the only thing that I still question is whether this
               9  program should be given a three-year  green  light  or  whether
                  it should be looked at in a year to make  sure  that  they  are
               10
               11 indeed following a new direction.
                              MR. TOOMEY: I have to  speak  against  Dr.  fless's

                  recommendation, not in principle truly, but  in  terms  of  the
               1 3

                  dollars,
               14
                              I think that you could cut back perhaps the
               15
                  first  ear.  nut they are assuming some additional direct
               16       y
                  costs, for instance, in their moves  to  bring  together  their
               17
               18 staff from several places into one place  which,  I  think,  will
               19 make a difference in the number of people that they,have.
               20             Having a decentralized operation is more expensive
                  in terms of people.and having them all together.
               21
                              Consequently, if Dr. Hess would give consideration
               22
                  to perhaps the  2.5 and then increasing it for  the  next  two
               23
               24 years, I tliinlz'l Cbul(l support this. But I'd- have to  speak
  ,ce- deal Reporters, Inc. against what he has proposed.at this point.
               211






                                                                           4 9


                             DR. SCHMIDT: All right. Let me ask  staff,,  do

               2 you have any comments? You've been silent. Do  you  have  any

               3 comments as to what in effect is i reduced funding level?

               4             MRS. MURPHY: I could see the 2.5 and we  do  need

               5 an earmark in the kidney.

               6             MR. TOOMEY:  But that's within the 2.5,, so that

               7 really is no problem.

               8             DR. SCHMIDT:  Yes.  John.

               9             DR. KRALEWSKI: I'd like to make  a,comment  about
              10 the principle of this,  unless I misunderstand what we're
              11 doing here.  I really think that we're voting on this or
              121trying to develop their budget on the basis that we  really
              13 feel tliey're'getting too much money for this region or some
              14 kind of an approach such as that and I'm really opposed  to

              15 that.
                             I really think that we've got to continue on  the
              16
                 basis of looking at programs, looking at their capabilities
              17
                 to do thi ngs, whether or not they've made a contribution,,
              18
              ig and then deal with the budget in those terms.
              20             Now, if we thin)-. that they haven't made-a contribu-
              211tion-and they don't have the organization to be'able to  make

                 a contribution, fine, let's cut them back.
              22
              23             But going on this basis that they've got  three
              24 million and-someone el-se has one million and @,ic need to,
  c e4*4al Repofteis,  liic.
              25 therefore, bring them 'Lnto a closer balance, I think is a bad






                                                                                      r, n


                    way to go and  I  would  be  opposed  to  cutting  them  below  last
                 2  yearts funding,  at  least,  because  I  think  that  they  got  some
                 3  things  going  here.  I  think  they've  indicated   some   changes.
                 4               1  think  they're  making  a  contribution,  both  to   the
                 5  rural areas  and other areas,  and  I  think  that  at  a  time  when
                 6  they need some  help  in  their  attempt  to  get  away  from  that
                    medical  school,  which  appe@rs  thel,lre  trying  to  do  and  attempt
                 7
                    to bring in a coordinator, which they're ap
                 8                                                   parently     closeto
                    doing, and  if  we  cut  them  back,  I  thiiik-thatit's  going  to
                 9
                10  put this guy to a real disadvantage.
                11               DR. SCI]MIDT:  Tliere.is one other issue that bothers
                12  me a little. Ilra  bothered  by  the  substitute  motion  a  litt  e,
                    bit. A part  of  it,  a  number  of  people  have  talked  about  the
                13
                    need to get out of the categorical      business.
                14
                                 I would  point  out  to  the  Committee  that  that  is
                15
                    in conflict with some of the statements that have come out of
                16
                1 7 the I-IS@',IIIA office and the RI.IP central office recently, and I
                    think there is need for a little clarification of this.
                18

                                 Harold.
                19
                20               DR. t-IATZGULIEI,3-: Well, I think  that  the,issue  on
                    categorical  activities  is  more  a  matter  of   how   they're.carried
                21
                    out..and whether  or  not  heart  disease  is  an  important  disease
                22
                    to take care of.  I           there  can't  be  any  question  about
                231

                    that.
                241
  ,(;eo,al Repolters, Inc.       What we're trying    to  avoid,  however,  in  moving  away
                25






                                                                               51

               1 from categorical, categorical  activities  is  the  support  of

               2  separate projects which are identified around a single aspect
               3 of a single disease located  in  a  single  institution  which
               4 Itends to split a delivery system  even  further  rather  than
               5 strengthening it.
               6               I think a good example of how to improve cardio-

               7  vascular disease management would be  one  which  involves  a
               8  strengthening of the total management, we'll say, of con@stive

               9  heart failu re or hypertension to  better  management  of  an
              10  existing delivery system,-and a bad example is the enthusiastic

                  development of accronary care unit  in  a  45-bed  hospital.
              12  I don't know if they're down to 45, but ,7e have some in similar

              13  circumstances.

              14               It is more of a matter of how you  get  t  ere.

              15               There's no question that one cannot have an
              16  effective health delivery  system  mounted  without  careful
              17  attention to the diseases with  cause  major  disability  and
              18  death.  But there is a sensible way to go about it, a rational
              19  way, and therels-a kind  of  impulsive,  fashionable  pattern
              20  which characterized the program in the past.
                               It isn't dealing with  categories  that  disturbs
              21
                       It's dealing with aspects of diseases which concentrates
              22  us-
              23@resources in limited areas at the expense of other needs.  So
                  that when @,76 use th(-, -,,Tord "catr-,c
              241                                  ioricil,," it gets us into  a

  .e - 'II Reporteis,  Inc.
              25  little difficulty,*






                                                                            52


                             If the program has-designed,. as an example,, a

               2 regionwide method for dealing with coronary artery disease so

               3 that the total management for all available people is improved

               4 at every level and is not simply restricted to training a

               5 few individuals to do a few things, then I think it's going

               6 in quite the correct direction,

               7             1 c-m a little worried, also, Mac, about using the

               8 word "categorical" as though it was a bad  thing.  It's  not

               9 bad.  It's a good thing if it's done the right way and I think

              10 troublesome if it's done wrong.

              11             MR. TOOMEY:  I wonder is I couldn't appeal to

              12 Dr. Hell to change his motion to allow for 2.5, 2.7 and 2.9

              1 3over a period of three years.
              14             DR. SCIIMID@.:  I'll rule that out of order.  that's

              15 tampering with a notion and I won't allow pressure to be put

              16 on motion movers.
              17             We have a substitute motion if you would like to
              .18 move a modification, a substitute motion, that is

              1 9            MR. TOOIIEY:  I would so move.
              20             DR. SCIIMIDT: All right.  !-fake a motion..
              21             MR. TOO@IEY: I would move that the amendment be
                 modified to change the amounts specified to two and  a  half
              22
              23 million the first year, t.7 the second year, 2.9  the  third

                 year.
              241
  -e-eal Reportefs,  Inc.
                             DR. SCH!,IIDT: All right. We have  a  substitute
              25





                                                                                    53

                I motion on the floor that     is now a motion to arnencl,,  two  five,

                2 two seven and two nine.
                3               MR. TOOMEY:  May I add    to  that  motion  then,  also
                4  with  this, that advice be sent to the ITU.IP not only as regards
                5  the resolution  of  their  problems  with  the  university  and  the
                6  resolution of the selection of a coordinator, but that attention
                7  specifically be paid to establishment of objectives which
                8  would support  their  goals  and  that  the  project  selection  be
                9  given  particular  attention'and  that  concern  be  directed   to
                10 the needs of the periphery.
                11              DR.  SCHMIDT:  All  right.  I'll   accept   this.   On
                   the  Executive  Committee,  unfortunately,  I  have  a  lawyer  and
                12
                13 he would point out   that your amendment is really a substitute
                14 for the substitute   motion and  I'm  stretching  it  a  little  to
                   accept that as an   amendment, but  we  did  it  yesterday,  and  so
                15
                16 I'll be consistent.
                                DR. THUW,IAN:   That's  right.  Consistent   in   being
                17


                   wrong.
                18
                19              DR. SCHMIDT:  Now, so we're speaking to the
                   amendment to the substitute motion which is two five, two        seven
                20

                   and two nine.     Dr. Luginbuhl.
                21
                                DR.  LUGINBUHL:  ilellf  it  strikes  me  that  we're
                22
                23 beginning to close in on some agreemen6.
                                Th e one issue that I-have  rais(-,d,  and  I  really
                24
                   haven't heard discussed, is the question of a site visit at the
                25





                                                                                    54

                1  end of the year'and just in the interest of moving things
                2  along, is that  a  dead  issue  or  is  there  any  sentiment?  Could
                3  we see if  there's  any  sentiment  in  the  group?  And  if  there's
                   not, I think we can drop it and proceed to settling the
                4

                   financial que stion.
                5
                6                DR. SCII@IIDT:  All  right.  Anyone  who feels that
                   the program   really should  be  site  visited  within a@year, raise
                7

                   your hand.
                8

                                 (Show of hands.)
                9
                                 DR. SC11r,IIDT-. All right then.  The  majority feels
                10
                11 that probably  they  need  good,  strong  advice  saying  that  we'll
                12 The out in a year  to  lookIat this and so on.
                13               All right.  Let's keep now to the motion on the
                   floor.  Are   you ready for the question?
                14

                                 DR. BRINDLEY:  Question,
                15
                                 DRo SCIIMIDT:  All right then.  We're voting on
                16
                17 the amendment to the substitute motion.  All in favor, s      ay aye.
                                 (Chorus of aves.)
                18

                                 DR. SCIR.IIDT:  opposed, no.
                19
                20               VOICE:  No.
                                 DR. SCllt,.III)T: The amendment carries.
                21
                22               (Motion carried.
                23               DR. SCIII.IIDT: We'll vote  on  the  substitute  motion
                   Ithen which i.s really kind of silly.  All in favor, say aye.
                24i
  "Ce*tal Repofters,  Inc.       (Chorus of ayes.)
                25







                              DR. SCHMIDT:  Do you understand that we're

               2              VOICES:  No.

               3              DR. SCHMIDT:  The motion was amended.  Now, we have
               4 to  carry  the main motion which we really just voted on, which

               5 is.two   five, two seven and two nine.

               6              VOICE:  So you.-have to vote negative then.
               7              DR. SCHIIIDT:  It's the same thing as yesterday.
               8              DR. LUGINDUHL:  We voted to amend the motion @arid

               9 now we're voting to pass the amended motion.

              10              DR. SCHMIDT:  That's correct.

                              DR. TIIUMIAN:  Question.

              12              DR. SCH14IDT:  All in favor,, please say aye.

              13              (Chorus of ayes.)

                              DR. SCHMIDT:  Opposed, no.
              14

              15              (Motion carried.)
              16              DR. SCHMIDT:  All right.  I believe that finishes

              17 us then with Intermountain.  Mr. Toomey.
              18              MR. TOO@IEY:  May I suggest, also, because the
              19 kidney funds in this project require earmarking, I thin),- they
              20 also require a separate motion; that is, that the sum of
              21              DR. SCHMIDT:  The kidney dollars are included in

                 that   figure.
              22
              23              MR. TOOMEY:  They are included, yes.  They need an
                 earmarking.' C an @.7c (lo -- Do You want a motion on the
              24
  ,e    I Repoitets,  Inc. earmarking or is it necessary?
              25







                              DR. SCliMIDT:  I don't believe it's necessary.

               2              MR. TOO@IE-Y:  All right.  They are earmarked.

               3              DR. LUGIIIBUJIL:  I-Ihere do vie stand on the record


               4 for a site visit?

               5              DR. SCIIMIDT:  Ile stand at:the review committee is

               6 recommending a site visit in one year.

               7              All right.  Thank you.

               8              I really feel that the discussion eias very, very

               9 good and important '-We.111 move on then to Maryland, and

              10 Dr. Ancrum.

              11              Well, do you want a break before we co in to

              12 Maryland?  Maybe we should.   We'll take a fifteen-minute break.

              13 Now I'm going to have to tighten up on time.  Ten thirty, we'll

              14 start.

              15              (Recess.)

              16              DR. SCIIMIDT:  Okay.  If we take our seats, we'll

              17 begin.

              18              The Governor of the State of Maryland gave a state

              19 of the state message yesterday, so iielve heard about that.  We

              20 will hear about the State of Maryland TV.IP.  Dr. Ancrum.
              21              DR. ANCRUII:  Well, just for a little bit of the
              22 background on the Maryland -@IP.  It covers the State of Maryland
              23 with the exception of Montgomery and Prince George County.

              24 Ilo@,:ever , it 'includes '..'ork Countv in Pciinsvlvani a,
  ceo,al Reportefs,  Inc.
              25              It has' a population of slightly over 3,000,000 with
                 I                    -




                                                                              57

                  70 percent of the state urban and 81 percent Caucasian residents.
                              Baltimore is the major city of the state and it
               2
               3  has a little,bit over 100,000 population.  All the other cities
                  in the state have less than 100,000.
               4
               5              For the health statistics, their  mortality  rates
                  in heart disease, cancer and stroke is lower than the national
               6
               7  average as well as deaths from all causes.
                              In health manpower and facilities they do have
               8
                  two major medical schools: Johns,Hopkins  and  the  University
               9
              10  of Maryland, both located in Baltimore.
              11              They have 25 schools of nursing awarding the RN
                Idiploma, 20  schools of nursing for LPNS, four schools of medical
              12
                  tec;iiiiolo(jy, t%,.,o !II          16 -Ln rad-,-ologic technology
              13
                  and one in physical therapy.
              14
                              For health manpower  they have 5,725 MiD.s,
              15
              16  approximately 10,000 RNs with about 50 percent of  them  being
                  inactive. Although there were 900 LPNs  with  about  one-third
              17
              Is  being inactive, they do have a complete range of  health  care
                  facilities including acute, long-term and extended care
              19
                  facilities.
              20
                              And I talking to the mike?
              21
                              VOICE:  You're all right.
              22
                              DR. ANCRUTI:  For a historical profile of the
              23
                  region, the Maryland M.IP was awarded an initial planning grant
              24
  -Clio al P@eportclis, ltic. in January of 1967 an(". was approved for operation in i,larcl-i of
              25





                                                                               58


                1 1969.
                2             This is a region that has had many concerns
                3 both to the national council,    the Rl,',P staff and the reviewers
                4 since about 1968.  The major concerns have been their lack
                5 of moving toward regionalization and also a lack of coordina-
                6 tion of the various projects of the program.  And there's also
                7 bc-,en concern about the program being co-opted by the  medical

                8 school.
                9             Upon receiving the second year  continuation
                10 application, due to the many concerns that were raised, there
                11 was a site visit made in May of 1970.   And this is the
                121 same concern existing from 1968 until 170, these being
                13 primarily the ones that I mentioned:  the absence of satisfactory
                14 outreach to the extent that the program was known as the

                  Baltimore program.
                15
                              There was an an absence of cohesiveness between
                16
                  the project program staff  units,  projects  and  programs  and
                17
                  there was no visible evaluation of the various programs.
                19            Also, their application  was  primarily  futuristic
                  in tense, and the RAC-, was predominantly a Baltimore based and
                20

                  controlled U.G group.
                21
                              A second site visit was made in Decem]Der of 171
                22
                23 and, at that time, I Has also one of the site team members.
                24 At that tin.c, there @,@,is still, most of the concern that had
  ",;*,ral Reporters,  Inc. been expressed early still present; namely, that it was a
                25






                                                                             59

               I  predominantly Baltimore based-activities for the programs  in
               2  the community and, also, for the medical school.
               3              There was an absence of a data base to substantiate
               4  the new program directions. At that  time,  the  application
               5  did contain goals and objectives based primarily on the
               6  new mission policy that had come out, but there  was  no
               7  way to determine how they went about establishing these goals
               8  or objectives or what base they had used to determine at'least

               9  what they needed to do.
               10             There was still a lack of  activities  being
               11 extended to the other regions other  than  Baltimore.  .
               121            Also, the ep idemioloqy and'statistics  center  was
               13 providing very little information to help them in making
               14 decisions. The PAG group still was  not.functioning  as  the
                  primary -- providing very much leadership in the program
               15
               16 problematic decisions or pointing out overall  goal  and

               17 strategy.
                              These were the major things I came  up  with during
               18

                  the 1971 site visit.
               19
                              Since then, in September of this year,-tlie  25th,
               20
               21  they-did have a review verification visit and also on the 26th
               22  and the 28th, a management survey visit.
               23             In summary, the verification was approved  at  a
               24 minimum standard and there ,.iere several recommendations made,

  ,ce -eral Reportefs,  Inc.
               25 primarily the ones that they' should be consistent in  their






                                                                              .60

                 I review process,-also in the management site team to    the

                 2management survey visit, I mean to say, the  major  thing  that
                 3 came out of this was that it was not an effective  management

                  ystem for carrying out the program.
                 4 s

                 5           The area advisory group had not taken on the

                 6responsibility for direction of the program.  Also, the program
                 7stiff lacked consistency an@, also, lacked a central direction

                 8and control of the funds.

                 9           -There were several    I'll@holdithe-recommendation

             10  now and I'll go on to about their application.

             11              In their new application, their  overall  goal  was

             12  adequate as far as the written statement.  They  sort  of  used

                             'dolines of the new mission  policy;  namely,  that
             13  zlgain Lne gui

             14  they would cooperate with other health groups, try to increase

             15  the availability of care, enhance the quality of care and work

             16  toward the reduction of cost of medical care.

                            Also, th eir objectives as written would  assist  to
             17

             18  accomplish these goals, these being primarily to promote and
                 demonstrate innovative delivery, assessibility, efficiency
             1   9
             20  and effectiveness type of programs, to stimulate and.support
             21  activities to help health providers to give better bare and to

                 also more effectively utilize available servicest and they would
             22

                 encourage providers and enable reg4lonalization of  facilities.
             23

                            Their priorities were, number one, N-7,-ts to increase
             24
       spotters, Inc. the assessil-)ility of health services to the urban underserved
             25





                                                                                  6 1

                I  and then those in the  rural area,  Number  two  was  to  increase

                2 Ithe availability of service.    Three was to work towards the

                3 prevention of disease.  Fourp    to help with the distribution

                4 of health services, and, five,    to improve the quality of care.

                5              In their new application there was still no

                6 indication as  to  what  they  used for a data base to define
                7itheir  goals  and  objectives,   or also the  process  for  what  was

                8 determining  that  these  were  the goals and  objectives  for  t  e

                9 program.
               10              In  the  area  of  accomplishment  and  implementation,

               11 they,have divided their program 3.nto three major areas.
               12 one being in health data and evaluation.  Number two being
               13 --.Iannc-vlcr development aitc! continuing communication. And  three

               14 being health care delivery.

                               For the progress report for the health manpower
               15
               16 development and continuing communication, I might add just

                  briefly, too, that these are sort of set up into three autonomous
               17
                  units so  that you do have Dr.  Ilerber-E  heading  the  department
               18
                  'or the unit of health manpower development and continuing
               19

                  communication.  And between March 171 and 172, they did
               20

                                               ne which is  based  at  the  Baltimore
               21 'initiate four projects.  0
                  City Ilospital on the management of   intestinal stomas.
               22
               23              The objectives for this   program was to provide
               241 teaching in sclf-care to patients.    And  between  June  and  this
        1 Repotters,  Inc. 1,I)ast November, they liaC. seen 430 patients.
               25 -





                                                                            6 2

                             The goal number two was to train  intromastal
               2 therapists, and for this, they  had 35 -- for this group, they
                 had 35 lectures and seminars.    And Nuriber B. they also had
               3
               4 individual teaching programs with all the 430 patients.
                             The third objective was to develop an audiovisual
               5
               6 pabkage which would consist of slides and brochures, books
               7 and et cetera, and a T.V. program, and this is also in the

               8 process,
               9             The second program  that was initiated was a drug
              10 information center.   This is a program that's aimed at giving
              11 information to health providers to reduce drug reactions in
                 prescribed medication.
              1 21
                             The third project that was initiated  was  the
              13 one on continuing education for non-Iletro primary  health
              14
                 care providers.  And, here, this particular program had not
              15
              16 been implemented yet, but they have completed the  survey,,
                 determined whit the needs were in the area  of  continuing
              17
              .18 education for the health care care providers in  the  non-
                 mettopolican area, and they have formed a regional educational
              19
                               'ttee which-has reviewed the survey data  and
              20 planning comnLi
              21 are now in the process of planning the actual program.
              22             The fourth program was the preparation  of  the
              23 nurse pediatrics practitioners with the University of Maryland,
                 and here again, they h,-tve recruited the faculty, have establ.ishci
              24
  ce 0111 Repotters, inc. Iconmittees and have developed all aspects for the curriculwn.
              25





                                                                                63

                               The'projected plans for the health manpower
               2  development and  continuing  education  division  --  continuing
               3  communication division is  that  they  have  recruited  additional
               4  qualified staff and they have written-several proposals
               5  to be implemented during the coming year.
               6               They also have a research  and  survey  analyst  to
                  do further  information gathering for program development.
               7
               8               The overall new programs that they have       in total,
               9  th6y have proposed six new programs;  four  which  will  be  in
               10 the Baltimore area only ai-id.only  two  addressing  themselves

                  to the outside region.
               12              The two that will  concern the  total  region  will
               13 be  a  kidney program- and organs  procurement  and  preservation,.
                  program, and the other will be the emergency care -- I'm sorry.
               14
                  It's the hospitals discharge aspect data.
               15
                               They do have a continuing  program,  three  in  the
               16
               17 education or  quality  area  that'l  mentioned  previously.  In
                  the area of services  availability,  they  will  be  continuing
               .18
               19 two 111,10 type of programs and the nurse Dediatric      pediatric
                  nurse practitioner progrdnt for manpower.
               20
               21              For the health care  delivery  which  is  primarily
               22 the  core  or the RI.IP staff itself,, it was pretty  futuristic.
               23i In   summary, they said they had been seeking funds and gathering
                  data but that-in the future, they will be putting more
               24
  @ceioal Reportefs,  Inc. emphasis on programs in  the  non-metropolitan  and  rural  areas,
               25






                                                                                6 4

                I and they plan to work with the. new ),,AG and II 11 explain'  about

                2  the new organization of RAC-, d little later,,  and also the

                3 policy planning information committee and that they will

                4  assist in implementing the inter-society commission on heart

                5 disease resource report.

                6              Maryland was quite a difficult application to go

                7 through. It came out in three  volumes  and  I  have  a  friend

                8 whose theory is that if you can't convince them, confuse

                9 them, and I think they were trying to confuse me at points.

