Transcript of Proceedings

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415 Second Street, N.E.
Wos!iington, D. C. 20032

NATlONWIDE COVERAGE

    Telephone:
(Code 202) 547-6222


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                    Conference Room.GH
                      Parklawn Building
                      Rockville, l1aryland
                      Wednesday, January 17, 1973

      The meeting convened at 8:40 o'clock a.m., Dr.

Alexander Schmidt, Chairman, presiding. !. :

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DEPARTLJENT OF HEALTH, EDUCATION, AND WELFARE

HEALTH SERVICES AND M?NTAL HEALTH'ADZ4JNISTRATION

     REGIONAL FIEDICAL PROGRAFIS SERVICE

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Review Committee


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CONTENTS
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Ager,ds Item

Welcoms.........................

Future Meeting Dates . . . . . . . . . . . . . . . . . . .

Report on the Regional Nedical Service Programs' - Dr.
   Margulies . . . . . . . . . . . . . . . . . . . . . .

Dr.Pahl................;.....

Program Reports on Activities supported through supple-
   mentary funding: _

Health Services and Educational Activities -

Dr. Conlay . . . . . . . . . . . . . . .

Emargsncy Medical Services - Dr. Rose . . . . .

PSRO, 1I.R. 1 - Dr. I4argulies . . . . . . . . .
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     Verification Visits to kgions - Mr. Chambliss

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Rwirw of Applications:                   : ,; ,,'I

Washington/Alaska . . . . ; . . . . . . . . . . . . .

Louisiana . . . . . . . . . . . . . . . . . . . . .

Connecticut  ......................

Metro D. C.   ....................

North Dakota  ...................

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         1                  PROCEEDINGS
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         2           DR. SCHI4IDT:  I have been waiting for some juice to

.*    3 get through the PA system here, and we are still having a

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4 little technologic difficulty. But I think that we can get

5 through, at least my part of the meeting, without the benefit

6  of the PA system.  Years of lecturing in large lecture halls

7  which also have problems with PA systems have led me to
8 develop a penetrating voice that ? hope carries to the back of
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9 thk room.

10       So I will call the meeting to order and welcome every-e

11 one here, this first meeting welcoming the members of the

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committee and staff and also at this meeting any public members

who might b,e here.  This meeting as you all probably know, is
the first one that is being conducted in accordance with the

Federal Advisory Committee Act, P.L. 92-463.

And all committee members have with your agenda

materials the rules for conduct of RJIPS public advisory group

meetings.  And there is no particular need to look at this now,

19 but it is kind of interesting and gives some ground rules for
20 the conduct of these meetings and the participation of the
21 public guests who may choose to join us during the open portion

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         23       I would direct your attention to at least one guest
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c     24 that I know of.  Dr. ~1 Florin is here representing Dr. Ingles

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     25 ar.d the steering committee of the coordinators. Later on today,


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12  I      Are there objsctions to those days?

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Dr. Phil White will join us, an old committee member, to cover

one of the applications.

We have found it necessary because of a conflict with

another meeting that is scheduled to look at change of date

for the May meeting.  And we need to pick days 'during the week

of May 7 to 11.  Those of you who bring your calendars may want

to check that out and pick days of the week for this.  Wednesda

and Thursday would be the 9th and 10th.  As I recall previous
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discussions, the committe e is kind of settled on Wednesday and

Thursday as being good days which would make it the 9th and

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;; .         If not, then we will settle on those.
    Ths other days are September 12 and 13 in 1973,

January 16 and 17 in 1974, and I-lay 15 and 16 in 1974.  We hope

that is not anticipating anything too much.

I have a letter to th e Regional Xedical Programs

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Rwizw Committee that was given to me a minute ago by Dr.

I",largulies from Vern Wilson.  end I would like to &ad that

letter to the committee.  It says:

       "Ladies and gentlemen:

     'IBy the time this reaches you, I will have already
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left the position of A&G.nistrat.or of the Health Services and

i&ntal Health `Administration to return to the University of


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Missouri.  I feel I would be remiss if I did not express my  I

sincere sense of gratitude for the cons-iderable advice and

counsel you have provided to me and to HSMIIA during my

incumbency.

"Please accept my thanks and most sin'cere wishes for

the successful pursuit of your personal goals.  I hope we will

mset many times in the future in our joint efforts to improve I

health care for the people of our country.
                                   .
     "Best personal regards, Vernon Wilson."

     Some people have asked me what Vern was going to do

in Missouri and particularly was h, 0 returning'to his academic

vice presidency.  And the answer to that is he is going back as

a tanurzd professor and will be teaching and in activities

having to do with community medicine and perhaps his discipline.

I am sure that the opportunities for Vern will be many, and he

will be able to select among many excellent opportunities to do

what he wishes.  But he won't be going back as the academic

vice president.
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There is a reorganization of the zledical
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in ;Gssouri as many of you know.  And they will be choosing  som

vice'provosts and so on.  And how that will settle out no one I

knows.

But it is appropriate, then, to lead from a note from
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Vern rdilson to Dr. ;,:argulies and the third agenda item, the

report from Dr. Xargulies and the Regional iledical Programs


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Service.  So I will turn the microphone over to Harold.

        DR. XARGULIES:  Thank you, Mac.

     The Review Committee may feel a little more prestigic

than usual for the moment.  If you have read what has been

happening sinca the election, there is virtually nobody left

between you and the President of the United States in HEW.

So you are very close to the seat of power.

We tried to arrange the meeting to be at Camp David
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but the roads were bad and the helicopters weren't flying.

     I have a few announcements to make to you which have

to do with specific situations within the REgional Idledical
Programs and would like to go through a number of other

information i terns before we get to ths reviews themselves.

Some of them have to do with changes in leadership in Regional

Xedical Programs which are very.key events as you all know

from having reviewed RMPs.

There are three Regional Xedical l?rograms.which

you knew wer, a seeking nsw coordinators and which have in fact

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solscted and officially appointed new coordinators.  One of

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them is Albany where Frank Woolssy has resigned and has been

rzplacsd by Dr. Girard Craft who has been with that program for

some time and is fully familiar with the activities and

purposes of it.  Frank resigned with a very positive feeling
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that he had b-en able to do a'good many things that he would

i like to gst don- Q and with the strong feeling that it was time


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13  selected.  That is Al Donnsll, D-o-n-n-e-l-l.  IS is a lifetime

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16  rogionalization, has worked with the IU4P and appears to be a

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18        There have also been some resignations since we were

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last here.  And I will just go through those quickly.
     Dr. Wantz from Xetro D.C. has rasignzd, and there is

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23  and Dr. Aronson is acting.  And there is a search for a new

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for him to take it a little easier and have a different kind

of leadership.  And it looked very positive.

As you may recall, in Iowa, there was also a search

for a new coordinator because the one who had been there had

left so that he could mov, 0 with his family to Florida. The

new coordinator  ther e is Charles Caldwell who again is an

individual who has proved his value as a member of the staff
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and is a very capable individual.  He was acting from the time
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that Dr. Weinbergcr' left and has bacome coordinator since

0ctobsr.

And in Oklahoma where Dals Groom retired around

.Sspt.ember of 1972 of the past year, a new coordinator has been

Oklahoman as I recall and has been very active in the general

hospital field and is keenly interested in the whole concept. Of

very attractive choice.

a search for a new coordinator.

Dr. Jay Brightman in New York Metro m4P has resigned,

coordinator.

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Dr. John Lowe in South Dakota left in October.  And


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Donald Brekkee is acting there.  And they are searching for a

new coordinator,

And we just received that Dr. henry Clark is

resigning as of iday 1 from the Connecticut NIP.   I talked

yesterday with Mr. Rogers who for a good many years was

chairman of the Regional Advisory Group in Connecticut.   He

described the way in which they are setting up a search committ:

We were especially interested there because there has been a

kind of uneasiness in the Connecticut PCiP between themselves

and the Stats Medical Society or at least some members of the

Executive Committee of the State Society.

     They appear to have good accord in the method of

sBarch for a new coordinator.  And the president of the

Stata bledical Society is on the search committee.

There are some regions which have not yet made a

final selection of-new coordinators where there is an acting

arrangement.  Indiana is one where Dr. Beering is acting.

He is Associate Dean, as I recall.

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In Intermountain, Richard Haglund who for years has
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been on the staff has been acting coordinator for quite some

tins'since Dr. Sadavil: resigned.  And they are still trying

to find a new coordinator.  I will get back to that in a moment

because there are SOLE issuss there.

In Idestern Pennsylvania, Dr. Reed had agreed to

stay on for one year.  That year will be ending in the near


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1   future.  There is a search committee for a replacement for him.

2  In the case of western Pennsylvania, you will recall that the

3  coordinator had resigned to seek another academic position

4  so that that ona.has baen open for a period of time.

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     One other change which is of some interest is in

Texas where a new grantee has been arranged for.  This was done

with mutual understanding on the part of the university, the

State Xedical Society, the Regional Advisory Group.  It appeare
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that the involvement of the medical school could remain very

full with a grantee which was a nonprofit organizational

structure and was actually done under the aegis of the

university and with their strong support.  That began on

January 1 and appears to be a satisfactory activity.   And there

will probably be something similar which will evolve from the

Zlatro New York R2:P although that is not yet official.

You may also recall that we did distribute during the I

past several months a very explicit policy statemclnt regarding

the relationships between the grantee, the Regional Advisory
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Group,  and coordinator and his staff.  This is something which
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20 had long been asked for.  There had been uncertainty in many

21 1 instances  abou t what. that relationship should be.

22          We have had discussions here.  We had extensive
2311 d' iscussions with the Council.  It finally did receive endorseme,. -1

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and was distributed.  With one exception, it has been greeted

either with enthusiasm or witn accord which requires some


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adjustment in the organization of Regional Xedical Programs.

Host people felt that it was overdue, that the statement was

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clear cut and did not repre,,
                  cant an unsatisfactory way of

conducting the business of a Regional Medical Program.

The-exception most notoriously is in the Intermountai

Regional Hedical Program where the administration of the

university feels considerable discomfort with the idea of a

Regional Advisory Group making decisions which they feel shculd

be made exclusively by the grantee.  That issue remains unresol

And as I hinted a moment ago, it is probably one of the reasons

why there has been some delay in th,e final selection of a new

coordinator.  I really don't know what decision they are going

to make in Intermountain about adjusting to that policy or

selecting a new grantee, whatever may be the situation.

But aside from that and some restlessness at least

in Tennessee mid-South, we have had no real difficulties with

that statement.  And for the most part, the response has been

a very positive one.
                     

     I think that it would be fair to say in Dr. Florin's

nams that New Jersey is making  som B changes in its organiza-

tional structure to accommodate it, but it doesn't appear to be

too much.of a problem.  In that case, as was rarely the

situation, the Regional Advisory Group and the grantee were

essentially the s.ame.  And this requires some new organizationa

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   II        to continue doing business, but to be consistent with I


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3 ~ moment because there may be som.e casual interest in the subject

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5 which for those who have not fully enjoyed that. kind of an

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8 ~ Congress may pass a continuing resolution which allows the

9  program affected --'in this cass, t.hose in HE11 for which

10  appropriations hav, 0 not been made available ---to continue to

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16  the proposed budget for 1973.  So we have been operating at

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During the period of time when we are on a continuing

resolution, VIP_ continue to act according to those kinds of

~ HEW policy.

Now, let me get on the subject of the budget for a

We continue to be operating under a continuing resolution

arrangement, I will provide an explanation.

          When there has not been an Appropriation Act passed

operate on the basis cf one of two alternatives -- either the

-1svel of budgetary allowance of the preczding fiscal year cr

thaw budget which was proposed by the President to Congress for

thz current year,  whichever is lower.                    _.. _

       Now, there was no gross difference between 1972 and

essentially the sams level of activity during thatperiod of

two years.  There were two Appropriation Acts p'assed by-.
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Congress,  and they were both vetoed.  Congress is now in

session and, of course, can pass another Appropriation Act,

can 'continue under the continuing resolution, and can do the

latter for an indefinite period of time.  And we don't know


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rules.  However, when it is as late in the year as it is at

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the present time, it requires a certain amount of fiscal

prudence on our part and on the part of OilB.  And so thus one

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accommodation we have mad, 0 until the budget for this fiscal

year which is now more than half over has been determined is

to limit the duration of grant support for programs which

began January 1 -- not the amount, not the level, but the

duration of support.        _

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We could not for programs which had their beginning

date of January 1 provide funds for th,e full 12 months. So

what we were allowed to do was release grant funds at the
-level anticipated for the full year, but only for the first

G months until there is an appropriation and a final decision

on fiscal 1973 and some action on fiscal 1974.

Now, I suspect that what will happen, and it is

really more than a suspicion -- it is based upon what informa-

tion I have received -- is that when the President does

present his budget message which is scheduled for January 29,
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it will include somu 0 recommendations for fiscal 1973.   These
will not necessarily bs the same as those that were proposed

by the Administration at the beginning of the fiscal year,  but

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will be adjusted to the fact that we are well into this fiscal

year and will reflect whatever kinds of recommendations are

made for the sub sequent fiscal year.  I think it is fairly

obvious that the path.. +arn from one fiscal year to the next has


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1  to remain reasonably consistent.

2       Congress will, of course, receive that information

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3 /I and ,act according to th, 0 way in which Congress feels that'it I

        4  should.  It has the choice of passing an Appropriation Act'

         5  at any time, of course.  It could do so today ir it wished to

     6 do so or wait for the budget massag Q or act on the same day.

     7 And there is no way cf predicting what will actually be done.

         8       So we are really no clearer in our understanding
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         9  of'what our level of support will be now than we have been in

     lo tho past.  That means, although I em getting into the issue

        11  of review now which is a closed part of the m&sting -- I may as

,r i        12  well comment on it -- that we will continue, I hope, to do

13  what we have in past years.  And that is carry out a review

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II       ess in which we look at what has been proposed by a

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  liegional rGdica1 Program, examine the application and draw a I
16 judgment based upon the merits of that application and not try

17 to figure out what the budget is going to be when we don't know

18 what it is going to be.  That is an issue which. is separate

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19 from the review of prog:ams based upon their individual

20  merit.  And this Review Committee has been able to do that

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  quit- effectively in the past, and I am sure they can in the

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      23       Axe there any questions about that illuminating
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1        I would like to mention to you that the steering

2  committee of the REgional Medical Programs will be meeting

3  in January, and there will also be a general meeting of all of

4 the cocrdinators.  And I would like to take a moment if I may

5 to refer to the activities of the coordinator steering committer,

6  so that you can appreciate what kind of an assistance they have

7 been.