               10              The other one, volume number  two,  was  from  the

               11 epidemiology and statistical center, and they did quite a
               12 Idetailed report and analysis  of  25  studies.  Thirteen  were
               13 evaluation s-tudies, twelve which were programs that were no
               14 longer being funded by JU-IP, and ten that was  to  be  related  to

               15 data information,
               16              Hoxrever,, most of them were not  geared  toward  data
               17 that could be used for planning  for  future  programs,  but  I

               18 thought they were very good research analyses.
               19              They"also  project  doing  three  additional  programs
               20 in the coming year.  One will be on the medical emergency
               21 service,  One to'study the survivorship and quality of care,
               22 and this will be based on  previous  studies  done  upon  heart
               23 disease,  cancer and stroke patients treated  at  various'types

               24 of hospitals.
  ce    I Reporters,  Inc.     it's 'lanned for more or less a longitudinal type.
               251                  p






                                                                            65

               1 They're looking at a five-year-survivorship.  The third one

               2 will be the effectiveness of a coronary care unit-and," here

               3 again, this is'sort of a long range.  They mention that there

               4 was quite an increase in the number of tCUs  throughout  the

               5 State of Ilaryland and so they plan to study 'the-pattern of-utili7_i

               6 tion of these coronary care units and then compare the
                                            1
               7 experience of the current use with what had  occurred  several

              .8 years before  that.
               9             one  of the other criticisms of the  previous  site
              10 visit was that  the RAG was not providing the  leadership  it

                 should for  program decisions and that there were a  lack  of
              12,lregional and minority representations on it and, also, on
              13 the major committees.
              14             They have improved in getting members  from  other
              15 parts of the state onto the RAG other than from the Baltimore

                 area and they have also increased their  minority  renresenta-
              16

                 tion.
              17
                             They have also restructured the RAG so  thit  in
              18
              19 the future, it will be able to take more of a leadership role
                 in the decision making an  in program planning.  Ho@4evcr, this
              20
                 restructure did not occur until September and  they've  only had
              21
              22 one meeting.  So at this state, it's hard to tell just how this
                 will come out, if they will be able to move  into  playing'a
              23

                  ore prominaint'role in guiding the program.
              24
  L'Oal Repoftets,  Inc.     But they did create a ten-member Fxecutive Corimittee
              25





                                                                               6 6


                  which will be m@eting                                    a
                                         monthly and the overall,,the  tot  1  RAG
               2  lwill be meeting less frequently. They felt  by  doing  this  --
               3  this was a recommendation they got last year -- that with the
               4  meetings being less frequent, then people  in  other  parts  of

                  Maryland could participate in the RAG.
               5
                              They have also created a health manpower and
               6
                  development and  continuing  communication  committee.  This  is
               7
               8  a 14-men@b6r committee which will be looking  at  data  related
               9  to the needs for health manpower and continuing communication,
               10 also reviewing the projects.for this area and making a
                  recommendation to the RAG for their implementation.
               121            They also have an epidemiology and statistical
               13 ladvisory coiiu'nittee which is a 13-member committee which will
                  be serving the same type of function for the epidemiology
               14

                  and statistical center.
               15
                              The policy planning  and  formation  committee  will
               16
                  be assisting in wor king with the director of  the  program  to
               17
               .18 developm implment and coordinate  and  evaluate  the  programs.
               19 They will Also be looking at the data  that's  gathered  by  the
                  epidemiology and statist@-@bal center to he used  for  decision
               20
               21 making aboul- the program.
               22             The core staff, as I said  earlier,  there  are  two
               23 major functions that I was able to pull out from their
                  application.  They have participated in a second P-londay series
               241
  cee'al Rcportets, Inc. @.7hich is one of the programs they had continued from a couple
               25





                                                                           67

                 years that's been successful with getting in some participation
               2 from people in other areas besides the Baltimore area, but it's
               3 been centered primarily in Baltimore, and that they will  be
               4 seeking funds and also working out cooperative  arrangements

                 with other health facilities.
               5
               6             To try to summarize this a bit, the principal
               7 problems was that -- also from the staff observations --
                 was that there is inadequate program development by the staff,
               8
               9 except for that Monday series, they seem to have done very
              10 little other work in getting any programs implemented.
              11             They seem to sort of wait until somebody in either
              12 the University of Maryland or Johns Hopkins or maybe somebody
                 in the city will come to them with a proposal and they  will
              13
              14 fund it.
                             And also the communications and the monitoring
              151
              16 of these programs have not been very effective.
                             Another thinc is that the committee structure,'-so
              17
              .18 far, Ins not been used in program development. It  is  their
                 ,olans from their-projection, againt that a new structure will
              19
              201 help to facilitate the comlmittee's function in this.area.
              21             Nuriber three is the productivity of the epidemiology
                 and statistical center.  flere aqciin,, as I stated earlier, they
              22
                 have done some very good research analysis.  However,  their
              23
              24 reports and their data have not been geared toward trying to
  ceifil Repofteis,  Inc. get data to help them 1--o decide what type of program to have
              25




                                                                                 6 8

                  or to say to go out to  approach  other  agencies  to  point  out
                2 a need and what  type  of  program  might  be  effective.  It's
                  been purely more of a research thing that would be just
                3
                  general knowledge for anybody.
                4
                               The other thing  that,  with  this  research  center
                5
                  this is going back,  I  had  trouble  trying  to  keep  separate
                6
                  what I was reading nolq and-iqhat occurred  last  year  on  the
                7
                  site visit.    The two seemed very close, and I could observe
                8
                  very little progress in  this  past  twelve  months.  It  was  like
                9
                  1 was reading the same application all over again.
               10
                               But when this came up in the site visit last year,

                  the team did recommend that  since  the  center  was  acting  as
               12
                                       rps@@rch and data center for liopi-,ins,  that
                  more or I e-z.-,;
               13
                  they looked at maybe  extending  their  services  on  a  fee-for-
               14
                  service basis to other  parts  of  the  country  and  to  become
               15
                  more self-sufficient.
               16
                               There wasn't  anything  listed  in  the  application
               17
                  about them getting any  additional  income  or  any  plans  for
               .18
                  getting any sources of  funds  to  keep  the  operation  going.
               19
                               The focus of  the  program  still  remains  pretty
               20
                  much    Baltiniore-city oriented. As I  pointed  out  earlier,,  of
               21 1
                  the six neii Programs that they  are  proposing,  four  of  them
               22
                  will be @fbr the Baltimore city area only.
               23'
                               One'of their major  proarams  that  they  are  working
               24
  ice  at Rcportets, Inc on is for the develo--,i@nt of an liliO znd, here again, I  didn't
               25





                                                                                 69

                I quite understand what ha'pened.%,7ith  this  program  when  it
                                            p

                2 came up last year and they asked for funding, they wanted

                3 over a hundred thousand dollars for this program.

                4              Their objectives were  not  in  the  proved  area

                5  that RMP  was funding.  They wanted money to not only look
                6  at possible quality.in monitoring  but  they  also  wanted  funds
                7  to establish a financial system and this type of thing.
                8  And this program was reduced in  funding  to  allow  them  to
                9  carry out the part that would  be  approved  within  the  overall

               10  RIIP objectives,
               11              They resubmitted the  same  program  and  they  still
               12  maintain the six objectives they  had  from  the  year  before.
               13 I don't know if you want to go into that now,
               14              Another problem  is  that  the  coordination  and
               15 direction of the program staff activity by the program
               16 coordinator is inadequate.  Here again, I said they have like
               17  three  separate  units.  The  epidemiology  and  statistical.
               18 center is a part of the School  of  Hygiene  and  more  or  less
               19 f uncti.ons completely autonomous f rom RI-AP, including  having
               20 their budc                                    hat-not handled
                            .jets and all their requests and w
               21  by the School of ilygien, and the coordinator of the M"-IP not
               22  being aware or knowing anything  about  their  budget  or  it's
               23  just the final reports that he gets from them in the end or

                   about their st,-iffinc     ngs of this nature.
               24                       T, tlii

       al Repot-ors,  Inc.
                               Also with the manpower and development unit, altliouc,-
               25





                                                                                70


               I  D3:,. Jlerbert reports to him, he-hc-is pretty much complete
               2 autonomy for the direction  and  development  of  that  particular
               3 unit. So there-is very  little  correlation  between  the  health

               4 data that's coming out of the l@' and S center or the evaluation

               5 of on-going projects or an interrelationship between the
               6 health manpower development unit and  the  health  care  unit,  so

               7 that everything is just like three separate programs.-
               8              Also, as I alluded to a  little  earlier  and  maybe

               9  someone  els e can pick this up a little bit better, is that

              10  the physical management is either minimal or nonexistent.

              11  This is from the overall management,  by  the  business  manager

              12  of the @?,4P unit.

              13              Maybe I should stop here and let      I have two

              14  backup reviewers,  and you can go from there.

              15              DR. SClitIIDT:  Okay.  Joe?

              16              DR. ITESS: I don't have a  great  deal  to  add.  I

              17  think  she's pointed out the major features.  I would just
              18  reemphasize that as I reviewed  this  application,  that  there

              19  are three, possibly four, major problems which I saw.

              20              one was the lack of  systematic  regionvilde  assess-
              21  irlent'of needs ind leadership by the Maryland Regional  iledical

              22  Proqram in developing now projects.
              23              As,mentioned, they seem  to  wait  until  something

              24  turns uT-) and then     look at it.
  .Ceo-lal Repoitefs,  Inc.
              25              Second is the lack  of  leadership  involvement  by





                                                                               71

                 the P-AG.  They appear to be, according to the reports, almost

                 totally dependent unon the technical revi.ev7  committees  and,
               2

               3 since, the RA(, almost becomes a rubberstamp.

                              DR. SCIIIIIDT: Could you speak up just  a  little.
               4
               5 The stenotypist can't hear you.
                              DR. HESS:  Okay.  And the third point was what
               6
               7 appears to be ineffective u'se of  this  extensive  epidemiology
               8 and statistics center. Now,  theoretically,,  one  would  think

                 this is an unusual resource;  Most regions don't have the
               9

                 talent, nor are they expending the money that amounts to
              10
              11 something like $166,000 a year going into this E and S
              12 center.  And somehow, it's not having much payoff in the
                          itself thus far, although they do  indicate  that  they
              13 program
                 have now appointed a  committee to start digging into this
              14
              15 data and see how they can begin to utilize it.
              16              But it seems to me a rather late date to be
              17 thinking about this,
                           .  Then some question about the effectiveness of the-
              18
                 mini-contract or feasibility study  mechanism  as  it  has  been
              19
                 used in the past. Now, this  may  change  in  the  future.  But
              20
              21 in looking over what has been used,, it seems to me that in many
                 instances, at least it's been the source of funding when people
              22
                 get in a tight snot, when money is running out from some other
              23
                 source, so that I think, the management of that  aspect  to  the
              24
  ,@eleal Reporters, ljic.
              25 program is another.area which needs tightening up and tends to





                                                                               72

               I  reflect some of the  looseness of the management program.
               2               I will just comment on the renal disease proposal.
               3  This does  look like a sound proposal.  It's had the-appropriate
               4  technical review as part of the state  plan  and  Dr.  Roberts
               5  in the.local review here felt that it was satisfactory so that
               6  1 have no questions about that'particular aspect.
               7               DR. SCII@IIDT: Okay.  Let's see.  Bi@ll?
               8               DR. LUGINBUliL: I had a great  deal  of  difficulty
               9  with this application. It  is  a  well-written  application  and
               10 it is hard to know whether the  changes  claimed  are  actually
               11 changes in fact or whether it is simply a good job of
               12 Imp_rchandising, and I gather from the other reviewers who have
               13 had some on--tl-ie-scene experience with the program, that  it

                  may be the latter rather than the former.
               14
               15              I think the problems have  been  well  stated.  The
                  progress that they claim in  the  application  centers  around
               16
                  the revitalization  of the RAG with the appointment  of  a  new
               17
               18 chairman and vice chairman that the RAG is now assuming
               19 programmatic decision  responsibility,  that  they've  appointed
               20 ?Ome subcommittees and tlat these are beginning to.work.
                               I honestly have no way of  telling  whether  these
               21
               22 claims are true or not. I think that  it's  fair  to  say  that
               23 the application does not show any product of this revitaliza-

                  tion.
               24
   0.11 Repottefs, Inc.        The projects that are listed are quite  limited.
               25






                                                                                    73

                 I              I don't  think  that-tliey  are  terribly  imaginative

                 2 or broad, but I honestly can't judge whether there may be

                 3 changes in the offing.
                 4              They claim that  they have made substantial
                 5 chan-?,es. I would be very  interested  to  hear  from  members  of
                 6 the staff that have visited this program as to whether things

                 7 have changed in fact.

                 8              I must admit that I'm suspicious because the

                 9 coordinator has been on the scene now for several years and
               10  it would seem  to me that if he had the ability to bring
               11  about change,, it would have occurred before this time.
               12               DR.  SCHMIDT:  All  right.  Staff  comments  at   this

               13 point?
               14               GEORCE HINKLE:.  I might start out at the beginning
               15  and clear up a couple of points that Dr. Ancrum brought up.
               16               DR. SCHMIDT:  Slide the mike a little closer.
               17               GEORCF, HINKLE:   I don't think it will.
               18               One of Dr. Ai-icrum's concern had to do with the
               19  Project Number Thirty -- can't get it any closer.  It won't

               20  stay-

                                DR. SCII'14IDT: Just speak up.  I-?e can hear.
               21
               22               GEORRE HINII,LE.  This will do it.
                                It had to do with Project Number    36  which  was  an
               23
                            je-t. It was s,@,-)onsored N.Yith Johns Hopkins university.
               24      Pro
  ,eoral Repofteis,  Inc.
               25               Last year, council and committee were both concerned






                                                                              7 4

               1  about the type 'of activity they said they were looking for
               2  RTIPS to support.  We didn't think it was within our prerogative.
               3              During the negotiation session,-the MRPM

                  personnel brouc
               4                 Tlit in a more detailed application of what
               5  they were going to do under that project.
               61             Dr. Farrell of the HI-10 up in the DPTD, he  looked
                                             1
               7  at the detail and he determined from looking  at  it  that
               8  they had some items in there  for  administrative  support
               9  systems.  Those are the things I think Dr. Ancrum was referring
               10 to, and also for some pharmacy patient profiles.
               11             All of these, the expenses related to these two
               12 items had to do with computer cost and amounted to about

                  $27,000.
               13

                              So based on council recommendation,  we  told  them
               14
               15 they could not support those type activities.  They concurred.
                  We reduced their funding for that project by about $27,000.
               16
                              Now, as the application comes in this time, it
               17
               .18 comes in exactly -- the narrative is exactly as it was  before.
               19 It-doesn't give enough detail to really interpret what   they're

                  talking about.
               20
                              Also in their co,-qDuter support areas, after  last
               21
                  year's reduction, they reduced the computer data processing
               22
                  support request from, down to $21,000.  This application they've
               23
                  jum-ped it back-up to @41,000, almost another $20,000 increase
               24
  .kc,*,al Reporters,  Inc. which is almost what we reduced them last time.
               25





                                                                            7 5

                             So it could be, they've put these things  back  in

               2 but our advice letter specifically said they could not

               3 support them,  It could be they're moving into other areas.

                 I don't know the answer to that. But we have made  a  note  to
               4

               5 make sure that they're still aware that t ey cannot suppor
               6 this patient profile studies and the administrative support

               7 systems.
               8             DR. SCHMIDT:  All right.  Dr. Ancrum, would you

               9 dare to make a recommendation.
              10             DR. ANCRUM:  I had trouble with this.
              11             DR. SCHMIDT:  Well, there's always a moment of
              12 Itruth.
              13             DR. ANCRUM:  Well, they'ke still applying for
              14 triennium and I wasn't sure what they were offering for a

                 program.  They were still ready.for a
              15
                             MRS. SILSBEE:  Last year, the action was for
              16
                 tiqo-year support, and this is the last year of that  two-year
              17
              18 support.  So this is just one-year funding that they're
              19 requesting.

                             DR. ANCRUM:  Oh,, okay.
              20
              21             GEOR(-',E IIII-ll'%LE:  Dr. Ancrum, may I make a statement.
              22             Last year,, if you recall, initia lly the site
                 visitors only recommended one-year support, and we  felt  that
              23
              24 they -viouldn't'have suf-4ici-ent,time to do all we v7anted them to
  ,;@0.1 Repoiteis,  Inc. do so we made it two years.
              25






                                                                             76

                              DR. ANCRUII:  Two years.  I'm getting my numbers

                2 mixed up .

                3             They were, for two years, and they've also

                4 requested an increase of funding over %%?hat was recommended from

                5 last year.
                6             They recommended that they stay at one million
                                            1
                7 two nine four for the two years, and they're requesting

                8 one point four million.
                9             And as I said,'Ilve had trouble seeing any real
              10  progress or any change in their plans from the year beforet
              11  and I would recommend that they stay at the same  level  as
              121they were this year to see if they can  make  s.ome   progress
              13 during the second year4
                              DR. SCHMIDT:  All right.  Then the recommendation
              14
              15  is for a level of funding with advice, obviously.

                              Dr. Hess.
              16

                              DR. HESS: I will  second  that  recommendation.
              17
              18  I think the major points of advice were made in the  Deceml)er
              19  follow-up letter,from the management survey, but I  think the
                  language could be stronger than what was in that advice letter.
              20
              21              DR. SCHMIDT:  All right.  Dr. Luginbuhl.
              22              DR. LUGIIIBUIIL: Let me ask staff three  simple
                3 questions   Is the coordinator any good?  Is the RAG actually
              2
              24  taking leadership with the now chairman -incl vice chairman, and
  ice0eral Reportets, liic.
                  have tlaev done what they were told last year?
              25





                                                                                 7 7


                                DR. SCllj'.,IIDT: I'll refer that to Dr. Ancrum.

                2               DR. ANCIKIJ' V7ell, for one thing, Dr. Davens

                3 has been   there, I believe, since the summer of 171.  This


                                -ive
                4 region  did  h@

                5               DR. LUGIIIBUIIL: 170.

                6               DR. ANCRTP'I:  170.  All right.  They did have quite

                7 a bit of trouble keeping  a  coordinator.  He  was  the  fifth,  I

                8 believe, from since they were started in 169.

                             "My impression from meeting him last year was
                9

               10 that I thought he would be  a  good  coordinator.  As  I  said,  I

                  haven't seen very much progress froim-the application during this
               121past year.
                                Also with the RAG,, here again, the recommendations
               13
               14 went out to them the first  of  the  year.  They  didn't  do  that

                  restructuring until September, so that they haven t had a
               15
               16 chance to really  function  in  this  new  organizational  pattern
               17 yet-  SO whether or not it can i,.Tork,, I don't know.

                                Their application, the one the year before and
               18

                  this one have both been very, you know, in the f    uture.  They're
               19

                  always, "I-le will do it i@-tl-ie year coming up,"
               20
               21               Now, I don't know ho@T much longer we  want  to  let
                  them go saying that, "Iie will do it next year,ii  or  if  we  can
               22
               23 give them some stronger advice that,  you  know,  "Do  it  now  or

                  else."
               24
  'Cleral riepotters, Inc.      DR. SCIlt-III)rl.':  Dr. Ellis,
               25






                                                                                  7 8

                                DR. ELLIS:  We have been talking about opportunities

                2 for really developing programs for minorities and I did not
                3 hear here that there  was  a  relationship  viith  the  Provident
                4IHospital which is  one  of  the  few  remaining  supposedly  good
                5 black hospitals that has possibilities for growth, and I just
                6 wanted to bring this up as a point of information.
                7               1 think that Baltimore is  one  of  the  cities  in
                8  the country with a tremendous number of problems in the
                9  minority areas; high death rates in many areas, and, yet,
               10  they do have a core of people who can work together in 'a
               11  fairly good relationship between the races in some areas,
               12  and I just wondered if the Provident Ilospi,tal. people have been
               13  brought in at all to,this RAG and who are the -- and where is
               14  the thrust for the IIMO?  Is it only in the east side of
               15  Baltimore or are they going  to  the  northwest  as  well  where

                   this  hospital  is  located?
               16
                                DR. ANCRUM:  Provident Hospital, per se,, was not
               17
               18  m6ntioiie@.'- Their thrust toward the minority has been primarily
               19  with an HIIO type.of a group that's been developed there.
                                Can you help  -me out with the name?
               20
               21               GEORGE,HIIIKLE:  Maryland Health.  They have the
                   Maryland Health Maintenance Committee, Incorr)orated, which is
               22
               23  doing the evaluation for their IILt-10.  There's one in east
               24  Baltimore TI,ILO 'that's referred to.

       al Report.,is, Inc.
                                DR. ANCRU.1-1:  East Baltimore,, yes.  That's Johns
               25





                                                                           79


                 Hopkins.  Pardon?

               2             DR. ELLIS:  Johns Hopkins?
               3             DR. AIICRUti:  So they have been helping with two
               4 fl@,10 groups and sort of an ambulatory care facility.  Provident
               5 Hospital was not mentioned but these have been their two
               6 major thrusts with the health service area toward minorities

                 and the other one is planned for the educational components,
               7

               8 two at Morgan.
                            .DR. ELLIS:  One other comment.  I was  just wondering
               9
              10 how different the statistical information that's being given
              11 now from -- I suppose,it's from Dr. Tabbetts office, that the
              12                           s differs from, the regular information
                Ischool of hygiene, how thi
              13 i.,-hi li the City of Baltimore, in its board of health, has
                    c

              14 been collecting over the years, and if this is not an a tera-
              15 tion in plan to help support an.office which has been     with
              16 people who moved out of the health department into this

                 Particular office.
              17
                             DR. ANCRU14:  Here again, the only thing that
              18
                 the application or the E and S report alluded- to was that they
              19
                 did do quite a detailed study on throat cultures that  have
              20
              21 been-run by the health department, using rheumatic fever as an
              22 indices, to see if there had been a change over time  which
              23 would prove that there had been an improvement in quality of

                 cc-ire .
              24
  ,@ee,al Reportef s, Inc.
                             The most of their work has been very laure research,
              25





                                                                                 80

                I  more so than sebing how it v7as.going to  relate  to  what  they

                2 were  going to do.
                3              DR. SCIIMIDT:  Mrs. Flood.

                               MRS. rLOOD: As  I  look  over  the  materials  and
                4
                5 hear the comments, I get  the  feeling  that  it's  a  Missouri
                6 mule that's already been hit with a two-by-four instead of
                7 Maryland and they still do@'t listen.
                8              This application reflects  26  percent  of  their,
                9 project dollars going into  data  systems  as  reflected  by  the
               10 printout and it just  doesn't  jibe  that  with  their  reduced
               11 funding as that clout that they've  been  given  to  get  with  it,
               121they still come back  with  an  application  reflecting  this  much
               13 of their project dollars going into more data systems.
               14              DR. SCHMIDT:  Dr. Iless.
               15              DR. HESS: Just  to  follow  up  on  Bill's  question
               16 earlier, I  think it would be useful to have some comment

                  from the staff.
               17
                               The description on the site visit report of      the
               18
               ,glcoordin,itor for last year might be of some interest-.  It    sa@s:
                               "In the opinion of the site visit team, the
               20
                  coordinator, Dr. Davens, has provided a great deal of      leadership
               21
                  to the Re(ional 1--ledica.1 Program of Maryland. lie  has  been
               22
               23 extremely sensitive to  the  new  directions  of  Regional  Medical
                  Programs and has played a  major  role  in  terms  of  transmitting
               24
  ,@eetal Reporteis, Inc. these new directions to the Regional Advisory (,roup as well as
               25








                 other health-related institutions.