8       During the past several*years, the coordinators

9 have felt that they can establish a more effective working

10  relationship with the Regional Medical Program Service if

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they have selected representatives who meet together as a

steering commit-&e to bring to us information which they feel

is not readily available to us and which repr.esents a consensus

of coordinators' concerns and to receive from us information

thich can be distributed rapidly to the coordinators.

     Now, the'coordinator groups within themselves are

organized on a sectional basis.  And so they meet Northeast.,

Southeast, West, Hid-continent., and so forth.  'They meet at
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; regular intervals ercund--the meetings of t.he,steering committee

, and around their own kind of business.  When the steering

COm;nit-.tes meets in January, it will take advantage of the fact

22 that ther-
II       F is to be a conference on quality assurance.   It. will I

      23 also be an cpportunity for all of the ccordinators to meet to

     24 elect new officqs and to consider any business they want. to

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That particular meeting is not one which is called

by the Regional Medical Programs Service.  That is, the meeting

of the coordinators is not.  They call that to conduct their

own business, to examine their own affairs, and do what they

think they need to do.  If they want to invite us to be present.

we are present.  If they have some other business to conduct,

then we are not present.  And it seems to be a very effective
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kind of arrangement.                   I
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     The meeting which then follows for the next two days

on the examination of the professional issues involved and

quality assessment and assurance is an invitational meeting

and is an official  par t of Regional 14cdical Programs Service

activiths .   That meet ing which is to be held in St. Louis

looks awfully good.  We have been working on it modestly begin-

ning a lit-12
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during the past several months.  We made several decisions

about it early on which we have stuck with and which have

appeared to be a pretty good idea.

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The basic one is that the meeting is to provide an
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opportunity for Regional Xedical Program coordinators and for

ot.h&rs who are interested to examine in a professional way the

major issues which are involved with quality assessment and

assurance.  There is no effort involved in this activity.

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The quality assurance conference is not designed to examine

neti legislation.   Ide are not there to consider PSRO or some


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11  meeting pretty much theater L -;nd of performance with the rapid

12 .pr,esentation of cogent papers group- ed together under general

13  subjects, very, very limited time for discussion, with a clear-

15  printed copies of the papers which are presented.

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Now, there will be approximately 28 people who will

17  have something to say in a formal way.  We have plans to

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special kinds of activities.  And it is very scrupulous in

its approach.  It is entirely designed around our understanding

last several years to look at all of the aspects of quality

There are some very competent people who we would

like to hear from.  And that is exactly the way it is designed.
                                                           -A.

But in order to make sure that what appears to be unusually
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good input will b e rapidly available, we have done two things.

One of them is to limit attendance and make the

cut understanding that there will be rapid distribution of

bind and distribute the papers within no longer than about 30

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days after the meeting.   He have already received something
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like 20 completed papers which is remarkable in itself.   And

I think that we will probably get,  if not all, virtually all,

of the papers completed, ready for binding  and for distribution

by the time the meeting occurs,   That means that we can

                                      

achieve our major pcryoses which it; to have a discussion of a

presentation and havs the widest possible distribution.


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e       1        Because of the quality of the confzrencz, WP are

        2  going to print an extraordinarily large number of volumes of

         3  the quality conference material and give them very wide

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distribution.  This allows us to feel more comfortable with the I

limited attendance.  If we had opened the attendance even by

word of mouth, the number of people wJ, * would have to accommodat

is staggering.  We learned that within a few days.  And since

there was no way to compromise on that, we decided to make it

a Regional $ledical kogram activity and restrict it accordingly

      We do know that some members of this committee are

.this will include Ancrum, Anderson, Ellis, Kerr, James, and

Thurman.

     There is an agenda which is in your book which is

Attachment B.

Now, one final thing that I would like to mention

17 /I to you -- well, there are two or three things which we should

18 II mention in passing -- just to-make sure that you do get all the I

19  news about what has been--happening within our structure. I
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2c  think you all know that Dr. DuVal has resigned as Assistant
21 II Secretary for Health.  You do know that Dr. Wilson has left  I

22 II as the Administrator of HS:MA, that Dr. Marston has left as

        23 the Director of the :Jational Institutes of Bealth -- has not

      24 left, but has resigned as the Director of the ZJational

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1  Administrator -- and it is clearly on an interim basis --

2  for Health Services and Mental Health Administration is Dr.

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3 David Sencer who is the head of the Center for Disease

4 Control in Atlanta.  That is a program director within HSNHA.
5 This is an arrangement until a new Administrator has been

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selected.

     Dr. Stone who is acting as Deputy has also taken ovs

the role of Acting in the position which Jerry Riso was serving
as the Deputy Administrator for the development group. And

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12       I think that there is jus t one other thing which I

13  would like to comment on and then perhaps, Herb, you might want

14 to pick up on any other iti-.
                 *ems that we need to present for

15  information purposes.

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20  terminate June 30 without new legislation.  There have been

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21  a nuinbrr of activities arcund the country in preparation for

22  new legislation.  What the form of that legislation will be,

      As a reminder, the REgional Medical Program legisla-

tion has to be extended in whatever form it will be extended

within the current fiscal year.  It is one of several programs,
                    

one of an extraordinaril-y large number of programs, which will
.

23 whether it will modify the directions of RIIP, whether it will
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     24 address othcx prGgra;ns in conjunction with K,iP, is a matter of
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good many suggestions, and I know some testimony to Congress,

proposing more specific kind of language to describe the missio

of Regional Xedical Programs and probably increased attention,

whether it is in the form of Congressional language or in

legislation, to the relationship between Regional Medical

Programs and other Federal health activities, most specifically

Comprehensive Health Planning.  The relationship between the
                                                           --A

two, the definition of the two, has continued to disturb pzoplc

since the legislation was first passed.  And despite some

strenuous efforts to rsach some clarification, it continues to

So that we may SEE anything from language of clarifi-

cation to some modification to some .restriction or some new

dir.ection,  I am not sure what. 33ut I think you will all be

interested in following the progress.  And in this particular

easier to do it as it goas on, some of the congressional

form of the legislation because it is extremely difficult to
                                -.

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write legislation which is as explicit as congressional

understanding would have it be.  This bsgins to bind the

legislation so that it is not maneuverable.  And I believe you

will be interested in following that kind of an activity.

I do not. knc;sr what. the schedule is for congressional

hearings either ir. the Senate or the House for new legislation.


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1      Ar? there any questions on these issues?

2        (No response.)

3        bet mo just get on two other subjects which are more

4 specific and have to do with professional activities with which
5 w2 are concerned.  Both of th.ese, WE have discussed in the
6 past and they have to do with the development of stronger

                                                                           .
7 working relationships and a more effective programmatic lank
8 for both cancer and heart disease; _

9     As you know, during the past year, there was an

10 incr.eased amount of emphasis put on cancer in the National

11 Cancer Institute, heart disease in the National IIeart and

      te, with som8 reorganization, with the proposal for
::I ~~~~t~~~:$:OZrl'gr~ater financial support, for both of these ,
14 areas of activity.  We have had, therefore, during the past
15 year a number of activities which have looked toward an
16 identification of th, e ways in which those InstitutEs and ths

17 Regional Xedical Programs can work effectively together.

18     As I have said to you in the past, what we would
19' like to see is a definition which is evolving of the roles
    .

20 of the Institutes and of the Regional Xedical Programs which
21 I think from our point of view are fairly evident.  It is

c.,   22 clear that the NIII is a source of research, biological research,
   I                              I

       23 as RXP is n,ot.  It is also clear that the IJational Institutes
o   24 are in a good position to identify major disease activities,
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interested in seeing developed or which they think are ready
for development and for which they can turn to the Regional

Xedical Programs for rapid expansion and for extension into the

health care delivery system.  This,  in fact, is totally consist

with ths original concept of Regional Hadical Programs which

was to do gxactly that kind of thing.

       Now that tha RIPS are nationwide and are dealing in

a kind of a network of activities Within their.rsgions and

across the country, the possibilities of doing this have been

increased.  One of the better examples cf what has already been

selected as a major targbt, I am sure you know, is the
secretarially sponsored program to establish a national

hypertension control activity,  During the last two days, on

Monday and Tuesday of this week, there was another national

meeting to address this problem.

     It is the general understanding of the peopla who
1 have been involved that hypxtsnsicn is a disease of great

prominsnco, that. it is probably afflicting som8 23 million

people in the United States.  Of that total number,. a relativol:
small number, perhaps not mors than one in eight, is diagnosed

and under effective treatmant.

It is also believed by those who have been working

most fully in the field that ths methods of management by
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covers the nation but is regional and local in effect --

program is perfectly possible developed around the concept of

screening,  of referral, of drug therapy,  and of maintenance,

understanding that this will require networks which will utiliz

physicians not exclusively, but rather for general guidance,

and a good many other people for screening, maintenance, and

for control.

I

      The energy behind this is very great.   In the

mseting in the last two days, there were assembled people f&m

many, many sources -- from medical societies, from voluntary

health agencies, from industry, from labor, the pharmaceutical

'industry.  The persons who were presented represented the

views of the Secretary himself, speaking for himself, the

current Secretary, Mr. Richardson -- and he gave us assurance

that Xr. Weinberger had already accepted the importance of this

as something he would continue -- the Commissioner of the FDA,

NIH, fISXI1A, all were fully committed  to this activity.   And we

anticipate thatit will be a major part of RXP activities in

*the future as well.       --

       In fact, it was sort of heartwarming to me, excepting

for 'one minor problem that they never mentioned, that a good

bit of what was represented as examples of how to control

hypertension was Ri"?P r,upported.  I was sitting in the front

row listening to-one example after another of the way it had

been done.  And I never heard the, words "Regional Lledical


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Program" coma out of it.  Well, v7e are sort of used to that

anonymity, but it happened to be a season in which I could
have selected a little different way of describing our work.

     Jerry Stamler presented a magnificent summary of

current knowledgs on the subject of hypertension, diagnosis

and treatment.  And I would say that 8 out of 10 of the

examples that h, c chose of ways in which the disease could be

managsd ware based on something which had been. sponsored by

Rsgional Medical Programs.

So it will not be a new undertaking, but it will

certainly represent a channzling of energy which I think would

be very exciting.  It is one of those kinds of things which

can be achiev-cd in a ralatively short period of time which I

am sure you will hear a gr-c
                    0-t deal more about.

Now, in the field of cancer, it will require further

definition than we have had at the prsscnt time.   But we are

lcoking to those Institutes -- NIL1 and the National Cancer

Institute -- to,give us a definition of those directions in

which they would wish to--go.  We will need to work out more
.

clearly the arrangements for staffing activities, for funding

activities, and so on.  But I think that we are now in a

position to serve the public interest and to take advantage of

a momentumwhich has been regenerated rather than newly
                             --WY,

gsnsrated.

Do you have anything?


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251

DR. PAIIL:  Just one thing, perhaps.  We have been

talking somewhat seriously, and I would like to just share a

personal cbservation with you and then make one point of

information.

In recent days, it has become very important to me

to go back to President Truman's observation as to when the

presidency fell into his hands.  And I just want to share with

you that Dr. Margulies didn't take full vacation time last

summer and so some time back decided that over the holidays,

he would take a few days leave.  And it was my good fortune

perhaps to have on the very first day that hs'was not in charge

of our program and therefore I was completely in charge ths

Washington Post indicate just how important it is to have our
                                                                      ,-
Director here full time.  And I believe that from now on, I

woulcl prefer if you didn't take leave, at least, and notify

evarybody.

The only pain,. + of information I would want to share

with you is that in a continuing effort to improve the

management of our program, trrt, have indicated to you that over
.

many, many months a policy manual has been under davslopment

so there will bz a single reference point for both our own

staff and all of the staffs of the regions when it comes to

what our policies are relative to the governing of the program.
                             --..

And that policy manual tnrough the cooperative efforts of

maw t many of our staff has now been developed.  md we have


25 I

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e     even managed to clear it through all the official channels

        2  so that we are in a position probably immediately after the

     3 St. Louis meeting to mail it to the regions where w,e will be

        4 asking the staffs to comment on the content and then following

        5  a consideration of those comments, we will revise it and send

        6  it out in completed form.  So I believe that we are trying to

7 pursua what we believe to be improved management practices.

8 And this, I think, is a vsry major step forward and is, I

9 believe, so recognized by the regions.

10       And I want to take this somewhat public opportunity

11 II to again thank our own staff for really the many months of

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effort and intensive effort in recent weeks to get it to this

particular point;

DR. SCBIdIDT:  All right, thank you very much.

Dr. Ellis.

DR. ELLIS:  14ay I ask a question of Dr. Hargulies,

please, ;4r. Chairman?

Dr. Nargulies, we are hearing quite a bit about
       

spacialized revenue sharing for health.  And I was just wonder-

.                                                                    . 1
ing that in the event that a decision is made to make bloc

grants to the States 'for health, do you see that this in any

way would affect th- 2 way the Regional Hedical Programs would

cperats or the legislation?  I ask this because it is necessary
                             -N. -.

to know in talking to so many people exactly how to co;nment

on this to the best advantage.


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        DR. MRGULIES:  As I said the last time that question

came up, that is a very good question.  However,  I will be a

little more helpful this time.  That is all I said last

time.

     I think there is no question about the interest in

the Administration in promoting the concept of State revenue

sharing.  That has been the President's position.   It was

initiated during the last session of Congress.

      There also has been an interest in what is probably

incorrectly called revenue sharing in health.  It really is a

matter of grant consolidation with State management of the way
.
in which the funds are being used, with greater latitude on

the part of th, Q State than they have under present categorical

circumstances.

        I think there is no question also that that kind of

arrangement is on, -.which could be proposed only by the

Administration, but which would either be accepted or rejected

by Congress.  And I think there is some likelihood that an

increased effort in that-direction will be mounted by the

.
Administration.  But I think it would be ratiier useless

speculation to try to'answer the question beyond saying that

therpu will really be two issues.

       One of them is whether that kind of an approach to

                             -. .
the support of health activities is acceptable to Congress.

And that would be ticbated, I am sure, very vigorously by


27

1 Congress.

2        And, secondly, whether if that did pass, it would

_.

3  include Regional :<Iedical Programs.