                              "It certainly appears that he has established a
               2
               3 %.iell-organized core staff and has given them the  professional

                 latitude to function in their areas of expertise."
               4
               5              They@were'favorably impressed by him on that  site
               6 visit, but I think there are broader issues that come up  here

               7 that we have to look at.
               8              one of them is the advisability of Johns IIopk'ins
               9 continuing as a grantee organization and, furthermore, the
              loirepresentation of the two medical schools in numerical
              11 representation and the influence that they have exercised
              12 on the IZAG, because v?hat I am saying is.. he may be a good
              13 man, lie may be in a next to impossible situation the way
              14 things are currently structured, so the other alternative
              15 we ought to be examining is whether the effectiveness of  this
                 coordinator might be strengthened by some change in arrange-
              16
              17 ment which would give him freedom and latitude to move,.
              18 because it,may not be entirely his fault.

              1 9


              20


              21


              22


              23


              24

  ce  etal Reporters,  Inc.
              25





                                                                               82



                                                                             -I the
                              DR. JA14FS: It seem., to me that we are  now  ii

               2 east coast of the country and the  most  developed  area.  IIhat

               3 is it known as? As  the  highly  developed  industrial  corridor

               4 of this country, and where, geographically, are located two

               5 very large and outstanding medical schools who have long

               6 traditions, especially Johns Hopkins.

               7              I wonder whether or not there may be some

               8  duplication of effort in the kinds of  demographic  --  no,.the

               9  kinds of collection of data which doesn't  really  meet  the

              10  needs of the people because of the predominance.  In other
              11  words,, Dr. Hess,, I@tliink- I w6uld-have'.to say yes to what you're
                  speaking of, primarily because you have  in  this  situation
              13 Johns TIopkins who has a long tradition  of  contributing  to
              14 technical developments in the area,  in  the  medical  field.
              15              It would seem to me that from what  I  have  heard,
              16  that most of the program is  predominantly  centered  around
              17  Baltiiaore while the rest of the state seems to  go  wanting
              18  so that a redirection from the hierarchy:or-from a.new approach
              19  from, say, just,letl---ing Johns Hopkins out of the picture, but
              20  jperhaps using another scarce as a grantee organization may then
              21  make-a picture more clear in terms of the kinds of material
              22  that is attempted to gathered that would  have  a  relationship
              23  to the needs of the people in the community  outside  the  area

              24  of Baltimore.,

       ial Repoftets,  Inc.
              25              Not stating,, however, and I'm not foregoing the





                                                                                83

               I  thought,liowever,  that certainly, there are probably unmet

               2 needs in the Baltimore metropolitan,district  as  it  is  in  all

               3  metropolitan and urban areas.

               4              Ilpi not suggesting that these problems be fore-

               5  gone.
               6              I think what I really am trying  to  say,  and  it's

               7  a little  bit difficult for me to put  it  into  succinct  words,
               8  perhaps the tremendous technical ability that Johns Hopkins
               9  already has, and with the availability of  the  work  that  they
              10  do do, maybe overshadows what an @IP might  do  in  a  community.
              11              In other words, I think that what we're really.
              12 Isayii-ig here is that there's so little progress being made,
              13 maybe one should look at the State of Maryland and to see

              14 whether or not our MIP is really needed at all in that

              15 community.

                              if it is needed in that  community  and  that  state,

              17  then it should be p ossibly centered outside the city of
              18  Baltimore, utilizing the two universities more or less as
              19  consultant services,  but to give them wider latitude in being
              20  more independent to develop a program  rather  than  depend  upon
              21  the strong influence coming from the universities.
              22              DR. SCHMIDT:  All right.  We do have recommendation
              28  then for level of funding.  It is obvious that the advice
              24  letter from,be'fore, and the advice being given  to  the  region,

        I Repoiters, Inc.
              25  must be given again a,-id given more strongly,, and even to  the





                                                                             84

               1  point of, you know, saying that you really should got out
               2 of this sort of a thing and, again, it's going to come up with

               3 at least one more area in which there is a kind of a one-year

               4 warning on this, and then I suppose going  back  and  looking

               5 at  it  again.
               6              DR. ANCRUII: Cotild'I add to the possibility  of
               7 what Dr. James said about @liem thinking of another grantee?

               8 That.'s one of the things I jotted down in my notes.
               9              DR, SCHMIDT:, Well, the other grantee  issue  is
              10 very, very difficult and I'm not -- I think that all a review
              11 committee can  do is to instruct the director of the
              12 Regional I-ledical Programs to take a good hard look at that.
              13              -But in this sort of a negotiation, I believe it's
              14 best conducted under the,careful auspices of the director
              15 of the program,, and I think that-this will be conveyed, that
              16 we are concerned about Hopkins and its interest being a little
              17 bit too limited for what is needed in the @laryland Regional

              18 Medical Program.
              19              1 think that the city of Baltimore is  in  great
              20 and dire need of a Regional liedical Program.  You go over to
              21 the eastern shore, and I know very well it is.
              22              MR. CTIN-IBLISS:  @lay I just inject here, the fact
              23 that this Pj,,P is in one of those so-called complex metropolitan
              24 areas.  This is an area that the IU-IP has had,, as we all know,
  cel*81 Repiftefs,  lt)c.
              25 great difficulty in operating.   It seems to suggest here that

                I





                                                                                    85


                I  rather than re,-illy gripping the real health problems that

                2 lie around it, it collects data.

                3               I'm wondering how we get at this fundamental

                4  problem. We need you to dig  into  this,,  to  show  us  some  new

                5  pathways not only as a staff  but  so  that  we  can  impart  this

                6  to the  PJ4Ps.

                7               Ile have been very concerned with the issues that

                8  you've been  touching on for some time here and your-discussion

                9  here is most needed.

               10               DR. SCH@ITDT: Well, before,  Bill,,  you  talk,,  we

               11  did, just thinking about yesterday, we can indeed, you know,
               121put a region on probation, number one,'and suggest to the
               13 region that the  concerns  are,  even  as  basic  as  the  grantee

               14 organization  and  that  these  things  must  be  answered  within

               15 one year or the total funding will be jeopardized and this is

               16 an approach that we kind of gravitated through.  Bill.

               17               DR. TIIUMIAN-. If  my  memory  doesn't  fa3l-me  too

              .18 much, we spent about  two  hours  last  year  oil  Maryland  around

               19 two  areas.  one of them v7as the 11@10 and the other was the B an

               20 S-

               21               And as I recall  the discussion, and certainly in

               22  r. Margulies advice letter,, the II!,IO bit,, we said forget, ill

               23 --ssence, and vou get the feel that it's  co:,,iing  back.  And  we
               24 .1s)@-ed for a lot better understanding ',,7ithi.n this one-year period
  Cel*31 Ricportefs, Inc. 1
               25  1r4 time of what E and S was really contributing to  Regional






                                                                                 86


                1  @ledical Progrc-ms in Maryland.

                2               So that even before you  had  the  opportunity  to

                3  speak, Mr. Chairman, that was going to be my comment.
                4               I don't feel that we can vote  yet  on  this  until
                5  we have a better understanding  of  the  continuing  impact  of

                   E and S on this PIIP.
                6
                7               Until we do that, I would be opposed to continuing

                8  level of funding.
                9               MRS. SILSBEE: Last year  after  the  review,  t  e
                10 powers that cane  into Rockville sat  down  with  Dr.  Margulies
                11 and staff to go over the advice letter and the advice, and a
                12 Ilack of the power structure coming in  was  from  the  Regional
                13 Advisory Group,
                14              The discussion about the E and  S  center  was  one
                15 in which it seemed, again, that they were on the verge -- the
                   data that had been co llected was superb,  the  base  line  data
                16
                17 that would help that Regional Advisory Group decide where they
                Is wanted the program to go throughout the state.
                19              And .1 think the issue at this point  ist  has  the
                20 Regional Advisory Group @aken advantage of that data and

                21 proceeded?

                                DR. SCII14IDT:  Joe.
                22
                                DR. HESS:  I'll have to confess.  I haven't read
                23
                24 everv nacre i.n'this vc)!.iime which is all E incl S data, but
  @CeO.,al Reportets,  Inc. several pages that I have reviewed, I would find very difficult
                25





                                                                                  87

                I in using that if I were on the-RAG because it  is  not  --  to  a

                2 large extent, it is not broken do,,.iii into geographical  areas

                3 or into a form that would be very meful  if  T  were  trying  to

                4 plan to define and then plan for the health needs of the

                5 region.

                6              And it seems  to Pie that there  is  some  conceptual
                7 difficulties underlying the gathering and the presentation

                8 of this information, and I think that's where..-- you know,, the

                9 technical skills are there but the conceptual rationale,
               10 just all whatever you want to call it, is lacking as it applies

                  to an JUIP
               121             MRS. SILSBEE: Ai-id there's no  evidence  that  the
                  Regional t@ledicil Program staff itself has done this translation.
               13

               14              VOICES:  No.  No.
               15              DR. IIESS:  You'd think if they were trying to
               16 impress us,  as the review committee  you  know  when  they  send
               17 this in, that  they would T)tit it in the simplest, most salient
               .18 form so that you could see clearly how you could go from,
               19 step A to B to C.,: but that just isn"t the case,  at  least  in
               20 my analysis.  I don'  t kndt4 what you thought.
               21              DR. AIZCRUlt,l:  This is what I meant when I said
               22 it's a very good research but it's more general as somebody s
               23 been doing a term paper or one who wanted general information

                  could use.
               24
  cel&i ReporLars, Inc.        I did-spend quite a bit of time on that report, and
               25





                  I don't  think  could use that.data as the way it's entered
               2  right now,'to really.use a base for making a decision within

               3  a local  area.

                               VOICE:  At least we did help you.
               4

                               (Laughter.)
               5
               6               DR. SCIlt.IIDT:  I've always felt a little bit
               7  anguished at Regional Medical Programs  in  metro  D.C.,  Virginia
               8  and   Maryland doesn't have a model RI-IP.  I was thrown out of
                  the St ate   of Virginia early on for even talking about it,,
               9
               10 and it's just too bad we don't have -- you kno@-7. you've got
                  to be able to point with pride.
               I 1
               12              DR. THUR14MI: If you crime back,  you'would  probably
               13 still be thrown out.  Not referring to you as an individual,
               14 referring to.the State of Virginia.
                               Then, on the basis of this  discussion  and  thinking
               15
               16 back to last year's discussion when  we  really  had  specifically
                  requested that the E and S information and support be
               17
               .18 directly related to the mission of T.-!P in Maryland and having
               19 some concern, again, I would not sl7>eak against Dr. Davens,
                  per se,, except to say that I'm sure that the advice that trickle-,,
               20
                  back-to Maryland, not being that far away, was reasonably
               21
                  good and we've seen little response to it.
               22
               23              I would offer a substitute motion specifically
               24 related to one of two -- no, that's bad.    I can't do that.
  kce*ral Reporters, Inc. I would offer a substitute Inotioii that we not continue level
               25






                                                                               89

                I funding but that instead, we cut them back at  this  point  and
                2 time with a site visit in the very near future  and  that  level
                3 funding be for no more -- that cutback- in funding  be  for  no
                4 more than a year so that the site visit can be accomplished in

                5 that period of time.
                              And that a specific component of  that  cutback  be
                6
                7 related to cutting back E and S until such time as its relevance
                8 to @IP programs within Baltimore and the remainder of Maryland

                9 could be demonstrated.
              10              DR. SClit4IDT:  All right
                              DR. TliUlVIAN: Everybodv has just reminded  me  that
              12 II did not give a level of fundii-ig,
              13              bR. SCHMIDT:   Right.
              14              DR. THUPJIAII: I've forgotten what your      Gladys,

                  what your recommendation was.
              15
                              DR. SCHIIIDT: Her recommendation is  one  point  two
              16

                  nine four nine six oh.
              17
                              DR. TIIUMAll:  Okay.  I would say then  if it's
              18
              19  one point three roughly, I'd say let's cut back to one point bh
              20  with the letter of advice and the intent to visit.
                              DR. SCIII-IIDT: All right. This  substitute  motion
              21

                  is  seconded.
              22
                              VOICE:  That includes the kidney.
              23
              24              DR. SCIT@l-L7--",T:  That would ;.nclude kidney?

      ei,,l Reportets, Inc.
              25              VOICES:  Yes.





                                                                             90


                              DR. SCIIMIDT:  All right.  Dr. Luginbulil.

                2             DR. LUGII,4BUIII,:  This program,, I think, poses a

                 very difficult dilemma.  I still don't believe my questions

                4have been fully answered.

                                                      'Regional Medical Program
                5             It seems to me that the

                6has three potential sources of leadership. one  is  in  the

                7staff and particularly in the coordinator.  The  second  is

                8in the RAG, and the  third is in the grantee  organization.

                              And ideally, all three are strong and are
                9

                 concerned and effective, but I think- that sometimes  we're
              10

                 getting by where only one is in that position.
              11

                              I'm concerned that in Maryland, maybe none of the

                ,three arc really sti:ung- concerned, well@organized.  Who's
              i3
              14 going to worry if the budget's cut back to a million dollart?

                 Who is going to take the leadership in changing the program?
              15
                              They've been warned before.  Pressure has been
              16

                 put on.  It  seems that not very much has happened.
              171
              18              MISS ANDERSOII:  Put them on probation.

                              DR. LUGINBUIIL:  Who is going to take this, "What's
              19

                 our level? What's our handle for  bringing  about  change?"
              20
              21              To me, this is an area that desperately needs help,
              22 not just outside of Baltimore, but within Baltimore-.  I
              23 xiouldn't even be bothered if the program were in Baltimore if

                 it were doing a good job. God knows that  their  needs  are
              24
   1031 Reporters,  Inc. there, but I don't see how we're going to aet a handle on this
              25






                                                                               91

                I at this point and time, and I still would like to have my

                2 question answered.

                               Is there strength in any of those three elements
                3

                  that we can  build upon to improve this program?
                4

                               DR. SCH@.IIDT: llell, I wouldn't like to  recycle

                6 this.  You know, you got as good an answer I think as the

                                              I
                                     d the thing and the staff could give.
                7 people who reviewe
                8              The coordinator seems to be good,  was  the  mean
                9 answer I would get.  fie has carried to the RAG the message.
               10 lie's doing vihat he can under the circumstances,, I would  guess.
               11 It's hard to go up against Ilopkins.
               121             one of the funniest things that ever happened in
               131the Regional fiedicil Programs happened in the early days of
               14 Hopkins when Tommy Turner was Dean and C-.' C.  Conrath  and  Elsa

                  and Rebecca went up to meet with the instigators of the
               15
                  program in'the august halls of Hopkins and  went  to  the  meeting
               16
                  room and opened the  door and there was  the  male  contingent
               17
               .18 led bv Tommy Turner sitting on the table,  and  around  the  table
                  and the three ladies -- this is early on  in  t@e  feminist  move-
               19

                  ment -- and the three lad-ies were told where the %,Yomen's
               20
                  bathroom was.  It was assumed they were looking for the bath.
               21
               22              (Laughter.)
               23              DR. SCIIMIDT: So they've come a  long  way  since

                 ithen.
               24
         Reporters,  Inc.      (off the -edord discussion)
               25






                                                                            92


                             DR. SCIII,IIIDT:  There is a motion on the floor,,

               2 one year  at one million --

               3             I-IR. TOO@IEY: I also am concerned just as Dr.

               4 'Luginbulil is, and I'd like to amend the motion, if I may,

               5 to SO  state tliit this WIP will be on probation for the period

               6 of one  year with the million dollar funding.

               7             DR. AIZCRUP-1:  I would second that.
               81            DR. SCHtlIDT:  All right.
               9             DR. LUGINBUIIL:  Could someone specifically comment
              10 ion this RAG. Ilas it been improved during the last year?
              11 lIs the new chairman and vice chairman,  are  these  people  an
              12!imrl)rovement?  Are they a base of strength?

              13             DR. SCIIMIDML:  Dr. Ancrum.
              14i            DR. ANCRUII:  I don't know, unless    the staff did
              15 make a management visit in September.   Whether  or  not  they

              16 met the RAG, I don't know.
              17             The other thing i@ that this restructuring only
              18 occurred  in September and happened like from January, and

              19 they didn  It do it until September.
              201            DR. LUCINBUI.I,L:  1,71ien they wrote the application?
                 I           DR. ANCRUI-1: Yes.  So that you don't really have
              21
                 anything that you could  really  evaluate  to  say,,  well,  they
              22
                 have a group that can work or cannot %.;ork,,  and  you  have  no
              231
                 @way of saying they licive done ai@.ytliiii(T excr-@i-)t to @-irite that they
              24!
      etat R,,portets,  liic.
                         e this reorganization,
              251'have mad






                                                                                    93


                 .1              MR. CIIA-IIBLISS:  Let me take just a  shot  at  your

                 2 question, Dr. Luginbulil, about the     RAG.

                 3               We did, in'fact, receive a letter from the coordi-

                 4 nator, I believe in the last ten days, indicating that a new

                 5 RAG chairman had, in fact, been appointed and that a new

                 .6 vice chairman  had,  in  fact,  been  named.

                 7               That vice chairman is the assistant administrator

                 8 of the hospital to which Dr. Ellis referred, Provident

                 9 Hospital.  That's a spanking new hospital serving the minority
                 jolcommuiiity at Baltimore and this  would  seem  to  indicate  that
                 11 they are aware or concerned about some of the key health issues
                 12 lin Baltimore,
                 13              Now,, as to the strength of  those  two  people  and

                 14 what they can do on an immediate basis    in keeping with the

                 15 status of this @,%Ip is  something  I  would think to be seen.

                 16              DR. SCHMIDT:  All  right.  We  will  vote  then  on'

                 17 the  move  to amend, which is to  add  the  probation  message  to

                 ]8ithem.  All in favor of that say aye.

                 19              (Chorus of ayes.)

                                 DR. SCIII.IIDT:  And opposed, no.
                 20

                 21              (1-lotion carried.)
                 22              DR. SCHIIIDT:  We're back then to an amended

                    ubstitute  motion which is one-year funding at one million on
                 2 3
                 24  robation, strong advice, a site visit soon.
  ,ce*tal Repottets,  Inc.       MRS. SILS13EE: I 6idn't quite understand when the
                 2 5





                                                                             9 4


                 si.te visit was to take place.

               2              DR. SCIIIIIDT: It was as soon-as-possible.
               3              DR. TIIUR-LAN:  If I might speak to that, I think
               41if    going  back to what iir. Chambliss just said, that they
               5 have a new  RAG,, maybe they're going to rattle the bag a little
               6 bit, then I'd be willing to put that off until such time as
               7 say, give them a year at.this one million funding with
               8 probation, but some time before a year from now, we'll be,
               9 looking at it again.  There would be a site visit.
              10              That's a personal opinion.  The rest of the

              11 committee may not agree.
              12              'DR. HESS: I would agree with that.  I think an
              13 early site visit
                              DR. SCII@ITDT:  All ric   We'll move  th  site
              14                                  _Tht.               e
              15 visit then.  Are we ready for a  vote then?
              16              IIISS ANDERS01i:  Yes.
              17              DR. SCHMIDT:  All right.  All in favor# please

              18, say aye.
              19              (Chorus of ayes.)
                              DR. SCIII-IIDT:--Opposed,, no,
              20
                              (Ilotion carried.)
              21
              22              DR. SCIIIIIIDT:  Okay.
              23              DR.           I think it's going to he most
                 1 interesting. to see lio,,-7 council handles review committee this
              241
  %Ce   I Reporwis,  Inc.I
                 itirie around.
              25






                                                                                95


                               DR. SCHMIDT:  Let's move on to New York Metro,

               2               The primary reviewer, Dr. Thurman backed up by

               3  Dr. Kralewski.   Dr. Thurman.
               4               DR. THUM.IAN:  Going back to what Dr. Scherlis had
               5  to'say yesterday, he visits and then coordinators resign.
               6               When they heard we were visiting, he resigned, so
               7  that I think that paints a little bit of the picture with
               8  which we were dealing.  We were fortunate in having Alex
               9  McPhedran who had been from the   council, who had been involved
               10 in the previous site visit, a very strong RAG chairman, an
               11 George Williams, Bill Grove  from  the  University  of  Illinois
               12 lwho is related to the same kind of  grantee  relationship  with
               13 the PIIP that was,,. at that time, existing in New York, and
               14 lastly, I..Lrs. Thieme from West Virginia MIP who handles  their

               15 fiances.
                               We were backed up by Bert Klineat the end of the
               16
               17 table, Waddell Avery, Bob Sha@i from SIIETI Region II, and again,
                  fortunately, for us, Ed Hinman was with us to discuss the
               18

               19 whole area.
                               I think that I'd break down the problems in'@
               20
                  metropolitan PIIP some@..71iat bv saying that we went knowing that
               21
               22 their entire program had just fallen apart so that part of
               23 our site visit was to see if there was anything salvageable
               24, and, if so, what kind of advice we could offer.

  kce-Fedeial Reporters, Inc.
               25              Historically, there's been a very poor grantee






                                                                             9 6


               I relationship in that the coordinate group of the medical

               2 schools in metropolitan New York had come together  to  serve

               3 as the grantee.

               4             This grantee had,  in  many ways, not related well

               5 to the RAG. As much as  we  could  make out, we did not meet

               6 the resigned coordinator, but  as  much as we could make  out,

               7 in many ways, had not related  well  to the coordinator.

               8             A clasiic example is outlined in Mr. Kline's

               9 cover letter in which following resignation of'staff professional

              10 in late 171 and early 172, the grantee actually said, "Don't

              11 recruit anybody to replace them."

              12             The second point  that  took much of our,time on

              13 the visit was that the grantee was totally unwilling to accept

              14 the new policy enumerated from PJIPS in Washington in reference

              15 to the RAG grantee policy relationship. The  feeling  was  so

              16 intense against that policy that a letter had  been  directed

              17 directly to the assistant secretary of ITEII asking for an

              18 exception and then 30 days prior to the time that we arrived,

              19 the grantee had more or less said that we want to  resign  as

              20 .3-rantee and they also requested that our site visit,be

              21 -lelavbd.