4'        Now, if one were to include REIP in a kind of bloc

5 grant arrangement with the deL- +prmination of support to be made

6 at the State level, it would obviously mean a different

7 Regional Nedical Program.  About that, there is no question.

8 But at the present time, I have seen oo legislation introduced

9 which describes that kind of an activity.

10

I am not in any doubt that it probably will be.   But

11 until something of
/I            that kind does get introduced, until there I
12 is debate, until there is decision about it, there isn't

13 any reason for us to considsr it as anything other than an

14 idea which is going to havsl to be somehow deliberated between

15 the Administration and Congress.

16

The nature of Regional Xedical Programs, as you

17 understand batter than anyone else in the Review Committee,

18 requires a different kind of an approach as we have currently

19 understood it to be.  And so if there should be that kind of
    .
20 a basic change, it would really change all the rules of play.

21 And then w-. 5 would have to go at it in a totally different

22 manner.  But at present, there is no proposal of that kind

23 which has been prU3 "vented to Congress and which is under
                                  'L-.

24 general consideration.

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          25 II          DR. ELLIS:  Thank you.


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DR. SCH?lIDT:  I won't ask if that answers your

qu estion.  I will ask if that satisfies you.

        DR. ELLIS:  Yes, it helps greatly.

DR. SCHMIDT:  I don't think there is an answitr to

the question.  Basically, of course, the problem is there
isn't enough mon,ey to go around to do things everybody recogniz

as good.  So in this instance, somebody has to decide where

the money is going to be.  And my,own personal interpretation

of things is that Congress is unable to make these decisions

right now.  It isn't equipped to do it.

There is some qusstion  abou t whether or not they have

the authority to do it.  If you looked at the Washington Pest

this morning, I think it was Congress is talking about soma

kind of their own super budget agency, Congress', own Office

of Budget and flanagemont, that would via with the exscutivo

?? o  This sort of a thing could share in the decision-making

of where limited numbers of dollars are going t0 go.   But I

i don't see that in the next four years myself.
                     ,
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   Fed at the Stat? level with the decision-making bsing put
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1 at the State level. .And in Illinois, since you are familiar

with Illinois, I now see the amusing businass going on of

everybody trying to divorce themselves from the health centers,
                            --
for exampla,  The lIile  Square, which is v3ry well known, is

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25 having its funding pulled back by the Federal Government.
I/                                                 And


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0   `1  Presbytsrian St. Luke's IIosp-,
                         ++-a1 is trying to pretend like they

        2  have never heard of llile Square.  martin Luther King is being

         3  peddled to Cook County Hospital of the University of Illinois
     4 because their funding which is now about $2.5 million a year --
     5 I think they see a couple hundred patients a year, something

     6 like that, for that money -- everybody is pretending like it

      7 doesn't exist.

8       And what is going to happen is that I think that

9 President Nixon will say to the State of Illinois, "I have

10  given you this money, you now have these programs, and you
11 decide what thz? State will support.." And the.Stat.e will be

12 deciding what to phas% out, what to keep, what to put together,

13  and I suppose might zvzn be deciding what of RM?? should be

14  supported in another few years.                     ',i .        ,.

15       Whether this will last when Congress really does find

16 out that the money.that is accrued by its taxation authority

17 is being spent by StaL,
                &=s in the next Administration, I would

18 rather doubt.  These things are kind of fun to think about and
                         I

19 to predict the future with.  But I don't think people really

    .

20 know.

21   DR. MARGULIES:  I think you should rcalizs that the

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22 idea of Congross having a sort of supsr 0143 of its own kind

23 was generated in the period of d:?pression following the Super
                                  'Lz- ._

24 Bowl and they felt th?y needed to reconstruct the conflict at

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   1            I don't know whether they worked out. the


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television rights, but it should be an interesting show if

they bring it around.

        DR. SCIIPIIDT:  I don't think the Super Bowl was

all that interesting mysalf.

     Well, we do have a number of progress'reports, or

,a few progress reports on various activities that have been

supported through supplemental funding.  And the first of these

relates to health services and educational activities. And

Veronica Conley will give us a report.

Veronica.

DR. COXLEY:  Thank you.

Dr. Schmidt, Dr. Hargulies, as was reported to the

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         IV at its last meeting,  57 health servic.e education

activities which are located within 25 RMPs wera funds in

June 1972.  Since that time all conditions for funding which
were imposed during the review process have been satisfied.

      At this point in time,, all but a few projects have

full-time directors and are moving ahead very satisfactorily.

They are in all stages of development, varying from the

fully operational San Fernando Valley Consortium, LAIJEC in

Erie; PEnnsylvania, and TAiIEC in Tuskegee, to the Batssville,
          >
Arkansas, EEA whose director just reported last week.

      The directors appear  to be predominantly from the
                             -s.
field of education, some of whom have had little experience

with the health services delivery system.  Xany of the director!


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have expressed the need for more orientation to the RIJPS

concepts for BSEAs and to RXPS policies.

      Communications between the projects and the RM?

staff is complicated by the great geographical distance betwe,zn

th.e R?lP office and the projec t sites in many regions.  They can

be 150, 200 miles from the office.

      Over the last few months, the need for more

                                                            .

orientation became so acute that t.>Jo of tho Directors of KS

planned a national meeting of IIC directors.  This was cleared

With Dr. Xargulies.  This meeting was held I-Ionday and Tuesday

of this week in St. Louis.  One hundred fourteen persons were

.'
in attendance reprssen,ting 36 IWPs.  On ths basis of attendzncc

at. that. ms~ting and as a result of many contacts which we had

$n cha past with the developing KS, we have made some obsarva-

tions which wo would like to pass on to you.

The directors have reported a general lack of manpowe

planning data in the communities whore t.hoy are establishing

IICS,  even in some cases in th? presence of a CIIP agency.
                     ,

Invariably, under the circumstances, the director sees as his

first task to conduct a raanpo\:sr survey.  All directors need

encouragement to look at health services nr?eds as z data bsse

in addition to the more traditional types of surveys.

     In the area of consortium formation, two problems

                              -.

havs arisen -- one tha issue of whn_ther to incorporate or net.,

and the issue of consumer involvement.


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On the positive side, through these consortia, the

EiPs have on a broadar scalz than ever before bsen able to

involve educational institutions -- tha, technical schools, the

.community' colleges, and the senior colleges -- none of whom are

necessarily in medical centers, but all of whom are participatil

in the education of our health workers.

In six IW?s, there are AIIECs which overlap with the

IIC projects.  And we have two vary fin% exanpln,s of coordina-

tion -- one between Ilorthlands XlP and the University of

;Iinnssota, and the iJeW :Iexico Ic:IP and t.he University of Jew
                                                    .

IIexico AIIEC.  The area of ovsrlap in 1~Iinnesot.a is in St. Cloud

where there  is an IX which has dzvt?loped and is the farthest

in devslo;>ment of the Xorthlands projects.  This is  also the
                             ._

outreach community under the AIIEC contract...                :

     Through coordinated effort.s, the IW? supported St.

Cloud consortium will serve as the community arm of the AIIEC.

All relationships between the university AIEC and St. Cloud

will be conducted through the consortium and not through

individual agencies,  institutions or hospitals.

      In New I.Iexico, t.hc AiIEC contract is directed

exclusively to the, Navajo nation.  The non-Indian population

in the geographical arsa covered by the AIIEC approached the
i?ew Ilsxico RX? because thlvy wished to have ths sarne services

                             - .
as the Indian population.  And the IJ?w i4oxico XII? is developing

a s?ct.ion to take care of the non-Indian population in the area.