                             So that we came to the grantee in that kind of an
              22

                          nt and it did not improve, in essence, during the
              23 2nvironme

              24 time that i,7e were there.

      eral Reportefs,  Inc.
              25              Specifically, Bill Grove came to try to help in this





                                                                                9 7


                  readjustment   an.d re-relationship and I think that you'll
                2 notice in his report which is a part  of  our  report  that  at
                  the end of our meeting, he said.that we    should allow the

                4 grantee to go ahead and resign.
                5              So that despite the specific task which was
                6 assigned-to him, both Washington  and  by  our  committee,  he
                7 came to the conclusion that we  should  allow  the  grantee  to

                8 resign.
                               Second major problem, of course, was    in the
                9
                10 coordinator. In essence I  think,  speaking  for  the  entire
                11 site team in general, we had the  impression  that  this  was
                i2 la one-man show.  The deputy coordinator was not involved in
                13 decisions, fiscal questions as to how money was    spent, things
                14 like this were somewhat vest  pocket  operations.  I  do  not
                15 mean to imply that they were illegal  or  improper  from  the
                  standpoint of accounting, but were vest pocket decisions
                1 6
                17 related to his gut feeling  about  what  should  and  shouldn't
                18 be supported.
                1 9            He had a poor relationship,  in  general,  with  the
                20 RAC,,. They were not involved in  the  decision-making.  process.
                21 He chose what to tell .them and what not to tell them.  And he
                  also requested that the site visit be delayed.  And when that
                22
                231 did not come about, he resigned eleven days before we arrived.
                              'Th(-- more i,ou heard about him, the more I kind  of
                24
  @ce9fat Repofters, Inc. expected him to jump out of a closet with tails ind a liorn.
                25
                . I





                                                                                 9 8


                               it just didn't work out  that  way  while  we  were

                2 there.
                3              Speal@ing to the third problem which was with
                4  the RAC:,, we had a very interesting chairman  of  the  @G  who
                5  had just accepted -- despite the problems that I've
                6  enumerated -- had  just  accepted  reappointment  as  chairman:
                                              1
                7  strong, interested, basically didn't understand the rules of
                8  the game as related to RMPS in a way.  Ile wanted every cc-nt
                9  possible of federal money for New  York  City  and  its  health
               10  problems and looked at RTIP money not so much as developmental
               11  or conduit money but as actual-(Iollar-spent money to help

               12  deliver health care.
               13              Ile didn't realize the depths of the problems
               14  within their brain organization.  Ile had never become involved
               15  in their turf problem, which I'll speak  to  in  a  moment,  to
               16  any  qreIat degree.  He did not recognize the staff's attitude
               17  and the staff's difficulties.  Ile had been kept somewhat in
               18  the dark by the- coordinator without really realizing it himself.
               19              Ile had not been included in the communications from
               20  Tt'.IPS here to the organization, and all of this -- and yet I
               21  still say that he's a very strong individual*  He was running
                   the RAr, and he thought he was running his relationship to
               22
               23  liew Yorl: Metropolitan MIP much as he had run his corporation

                   in the -past,
               24
  "Ceetat Reporters,  Inc.
                               He his president of the board and I think that if
               25





                                                                                                9 9


                   I  there was one useful thing that came out of our visit ind
                   2  the feedback session associated with it, it was that I think
                   3  we chanaed his perspective in what the RAG should be and

                   4  how  it should be involved.
                   5                  Another  weakness of the PAG in general, that
                   6  despite ',,Iew  York,, Iletropolitan I-lew York and all of its
                   7  problems related to minorities and their cares and concerns,,
                   8  there's minimal consumer and minority involvement on the.
                   9  board.   I thin],. that this is partly again the reflection of
                   10 the attitude of the RAG chairman in feeling that there Niasn't
                   11 much need to.really involve them because everybody understood

                   12 that IU-IP was out to help them.
                   13                 I'm not'so sure that everybody understood that,
                   14 but that was his feeling and there was minimal involvement
                   15 and all through our relationships with TCPS, review process
                   16 and everything else, it became clear that they often
                   17 considered minorities and consumers to slow down the process
                   IS of helping the people, rather than having them involved.
                                      But.I would again strongly emphasize that the
                   19
                      present RAG chairman is a very strong individual who is
                   20
                   21 educable  and 1-7clS very receptive to the feedback situation,
                   22                 The RAG used to be much larger than it presently
                   23 is.   It's presently 52 people.  lie believes that you can use
                   24 a 52-man PA<', as .i fui@r-tioning body and,although he somewhat

           Reporteis,  Inc.
                      denies it, the priorities and screening committee, in essence,
                   25





                                                                                100


                  is servincT @is'an executive committee because  lie does not
               2 want an executive cor-nittee in that  sense  of  the word.
               3              In reference to goals and how decisions are
               4  made, they've established their goals as three:    health care
               5  services, health manpower,  pool  improvements  and the quality
               6  of care. And they  made  this  decision  reasonably early,,'and
                                             I
                  the great majority of their Projects li@ive sin ce  been  directed
               7

                  toward  those
               8                Ioals, and that's worked out reasonably well.
                              They established, in the early  days  of  WIP,  their
               9
               10 R!@P because- this program  was not established until 1967.  But
               11 they established early, technical consulting panels i-7hicli were
               12 Imade up not  onl.v of individuals from medical.schools but
               13 also from practicing physicians in the City of 14e@.7 York who
               14 have particular expertise in a given area.
                              These panels were excellent, obviously most of
               15
                  them initially i.iere categorical, but as the  mission  statement
               16
               17 lbecame available to New York Tietro M-IP, they developed other
                  TCPs along the lines of  the mission statement.  So  that  they've
               18
               19 been touch @,7ith,the times in that sense of the word.
                              The one thing that they didn't do and that has
               20
                  hurt-them consideral3ly,, as far as visibility and acceptance
               21
                  in the community as the mission of RIIP chancre, they did not
               22
               23 bother to inform the TCPs related  .to cancer, liecirt disease
                  and stroke, and ,ie ran into some very, very bitter individuals
               24
  @cceral Reporters, Iiic. from the TCPs in -rayincT that they'd heard nothing from lietro
               25





                                                                                 101


                   for several years.

                               So that it was this kind of a hard feeling in the
                 2
                 3 medical community and in the consupier-related  corT-,iunity.
                 4             I think that  they've  done  reasonably  well  on
                   their TCPS, in particular, and also  in  their  RAG  in  having
                 5
                   representatives of other than physician-related providers
                 6
                 7 involved, and this was particularly  true  in  the  TCP  statement.
                 8 But the gist was zero communication,  and  again,  I,  and  not
                 9 only myself, but others felt that part of the zero communication
                   with the LTCPs,no longer functioning and --ictive, was that the
               10
               11  coordinator just decided he didn't need them anymore, didn't
               12 lwant to disband Ithem for fear of hurting their feelings, so
               1 3 he just clidn't talk to them.
               14              As the new staff came  on,  nine  of  the  twelve
                   staff were within four months of our arrival there, they did
               15
               16  not understand the situation  either  and  they  didn't  bother
               17  to go back and try to relate old  TCPs  to  new.  Some  of  t-he
                   new TCPS, particularly related to ambulator care improvement,
               18
               19  were rehashing or did not recognize  it,  but  were  rehashing  old
                   projects that had been tlfbught of bv the categorical TCPs and
               20
                   no one was relating the two TCPs to each other.  Until we got in
               21
                   the room, some of them didn't even know what the others were
               22
               23  doing, so that the site visit survev served that purpose.
                               .And, again, I N-ioulcl emphasize that these TCPs  have
               24
  cee"t Reporteis,  Inc. done their job quite well. Some of them --  and  this  was  going
               25





                                                                             10 2


               I  on while vie viere there  the respiratory TCP v7,is right in the
              .2 middle of a study evaluating needs throughout the entire I-letro
               3 area and they had continued to do this, some  of  them  without

               4  RMP  support.
               5              Gradually, the TCPs have moved away from the
               6  medical schools and have become more community based and,
                                            1
               7  again, as I said before, they have a very broad base of

               8  representation of  TCP s.
               9              TCPs are actively involved in the  review  process
              10  and what happens is that a letter of intent is directed to
              11  the priorities screening committee which is a committee of the
              12  RAG and.. in essense, is the executive committee in many  ways
                  of the PA(-,, -tlicit letter of intent is evaluated by the
              13
              14  priorities and screening committee as to good or bad.
                              If it's bad, they siy, "Don't bother  utting up a
              15                                                    p
                  qrant application."  And if it's good, the staff member is
              16
                  assigned and then a grant application is actually N-7ork-ed
              17
                  through with the staff member.  It then goes to the TCP for
              18
                  its reaction.  The ar)plican-L is in the room with TCP (luring
              19
                  discussion of his application and then is excused at the end.
              20
              21              sometimes that has fallen down in that  he was
              22  excused at the end,  tIhe decision that was negative was made
                  and he wa s never informed. But in other  instances,  the  TCPS
              23
                  have been ccirelul to i-.nforri Iiirl if things didn't cTo
              24
  lce*tal Reporters, Inc.     The TCP aT)nroves the idea.  It then goes to the IZ7@(',,
              25






                                                                                  103

                   is presented bv the  TCP  chairman  in  general.  So  that  there's
                2  a very smooth and well functioning priority relationship and
                3 relationship to the TCPs that have     laid out  fairly  good  plans

                4 f or !@letro
                5               Speaking to the  staff  problem,  as  I  indicated,
                6  -nine of  the twelve were new.  Unfortunately, again, the
                   resignation  of the coordinator just  before  we  arrived.,  put
                7
                8  the staff   in the position when we walked in the door of
                9  polarizinc for and against  .the man who was actinc
                             'T                                        _T coordinators
               10  and  again, we were  often  asked  to  adjudicate  disagreements
               11  in the  two days that we were there between the members of

               1 2 the  staff.
               13               And I think that all of  us  were  of  the  opinion
               14  that  there were some. talented people on the staff.  I think
                   the  future direction of Iietro RZIP may require that  to  some  of
               15
               16  that  staff be said either, "Cet with the policy or get out,"
               17  because the polarization was quite noticeable to all of.us.
                                The morale is quite low as one might expect.  In
               18
                   the proposal before you, thev have requested several new staff
               19
                   Positions, particularly   beefing up the evaluation area because
               20
               21  that-is one of the weaknesses that they had in the past.
                                The other thing that was  noticeable  to  us  as  a
               22                                                                  site
                   team was that they have not used  their  staff  in  the  areas  for
               23
                               ,.ier(-         at ti@-,i-eq.  But ac-@ain, I think that
               24
  ilce*ial Reporters, Inc.
               25  partly relates to-the rapid  turnover  in  that  one  person  never





                                                                                    10 4


                   knew i-7hold be in the next office the next day       So  that  that's

                2  created some problems.

                                 1 think, again, that the   relationship to the

                4  acting coordinator is most important     and, certainly, will be

                5 very   important in reference to retention of the good people
                6 of the staff if they don't too quickly polarize aqains       t him.

                7                They have a tur.1 problem not  unlike  tir.  Toomey  has

                8  discussed in that .1lletro R!-IP covers all five boroughs or

                9  counties of New York Citv and three upstate counties.

                10               one of the five  borouqhs  of  New  York  City,  for
                11 those of you who are not familiar with the metropolitan area,
                12 lone of the five has always felt    it's never been a part of
                13 anything and it never developed a level of civic pride.  That's

                14 Queens.
                15               The Bronx, it was entirely different.      Brooklyn's
                16 always been   very different.  But the Queens has always felt
                17 left out of   everything, and  we  really  walked  into  that  one
                18 in that, in   essence,  anything  that  someone  proposed  for  health
                19 care delivery pr'ograms in Queens, it was medical school related,
                20 created a mediate problem  because  Queens  has  been  pushing  I-lard
                21 to get a citv medical school in     Queens itself.     So that they
                22 arqued back and forth a fair amount about "What are you going

                23 to do for Queens>"
                24               And the vi-ce cli@ii'r,-icin of the PAc, is  one  of  the

  %ce - ,a[ Repottefs,  Inc.
                25 IT)ror)one-nts of telling Queens what to do, and  this - has created






                                                                                105

                I  some real problems,  But at the session with the RA(,,, the

                2 representative of Queens was there and, in essence, he

                  reflected the feeling that Queens h  ad been left out and they
                3
                4 hoped to be involved but theNy didn't want to be told what to

                5 do medically.

                               I think the unstatO counties have also felt
                6
                7 somewhat left  out, that the P@IP dollars. Here primarily directed
                8 to metropolitan problems.  Th  ere's been a change in attitude
                9 by the coordinator before he resigned in that he was beginning
               io to activelv look toward the upstate counties.  But there
                  still was a feeling of being left out,  which  was  reflected  to
               1 2jus several times.
                               -The last,problem,-- not the last, but the other
               1 3
                  problem that iip, 3an into that was terribly  concerning  to  some
               14

                  of us was the whole business of  the  finances.  The  money  goes
               15
               16 to the grantee and then from that point on, the man wliols
                  business manager of the grantee is also business manager of
               17
                  @IP and they are switching money back and forth to pay    for
               18
                  X number of hours that he's working for each.'
               1 9
                               The accounting.certainly was all right, as indicated
               20
                  in the management assessment document available to you, but
               21
                  the man who was responsible for the money did not have a primary
               22
                  feeling that he belonged to anybody and lie kind  of  floated  in
               23
               24 )3c-@t@,7een aiici.lie often vestll)oc)retecl from the standpoint
   0   tat Repottets,  Inc. that.sor@.iebody, particularly the coordinator,would pass him  in
               25





                                                                                106


                   the hall and say, "I think that it's a good idea for    X to
                2 receive $48,000. Issue him a letter of award  and  set  up  an
                3 account." And that's kind of the way  things  were  going  and
                4 this  was a terribly good man. Several of us  spent  a  lot  of
                5  time with him, and he desperately wanted to be included in iiIP
                   and not in the grantee, but he had never been  able  to  work
                6

                7  that out.
                8              Because he had no authority on either  side  of  the
                9  fence, one of the major problems with fietro WIP  has  always
                   been that they had tinpT)ent monies, and nobody knew where the
                10
                   monies v7ere until the end of the accounting period and there
                12 was no attempt to try to switch them to other areas.
                               With the,financina situation, one  of  the  major
                1 3
                14 concerns has been that the impact of the new,, thrust'of New York
                   Metropolitan TIIIP had been too much directed toward  renovating
                15
                   out-patient facilities in a series of  hospitals.  And  the  man
                16
                   at the accounting level was very concerned  about  that  because
                17
                   he didn't feel that he could necessarily  justify  grant  funds,
                18
                19 as lie understood.tliem, to renovate ambulatory facilities.
                                So that T think that's a general rundown  of  the
                20
                21 problems as we saw them when we arrived.  The vice      chairman
                22 of the PAG promptly laid us out by saying that lie,understood
                23 we -,,.,ere there to look at the problems of Ilex.; York !.Ietropolitan
                   T@,14P and there'i.iere no problems. And so that he didn't  really
                24  '
        ral Reportets, Inc. understand why we:i.,?ere there. That i-)ut us off to a very  good
                25





                                                                              107


  6             I start,, and from there on, I think that we served  the  purpose,

                2  primarily of listening which, in essences, was psychotherapy

                3 because they all needed it.

                               I think that our evaluation of the  projects  as
                4

                5 presented, there was no increase with any great degree requeste,,

                6 in core staff and office expense, but they  were  asking  for

                  additional monies for contracts and grants.     They've  used
                7

                8 the contract mechanism a lot.

                9              Just to give you a feel for the fi'gures, and  I

               io will not make a recommendation at this point and time,. for the

                  period of Januiry 1, 172 through 12/31/72,  a  one-year  period,
               121they were funded for $2,235,000.  For A subsequent one-year
               13 period, they're requesting $3,310,000, so that  this  is  the

                  level at which they've been operating and, again, I would
               14
               15 emphasize that they  have related their projects well  to  their
               16 previously accented  and established priorities.

                               the type of projects, such as the Bronx manpower
               17
               ,8 consortium,  where they are trying to find health care delivery
               19 people of an entirely different type from the  usual  to  attack
                  the health manpower problems in the innercity, that-%,ias well
               20
               21 structured to i.ihat the. priorities were and how they were
                2 accented.
               2
                               Siriilcirly, the improvement in ambulator care, which
               23
               24 the -LCP on cimb'lllatory care was trying to idOrc-!sr, in a meiiiinqful.
  kce*eial Repotteis,  Inc.
               25 i.' ,-iy and had related their priority structures to the PAGT from





                                                                                  10 8


               1  that standpoint, is reflected in the projects that are

               2  suggested for funding.
               3               So that despite  this  long  list  of  problems  and
               4  despite the  internal stress and strain that has been in
               5  New York Metrol-)olitcin PJIIP for quite a while, they have
               6  continued.to move toward the goals related to the mission

                  statement and have moved reasonably well.
               7
               8               1 could certainly not defend the quality of some
                  of the T)rojects well, but again, as far as extending themselves
               9
                  to meet health care needs, the  I-letropolitan  New  York,,  they
               10
                  certainly have moved toward that quite well.

                               Prior'to'recommendation, I'd like to have the
               12

                  others comment, if they would now.
               13
               14              DR. KJZALENISKI:  I'll  keep  my  comments  limited.
                  I haven't visited this  program,  either  this  time  or  in  the
               15
               16 past, so my comments are from the grant application and the
               17 things that I could glean from that application are far.
                  outweighed by the insights brought back by the site team.
               18
                               Suffice it to say, I think this is another
               19
                  candidate for our receivership kind of approach.
               20
               21              I think. in looking at the projects,thcit they show
               22 some promise. I think  in  looking  at  RAG,,  they've  got  some
               23 real  talent on the Regional Advisory Group if they can bring
                  that  til.ent-toqeth(-r F%nd if tl-iev can get someone to  assume
               24
   lei Reportets,  Inc.
                  the  leadership, and I think there's some good talent on the
               25





                                                                                 109


                   program staff, the way:it would appear.
                2              In many ways, you know, the RAG is large but, again
                   if they  get it organized pronerly, I think they can turn it in-
                3

                   to great advantage.
                4
                5              I suppose that a program such as this, with so
                6  many problems that they had, in a way,  it's  an  advantage  for
                                              I
                   them to have evervone resign as they're doing and have a
                7
                8  chance to restructure the whole  thing.  I  think  our  question
                9  now is, how can we help the m do just that?
                               With that all, I'll cease and desist,
                10
                               DR. TIIUPJIAII: @ir, Chairman, I would like to  have
                12 ltlr. Kline comment if he might because he's been very much
                   tied un in their problems.
                13
                14             DP,. SCIITIIDT:  Bert.
                15             MR. KLINE: I think I can  lend  very  little  to  the
                   report  that Dr. Thurman gave.  I may give an update if that
                16
                   might be  of any interest.
                17
                               There was concern, as Dr. Thurman indicated, on
                18
                   the Part  of the.i-)roqrim staff who inherited Dr.  Aronson,  the
                19
                   previous deputy,  as the interim-direCtO2.-, and there was  this
                20
                   polarization; however,  in the past,tliree to four weeks, there's
                21
                   certainly evidence that Dr. Aronson has  grabbed  ahold  of  that
                22
                   staff and resolved some of the internal problems.
                23
                               116     cc,..7.e up with a reorcTc-inization,, internally.
                24
  @ce*lal Repotters, Inc. Ile has given each-orgz,.nizitional function a description of
                25







                                                                             110


                I what it is he expects and it's'quite clear and to the  point.

                2 Ile has (
                         .Tiven each individual an assignment and, all of a

                3 sudden, the internal turbulence seems to be dying off.

                4             Dr. Aronson, again, .. somewhat different from

                5 his predecessor, is beginning to relate to the Regional

                6 Advisory Group, the CPPE ar)d other important aspects of  the

                7 program.    Ile is also somewhat different from his predecessor

                8 from the standpoint that he is beginning to make  decisions.

                9 lie's beginning to find out where the dollars are, iqhols got

              10 them.  If they're being spent,- if not, why not, and beginning

              11  to reprogramming and rebudcieting within, and h(--Is doing this,
              12 Ifrom where T see at least, in a reisonablv,.effective @,7av.
              13             Since-the site visit, there seems to  have  been  a

              14  significant upturn, if you will, in terms of what the program

              15  is currently doing.  Popper, the RAG Chairman, who is identified'

              16  by Dr. Thurman as a.point of strength, has come here  to  MIPS

              17  headquarters and has pursued a number of issues to, if you

              18  will, educate himself and also to speak very  specifically  to

              ig  the new grantee and some characteristics and to  explore  this

                  wi.th some people here and to get some help.
              20

              21             So all things looked at subsequent to the site

              22  visit have been, to my way of thinkinq,;leastwise, very

                  ,positive showing,  I think a positive impact of the site
              23

                  isit.
              24  v
  !-Fedetal rieporteis, inc.
                             I think that both  lir. Popper and Dr. Aronson  are
              251






                1  beginning verv firm,-positive movements.
                2              DR. SCliMIDT:  Okay.  Thank you.  Dr. Thurman.

                3              DR. TIIUR?IAN: Thank  you,  Bert.
                4              I think there's one question that still has not
                5  been resolved and that was one we were just discussing.  That's

                6  the resignation of the grantee.
                7              Despite all of the problem-. that  we  found,,  their
                8  request is on the left-hand side  of  the  ch art up there,
                9  $3,310,000 for the year beginning 1-tay 1.
               10              Our committee came  up  with  the  recommendation  of
                   $710,000 for office, have drav7n lines through the $100,000
                   for development, basical ly, and then operating monies of
               12
                   $lt2OO,OOO.  So tha@ we are recommending -- I would move that
               13
                   we anprove for them, assuming that the grantee situation
               14
                   will be resolved to the satisfaction  of  PIIPS,  $2,010,000  for
               15
               16  the period relay 1, 173-April 30, 174.

                               DR. SCIII,"-.IDT: John.
               17
               18              DR. I'RALrV7SI,'I: I  second  that.
               19              DR.,SCH@IIDT:  All  right.   Then we do have a notion

                   that's seconded.        Anderson.
               20
                               IIISS A14DERSOIJ: Bill, do  those crossed  out  lines
               2 1
                   mean you're going to disallow the developmental component?
               22
               23              DR. l'IRA-flER: No. It's just that, in  my  mind,  in
               24  reference. to the discussion yesterday, I don't think       ]@novi
  ,ce- eral Reporteis,  Inc. what developmental component is anymore, so that
               25






                                                                                  11 2


                                @IIFS ANDERSON:  okay, so if I add that, it would

                2 make nine.    It makes 19.  You put one million nine if you

                3  don't include it.
                4               DR. THUITMAN:  Yes.  It'll  be one point nine.  I
                5  just put those lines there because our site team, basically,
                6  recommended $100,000 for developmental component and I thought
                   that I ought to reflect that and then we'll just have to
                7
                8  decide     not "we." Someone  has  to  decide  what  happens  to

                9  developmental component.
                10              IIISS Alql)ERSOII:- Are they actively recruiting  a
                11 new coordinator, do you know?'
                12              DR. TIIUPIIAII: I can't answer that,  active   recruit-
                13 ment of the  new coordinator,  The committee was       lir. Popper,
                14 who is chairman of the RAG, told us that he would have      a
                   committee as soon as he  had  the  opportunity  to  get  back
                15
                   together Niith- all of his other people.
                16
                17              MR. KLINE:  The only information    I can lend.along
                18 that line is that the steering committee of the grantee and
                   the Regional Advisorv Group have met since the site visit, they
                19
                20 have appointed a search corimittce for a new coordinator.  It
                   consists of two members of the outgoing grantee, if you will,
                21
                   and three key members of the Regional Advisorv Group, including
                22

                   Tir. Popper.
                23
                                DR. SCIT!.ITT!T:  I was just cl,-iri,fvi-.ic  status
                24                                                    f,, th e
  4c    jal Reporters,  Inc. of the developmental. I,.le can, indeed, approve $lDOtOOO  of
                25






                                                                               113

                I developmental funds.

                2              Well, I gather my overall question  was,  is  there

                3 anything there salvageable. And  the  overall  answer  is,  yes,

                4              DR. TIIUIUIAN:  Yes.  I think that i.@e're hanging

                5 our hat on 1.1r. Popper and a staff that's  reasonably  good,  a

                6 deputy coordinator who has become  acting  coordinator  who  may

                7 seriously have difficulties if  he  doesn't  become  coordinator

                  in readjusting to the svstem.
                8

                9              If I had to guess, I guess he would   resign.

                               But I believe it is salvageable.  I   think that the
              10

              11 loss of the   grantee is going to be to their advantage, and
              121any number of times several of us had one meeting with the
                  deans of the-medical schools, separate from everybody else,
              13
              14  both in that meeting and in other public meetings  came out

                  over and over that the New York medical schools would
              15

                  continue to support RIIP in every way  possible  and  contribute
              16
              17  to it and their departure as grantee should )De in no way.

                  construed-as a desertion of R@IP in Iletro New York,
               .18

                               DR. SCIIMIDT:  All right.  Are you ready for the
              19
                0 question?
              2

                               VOICE:  Would you repeat that,please.
              21
              22               DR. SCIIIIIDT:  The motion then is for approval at a
              23  one-year level of1 $2,010,000 brol:en down as you see it on the
              24  board:  seven ten, core; one, development;  and  one  point  two
  ,..*1 Repotters, Inc.
                  recom@mended for project.
              25






                                                                                11 4


                               DR. LU(,Il,.'BtJIIL.  I'@hy are we breaking this one


                2 down?

                3              DR. SCIIIIIDT:  I'le really aren't breaking it down.

                4 Th,-xtls just in order to understand the level.  So it's at

                5 two zero ten.  But it's helpful in understanding, explaining

                6 the rationale  for  the  amount.

                7              If no one wishes the floor then, all in favor, please

                8 say ays.

                9              (Chorus  of  ayes.)

               10              DR. SCIITFIDT:  And opposed, no.

               11              (notion   carried.)

                               DR. SCIIIIIDT:  All right.  Thank you once again.

               13              Is it the  wish  of the con, mittee that we break
               14 for lunch at this point'or would you like to go ahead?
               15              The cafeteria closes, I understand, at 1:30.  They
               16 usually run  out of pumpkin pie about tct to one, and they run
               17 out of salad about five after one,  They run out of other

               .18 goodies about one fifteen.
                               Joe,,,Ihow long are you going to I)c- with Tennessee
               19

               20 tlid-South?
               21              DR. HESS:  Very short.'
               22              DR. SClirIIDT:  All right.  He'll move on to
               23 Tennessee !.Iid-Soutli and if we have to break for lunch, we will,

                  before they run out or pilmpl@in Die.
               24

         Repoitets, Inc.
               25              DR.  HESS:  I  think this can be possible taken care




                                    I    of  rather  quickly  because,  ordinarily,  this  region  is  in
                                    2   triennium  and,  ordinarily,  would  have  been  handled  only  by
                                    3   SARP,,  except  that  there's  been  a  little  change  in  funding,
                                    4   in  the  allocation  of  funds,   and  there  was  not  previously
                                    5   awarded  a  developmental  component  authority  and  that  question
                                    6   has  been  raised

                                    7                       And  then  the  second                  issue  has  to  do  with  the
                                    8renAl  project  in  this  application  so  that  what  I'll  try  to
                                    9do  is  just  to  summarize  in-a  very  general  way  my  impression
                                    10 of  what's  gone  on  and  what  the  issues  are  and  then  I  think
                                    11 Dorothy  can  supplement  that,                       and  then  if  we  have  to  answer
                                    12 further  questions,  we  will  try  to  do  so.
                                    13                    This  region  includes  the  eastern  three-quarters  of
                                    14 Tennessee  and  the  southern  !)orders  of,Kentucky.    It  is
                                    15 currently  completing  its  first  year  of  triennial  status  and
                                    16 this  is  entering  into  the  second  year.
                                    17                   A  number  of  suggestions  were  made  as  a  result  of
                                    18 the  triennial  review.    There  has  been  a  number  of  visits  to
                                    19 the  region  or  review  process  verification  with  site  visit  in
                                    October  171,  anniversary @eview  in  '71,  and  then  a  management
                                    20

                                    21 assessment  visit  in  172,  and  out  of  these,  a  number  of
                                    22 suggestions  have  been  made  and  most,  if  not  all  of  these,
                                    have  been  complied  with.
                                    23
                                    24                  So,thcit  iiliit  I'm  trying  to  s,a@,  is  we're  not  dealing
               Rer)orters,       Inc.
                                    25 with  a  Missouri  mule  here.    Tie're  dealing  iiitlat  what  at  least






                                                                             116

                Iappears to be, a response of  region. And  the  assessment  by
                2the staff anniversary review  panel has been basically
                3favorable in terms of their response and the  way  things  are

                4go I iig.
                5             I would like to see if we could go to  the budget
                6questions and just point out for you what the issues are.
                 If you'll turn to the budget sheet which is the third pac
                7                                                           fe,
                8you can see that in the  current year, 05 year funding, there
                9was $385,000 that were used for contracts.  Part of that has
              10 qone into developmental component.  There's  a  little  increase
              11 in program staff. But, really, it's a  sort  of  a  different
              12 lway of using developmental component.
                              They are approved at the level of two  point  three
              13 eight million.  They're only requesting two point one six  six
              1 4
                 which is the same as theA!.r current year. It seems to me  t  at
              15
                 this was a prudent kind of management decision  and  gives  me
              1 6
                 confidence that they really had a handle on what thby're doing
              17
              18 and that they're trying to use their money wisely and effective-
                 ly.
              1 9
                              The kidney project was submitted at  $176,439.   On
              20
              21 the basis .of the staff review, it was felt that  this  could
                 be reduced to a hundred and  fifty-five,  -fifty-six  thousand
              22
                 dollars,  and that the proposal itself -,was in keeping with
              23
                 all the guidelines for renal disease pro"osals.
              24
  ceoal Reporters, Inc.       So that I would like to suggest that  I  support
              25




                  I  the recommendation tll,                                         117
                                            _It
                  2 component of               they be allowed to have   I do'lreloprne.t.,
                                   this magnitude.
                 3
                                 I  right  mention  that  their       for this
                 4  develol-)Mental
                                   component include 34 activities ranging ill
                 5 cost from
                               $1500 to $75,1000,, the
                 6 cost  is about $6300.              Most expensive.  The average
                                           So that it seems to me that they're
                     intending                  I
                              to stimulate a great deal
                   this money.                            of activity      the use of
                               DR. SCHi'IIDT:  Okay.  Dorothy.
                               I-IISS ANDERSON:  IIhy,,
                                                      -T concur with what he is
                  saying.    T
                             he part that I'm concerned about,, I thought the
              12  kidney  proposal  recommendations  were  good
                                                                  But their
              13 continuing education program has
                                                     continued to be the same as
              14 it was many years ago, ,ind there's nothing really innovative
             15        it.  it#S the same fragmented type of individual
             16        line education, and T think this area needs to be looked
             17    and Maybe certa3.nl3, reduced or that type -- eliminated, U'nles
            )8     y can do something that's innovative for the programs
            19               DR. SCIII.IIDT:  All right.  Would you phrase a
            20  pecific motion then?
           21               DI,,. IIESS: Yes.  1-7ell,,
                                                       would like to move aj)prbva
           22  f the funding request as submitted which is for two Point one
           23     slx million dollars,, thit
                                               the recommendati
                                                                ons Of the statfl@".
                  versary
           24              review pal)el which  ire outlined  here be approved
  eral Repofters, Inc.
          25      there are
                             -iust'a couple of additional to  til





                                They point out the.need for more minority
               2  representation for -- more nondivider representation on the
               3  RAG.  In addition, something  they should do continuing work
               4 on, there is a vacancy in the director of planning evaluation.
               5  I think the advice letter should encourage them to try to
               6 fill that as  soon  as  possible.  But,  basically,  their  core

               7  staff is fairly complete.
               8                DR. SClif-IIDT:  I understand 1-tiss Anderson seconds

               9  that.
               10               MISS ANDERSON:  I do.
               11               DP,. SCIIMIDT:  She does..  Questions  or  comments
               121 then to either of the reviewers.  Yes.
               13               MR. LEE VAN WINKLE:  %That was the funding level
               14  on kidnev in the discretion of the committee.
               15               DR. IIESS:  One point- five five.
               16               MR. LEE N7AN WI14KLE:  And the same with the SARP.
               17               DR. SCIIIIIDT:  In other words, this is confirming
               18  the SAIZP recommendations.  Other comments or questions?
               19               If not then,-all in favor of the motion, please

               20  state aye.
               21               (Chorus of ayes.)
                                DR. SCIltlIDT:  And opposed,, no.
               22
               23               (Motion carried.)
               24               DR. SCIII,"IDT:  All rieTht. I do  not  believe  it
  ce-or"l Reporteis,  Inc. would be T3rudent-to go ahead with Arizona before lunch.I
               25





                                                                             119


                 would faint someplace in between Tucson and Phoenix, and we

                 do want to do justice to that program and the other SARP
               2

                 recommendations.
               3

                              Dr. Thurman.
               4
                              DR. TIIUP     Vle would not want to see you dry up
                                      f-IAN:
               5

                 in the desert, tlr. Chairman.
               6
                              DR. SCIIIIIDT:  I think that if we go now, we will
               7
                 be able to get back easily in one hour.  So we will reconvene
               8

                 at
               9
              10              VOICE:  One o clock.
                              DR. SClit.IIDT: All right.  There's a ground swell

                 of enthusiasm for one o'clock.  So I'll begin talking at one
              12

                 O'clock.
              13
              14              (Whereupon, at 12:15-p.m., the conference recessed
                 for the noon hour, to reconvene at 1:00 p.m.,, this same
              1 5
                 day.)
              16


              17


              18


              1 9


              20


              2 1


              22


              23


              2 4

       I Repofters,  Inc.
              25






                                    p R 0 C r:, P D I 11 C, S


                                                                       1:00 P.M.

               3             DR. SCIi!lIr)T:  We've hid a couple of references

               4 to I-lissouri mule
               5             DR. TIIUIlr-IAN:  It sounds like we're into a new

               6 joke.
               7             --DR. SCIiiNlIDT:  Vo.  I just might say in terms of
               8 archconservati@-ri or-reactionarism, Arizona really doesn't take

               9 a back seat to very many places.
              10             Ilri reporting as a result of review of the
              11 application as well as tlie'si te visit.  I was privileged to
              12 have a  Very strong team on a site visit that followed very
              l@ closel-,7 nn The bppls r)f ;another si.f-(- visit ci yeir bf--fore, that

                 very clearly outlined some concerns.
              15             There had been management assessment visit and
              16 other  types of'visits.  This has been a well visited region.
              17             We had-Bland Cannon from the council and h6.was
              18 verv  strong and very good.  Heis got a good nose on. him and-
              19 we really got to the root of a bunch of problems.
              20             Dr. James from the committee here was on the
                 team-as  was Bob l@lurphv, the new director of the Tri -State
              21
                 Regional tiedical Progrcm, following Naomi Baurigartner4
              22
                             There was very good staff support:  Dick Russell
              23
              24 and Peggy Noble and Rebecca Sadin, flr. itorales and the Regional
  'e *I Reportefs, Inc.
              25 1 T,Ioaltii Director from ran Francisco.





                                                                               121


                              Tlie'site visit report is before you and  it  is  a

               2 remarl-,ablv concise document. I could never  have  written  it

                  yself.  It would be two or three times as long and not nearly
               3 m,

                 as good.
               4
               5              The words are in the site visit  report  and  what

                 I will hope  to do is give you the music that  goes  along  with
               6
                 the words, and I'll tell y6u right now, I'm  in  trouble  and  I
               7
               8 ordinarily like to kind of keep the suspense for the last.
               9 But the reason I'm in trouble is that I'm going to have
              10 trouble justifying the funding level  that  we  recommended  by
              11 the music that I'm going to play for you.
              121             The point I would like to make right  now  at  the
              13 Deginninq before I say anything else is that the region
                 has done some very, very elegant and  very,  very  good  things
              14
                 and nothing that I will say will take aiiay from  the  fact  that
              15
                 they have been out in the region.  They  have  done  good  things
              16
              17 for neople that relate to their  health  care  needs.  They  have
                 done some very elegant things.  A little by accident, but
              18
              19 they'veldone it.,.And that is an important point to make.
              20              The region, as I said, had been given a  .lot of
              21 advice, and  111-1 go now right to Dr. Luginl)uhl's concern  and
                 saV that they have a very strong coordinator.  Dr. Melick
              22
              23 reminds me a little bit of the coordinators   who  were  retired
                 Air Force generals.  Ile knows what is right.   Ile has the courzt(Te
              24
   0111 Rcpoitc-rs,  Inc. f his convictions..  Ile is a very courageous individual, or else
              25





                                                                              122

               I he's cot a lot of convictions. Either way  you  want  to  look

               2 at it.
               3              lie really has known all along what WIP is,, what it

               4 should be doinc
                                   what it's for. Ile has had the  answers  and

               5 as he is quick to point out, about half the time he's been
               6 right, as far as Washington is.concerned.
               7             --The-other half-of the time, he's wrong.  But  if

                                                                     h  the  next
               8 he waits enouglit he feels, he'll be right again wit

               9 switch from Washington.
              10              He resents the visits.  lie calls avisit from
              11 Washington being brushed by the wings  of  mystery.  I  didn't
              12 suggest that lie shouldn't really feel brushed by the  wings  of
                                  c-.s; !)eii-,,j clutched by the c'aws of criticisi@t,
                          as muc'.,.,
              13
              14 but he obviously  .was somewhat antagonistic'to the site Visitors,
                 didn't quite understand ,7hy we were there.  Ile admitted in
              15
              @16 times past, and again, in so many i,7ords,, that he really
              17 didn't understand the criticisms, and if lie  didn't  understand
                 them, he'didn't agree too mucl-i with the criticisms.
              18
                              He is strong and I strayed away from the word "good,'
              19
              20 but now I will say he is,--_lie is a good administrator.  Ile is
                 extremely skillful in working with the staff.  He's  kind  of  a
              2 1
                 hardnosed administrcitor who keeps his staff on a  loose  rein
              22
              23 but, nevertheless, on  a rein, and it's obvious that  there's  a
              24 carved bit at,the other end of the rein, and every once in a

       at Repoitets, Inc.
                 @.ihile, lie picl:r,
                                  these upland jives them a good txiitch.  And all
              25





                                                                                123

                I of the staff knows he's on the other end  of  the  rein,  but
                2 yet, they feel perfectly free to pursue the agreed upon
                3 objectives that they are working toward, and there's a
                4 remarkable esprit de corps in the staff and a feeling of
                5 solidarity and so on reflected  very  well  on  the  coordinator.
                               The staff is good, without any  question  at  all.
                6
                7 The staff is good at what they were doing, and they felt
                  also that what they'were doing was  good  and  right.  And  the
                8
                9 basic questions that we  had really  concerned  whether  what
               10 they were-doincl well was what they should  be  doing  at  this

                  point and time.
               11
                               Similarly with  the@Regional  Advisory  Group  and
               12
                  the other           o@ ,the prog--aT,-,, -'@-i'ley really felt qu-i'- tE:-
               13
               i4 confident on how they had been  and  what  they'd  been  doing.
                  The reasons for them being like they were but again the
               15
                  basic criticisms, with their  understanding  at  this  point  and
               16

                  time, in what ]Zec
               17                  Tional @led.ical Programs is all about.
               18              They know what quality is and,  again,  even  with
                  the @G members we talked to,  they  might  at  an  intellectual
               19
                  level understand  the criticisms but at a gut level, they   really
               20
                  kind-of resented  them and didn't  quite  understand  what  was
               21

                  going on.
               22
                               So I began by pointing out  that  the  program  does
               23
                  have real strength.  We feel it has   a great potential.  It has
               24
       I  Reportets,  Inc made substantive and vorv honest acdomplisl-iments, and so,-ie  o
               25





                                                                           124

                  them really qui-te exciting.  @et, we had to say that the
               2  program has fallen quite short of what could have been done
                  in a region that, in a way, is as simple or could have been
               3
                  as simple as this one medical school in a not too highly
               4

                  populated area.
               5
               6             As I mentioned, the program has been visited  a
                  num ber of times before.  I'll go back to the August 168 site
               7
               8  visit which is the last pertinent one.  And up to that point,
                  the region had been nlanning for operational status for two
               9
                  yea rs, and at that time, the site visitors felt that they
              10
                  weren't quite ready yet and advised a third year planning.
                             Another site visit then in Play of 1969 did
              12
                                              Which %.,,,is given,
              13
                             Very briefly, the region is the state where there
              14
                  are 1.7 million people there, which eight percent are Indians,
              15
                  136,000 Indians, most of them as I'm sure you know are in the
              16
                  Navajoland Reservation which occupies about a fifth of the
              17
                  area of the state, if my memory serves me properly.'
              18
                             Additionally, there are eleven percent Mexicans,
              19
              20  187,000,, so this is 19 percent of the state which are minority
              21  group members.
              22             The state is 114,000 square miles. The s a e
              23  has been very conservative. I'm sure at this point it still
              24  is accepting federal welfare Ifunds. They may have changed.
  ,,coal Repotteis, Inc. T IM just sii@,ply bloc',-,inc   t tliayl-ye really very,
                                         T that point.  J3u
              25





                 very conservative and, in some respects, even worse than

                 Virginia.
              2
              3              They're quite suspicious. The  medical  society,
                 in particular, is conservative and, initially, they  wanted
              4
                 nothing to do with Regional ttedical Programs.  Ai-id about the
              5
                 time that lt'IP was coming along, a new medical school was
              6
              .7 coming along and the medical school was put in Tucson,  and
              8  with Phoenix being the population center with the majority of
              9  the medical expertise and organization being in Phoenix, one
                 is naturally curious as to why the medical school would  be
              10

                 in Tucson.

                             And it gets down to politics, as you might
              12
                 imaaine.  And the storv that v7e. b(-ard from good -grounds wci.-,
              13                     I I
              14 that Phoenix needed the support of Tucson in that area in order
                 Ito get a water project going, and in effect, Phoenix  traded
              15
                 the medical school to Tucson for Tucson's support of the
              16
              17 Central Arizona Hater Project.
                             But it leaves kind of an embarrassment, in a way,
              18
                 with the medical school in the center of these sorts of
              19
              20 activities in an area that  is  not  the  population  center  or
                 necessarily the center of need.
              21
              22             Early on,'?Ionty Du@7al was the  power  in  Arizona,
                 in this area.  lie started the medical school, As most of you
              23
              24 know, !Ionty  Du.1.7al is really kind of asaintly, very charismatic
       I Reportefs, Inc. f i-gure in Arizona, anO, it v7aq ol)vj-oiiq when @,7e were there, I was
              25




                                                                               126


               I  the only one at that point that knew he was coming back
               2  exactly when, which kept running into I-Ionty DuValls ghost

               3  all the time, and a lot of people just said,  "Ilell,  that  was

               4  the way P4onty wanted it," or "That was the way 1-ionty would
               5  have wanted it," or "Tliatis the way flonty's going to want it,"
               6  and it was kind of interesting because I  spent  the  two  days
               7  be-fore we went out there with Ilonty and Ilonty really ran down
               8  absolutely correctly and with great  insight  the  problems  of
               9  this region. And I think that this  influences,  in  a  way,  my
              10  thinking about the region because tionty is now back in
              11  Tucson, as you know. And he really does  know  what  has  to  be

              12  done.
              13               The program  was initially set up then  with  this
              14  brand new medical' school  as the base, and the steering committee
              15  that @ionty put together  was appointed finally, in  part, in
              16  desperation by  the  Governor as the  Regional  Advisory  Group.
              17               Now, 1-ionty was interested in that point in a
              18  state health planning authority, and in conversations %,7 ith the
              19  Governor, this concept was bought and the state health planning
              20  authority was established.
              2 1              The steering commL ittee which became the  Regional
              22  Advisory Group of MIP had, I think, then 16 people or 12
              23  people, some small number, and was combined with another group
                  that was largely consumer which served as the CIIP A Board, and
              24

  ce    I Repoftefs,  Iiic.
                  the PL',IP/RAG and the CIIP Board were then put together  with  a
              25





                                                                                 127

               I specified number of people, and,  of  course,  the  CIIP  specified
               2 composition of  consumer/provider  as  the  state  health  planning

               3 authority.
               4              Now, one of the  consistent  criticisms  of  the
               5  Arizona Regional  Medical Program.- is that they've got a
                  lousy RAG.  And, consistently, th  is has been  defended  by
               6
               7  Arizona Regionil Medical Program as  a  size  and  a  composition
               8  that is dictated or mandated by the state health planning
               9  authority, which can only be so big, which represents then the
               io size the RAG can be, and  the  Arizona  Regional  Medical  Program
                  knows that @?-IP is the provider arm and that the RAG is, to the
               12 state health authority, you see,  the  provider  input  and,  you
                  know, "let oil, be consumer that   s i-iot really liart of Regional
               13
               14 Medical Programs or the RAC,."
               151            So the RAG is small and it's very skewed toward
                  provider and toward the position, and until very recently, with
               16
                  no minority representation  because,  in  essence,  there  aren't
               17

                  minority type providers.
               18
                              No%.7,, they could have gotten around this and a
               19
                  number of thincs  have been suggested such as liget a decent
               20                f
               21 PAG and you can elect peoole out of the RAG to the state health
               22 authority," but flonty either didn't @,7ouldn't, never,willi,  not
               23 want this and, you know,, you got tied ur) very  quickly  by
               24 reasons given for not doing this sort of a thing.
  le 01 Reporters,  Inc.      Tioiity ap'ointe,-l !11--lick as coordinator and he was
               25                      p





                                                                                  128


                I  a, good choice with 1-ionty there@  1,7ith Ilonty c
                                                                  .fone,  he  might

                2 not have been such a  good  choice  because  he  kind  of  stayed
                3 with the initial  concept  and  never  budged  a  millimeter  from
                4,Day One and the concepts that came along.  And it's going to
                5 be fascinating to me to see what  lionty  does  because  lie  made
                6 that bed and he's gone home and  climbed  in  it  and.hoi-i  he's
                7 going to lie there, I don't  know.  Ile  won't  be  able  to,  and
                8 he's got to say, "well,-we're going to do something," and
                9 then do it and I know that 'he will.
               10              Now, I'm ignoring my notes but I think I'm doing

                  all right so I'll keep going.
               12              The WIP also thinks that nobody else is any dc-mned
               13 good, so  that they know that they had to get a data base.  And
                  in the  early  days,  continuing  education  was  good.  So  about
               14
               15 the first day,  they said "our thrust is collecting A data base

                  and continuing education."
               16
                               And a year later, and a year later, and     successively,
               17
                  the site visit teams went out and tried to convey that        this
               18
               19 really wasn't so,hot anymore.  The site visit team said, last
                  year, "well, that really isn't too good," but an opening shot
               20
               21 of Dr. Melick is that )@egional liedical Programs' thrust is a
                  data base collection and continuing education.
    c@ll       22
               23              So that thev  have  continued  with  the  very  large
               24 and ambitious il,.ita coll-ecting,activities,  in  part,  because
  r.eleal Repoitefs,  Inc.
               25 they-kno@.7 it's necessary and, in part,, because CIIP %,icis not ible





                                                                              1 29


                I  to do it and wasn't doing it and they have never forged a

                2 decent relationship with the CIIP A Agency in Arizona.