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              33
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      Areas of activity which may illustrate the potential1

broad scope of activities of KS include, for example, the

Rhode Island State Hedical Association which has requested that

'RISEC which is our IIC in Rhode Island under Tri-State RMP

requested that RISEC participate in PSRO plannihg particularly

to provide advice on continuing education..

      In Arkansas the School of Uursing has asked the IIC

to establish scme affiliations with rural hospitals so that

its persons trained a t the university will have rural

hospital experience and, therefore, would be encouraged to

serve in rural hospitals.

There is also a growing SUrplUS of nurses in Little

Rock which has brougllt this about,

And another IIC has  b een asked to represent the

health community to work with architects in the planning of

a hospital.

And, of course,  several have been approached by

State m=dical societies and local madical societies as they

move towards mandatory continuing education for relicensure or

.
for continued membership in the State association.

And, finally, in the meeting in the last two days,

although they originally called  th e me'eting to talk about

program development, the issue which became an overriding one

                              --..
whs what thz directors call their survivability.  They quite

realize it will take many months and perhaps a ysar or more


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before they can become self-supporting.  And they are, of tours

very concerned about NIP support and the possibility of its

discontinuing.  They explored many possibilities at length for

'obtaining funds, one of which was revenue sharing.  And they

were encouraged to immediately begin to set up relationships

which would be important in any revenue-sharing activity.

And before they left yesterday, they appointed one of

the directors to publish a regular nawsletter so that they

country in HCs and also about what is going on in RXPS.

And their last action was to appoint. a steering

comiiittsz.  And its first charge was to explore ways and m%ans

how ths directors both individually 2nd collectively can

assist the RXPs in the months ahead and in particular in regard

to the upcoming legislation.  And the chairman of that

steering committee'will be in touch with the chairman of the

steering committee of the coordinators.

Thank you.
       *

DR. SCXXIDT:  I thank you.

Are thers questions?

-

Bill.

MR. I1 ILTOX:  Just a couple of small points.   The

PSRO is what?

DR. CO!LEY :   Professional Standards Review

Organization.


35 I

1            DR. SChIIIDT:  That is a nomenclature for peer review

2  group.

3,           MR. IiILTOiJ:  Another thing, in your comment for the

4 'developing needs of the AIIEC director, you mentioned the lack

5 of manpower planning data and a couple of other'comments you

6 ma& which suggested that the system that is being developed

7 among these project directors may be forced to replicate some

8 of the things some RilPs -- I have visited and talked with
                                                  ,

9 people -- think they should be doing.  Are the coordinators

10 of Ri:IPs familiar with these neads and is it your feeling they

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ar,e responding to those things they can best do or Clips, for

that matter.                                                  

        DR. COliLEY :  kJel1, there is a cont.inuing.need for us tc

-*work with our regions in reorienting their thinking about.how

one arrives at what kinds of manpower w2: need and how that

manpower should be.trained.  It is usually to conduct. surv.eys

and send questionnaires to find out how many vacancies there

18 arc  how many people are being trained.  But. it is our feeling
                         .

19  that one must first look-at the health services needs.  And thi

    .                                                            -.
20 is a n3w concept and one that is not easy for people to under- i
21  stand.

22           MISS XERR:  I would like to ask a question if there

         23  is any distinction between "needs" and "demands."  AS you do
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DR. COXLRY:   That did come out at the last. meeting

2 II and was stressed as a responsibility of the develcping IICs to I

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4`         DR. ELLIS:  Doctor, do any of these programs extend

5 to education of psople in the communities?

  6          DR. COIJLEY:  They are moving into this.

  7         ' DR. ELLIS:  And how do they relate to the profession21

8 health educators as w8 understood'it in years gone by?

  9          DR. CONLEY:  In the consortium representation, you

10 would have representatives of the various health provider

11 groups o  And there are consumer-represantativ,&s on the consortium

: j 12 as well.  And as they move into the operational phase, thay

: j3  will mov3 i!nt.o consunzr education, although each of these will
;':'i4 ,probably develop quite differently from the' other.     ....'

15          DR. ELLIS:   Because one of the really great nezds in
16 health education is broad, across the entire population of
17 consumers from childhood on through adult life,   And I was
                                    1

18 just wondering if this wouldn't. bz a very important thing to

19 build into some of those'--training programs.  It really could
       .

20 be done without altering the pattern too much.

21   I think it would make a tremendous difference in the
22 overall contribution of the program to the needs of pc3ople.

23

DR. CO:ILCY:  This is one of the elements in our
                --...

24 concept, Dr. Ellis, wilich we are trying to promote.

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DR. SCHi-IIDT:  Thank you very much, Veronica.   That


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was a very good report.

Emergency Xedical Services. Dr. Rose Will gi.VP, US

a briefing.

* I believe he has a handout.

        DR. ROSE:  A rather large amount, about half of what

I am passing out there, most of you have seen previously.

It is a reminder and updating as to where the supplemental

RMP awards of last spring went. and in a general sense for what

jqrposss they were to be spent..

As you will also see, there are some lists of

applications, both those that went through November Council and

those whic!~ are coming up nc:J,  which are off.er.?d more as an

indication of how much int.srzst has bo,en stimulated in the

R4Ps to work in problems of emergency care.' 'And. I am not'     "

suggesting that is a cornplate list.  We are still a little way

from a real definition as to when a coronary care training

program is hear, + disease and when it is 32X3.

        There is also a list of the regions that we have

visited over tha last fzw months and those that. wo hope to

contact within the r,ext few months.  Again,  a list of visits is

not set in any fashion.  It is largely a matter of where we

                   .
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~ feel a ne$d for`thrsa trips.
                              --
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people in the RiIPs -- those specifically interested in ona


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)articular area of emergency care, members of the BAG,
:xscutive committees, coordinators, evaluators, various kinds

)f people within each of the RHPs.

    A few words about the status of Emergency ;&dical

jervices within some of th e other programs around the building:

XiP, the 'Compr,ehensive IIzalth Planning Program, has expanded

its interest somewhat over the last few months.  They have
done a series of planning sessions around ths country for

uembers of B agency staff. . They have had three such meetings.

Tha fourth one is coming up next month in New Jersey.  They are

designed to acquaint members of the CHP staff with the concept

ofplanning for emergsncy care and the value of this care.     :

I have attzndtd two of these mestings.  I hope to :

although I am not sur,e that the audience has seen in t.hes.e kind

of ssssions what they would like to see.

As is usually the case, thzrs is 2 lot of concern

about how much money are we going to get and how are we going

to get it and that kind of a simple question.        .