                3             Now, they do have letters from CIIP A,  saying  that

                4 they support these data collection activities and they would

                5 be very useful to CIIP in the future.  But Bland Cannon smelled
                6 something here and he got the CIIP A Director aside in a meeting

                7 and kind of zeroed in on that and it turns out that CTIP
                8 really has no intent of picking it up, which  RMP  has  said,
                9 and doesn't like the data and really doesn't  intend  to  use

              I 0 these data that WIP has picked up.
              11              And this was kind of a disaster, as  far  as  the
              12  site visit team was concerned.  They were cau tioned a year ago
              13 that they must develop a relationship with CIIP A, and the
              14  ironic thing is that Ilority set this up so that there  would
              15  indeed be a kind of hand in glove relationship with CIIP,,  MIPI
              16  but all there has really been is MIP and they just  do.nlt  work

              17  together at all.
              18              Now, it's very easy if you're visiting Dr.   I-lelick,
              19  to fault Dr. i,lelick. If we made a site visit to  CHP,  iye'd
              20  probably be faulting CIIP and it takes two to make a.n  argument
              21  and two to make an agreement, and as I read  the  thing,  I'd
                  have to assess the thing about equally between @IP and CIIP.
              22
              23              But the previous site visit tec-Lms did caution
                  about this heavy data gathering activity and  pointed  out  that
              24

       I Pepo!t,@-rs,  Inc.
                  it was kind of a smooth wheel and it should be a  ear wheel
              25                                                    9





                                                                                  130

                I with cogs on it that would  kind  of  liook  into  another  wheel
                  with cogs on it  that  would  start  grinding  out  the  objectives
                2
                  of the program, and that gea   r wheel  with cogs on  it  would  be
                3
                  grinding out projects and they've got these wheels, but
                4
                5 they're all very  smooth  and  they're  all  spinning.  But  they
                  really don't have the  relitionshiD  to  each  other@  that's  kind
                6
                7 of a drive chain  effect  of  producing  what  is  obviously  being
                  generated as needs-by the data collecting activity.

                                This has been said about  a  number  of  regions  and
                9
               10 during this two-day period.
                                The good, strong  director  and  the  good,  strong
               12 Icore have'set about doing some of the things     .that  they  were
                  instructed to. One is to  come  up  with  a  new  set  of  goals,
               13
                  to come up with a plan, to  come  up  with  a  review  system,  to
               14
                  come up with the sorts of sine qua nons of the Regional Medical
               15

                  Program,
               16
               17               They spent a year developing a planning      note.book
                  that  outlines  a  gorgeous  progression  of  project  generation,
               18
               19 evaluation and approval.  It took them overly long to do this.
               20 It is gorgeous, but tl-iey-haven't used it.
               21               They worked very hard and they've developed goals
               22 and  sul3goals and sub-subgoals  and  I  think  sul3-sub-subgoals,
               23 and  the staff understands  these  and  they  are  really  very
                  elegant.  I don't mean to Put,them down.
               24.
  ce    I Reportets,  Inc.      Ilr@i 99 percent sure ?@ielick understands  them. I'm
               25





                                                                            1   31

               I  100 percent sure the staff does, but the few minority people
               2 that came in, some, we asked for, obviously don't know  a  sub-
               3  sub-suv-)goal from a goal, and tliev're confused, and they
               4  don't understand either the process that was used which
               5  was inhouse based, in part, I suppose, on the data  base.  But
               6  the JUIP has not developed the understanding of what it's doing,
               7  the understanding of why it's doing it.  They,have not developer
               8  a constituency in very large and important areas.
               9              In a way, it was almost as if they.were getting
              10  ready to come in for operational status.  I had that feeling
              11  that, you knout, they're recycling and if they really did
              12  implement the goals 6ndthe process and- all of these things
                  they've got,- it would be one of the most elegant regions
              13
              14  there is.
                              They have begun to -- another criticism was in
              15
                  continuing education.  A little bit here, a little bit  ere,
              16
              17  a little bit here. You kno@,7, put it together, get a program,
              18  put it out in the state, and they have indeed started to do
              19  this in a very sound and very good way.  And perhaps one of
                  the best thing they're d-oing, and what'they'call CESA, their
              20
              21  continuing education service areas in which they are putting
                  people out all throuqli the region, generating educational
              22
                  needs and doing this in a very sound way.  It's sort of
              23
                  decentralization, aiiav from the medical school of continuing
              24

  -e   I  Repofters,  Inc.
                  education in a very good and sound way.
              25





                                                                              132

                              They have six of these- areas set  up.  They  have
               2 very definite -ind good plans to go  ahead with this.regionaliza-
               3 tion or subregionalization of education.
               4              They say they're goiiicT to phase out the data
               5  collection.  They 've been told explicitely to get out of the
               6  data collecting business. They've  been  told  explicitely  to
               7  phase this into CIIP A. They've been  told  explicitely  that
               8  theirs is not to generate a state plan. That's the  job  c)-f

               9  CHP A.
              10              What they should do is catalyze and push and force
              11  CHP A to take over the data collecting, to take over the
              12 Igeneratio-n of a statewide plan.  rut that's hard to do if you
                  aren't talking to CIIP A, and they really haven't been talking
              1 3


                  to CIIP A.
              14
                              They did say  they would be getting out of the
              15
                  data collecting business,  and that CIIP A would be takina  it
              16
                  over, but I've already indicated that CHP  didn't  know  about
              17
              18  that and didn't really agree.
                              At this point, they really have no sound plans to
              19
              20  increase the size of the !Zegional Advisory C-roiip al.though they
              21  are beginning to change the composition a little bit to include
              22  some of the minority representation that's needed.
                              Well, just to move into  the  site  visit  report
              23
                  which I hope you have scanned, and to make one  or  two  more
              24
  leo,l Reporters, Inc. points based on the report, in the  introduction,  the  three
              25





                                                                                133


                  main thinc     'I think I've kind of flushed out, %.:ere to
                            Ts noi-i
               2  coordinate the continuing education things %.iliich indeed  they
               3  are doing, and in this, we give them an A-plus for strong

                  support.
               4
               5              I really talked about   the organizational structure,

                  data collecting and the CIIP business.  I've covered pretty
               6
               7  well the goals, objectives and priorities.
               8              They haven't gotten to the point of setting
                  Priorities yet.  They havethis complex and elegant set of
               9
                  ffoals and subgoals which we would call objectives, and they
               10

                  do have a retreat scheduled with the ReF
               'II                                         Tional  Advisory  Group
               12 land there'is understanding on the part of the  RAG  of  the
                  need for setting priorities and organizing this and getting
               13
               14 on with it and they do plan to do this,  but  they  haven't  done
                  it yet, which, again, is kind of.this feel that they're
               15
               16 approaching a better operational status.
               17             I mentioned  several  of  their  accomplishments. They
               18 have done some other things and the  accomplishments  listed.  on
               19 pages two and three of the site visit report are not inclusive.
                  They're just meant to be things that vie put in  the  report  as
               20
               21 exc-nples of their solid accomplishment.  Their echo is the
                  part of the data collecting  activities.  But  they've  been  in
               22
               23 the community health business.  They  have  really  helped  otior
                  areas to got things going or helped other 'orci,-iniz,,itions to 7,et
               24-
  ce*tal reporters  inc.
                  things going, to get monev.  They have done   some very much neeciel
               25





                                                                                13 4


                  things in the Indian land.
               2               They have done one of the most elegant evaluations
               3  of the nurse education project in a hospital I've ever seen.in

                  which they set up criteria of  nurse  behavior  that  would  be
               4
               5  influenced by  an educational  program  which  was  specifically
                  directed at nurses' behavior, and this was a beautiful piece
               6
               7  of work that is really quite publishable.
                               In general, the activities  though,  as  you  might
               9  have guessed from what I've said, have been more    or less   on
              10  the opportunistic side.  I intimated this by saying that     some
              11  of it probably was accidental   in terms  of  taking  advantage
              12  of existing situations.

                                                                     r-r e reall,,
                               They I re st)nf- ty.  In f tinn,., i,7a-, c; I th@,,
              13
              14  very mature  and advanced. They  do  not  accept,  for  example,
              15  projects that don't havo,built-in plans for other support
              16  and we really were relatively unconcerned about the business
                  of decremental funding  of  projects  because  they  seeme  very
              17
                  well aware of this and have no intent to be in the long-term
              18
              19  funding business.
              20               The bottom of--page four mentions  Dr.  Goodwin  as
              21  the director of the CIIP A Agency who stated, finally, to
                  Blcind that he kind of 'worked out of them,  that  Dr.  Goodwin
              22   -
              23  considered that the joint meetings  we're  and  would  continue'
                  to be unproductive.
              24
        Rcpofters,  Inc.            art oL my recommendation is that  soiiebod,,,
                               And p
   -lot       25





                                                                                135


                  visit with Monty, and I think tlonty knows  but  it  should  be

               2  stated explicitely that somebody's  got  to  knock  some  heads
               3  together there, and two of the heads are l@ielick and Goodilin,

                  and the only question is how hard  those  heads  are,  and  how
               4
                  hard you have to knock  them,  but  there's  some  headknocking

                  that must be done.
               6
                               It's interestiAq.  You know, you can be concerned

               8  about racial discrimination in the south, but having growp up
                  out west, not knowing reallv about the situation in the
               9
               10 south tntil my adulthood, I really  say  that  I  believe  that
               11 the racial discrimination in the  west  toward  the  Indian  is
               12 much more serious than in the south   toward the black.. I
               13 really             s@L,6- L]iE@-re and cry at even lack o@@

                  recognition of th e Indian and
               14
                               VOICE:  They're human beings.
               15
                               DR. SCIIIIIDT:  -- part of the oldtimers there as
               16
                  being even part of  the human race, and this is really a very
               17
               18 bad problem and it's a real  problem.  And  so  you  only  push
                  but you don't push hard enough on this particular one to
               19

                  break anything.
               20
                               I am suffering  now from.having  to kind of   talk
               21
                  without my notes initially.
               22
               23              In each section  of the site visit report, as you
               24 can it, youl.1l.see a very explicit recommendation made by
        1 Reporters,  Inc. the team in each subsection of the site visit report.
               25





                                                                              136


                              The-recommendations really of  the  site  visit  team
               2 follow very  closely the recommendations that  were  given  to
                  them a year ago,, and I really have indicated what the
               3
               4  recommendations are already in my remarks.
               5              Evaluation, I've mentioned, as being quite good
                  and, interestingly enougl   ie had no big problems in this
               6


                  area.
               7
                              The needs are to  do  these  several  things:  decide
               8
               9  what the difference is between M4P and CIIP and get  on  with  it
                  and I think that Montv has to pick this one up and go with it.
              10
              11              The W-IP must phase out these data collecting
              12jactivities  and put their core staff and their money into
                  qer-t,iiiq out or '.Vucson and furthering the reg'Loiialization,
              13
                  the subregionalization of this MIP.
              14
                              They have a very small office in Phoenix, which is
              15
              16  totally inadequate.  They do have people paid by JUIP and active
                  in the continuing education subregions, but  they  need  very
              17
              18  much to viork with the B agencies that are there and to ge@L.

                  the activities out.
              19
              20              They need to-follow through on   a very elegant
                  start and get their priorities and link up now their objectives
              21
              22  and their project generating and acitivity generating
              23  mechanisms so that they will have a program that will relate
                  to the needs that they can now document.
              24
       al Reporters,  Inc.    llhc-,.i-i I went there, I really %.Hasn't sure  about the
              25





                                                                                 137


                  coordinator and I thought maybe   this would  be,, I think,  the

                  third or fourth region in a row   in which the coordinator
               2
               3  seemed to be the key to the problemand maybe should go.
               4  And, personally, I'm not willing to state that at all.
                               I think that Dr. lielick, along with somebody else,
               5

                  could be very superb.
               6
               7               The grantee organization is the university and
               8  there ire absolutely no problems there whatsoever.  It's a good
                  and strong supporter as a grantee organization should be.
               9
                               Well  we knew that llonty was coming back.  We knew
               10
                  that they had done good  things.  We  were  absolutely  sure  that
               11
               12 they had been hit on the head with a ti,7o-by-four several times
               1 3anu I rea.L-Ly,. vie- caiTte down to the moment of truth, I suppose,
                  and that is whether you had to get  their  attention  in  a  way
               14
                  that hadn't been tried yot, which really ultimately     gets  down
               15
               16 to the dollar or not, and I do want a little bit of     suspense
                  here so I'll turn the microphone over to Dr. James-and let
               17
               18 her  fill  in.
                               DR. JAIIAES:'  Sir,, there's very little that I can
               1 9
               20 add to the description that you have just heard and    .the site
               21 report that's in the book also.  It's quite conclusive.
               22              Iloiiever, I have a feeling that -- and, incidental y,
               23i this was my first site visit, too, so with  me,  you  can  under-
                  satnd my  struggling in going  into  a  very  sophisticated-type
               241
  ^e    I Rt-porters,  Inc.
                  t)roc
                      .jrciri as we raw-tliere.  But I have ci feeling that as we
               25





                                                                           13 8


              I  glance(:, through the Ar,-zona Regional I-ledical Program planning

              2 notebook which, just by this alone -- and also I'll wave a few

              3. more flags here--".in looking at their programs in terms of

              4  the structure of the planning and this  is  where  when  we're

              5  talking about qoals, it comes down to  goals  and  subgoals  and
              6  then sub-sul)ctoals and on a couple of others over here, it's

              7  sub-sub-sul)-sul)-subgoals.  So that in trying to understand, I
              8  thought that I might have been at a  full  dress  formal  ball

              9  with the lady in plumes in the Gay Nineties  and-as  she  was

              10 dressed and no place to go, because I was,  I  think,  first  of
              11 all, struck with the e.,-.cellent in-depth planning that  this

              12 group certainly has utilized.

                             But then as we looked at this, we  wanted  to  know

              14 what does it relate to?  And after looking back at the previous
              15 site visit, and they had said the same  thing,  and  then  we're
              16 presented with I think three times more  maybe  than  what  they
              17 had T3resent@-(--d before, it gave one a feeling of just being
              18 lost in a maze, in the forest without being able to see the

              19 tree-.,;.
                             It appeared to me that the excellence in the
              20
              21 direction that the -- I want to'say'coordinator, and I  don't
              22 mean Dr.11@lelick, I mean Dr. Ivey, his title
              23             DR. SCIT.@IIDT: Deputy Coordinator.
              24             'DR'. JA!.!",S,- The coordinator.
  ,e-*,al Reporters, Inc.    DR. SCIIMIDI'LL: Deputy Coordinator.
              25





                                                                               139


                              DR. JA!IES:     Deputy Coordinator had, in terms

               2 of     the influence that he had in terms of the direction that
               3 he was able to give to the staff who are all specialists in

               4 their ox-in rights, should be the envy of every PJ,,IP throughout

               5 the   country.
               6              I %.Iould think that-many of the programs that we
                 have discussed here yestex4ay and today, if they had the
               7
               8 availability of the expertise of the planning strategy and
               9 ability that the Arizona R.'L'.IP has, that none of them would
              10 be in trouble because they would have a way to know what
                 their programs were by the data collection and understanding
              121what the needs are and also be able to translate their
              13 programs into something that is meaningful to the people.
              14              But, here, we have just the opposite of page ifter
                 page of documented information, and I might  say  that  we  don't
              1 5
              16 have with us today, but there must have been four or five
              17 books of this magnitude that were full of data collection which,
                  f course, have not really found their way into any meaningful
              .180

              19 program,
                              I think one of the other things, too,, that  I  felt
              20
              21 keenly about, related to the minority concern and I don't think
                 that I could express what really happened at that meeting'
              22
              23 the first day that we  %,,?ere there. I could not express it  any
                 differently than what  k!ou have alreadv heard in regard  to  the
              24                        i               -
  ;e of Repofters,  Inc. tremendous conservative attitude toward the American Indian iiid
              25






                                                                                 14 0


                  it was indeed embirras:-,ing. I  think  it  was  embarrassing  to


               2 me.
               3               I'm not going to go  into  any  specificity  but  it
               4 reallv lets us know how conservative the State of Arizona
               5  apparently is to the Native American who-is on the       soil.
               6               We also looked at the blacks and I was    very
               7  keenly  aware of the fact that the lady's name that    is   written
               8  in the  first site visit, I-Irs. Tommie Thomas,  was  their  chbice
               9  for A RAG  consultant  --  or,  rather,  not  RAG  consultant,
               10 but a @.G member who is  a  member  of  the  Community  Action
               11 Commission and who would indeed, I would assure you, have
                  tremendous t)rol)lc,-ms viith understanding   anybody's   terminology.
               1 2
                               And then we recognized that there was a young woman
               1 3
               14 that they had brought in to serve  is  a  junior  intern  in  the
               .15 area of professional relations who was there, as we could see,
                  as window dressing. And I  spoke  to  her,  and  in  the  fifteen
               1 6
               17 minutes,@we had a list  of  professional  blacks'in  Phoei-lix
               18 who are on the staff of the University of Arizona, who care
               1 9well-known to the Dean of the medical school, who are called
               20 uT)on at his v7ill to  perform,in  certain  services.  And  in
                  fifteen minutes, we were able to say, "well, here are I-)eor)le
               2 1
               22 who are knoviledgeal-)le, who are professionals, who are   in health-
                  related fields, who could lend support to a RAG program.ti
               2 3
                               So' we rc-c7)gniz(-O, i.Tr,@-necliit(-@ly that the reason thit
               24
       I Reporteis, Inc. they didn't have  @nybody  there  in  a  minority  representation
               25






                                                                             1 41


                 frc)m the blac}-, ol)ulat-Lon "that they couldn't find,"  was  not
                                p

              2 at all true because they were right  there  under  their  noses.
              3              I would think that perhaps that --  I've  lost  the
              4  pader-here.  If I could find it among all the maze -- this
              5  is like the Arizona program, maze of materialsi
              6              'I think that what we really saw was  a  performance
                 personified, a process which ha-, been termed "riianagement by
              7
              8  objectives by the deputy coordinator" which does  indeed  sfiow
              9  that there is tremendous amount of donceptualization with
              10 an overemphasis on Comprehensive Health  Planning,  and  I  can
              11 see oihy, at the beginning, there may have been this thrust
                land that was before the Comprehensive  Health  Planning  agencies
              12
                 came into being, but now that the Comprehensive Health Planning
              13
                 agencies are there, there is somewhat, as  already  been  stated,
              14
              i5 a reluctance on their part to give up this area of Comprehensive

                 Health Planning.
              16
                             And just to reiterate this  point,  someone  stated
              17
                 that perhaps within a very short time that  the  data  collection
              18
              19 and the goals and the subgoals and the  sub-subgoals  and  the
              20 siib-sub-sub-subqoals will have reached a critical mass  witjiin
              21 a very short period of.time unless something were done to
                 allow this -- it would, really literally,  explode  unless  it
              22
                 were allowed to be disseminated and to become implemented.
              23
                             So,this is what i.i(-- hFve seen. There's very,  very
              24                                                         i
       I Repottets, Inc. little implemeiitation, very little of a relationship  to  the
              25





                                                                                14  2


               I  social welfare problems o  f the ctato of Ari,-,ona, very little
               2 relationship  to  interrelated  health  agencies  whose  projects
               3 would relate therefore to the people in the community.
               4              We see a staff  which  is  highly  trained,  highly

                 educated all known as staff       I would say they're staff
               5

                 specialist oriented.
               6
               7              The planning looks like it almost became an
               8 obsession.  The planning process has become, as I see it, like
               9 an obsession  to  the  Regional  Medical  Progrm  and  unless  there
                 is some way that there could be an  interest  to  help  the  B24P
              10
              II to change its focus and to become a facilitater and a
              121catalyst for the planning and planning/developTnent and implementa-
              13 t."Lon of the program into the communities,  then  I  think  that
              14 the continued data collection  will  only  simply  lead  to  more

                 data   collection.
              15
              16              They  have  established  a  tremendous  base.  They
                 have   established a tremendous data base  for  both  needs  and
              17
              18 resources,  and  I think that what they're struggling with is to
              19 find a way  as  to )iow they can relate to the community in order
                 to be able to  put  in  and  implement,  rather,  sub-sub-,@ubgoals.
              20
              21              DR. SCIIPIIDT:  All  right.  Before  I  relinquish  the
              22 chair to John for discussion, @il-iich I        Rebecca,  do  you
              23 have anv comments at all to add?

                              MS@ SADIT,,T:  No.
              24
        Repoiters, Inc.       DR. SdlllIIDT:  Peggy?
              25





                                                                                  14 3



                                IIS. NOBLE:  No.

                2               DR. SCIIIIIIDT:  All right.  At  this  point,  I  will

                3 steT) out of  the chair which I  ordinarily  would  do  before  I

                4 began, but I didn't, so, John, you're in the chair.

                5               DR. I'%RALEI@ISKI:  Could we get a motion.  I-lould you

                6 like  to   make recommendations on it then and a motion for

                7 funding and   we could go from there perhaps.
                8               DR. SCHTIIDT:  They are now at an annualized level

                9 of one point three eight six two six oh.  Of this, about seven
               10 oh one five oh nine supports what v7e thought, and I would
               11 repeat, it is an excellent core staff type of activity.

               12               They have  95,000  in  developmental  component  now
               13 and in "other," they  have  about  600,000  which  makes  up  this

               14 one point three.
               15               Their 04  request  was  for  seven  sixty-one.  They

               16 wanted to add   some staff to round it out.
               17               We felt that, really, they should add more
               IS staff tha n thev wanted to in order to get out and subrecfionalize
               19 and do what theyireally said they would do and wanted to do in

               20 one area of their program.
               21               Some of the increased  staff  would  be  down  here
                  in their 2,000,000 that they requested, which would be to allow
               22
               23 them to expand the CESA,, the Community Education neti,7orls
                  throughout tlid region inr-,tead,of.-u-,t the six.  They have datc,!:-,
               24
  :e-o.,l Reporters,  Inc.
               25 for establishing eight or ten more of those.





                                                                             14 4


                             Their request was  for two point nine.

              2              Ile really spent quite a bit of time  in  generating
              3  a level in the team and we were, in a way, quite detailed

              4  about it.  I-le got down to a sealed balloting.  And what we

              5  really agreed upon was 700,000 for core.  We want them to
              6  maintain the core and, in point of fact, to be  able  to  expand
                                            1
              7  the core which they could do by getting the hell  out  of  this

              8  data collecting business.
              9              We wanted them to have  a  developmental  component
              10 and the funds,, flexible funds to do the right sorts of
              ii things with it, and we finall y settled on 810,000, looking
              12 lat their projects,, looking at the sorts of activities that this
              13 could fund and, of course,  the difference between --  we  were
              14 Impressed.  When you're in  Arizona, you're  impressed  with,the
              15 drop from 2,000,,OOO down to 810,.OOO and itis a little  harder
              16 to be impressed with that drop here than it was down there,
              17             We came up with one point six which  we  would  say
              18 would be a level of funding that would  be  great.  It  wouldn't
              19 strap them,  providing they freed up other money and they could
                 really do v7hat I think really, with Ilonty there, they will  do
              20
              21 which is to get their heads knocked together, settle out
              22 very quickly the differences between CIIP and I;UIP and we
              23 wanted them to have the monev to make this program as it could

                 be.
              24
  :e-*al Repoitets,  Inc.
              25             So that on behalf of the team, I would move approval






                                                                                    145

                   at a level of one point six for  the  next  two  years  -,ihich  is
                2  what  they're  requesting  with  the  strong  recommendation   that
                3  Harold  Margulies  and  perhaps  Bland  Cannon  --  "Bland  Canyon",
                4  how about that,  "The  crand  Canyon"  --  and  Bland  Cannon  talk
                5  to Monty and kind of  explore  with  him  the  feelings  of  what  I
                   know will be  the  councils  feelings  as  to  what  must  be  done.
                6
                7               So one point six with strong advice and
                8               DR. JMIES:  I second the motion.
                9               DR. KRALEI-ISY@I: 'Second?
               10               DP,. JA@T-.S:  Second.
               11               DR. KRALEWSKI:  Discussion?
               12               MRS. FLOOD:  I must express concern for the
               13  approximate  20 percent of  the  population  that  is  of  IleXican
               14  American origin in the State of Arizona.        Distress  has   been
                   expressed for the black and for the Indian population, and
               15
               16  20 percent  of  the  population  in the state is Spanish speaking
                   and, yet, I  can  find  hardly  any projects  that  have  as  their
               17
               18  prime --'well,  I  can't  find  one project that has as   its  prime
                   emphasis  addressing  the   problem of the health delivery systems
               19

                   to serve this minority group.
               20
               21               There is a project that serves it as a        secondary
               22  influence only, and if you thought the ):)lack employee was
               23  window dressing, 1 don't  doubt  that  the  Ilexiccin  American  is
                   window dressing, and I would probably assume that he is
               24
  @e-ol Repoiters,  Inc. stationed in that -.small  cubbyhole  in  Phoenix,  away  from  the
               2 5





                                                                              14 6


                I main core staff.  Thit's'so they won't have to see him too

                2often.
                3             I feel a tremendous consternation that we insist
                4that  the coordinator is a good coordinator; that he is strong,
                5there  is no doubt in my mind, but a good coordinator.

                              You know, we baridy,that term, around this  table.
                6
                7We say, "Ife's a good coordinator."  But this is happening
                8in the program.  That is happening in the approach.
                9             There's no doubt that this coordinator is strong,
              10 that curved  bit and those reins I thin],, also have a crop
              11 hiding somewhere behind, and if anybody  tries  to  mesh  those
                  heels to a productivc,-,.interproductive mechanism, I thinl@,
              12  lw
                 the crop comes out of the riding boot and (cluck) flips them,
              13 too.    At least that's the feeling I get.
              14
              15              And I feel strongly that the  advice  letter  that
                  oes forth should no longer allow this to continue for
              16 9
              17 another year or more.

                              DR. SCII@.IIDT:  Point of
              18
                              DR. KRALEYISKI:  Would you like to comment?
              19
                              DR. Sclll-IIDT: -@Just point of clarification.
              20
                              There are eight percent  Indians,  eleven  percent
              21
                 Mexican and  Spanish Arnerican.  The combination get-, close to
              22
              2 820 percent but it's eleven percent   Mexican Americans, I think.,
                              MRS. FLOOD: But tl'lere's 19 percent,  I  believe.
              24
  @e   I Reporters,  Inc.     DR.  SCIII@,'@IPT: Pc-ir(lon?
              25






                                                                                    14 7


                                                                              Spanish
                                IIRS. FLOOD:   I believe it's 19 percent

                2  surnamed.    At least the  briefing  document  listed  it  as   19
                3 percent estimated at --    the SDanish speaking is
                4               DR. SCIIIIIIDT: Okay.  There  is  a  problem   here.
                   I think that the Spanish    surnamed  individuals   are   accepted
                5
                6  into the culture, you }@noli,  just  way  above  the  Indian  who
                7  really isn't considered much of anything and, of course,
                8  some  of  the  aristocracy  is  Spanish  surnamed.  -For  purposes
                9  of P14P, they are not counted as a minority group.
               10               The eleven percent I'm referring to is not -- this
               11  is complicated, and it was explained but they didn't --
                                14RS. FLOOD:    The purposes-of, Arizonals PJ.@lPs,,
               12
               13  they're not counted as minorities.
               14               DR. SCHPIIDT:  Well, they really aren't in Arizona.
                   Some of the  aristocracy  in  Arizona  is  Spanish  surnamed   and
               15
               16  they  are  not counted  in  --  the  eleven  percent  includes,  in
               17  essence, Ilexicans;  does  not  include  all  Spanish  surnamed..
               18  So I'm saying that  you  may  be  correct  if  you  count  racial
               19  extraction.  It would be higher than my eleven percent, which

                   is Mexican American.
               20
               21               DR. KR7tLEIISI'%I:  I think if you consider the
               22  uiiderserved  population  in  Arizona,  you'd  have  to  conclude
                   that the Chicano  population  makes  up  a  good  part  of  that.
               23
               24               But as I recall frori-the visit a year ago, a numl3er
   -*I Reportets,  Inc. of their programs-that they had developed, not specifically
               25





                                                                               14 8


               I developed by IU.IP but developed as a result of the data provided

               2 by RI@'Pland the TU@IP staff effort, those programs were  oriented

               3 toward the underserved areas including the Chicanoes.

               4              I would hope that  those  programs  had  proceeded

               5  over the years.

               6              DR. SCIIIIIDT:  Yes, certainly the identification

               7  of streptococcal, that project is really  very  much  in  the

               8  core areas in this project that is  an  example  of  something
               9  that is directed right at need and, of course, the rheumatic

              10  fever statistics in this area bear this out.
              11              There are indeed activities that do involve -- it's

              12  One of the first things I said     that do  involve  care  to

              1 3 Indians and care to the Mexican Americans.
              14              DR.  JAMES:  The  streptococcal  program  relates
              15  Primarily to the Indian-populati-on.  I think that there was
              16  clearly elucidated one of the severe problems that the
              17  Mexican Americans were involved, and that  is  not  being  On
              18  various bcards to help at the  decision-making  level  and  they,
              19  through their own efforts, have received a federal grant to
              20  help train the ilexican American in  developing  themselves  into
              21  individuals who could  serve  as  policy-making  people.  And,
                  this, they had attempted to do, as far as I  was  led  to  under-
              22
              23  stand, through the RI.IP.  But because such help was  not  forth-
              24  coming, they sought outside help' and  I think that miny  of  the

        Reportefs,  Inc.
              25  councils, the Southwest Council of La Raza -- is that correct?
                  I






                                                                            1 4 9


               I  and many other of the Spanish speaking councils were

               2 tremendously involved in this so that they are  able  now,
               3 through a federal grant, to have a formal program which  viill

                help to train the Spanish Americans in this role.
               4
               5             We certainly also were aware of the fact  that  the
               6community health service in Phoenix, I believe,  came  from  the
               7help that the Regional Pledical,Program vias able to o  er.
               8             But there is no such program elsewhere in the-
               9state that I could discern or as I remember that  this  is  the
             10 beginning of a kind of program as it relates.
             11              We were talking about the CESA program.  It was
             12 noted that the CESA program was certainly very high up in
             13 the community that is, not related.directly to the people
             14 but more or less professionally oriented to the  nurses  in  the
             15 hospitals and it  wasn't yet clear in terms of  their  household
             16 survev as to how  they were really going to translate their
             17 continuing education program into  meaningful  health  deli.very
             18 services.
             19              At least it wasn't clear to me.  It may be more
             20 c-lear if I perhaps read it a little bit better, but.tlicre
             21 was just -- they got so far, it seems, and they got hung up
             22 and they couldn't spread the program to  involve  the  majority
                of the people, and I think a lot thathas to  do  with  that  is
             23

                geography.
             24
       Reportefs,   Inc.     DR. KRALE14SI@I:  Thank you. 'Llliss Kerr,
             25





                                                                                 150


                               MISS KERR:  Of consternation to me, if it    is true,

               2  why hasn't there been a site visit prior to that.  That is,

               3  it seems to me that this is the second and this the first that

               4  I've been hearing on it.

               5               We've had the sam6 concern about the data

               6  collection,  the reluctance to give it  over,  I'll  put  it  that

               7  way, to CIIP, all these promises     CESA was going in and I

                                                                                   sinc2
               8  don't think it's broadened it out too much more since:thbn,

               9  I've seen this.

               10              I think the stem-i,;inder of the staff is tlr.   Ivey

               11 and not Dr.  I-lelick.

               12              I agree with  you.  I thinlz'lie behaved like a

               13 general. But I thin@. that Dr. I-lelick --  and  I  also  feel  as

               14 Dr. James, that I think thev're making too much of this

               15 planning, the sub-sub-subgoals were established before we were

               16 out there.

               17              I don't see that they clarified them or started

               18 working w ith them and make them meaningful or that T)eople

               19 can even understand what they've done with them.

               20              And I would make two comments.  One, I hope we

               21 don'-E, as a review committee, tend to  sanctify  Plonty..  too.  I

               22 don't know who 1-tonty is. I've never  met  the  man.  But  I  hope

               23 we don't tend to sanctify Iiint.  I  don't  know  in  what,position

               24 he Ill be brought in       he returns.  Can somebody tell me

       I Reporters, Inc.
               25 this?






                                                                                 151

                                                                 ng )-)ack as the
                               DR. SCIII.Ill)T: Ile, @ionty, is goi

                  vice president for health affairs.
                2

                               MISS I',ERR:  At the university?
                3

                               DR. SCII@IIDT:  At the university.
                4

                               MISS KERR:  Well, are they going to have all these
                5
                6 strings to  pull on the Regional iledical Program, and the
                7 grantee institution?
                8              DR. SCIIMIDT:  When  Monty goes back, Monty is going
                9 to be the one  single,  overpowering,  powerful  voice  in  health

                   f
               io a fairs in the State of Ari7,ona.
               11              The medical school  has  never  usurped  or  co-opted
               12 any Regional Medical Program in the typical sense.

                               mlss         No*  I know it hasn't.
               13
               14              DR. SCII,"IIDT: But what happens with CHP, IV-4P  and
                  son, Monty is going to say, and thatts just a fact.
               15
                               MISS KERR:  Then my other statement    is as  I  read
               16
                  through the  site visit, the recommendations, I    saw many "ifs,
               17
                  if such and  such happen s and if such and such happens,     And
               .18
                  I don't think we're sure what's doing to happen, and what little
               19
                  change I've seen between-tlie two site visits, I'm not too
               20
               21 encouraged.
               22              So I frankly think that your fundincT recommendation
               23 is   generous.
                               DR. KTZALE@,?SKI:  Yc@-s, sir.
               24

  ,e -
   *I Repottets, Inc.          MR. T00i'IEY:  I @.7ould ask Dr. Schmidt.  Your
               25





                                                                                   152


                1  recommended level of funding is $220,000 approximately above

                2 the 03 year, the current year, and you do talk about the

                3 Potential for reduction in their program, staff expenses if

                4 they  do get out of this data gathering.

                5               It would seem to me that when you look for a

                6 lever to get them to do something
                                                      .T that you want  done,  you  know

                            id yourself, you look at the money, and it would
                7 as you sa
                8 seem to me reasonable to reduce that from the one million         six.
                9 Leave it at a leval funding of what it was a year ago and
               10 encourage them in terms of their groi-ithl encourage them this
               11 way to leave the data gathering elsewhere.

                                And if it's feasible, llr. Chairman, acting Chairman,
               12
               13 I'd like to   so recommend.
               14               DR. KRALMISI\'I:  I will take that as   a recommendation
               15 but not just as a substitute motion at the moment if that's
               16 agreeable with you.  1,7e would like to have a little more

                  discussion.  Thank you.
               17
                                DR. THUP-7,11@l@l:  Iguess I voice the same degree of
               18
               19 concern. I share  I-Irs.  Flood's  concern  because  anyway  you  want
                  to get around the Spanish surnamed business, it's still putting
               20
               21 them-down.
                                I think the second thing would be that I don't
               22
                  see that there's any degree of reaction about Dr. Margulies'
               23
                  letter of Decc,-il)er tht--, lOtli of 1971 in that he says there  what
               24


  -e -
   *al Reportets, Inc. lx,7E,'re sayin(i here,' which is really %.!hat Elizal-)eth is saying.
               25 1





                                                                            1.53


                             Ily questions I think to the site visit team  would

              2 be:  who is  going to knock the heads? And if  that's  going  to

              3  be Monty, whols going to tell Tionty? And how long is  @lonty

              4  going to be vice president?

              5              Those are the three very critical questions.  They

              6  are asking in that data business, when you get right down to
              7  it, they asking for an 04 and an 05 year.  The 04 year is well
              8  over $500,000, and I think that the most damning  thing  that

              9  I saw, although somebody recommended it be included, was the
              10 speech that he delivered on-lzovember the 14th, 1972, "awaiting
              11 your arr3-val," in which he said,"i.;elre going to be more
              121independent," not less dependent and that they're  going  to
              13 let us do what we want to do and that we plan to carry on

              14 the collection network.

                             lie specifically speaks to 1974 and 1975, with no
              15
              16 feeling about them being funded from any place  else.  So  that
                 I think weire being much, much more than  generous  with  the
              17
             .18 one point six.
              19             1 agree that Dr. DuVal is certainly the power
              20 in the state and I think that to pull it off  well,  there's
              21 no reason why they couldn't come back in a year of performance.
                 But a year of no performance, to me, doesn't justify an
              22

                  dditional $300,000.
              23
                             DR  KIZALET-;"',I\'I: I think the discussion then has
              24

       1 Reporters,  Inc.
                 centered then on teallv three issues. One if-, the  minority
              25






                                                                             15 4


                I  problem on whether this T)rogram is responding to the  needs

                2 of the underserved and minority grouses in that region.  Number

                3 two, whether the site visit team really believes that the

                          will take a turn in kinds of activities they are
                4 procTram

                5 involved in, whether they'll make some changes  this  coming

                6 year that they perhaps have not made last year,  whether  the

                7 progress last year justifies this trust.  And  then,  number

                8 three, whether we need to use funding or some kind of

                9 conversations with Dr. DuVal or whatever to try to bring

              10  that about.
              11              I wonder if I can get the staff at this point to
              12  make some comments on those issues or any one you might want

              1 3 to raise. 1.1r. Russell, do you have any  comments?

                              MR-* . RICHARD L. RUSSELL:  I'd like to, but I would
              14

                  like to go off the record if I might.
              15

                              DR. SCHMIDT:  All right.
              16
              17              (Discussion off the record.)
              .18             DR. KRALEIISI,"L:  Do you have any comtntents you
              19  would like to make?

                                          -he only thing I want to say is 1
              20              IS. SADIN:  T
              21  don't know whether they had those new projects last year, the
              22  ones that they're going to move out.  They  do  hav.e some  new
              23  ones, one noint five or something, stre0tococcal,  one  point
                  four or something, and I don't )-,now that they do have a new
              24
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              25  program.






                                                                             155

                              MISS KERR:  Since Mr. Russell has spoken  so  frankly,

               2 I feel that
               3              DR. SCHLIIIDT:  Hold it a second.  Are we on the recorl

               4 or of f the record?
               5              DR. I'%RALEWSKI:  I think we should go back on the

                 record.
               6
               7              DR. SCHMIDT:  Back on the record.
               8              14ISS KERR: I sense a feeling of  defiance.  I  didn't
               9 say it before, but in a sense, I do in comments from the staff.

                              They've known and, yet
              10                                     , they don't seem to listen.
                              DR. KRALEI,7SKI:  Do you have any response to that,


              12
                lDr.   Schmidt?
              13              DR. SCIltlIDT.  Yes, I do. This is admittedly
              14 difficult.   I began my remarks by saying that I kind of
              15 figured I'd  be in trouble. I knew why, and I think  I  was  right.
              16 But I don't  like to punish a region.
              17              And'the last remark, I think, conjures up some
              18 type of a retributive "l@,le'll teach them to pay attention to
              19 us" type of act and I really would caution very much against

                 this sort of thing.
              20
              21              our goal  in evaluating the program, and believe me,
                 when we  left,  everybody was kind of shaking.  1,7e iieren't
              2 2
                 exactly  escorted out  of town by the state guard but we were
              23
                 not easy on them.        of the feedback I've gotten since is
              24

  :e   I Repofters, Inc.
              25 that thev maybe  for  the first time did begin to get the  message,






                                                                            156


              I That may not be true.

                             But our goal is to build a good program.
              2

              3              Novi, the coordinator is strong and he is good

              4  in many respects. The word "good"  is  obviously  judgmental

              5  and, you say,, what are the criteria?  And in some respects,

              6  he's bad and strong.  I think he has been leading them

              7  sometimes in wrong directions and sometimes he's not been

              8  leading them in a direction that we would consider good.

              9              So I would re-emphasize some of  the  activities

              10 in the CESA and some of the others, he is leading  them  and

              11 permitting Ivey to lead and so on, in very  good  direction,
              12.,Iand some of the things they have done are good.
              13             They are planning the management by objectives.

              14 These are good things.  These are not bad things,  These

                 charts are superb.  They are elegant, they are eloquent and
              15

              16 they are needed and they are good.
              17             The question is, will they take the  next  step?
              18 And part of our recommendation is that they be  instructed,,
              19 they be ordered -Lo get out of the data collection  business
                 in one ye-ir, within one year, and there will be zero funding
              20

              21 for that after this year.
              22             We recommend that they be instructed that there must
              23 be a statewide plan and that is not their job, that will help
              24 guide the generation o@L the projects, that they.be instructed

      at Repotti-is,  Inc.
                 to follo@-i un on these things,
              25






                                                                                157

                              No%.i, I am franl:ly biased. I  am  biased  by  the
               2  conversation I had with Dr. DuVal before I went out in which
               3 I ate dinner with him the night before I went out.  That
               4 afternoon, I'd been  in  the  Secretary's  office  when  the  call
               5 came from Camp David announcing Weinberger's appointment, and
               6 Monty turned to me and he  said,  "Wellt  I'm  going  to  be  home

               7 by Christmas."
               8              And we went out, and everybody  fled  from  IIETI  to
               9  the nearest friendly bar and llonty and  I  went  out  and  had
               10 dinner and he wanted to  talk  about  Arizona,  and  he  reviewed
               11 the history of the program and he told me exactly what we would
               12 find, and, indeed, we  did  find  that.  You  heard  it  today.
               13 And Ilonty knows this.
               14              He also knows  what must be done,     It is not more
               15 than 50 T->ercent the fault of P-@@IP that there is not a state
               16 plan or that they don't have relationship with     CHP.    It's
                  not more than 70 percent their  fault  on  some  of  the  other
               17


               18
                               To no, the issue is whether they can build     a good
               19
               20 pr                                              ce that t ey
                    O.Tram and their projects would give eviden
                  can.. Their core staff is excellent.  Their planning is
               21
                  excellent.  The strength of their leadership is there, and
               22
               23 really, it comes down to our not wanting to deprive them of
                  the funds that it fill. take to move ahead in the right
               24
  :"*I Repottefs, Inc.
               25 direction and N-ic are banking, whether the team   banking or my






                                                                                       158

                I  own  banking,  on'what  the  instructions  are  from   here   as   to
                2  what  they  may  not  do  anymore,  ptr3.od.  Ilot  suggested   but.to

                3  tell them.
                4                 And I said,that at least Bland Cannon and Ha)-old
                5   I-largulies sho uld talk with  1--ionty  DuVal  and  we  should  mount
                6   a return visit, in other words, out there to lay down the
                                                  I
                    law.  Ilow, this has been done before and it's been done quite
                7

                8   effectively.
                9                 So that the  reason  for  the  one  point  six,  and  I
                    will say that I  am  not  --  I  wouldn't  stick  my  arm  out  under
               10
               11   a knife  at  one  point  six.  I would  begin  to  dig  in  my  heels
               12,lquite  strongly   much   below tl-ie  current  funding  level  because
               13   my betting  is  that  @ionty, et al. will build a good program anCL
               1 4  that is what  %.ie're  about.
               15                 DR. KRALEIISI'%I:  Response  to  that  or  new  issues?

               1 6  Yes.
               17                 DR. BRIIIDLEY:  Could I ask just a question of
                    "our former   chairman.'' lihat would  you  thin)-,  about  have  it
               18
                    reviewed at   the end of one  'ecir rather than approving two
               19                                  y
                    years' funding  with  the  thought  that  if  they  do  a  real  good
               20
               21   job as we all liope,they %%,ill, actually one point six may riot
                    be enough to do the things they could do, if they do not
               22
                    respond  to  your  suggestions  and  recommendations  and   do   not make
               23
               24   any change in their thrust, one point s      ix is probably too much.
  ;e -*at Reporters.  Inc.
               2 5                DR. SCIILIIIII@T:  I-lell, I wouldn't -- you know, in effe t





                                                                            159


              I given the last two days' discussion, I'd put them on probation

              2 at the consisten funding level and, you know, tell them.