The Comprehensive BPalth Planning Service has

also'printed -- it is in the final stagcjs now, should be out

next. week --  a ganeral,stat.ement of their approach to

emergency cars which v:ill be distributed to the CM? A and B
                             -*-

agencies.  And we will send it out to the IWP as well.  It is

an cv5rall policy statement, not much different than the sort

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2.        What used to be called the Special Project Office

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for Emergency Xsdical Services -- I mentioned this to you last

'tims -- this is the office which sst up and monitors the
contracts for model emergency medical services in five places

around the country -- is likely to become, probably already

has become as of this week, the Emergency Xedical Systems

Service.  And it. will include personnel from the Division of

6margency Health Services ads part of their organization. A

large part of their activities will continue to be the

monitoring of the five model programs plus a sixth which was

activated in December in Xaryland and a likslihood of the seven

one which is in an innocuous phase now, baing carried forth     v'

within the next few-weeks or months.          .        
                                                         *,,,  ,;, ;. .,', ..a,

As far as Emergency Nedical Services legislation is

conc.-lrned, which at the moment, it appears will not affect IWP,

hearings are scheduled or plannc-d to be held on legislation

very much lik- ,
        n the Rogers bill of last year.  Th'e hearings are

tentatively set for next-month.  It is likely that this year
                                                              . . . -.
there will be the sama bill introduced in both housas.

You may rcmembor last year there was a Senate bill

and a House bill.  And they never cane to conference.   That

bill relates to rather categorical C:IS activitiss -- ambulance
                             --.. . .

with people to ride on ambulances, very straightforward

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    One final statement, if I may, about some of the
concerns we have been having in talking with the regions. I
think the overall concern that I mentioned last time still
.exists.  'A number of the regions are still treating emergency

medical services as a separate sort of health activity apart

from the rest of the thing that the R!lP is interested in or per!

shculd be interested in.  And 2 large part of our conversations

have been trying to encourage th., a-idea of emergency care as
just a requirEmsnt of the tot21 health system rathsr than as a

separate project.

responsibilities for contractors who have receivrd money from

f&ES:2 supplnm2ntal earmarked funds versus the responsibility;
the management responsibility, of the n'Q itself.  And this

has generated a fair amount of co., ncern on our part and I think
is a fairly significant problem in some of tn,
                              ' 0 RXPS which we
hops to bs talking with over th.2 nc=xt feW months.
    Who is responsible for designing and evaluating

hardware orientation is still there.  Vlh5re can I get money to

buy radios is a common question.  And w2 try to get away from

that.

       I think the key issue which is coming along now both
                             'L->

in the Ri4P activities and in the model systems is the matter

of how one valuates t he effectiveness of the systsm both in


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18  RXP in no way separat, = or distinct from their other activities.

                         .

19       DR. SCIERLIS: --In short, are you including in any of

                                                                        *

terms of the project goals and in terms of its affect on the

rast of the health problem.   We have been  working rather hard

in this area with our Office of Planning and Evaluation hEre.

      The National Center for Iloalth Services R&D has    1

stimulated a fair1 amoun, + of interest in their 'staff in this

area.  And, of course, there is a major requirament for

evaluation techniques of this sort in the model systems.

DR. SCHMIDT:  Are there any questions or comments in

this area?

        DR. SCHERLIS:  Are future requests for Emergency

:.isdical Service funds as they come from the individual regions

being looked at by your group or ara they being looked at as

part of the general rev-,
              :cw mechanism without input .from your

     How are these to be considered?        .,..                 .
group?                                                                  i
  

        DR. ROSE:  There are some in the present cycle.   WE

ar8 trying to pick them out for our own interest, but they are

being thought of at least by us as another activity of the

20 the data which we have specific evaluation by yourself as

21 far as the E!IS proposa Is as they come in from individual

regions at thz present time?

        DR. ROSE:   170.  There may be staff input just as

                             - -.       ,
there might be for any other kind of activity, but there is

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1' Em.  There is no such.

2           DR. SCIIERLIS:   There are no earmarked funds, I assume

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then at this particular time.  This is just that'one go-around,

is that correct?

DR. ROSE: Yes.

        DR. SCIIERLIS:  They come in as part of the total

overall requests.

DR. i4ARGULIES:  Correct,

MR. HILTON:  Len's question raises a pcint that is

precisely what I wanted to ask with regard to the ErIS.   Is that

floated in exactly the same way?

         DR. KINMAN:                              '.,
                YES r  it is.                      i

DR. SCI-IXDT:  Are thrre other yu5stions or comments?

DR. SLOAN: \?ould you like to mention the conference

with the American Heart Association  on emergency care of

cardiac patients?

DR. ROSE:  No more than I guess just to say I am not

as up on that as I should be.  There is interest in a conferenct
                     ,

There is to be a ccnference which I believe is Xay.

      DR. SCHXDT: Dr. Sloan, would you care to comment?

        DR. SLOW:  Well, the American Heart Association

askad US to COOpSrate with them in dsvslopment of a conference

2311 on tha omargancy handling of cardiac patients in relation to  I

                                   ZI .       . .
24 our interest, ths RXP ;bnterest, in general emzlrgency medical

25 services.
I        And I think it is just worthwhile to note that we


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trying to cooperate with them and that such a conference will

be held, the proc..-
          -dings of which will be made available to

all Regional Xedical Programs.

DR. SCBI'jIDT:  We have learned in Illinois through a

disastrous train wreck, two airplane crashes and Florida

recently learned that th- 0 real trick in this whole area is

to have the emergency occur whsre you can handle it.  And if

that doesn't work, you are out of .business.

Len wanted to say something.

        DR. SCHERLIS:  I was going to ask in reference to

Dr.  Sloan's statmznt if the interest to RMP extends, I would

hope, to participating in the financial support of this .     .~~ .:.

confereme or is it as one of the many agencies, and therz.arE

many, which are listed as cooperating in this conference?

It is an important on8.  It is for emergency cardiac care. It

is being held at the Hational Research Council much like the

earlier one was several years ago when CPR was stressed.  This

is  for total early care.

      Have you b-.-
             eon asked for financial support?
.                                                                   - .

DR. 14ARGULIES:  I don't know Wat we have been asked,

Len.'  I am not sure.

I understand we have not.

        DR. SLOW:  The MIA has a sufficient appropriation.
                             ---b .

        DR. P'~RGULiX3:  \I2 have , as you know, a continuing

and to be renewed major contract activity with American Heart


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1  Association.  So if they need funds, they know the channels.
2 And if we haven't heard from them, I assume they can do for

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3 thz moment without us.

4'     I would also assume from that they have something

.5  else in mind later.

6          DR. SCiIMIDT:  Well, Bill Hilton mentioned PSROs, and
7 this stimulated our thought that there is something going on

8  in this arca.  And Dr. Hargulies perhaps could comment on the

9 H.R. 1 type of activities with PSROs and even perhaps the

10 kidney prcblsm.

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     12 for the,moment.  I suppose that WB will forrver refer to what
e   13 really has anoth'3r title as 1I.R. 1.  As I recall,  it -is 92-607

   14 o,r something of that kind.
  /I                But 1-I.R. 1 is d catchy title.
;..                       .'
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15     That, as you know, is the very, very large and
16 complex series of amendments to the Social Security Act.  And

17 it includes some striking new act.ivit.iss, the full extent of

18 Ii which is still to be realized. One of them had to do with a
                         8 .,          I

19 new method of reimbursement for the services required fcr
    .

20 individuals requiring dialysis and transplant. This is

21 in such a way that the source of funding for the payment.

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    23 way it has been up to the presant time.
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         DR.   HIN1~lA.X:  July 1.

        DR. NARGULIES:  And it is at the present time being

worked out by the Social Security Administration.

      What we are hoping for, and WE have had good coopera-
tion up to the present time from the National fjidnsy Foundation

from the people in NIII, from Social Security, from CM? and

others, is the recognition by those who must reimburse for

paymc,nts of the need to identify those settings for dialysis

and transplant of patients where the quality of car,e can be

well attested to.