              3              DR. BRI14I)LEY:  But reviev7ed in one year.
              41             DR. KRALEV7SKI:  All right.  Let's go on to;ftirther
              5 discussion and we'-11 come back.

              6              DR. LUGINBUIIL:  Where do we stand in terms of

              7  the motion on the floor?

              8              DR. K@LEIISKI:  We have a motion on the floor  and


              9  seconded.

              10             DR. LUGINBUIIL:  Are you doing any point of

              11 amendments?


              12             DR. KRALEIISKI:  Yes.

              13             i)R. LUCINBTJIIL:  I'll move to amend the motion to

              14 level funding and review in one year.

              15             MISS KERR:  I would second the motion.

              16             DR. KRALEIISI'xl:  Okay.  It's been moved and

              17 seconded that we fund them at level funding and review them,

              18 site visit

              19             DR.'-LUBINC,,UIIL:  Yes.
              20             ])R. KRALM-7SI'.T: -- cat the end of one year and then

              21 decide for future funding.  Any discussion on that?
              22             DR. JAPIES:  Yes.  And relative to the advice, i-7e've
              23 put tremendous amount of concern in terms of getting out of
              24 the data collection ID,,.@;iness,'l would like this committee to
  @e I*
       I Repofters,  Inc.                          vise them that they must pull
              25 make-a strong recommendation to ad






                                                                           16 0


               I in quality/qualified representation from the three  minority
               2 groups that are highly representative in that state, including
               3 the American Indian whom epitaphs were spread out about  the
               41table, including adequate American Indian representation, includi-r
               5 adequate qualified Mexican American representation and,
               6 certainly, from the minority black group in the state.
                                           A
               7             I would highly recommend that this committee also
               8 Include that as a specific in the recommendations; ad vice,

               9 rather.
             10              DR. KRALEWSKI:  Dr. Schmidt, was that inherent in
                 the advice that you had in mind in your original motion?

                             DR. SCII@IIIIDT: Yes. I think that the  site  visit
             1 2
             13  report, one by one, ticks off really all of the advice  that
             14  we would give.
             15              DR. KRALEIISKI:  Is there further discussion?
                 If not, then we will vote on the amendment to the original
             1 6
                 motion and that amendment is that we fund them at level
             17
             18  funding for one year, site visit at the end of that time.

                             Is that clear?
             19
             20              All those in favor, signify by saying aye.

                             (Chorus of ayes.)
             21
             22              DR. KrtALEWSKI:  Opposed?  Carried.
             23              (notion carried.)
                             'DR'. KRALMI@il'%I: l@7e now need to vote on the original
             24
  -e-ol Reporters, Inc. motion since tliat-was an amendment to it. Everyone in favor
             25





                                                                              161


                I  then of passing this as the motion.  It will be level funding
                2 until the one year, as mentioned.  Please  signify  by  sa@ing

                3 aye .

                4             (Chorus of aves.)
                5            'DR. KRALEWSKI:  Opposed?  So carried.

                6          @--(Motion carried.)
                7             DR. SCHR.IIDT:  All right.  Thank you.
                8             One housekeeping bit before we move on to the-
                9next agenda  item and that is if you want your  book,  leave  a
              10 Diece of paper here saying you want  it  sent.  If  you  don't,
              11 say "please don't send it."  So here's a --
              12              VOICE:  Just a technicality.  What do you do with
              13 the third year as far as showing our support for the program
              14              DR. SCHIIIDT:  I would interpret this as a review
                 committee as unwilling to make any  commitment  for  the  third
              1 5
              16 year at this point. They are,  in  effect,  on  probation  and,
              17 you know, they're zeroed out unless they shape up,
                              f@ionty ought to be able to explain that to them

              19 all right.
                              DR. TliUP,',,IAN: --Would M.IPS pay for the armor for the
              20

                 site-tezm..?
              21
              22              DR. SCIIMIDT:  I don't know about that, but I'm
              2 3glad I'm a few miles away.  I now can't qo into Florida,
              24 Indiana, Arizona, Virqixiia and some ot  ors.

       I Repofteis,  Inc.
                              All right.  Well, I think this discussion, like so
              25





                                                                           16 2


                 many others, demonstrates the wisdom of a review  committee

                 and the
                        ,peer review process.
              2

                             We have one last piece of business which really
              3

                 is more informational than anything else. It's  the  report
              4
              5  to the review committee on the actions of the staff  anniversary
              6  review panels and these recommendations will be recorded by

                 committee members.
              7
              8              So let me first call then on llrs. Flood.
              9              tIRS. FLOOD:  For Alabama.
                             DR. SCHtlIDT:  For Alabama.  You have only the
             10


                 one or
             11

                             I-IRS. FLOOD: No. I have Alabama, Illinois  and
             12


             1 3
             14            @DR. SCIIMIDT:  Okay.  IIell,, just take them in order.
                             IIRS. FLOOD:  All right.  We will begin with Alabama.
             15
             16  Tbore is an item of interest in the SARP report regarding the --
             17  I will quote from the report -- the dropping of Dr. ilill.as
                 Alabp,r,ia.@iPs paper coordinator which was felt to be a positive
             18
                 step in the development of this regional program,
             19
                             The program has some deficits in minority interests
              .20
                 but is recognized as a leading group in the development  of
             21
                 answering the problems of health care in that state.
             22
                             They were requesting for their third year,
             23
                 operational year in the triennium -- it's their fifty operational
             24
       I  Reporters,  Inc. year $875,908 for T)rogram staff.  The SARP recommends that
             25





                                                                          16 3


              I th-at be the approved level.
              2             Contracts allowed at $10,000, the same requested

              3 level.
              4             They are recommending a developmental component.
              5 They have markedly decreased the amount in the reqion's
              6 request for operational projects from 2,141,224 to 779,649
              7 which then totals to the amount approved by council for  the
              8 third year of their triennium of 1,765 dollars -- 65  thousand
              9 five hundred and fifty-seven dollars, which is quite a  drop
              10 from the region's request for the third year of its triennium.
              11            I have no other comments regarding Alabama on this.
              121           DR'* SCI-IMIDT:  We'll just say if any committee
              13 member has a question, if you will break, otherwise just  go
              14 right on ahead.
                            MRS. FLOOD:  The next region that the SARP reviewed
              15
              I Was Illinois which was, again, rated as an excellent  program.
              6
              17            Their requested funding level of  $2,000,800,for
              18 the second year in the triennium and is also council-approved
              19 level,, and the SARP recommends approval of the funding at
                @his level with a developm ental component of $152,428.
              20
                            Therels,one question that I would like to pose
              21
              22 as to the Illinois Pegional @leclical Program.  There,,is mention
              23 in the briefing document that in the  October"72  RAG.meeting,
                that body for the 1113-,'iois Regional Pledical Program acloT.)tc-d
              24
   -lot Repottefs,  Inc.
              25 unanimously a rescvlutic)n!defining their region of concern as the





                                                                              16  4


                  entire state of Illinois,

               2              I have to ask what effect this has on the bi-state
                  REgional Medical Program in its endeavor to serve   the   south-
               3

                  eastern portion of the state.
               4
                              There was some discussion  of  turf  problems  there
               5
               6  at the September review committee at  which  time  bi-state  was
               7  reviewed and I had thought that  there  was  some  recommendation
               8  that the two coordinators  and the RAG representation, also
                  grantee institution, get together and try to define the
               9
                  responsibilities in these overlapping areas.
              10
                              I would like to question if any other member of
                Ithe committee or member of staff could offer us any insight
              12
              1 3 as to wlaat poteii-Lial-problems this resolution of the  Illinois
              14  RAG will provide.
                              kiRe CI-IAIIBLISS: Mrs. Flood, I think Mrs.  Ilou,.3eal
              15
              ,6 could answer that question.    She's  the  operations  officer  for

                  bi-state.
              17
                              MS. DOIIA I-IOUSBAL:  Can't remember.  Staff has
              18
                  gotten together on this and in the near future or some time in
              19
                  the   next couple of months--- Dr. Margulies intends  to  begin  the
              20
                  sters   of bringing about a resolution of this which will include
              21
                  brinqinq the coordinators together.  Ile are taking  steps to
              22

                  do  so  on that.
              23
                              -DR. TIIUPIIA!Q:  Does that answer the question?
              24
  ;,_*I Reportets,  Inc.
                              MRS. FLOOD:         it  doesn't  really  resolve  the
              25





                                                                                  16 5


                  problems, but I'm not sure thit we care
               2                MR. CIIA,@IBLISS: It may not  resolve  the  t3roblem.

               3  because the problem is not resolved.
               4                MS. HOUSEAL: There  are  no  plans  to  abolish  the

               5  bi-state out.
               6               .11R. CIIATIBLISS:  No. there is not.
                                There will be discussions with the coordinators.
               7
               8  perhaps along the lines of the Intermountain concept that
               9  you heard  explained  earlier.  But  there  will  be  efforts  to
               10 bring them together to work-out this issue.
                                MRS. FLOOD:  Point of interest,    I'd like to know
               11
               12 lwhat the results of these conferences were      for future-
               13    information.
               14               MR. CII@.IBLISS-. We will report  those  results  to

               15 this committee.
                                MRS. FLOOD:  Thank you very much.
               16
                                The third region assigned to me  was  Nortl-ilaiids.
               17
               .18 They were requesting,  in  the  third  year  of  their  triennium
               19 application, $2,699,447.
               20               The staff anniversary review panel made.s.ome
                  comments  regarding  minority  involvement  in  that   particular
               21
                  PNip. There was  also  some  concern  about  the  development  of
               22
                  their goals and objectives since there had been little
               23
                  minority or consumer -;-:iput into the development of the goals
               24

  'e    I Reportefs,  Inc.
                  and objectives, and their recor-,-,iendation %@iis for this  third
               25





                                                                                     16 6


                   year of their  triennium  to  fund  them  at  $1,750,000  @@7ith@a

                 2 developmental component not to exceed $150,000.
   0
                 3               DR. SCIIMIDT:  All right.

                 4               MRS. FLOOD:.  Any questions that I might be able

                 5 to answer?
                 6               DR. SCII!.IIDT: If  there  are  no  questions  then,

                   Dr. Elliss.
                 7
                 8               DR. ELLIS-..   All right,, Mr. Chairman.
                 9             .1 have been assigned the office of.Regional
               10  Medical Programs.  The program was reviewed-by the staff
               11  anniversary review panel.  I can be very brief.
               12                The request from the region was for $2,388,000 plus
                   @-,na c.,ie rccc)=c;ic:ation of the council-approveu- level for  th'Ls
               13
               14  year was one point seven hundred thousand.

                                 The recommendation of the SARP is that the
               15
                   council-aPT)roved  level  --  They   approved   the   council-approved
               16

                   level  of  one  point  seven  hundred  thousand  in  direct  costs
               17                                                                 . I
                   and this  recommendation includes a developmental component and
               18
               19  maximum funding of $375,000 for kidney disease project..
                                 The request of  the  region  was  more  but  it  was
               20
                   the  reasoning  of  SARP  that  although  the  region's  track  record
               21
                   was good, they had   not given evidence of extraordinary progress
               22
               23  during the past year or they saw no reason for increasing it
                   above the councils level, particularly because some of the
               24
  ;e -01 Repofteis, Inc. existing problems  which  had  been  pointed  out  had  not  yet  been
               25





                                                                               16 7


               I  corrected completely, but progress,, great progress has been

               2 made.

               3              The second one is the Iowa Regional liedic,,il  Program.

               4 For the fifth year, the region requested $918,000 and this

               5 was recommended also but the council level of funding was a

               6 little   less.

               7              The panel, the staff anniversary review panel

               8 recommended that the program be funded in the amount requ6sted,

               9 and this includes $79,000 for kidney disease activities and

              10 this program has really made excellent progress and has     moved

              11 beyond expectations in many of the areas that had prevented a
              121very well-coordinated plan of 173,  174  which  indicates  that  they
              13 are working according to plan.

              14              And the other is the Ohio  Valley  program  and  the

              15 request -- the council-approved level  for  the  second  year  is

              16 $1,639,000 and the request is two million five hundred and

              17 seventy-one million   (sic.) and it is the recommendation of

              18 SAF-P that the region be funded at its fifty operational ycar,

              19 second year triennial at the  council-approved  level  of  one  point

              20 six.  And this includes the developmental component..

              21              It was the feeling of the SARP that this region is

              22 strong, a strong, viable region,   but I think  it  probably  has

              23 Developed some of the best relationships in working with      the

              24 CTIP and OEO and all of the other areas.    I myself am not  so
       1 Repottefs,  Inc. ure about the involvement of the  minorities  and  the  panel  point
              25






                                                                             16 8

               I out that this is an area, too,.tliat needs strengthening..
               2             The only thing the panel did do which  put  them  a
               3 little below the recommended level is that  they  discussed  at
               4 great length the university continuing education resources and

                 they felt that this program had been in operation for about
               5
               6 four years and is scheduled to continue and that  it  is  based
               7 on activity vyithin the three medical centers and they feel

                 that they be advised, the region be advised to seek other-means
               8

                 of support beyond the committee period of this support.
               9

                             Do I do anything by way of making a
              10

                             DR. SCII !,IIDT:  l@lo.  Thank you.  And Miss Kerr.
              11
              12,1           MIS8 KERR: I'll try  to  be-brief.  Florida  is  in
                     second year triennial and I might report that you wil-i
              13

                 recall that Florida had some bumpy times prior to about a year
              14
                 ago when the site visit team came back excited and excited us
              15
                 about the turnaround they had made, and they  were  then  rated
              16

                 354.
              17

                             It seems that rlorida continues  to  do  well.  Tie
              18
              1  panel indicated it has shown dramatic program development.
               9
                 Nei.? priorities have been Established in the areas of neonatal,
              20
                 :care, midwiferies, sickle cell disease and outreach   programs
              21
              22 utilizing indigenous personnel.
              23             There were minor -- two  minor  concerns.  I  don't
                 know how minor, but at least not major.  It  was  noticed  that
              24
   01 Reportets,  Inc. the T)rojects, several of the projects were supported  --  were
              211





                                                                                 16 9


                  university-'based junior  college  affiliated  or  associated  with

                2 state agencies and the  panel  felt  perhaps  that  the  region
                3 should look  beyond  the  traditional  or  formal  establishment

                4 grounds to support new projects.

                5              And then there is a Project 44, Manpo@,ier Development

                6 in Education which, at this point, seems to focus on medical

                7'education and it is  concerned  that  it  should  and  eventually

                8 hopes it will  be  directed  toward  other  health  professions-lso

                9              At this point and time, the last year  they  %..,ere

               10 funded at two  thousand  two  hundred  and  forty-eight  thousand

                  seven hundred and six  (sic)  and  council  approved  that  amount.

               12              The request for this  year  is  two  thousand  eight

               13 hundred and three  dollars,  two  thousand  --  no.  Two  million

               14 eight hundred and three four ninety-nine.

               15              Council had approved  the  level  of  two  million

               16 two forty-eight, seven oh six, and the panel has recommended

               17 that it be kept. at the level of  two  million  two  hundred  and

               18 forty-eight thousand seven  hundred  and  six  for  the  ensuing

               19 year and gave it,a rating of  342  which  seems  to  indicate  a

               20 real strong approach.


                                   SCITIL
               21              DR.      IDT:  Before you go on and for the benefit

               22 of Drl Luginbuhl and others v7l-io have really been  in  a  way

               23 very interested on N@7h at the effects of review committee

               24 actions and-site viEi,@r@- and so on can reall@,, be, what kind  of

       I Reportefs,  Inc.
               25 leverage, what kind of clout do you have, I think it's safe to





                                                                             170


                 say that this region vi,-s unmitigated di--,aster area at one

                 time.
              2
              3              There were subregions trying to secede from
              4  Florida, if you can imagine that.  It was really a mess,.and
              5  as a result of site visits and strongly worded concerns of
                 review committee and so on, this region did, in fact, turn
              6
              7  around in the face of problems with the grantee, the  RAG,  the
              ,8 staff, the whole business, and it is an example of the effects
              9 of the  review committee and the site visit processes, I think.
              10             Okay.  Thank you,
              11             IIISS KERR:  Now, we go to New Jersey which had a
              12 previous rating of 413.  New Jersey is in its third year of
              13 triennial, and essentially, I think the same thing can be
              14 said about New  Jersey.
                             The panel feels that it is moving along  very  well
              15
                 and carrying out its@prograns as intended and is effective.
              16
                 It did,;ho,,.Iever, recommend that more professional minorities
              17
                 )Do represented on the technical review committees and the urban
              18
                .I@-alth task 4Lorce-committees. This was the  primary  criticism.
              19
              20             In view of the success of the program and the
              21 endeavors that have  no.unted and its accomplishments, the panel's
                 recommendation is to increase the funding level for this
              22
                 reqion of medical program in recognition of its continued
              23


                 success.
              24

       I Repottets, Inc.
                             The year four was funded at the level of two thoiisan
              25





                                                                               171

                  one hundred. Council approved a  level  of  two  million  one
               2 hundred thousand.  Council approved the level of two million

               3 nine hundred and ninety thousand.
               4              This year, the region  is  requesting  two  million
               5  nine hundred thousand. It has  been  approved  by  council  and
               6  the recommendation for funding'level is two million five
               7  hundred and fifteen thousand dollars.
               8              Now, the next one I may have to ask some staff
               9  support on because it's a little knotty.  I neglected to
              10  tell you that the previous rating was 413.  The present
              11  rating was 403, so that would seem to indicate continued

              12  effective activities.
              13              This is Tri-State  which  is  Massachusetts,  Rhode
              14  Island and New Hampshire.  It's in its third year of
                  triennial. Its last  rating  was.343.  Its  last  site  visit
              15
                  was in October of 170 and it's had four staff visits    in  the
              16

                  last twelve months.
              17
                              There seem  to be problems that  the  staff  have

                  observed.  Principally,  they are the followings  in response
              19
                  to the 1971 advice letter, there are seven major points
              20
              21  directed to the region. One was  a  need  to  strengthen  the
                  program activity in the primary  care  delivery  area.  And  in
              22
                  response to that, two of the  regions'  new,  not  previously
              23
                  aT3proved,projects are in the primary care delivery area, and
              24
  ;e-ol Repoiters, Inc.
                  an emerging medical system project was initiated last     yeir.
              25






                                                                             17 2


                              There was concern over limited minority involvement

                2 in the Tri-State structure and on the program staff.  That
                3 situation evidently continues; inadequate minority reidresenta-

                4 tion.
                5             The categorical subcommittees do not appear to

                6serve the needs of the overall program.
                7             An increased effort toward strengthening the
                8program evaluation was indicated possibly through the redesign

                9of the subcommittee structure.
              10              The problems category as identified by interviews
              11 with  health leaders are being used as a framework for Tri-State's
              12,lprogram evaluation.  It appears, however, that they have
              13 no relationship  to the four program elements or goals of the

              14 regi.on.
                              Another concern is the program priorities
              15
              16 established  in 1970 do not relate to specific  regional  or
              17 subregional  problems which are identified as warranting
              18 immediate attention.
              19              There appears to be a lack of  program  thrust.
                              Concern was also expressed that was was.formerly
              20
              21 Project  17, The Regional organization for the Care  of  the
                 Cancer Patient, was initiated as a contract in amounts over
              22
                 the $25 000 limit and it was felt that the region may be
              23
              24 bending  its rules to accommodate special interest  group,;.
  ,@*1 Reporters,  Inc.
                              So there are some accomplishments, .ind it  all
              25






                                                                            173


                 isn't backsliding. It does have a new structure  committee  and

               2 it's under review.  Central staff positions have been

               3 reallocated to the subregional offices.  Program staff

               4 continues to be recognized as a resource to those seeking

               5 to improve the health care in the region.
              16_1           The budgeting 2;eflects categorical primary care
               7 emphasis and there are an increasing number of funded  projects

               8 and contracts which have demonstrated evidence of joint

               9 funding.

              10             In recommending funding, the rationale behind

              11 it is that the region's progress was not considered satisfactory

              12 to warrant an increase of its 1971 council-approved level.

              13             The issues that were addressed in the advice letter,

              14 especially minority involvement, the Tri-State PI--IP was not

              15 adequate.
              16             Requested increases in personnel and  developmental
              17 component were not justified since the region is in the-

                 process of evaluating its total program.

              19             No,,,-i,, it may be that staff will want to go in to
                 more detail on this, but I point out the fact that @here are
              20

                 ome-concerns that .have made both staff and SARP take a very
              21 s

                 close look at the funding level.
              22
              23             In year four, present year, it's two million and
                 -i half, and '-his was z,,,@nrovc-(l by council.  Council also a]-)I-)rovc--,,-,
              24 ,           LI                                            I
  @e-Federat Repofters, Inc. two million and a half for the year five. However, the  region
              25





                                                                             17 4


                 has submitted a request for three million four hundred  --ind

                 seventy-five thousand and it is SATZP's recommendation, it
               2

               3 seems reasonable to me in view of  their  observations,  that

                 the level for this year he at the sustaining level of two
               4

                  illion five hundred thousand which is as it was last year.
               5 m

               6              DR. SCHIAIDT.-  All right.  Thank you.

               7              1 think we'll leave it at that.  It w6uld be

               8 13roper for me to say that these recommendations must  go  on

               9 to council and that these are included in the confidentiality

              10 statement and these are to be considered in the same way as
              11 any other applications and actions.
              12,1            I would receive a motion that these reports from
              13 SARP be accepted and endorsed by the review committee.

                              DR. BRINDLEY:  llalze such a motion.
              14

                              DRI*'.:. THURP4AII:  Second it.
              15

                              DR. SCHI-IIDT:  All right.  It's moved and seconded.
              16
              17 All in favor, please say aye.

                              (Chorus of ayes.)
              .18

                              DR. SCII@IIDT:  And opposed, no.
              19

                              (1-iotion carried.)
              20
              21              DR. SCIRIIDT:  All right.  ilith a reminder to
                 signify whether you wish or wish not the material sent, I will
              22
                 once again say to a hard working and most excellent committee,,
              23

                 thank vou, and'we shall. meet a(iiin.
              24

  ,e   I Repoftets,  Inc.
                              l@IR. CIIA@IBLISS:  I-lay I just ,3ay that inasmuch as
              25





                                                                               17 5


                  I)r. I-largulies was unable to return that we do appreciate your
                2  time, your interest and your  effort and on behalf  of the
                3 staff, may I let you lzno@,7 that.  Tha@,s.

                               (WI-iereupon, at 2:45 p m., the conference was
                4

                  adjourned.)
                5


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               25