There is always a risk when something can be paid

for that there will be people available to provide the service

bocauss it could'be ?aid for rather than because they are

expert at it.  That is not a pejorative statement aimed at

the profession; that is a sort of general human reaction,

In this particular case, it is urgently important

that the institutional setting -- and by that, I moan broad

institutional setting -- in which patients are to receive
                     ,

dialysis leading to transplant or without. transplant, be well

identifisd, well qualified,  and that reimbursement be limited

to those situations Wizrc, the patient will get the best

22 possible
I/       care without interfering, of course, with his access I

         23 to care.
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         24          It fits in extremely well with our own plans for
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kidney network which has been making good progr,ess.  We have
been meeting regularly with the people in SSA.  And at the

present time, I feel quite encouraged that through a combina-
.tion of the various Federal agenci- '0s and the professional bodie

which are involved, wo will corn2 out with som&hing which
represents both access to patients and protection of patients
with assurance that t.hey will get good qualitiy care.  But thr!

final definitions have not been rezched.

: .'.

On the subject of PSRO, let me just spend a few

minutr s on that one because it is an extramsly important subjac

and one which the whole health com,,unit.y is interested in and

so also a323 patients or certainly organized consumer groups.

It is essentially a proposal which was known usually

as the Bennett Amendmen, + which states that there must be a

mechanism associated with Social Security-SRS reimbursement

mechanisms to giv- ~.assurance that the quality of care which

is being provided meets acceptable standards.  And for that

purpose, it was agreed that thcJre should be established what
                    ,

has already been described as a Professional Standards Review
                                -.

'Organization which has been very, very broadly described in tine

legislation.

The main elements of it which are clear at the

present time are that the initial phases of this kind of
                             --w. -_

quality assessment and assurance will be confined to institu-

tional settings which means hospitals, intermediate care


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facilities, and nursing homes;  that. there will be a total

dependence upon a peer review mechanism,  but wi% full access t

this  peer review mechanism on the part of all major provider

of medical care.

The circumstances in which a PSRO organization

will be established need to be described so that there is a

long series of regulations which must be written.  They will,

and within portions of States for professional groups to

establish paar review organizations which will then set some

kind of criteria, measure performance againstthose criteria,

and  use these as a basis for giving assurance to the public
that ths quality'of care they receive is what it should be with

of course, the controlling olemant being reimbursement. for the

services being provided.

    The present state of development of that consists

approximately of the following:  The Office of the Assistant

Secratzry for Health --  Incidentally,  that is a new name for

                    .

the position which Dr. DuVal was occupying.  It was Health
                                -_

'and Scientific Affairs. It is now Assistant Secretary for

Health.  Thsre has been a new description of the position in

the Federal Iieg-J +ctor wit!! a full-r understanding of what. thsir

furxtion is.  The basic responsibility for the development of

                             'LI- .
t'n 2 PSRO lies in that. office.

     There is under way, and I have been out of touch for


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a coup15 of days so I don't know if it is ccmpleted -- I think
I would have heard if it had been -- the search for a director

for the PSRO activity who will be located within that office.
'It will then from the Federal point of view be necessary for a
number of activities to be carried out which ringa all the way

from the establishmen, + of a National Council for PSRO to the
definition of what the PSRO is to do, to the establishment of

regulations, to the creation of reimbursement mechanism

through the Social Security Administration, to the establish-

ment of a range of technical and professional advisory function

which will have to be carried out within and outside of

government.

From the ILSIIIIA point of view, there has been

established within the agency a group of people to work on PSRO

as a general activity for us to understand more fully and to

allow programs to be as prepared as they can be for whatever

responsibilities they are given.

There has been no explicit assignment of responsi-

,

bilitics excepting for preparation for whatever support the
                                -.

'Department is going to need when it does make its assignments.

Within HSZIIIA it is organized as follows:

      One individual who is one of the Deputy ndministratcr

Emery Johnson, is the key person involved in the PSRO activitie
                             -.
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rl,presents a number of programs, including RLIP, National Center


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for Health Sarvices R&D, which has
for Health Services R&D, which has basic quality R&D responsi-
                     basic quality R&D responsi-

bilitizs,
bilities, Community IIealth Services, National Institute of
     Community IIealth Services, National Institute of

Wental health, and so on,
Wental health, and so on, which are all on this PSRO coordinat-
          which are all on this PSRO coordinat-1
.i.ng committee.
.i.ng committee.

It also has an executive committee on which I sit as

     It also has an executive committee on which I sit as I
the Director of RJIPS which includes some of the same groups I

the Director of RJIPS which includes some of the same groups I

just mentioned -- NIHI-I, the Offic~e of Planning and Evaluation,

National Center for Health Services R&D, Community Health

Services.  They haveassociated with them a working task force.

      Now, this executive group and the coordinating

committee and the task force are working very'closaly bcth with

the Departm-n,
      p * and the Social Security Administration as we

begin to develop,an understanding of what a PSRO prototype

would be, what the elements would be, how criteria are to be

established, what kind of continuing education will be

required.

We have also primarily on the urging of Iw4P.7, R&D

and CIIS, been asking groups outside of government to come in an4

                    ,

share with us their own interests and their own activities.

                                -_

.

And we ar5 going to set up a series of such meetings so that wa

can make sura that the interests of the Amclrican IIospital

Association, the American :Iedical Association, the foundation

groups, etc., are involved.   And WP, see -- and this is really
                             - . .

a judgmental statement.. rather than a bureacratic one -- a

great r.esponsibility on the part of the Governmsnt to assist


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1  the health activities, the organized health activities, outside

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10  willingness of groups to not only come in and share their

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16        Generally speaking, as a kind of a basic principle

17 which Peters has not approached so far as I know, bureaucracies

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of government to act together to coordinate their activities

rather than to go about it separately even when they are not in

'conflict.   Because if there is dysjuncture between groups like

AMA, American Hospital Association, foundation groups,

associations of medical cinics, and so forth, it will be to

everybody's disadvantage and certainly will not help to

So far we have been deeply encouraged by the great

interssts with us, but to join their organizational peers in

mc;eting together.

At the.same time, I rather suspect that some of those

same groups are going to have to help us from the outside

can be organized better from pressures from outside than they

                     ,
can by energies from inside.  You may quo,,
                                 +o me on that.   so WC?

iJill look to those outside us to bring us together,' and we

will~look at oursslvb,s to bring them together.  And I think

that the prospects are very good.  It is hard to predict. what

the actual impact of PSRO activities will ba.

        Two or thrr;p things are clear.  There will have +o be

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existing utilization review, but also PSRO activities and as

well the kinds of basic informational demands for health

services which Veronica Conley was referring to when she was

talking about the health educational activities.

     We must have a common, well-defined, consistent

source of data which can serve planners, which can serve PSRO,

utilization review, and do it in such a way that we know what

we are talking abou t or at least ws are all looking at the

same set of data rather than at a whole range of incompatible

data which mo,an whatever you think they msan at the moment.

      There is real movement in that direction.   And I

think that SSA is going to help a great deal as will be ths

rapidly zxpandinj Federal-State-local health data system which

is emanating from IISNIIA.

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      Secondly, it is clear that there has to be a continuu

and a linkage between utilization review as it is presently

carried out in institutions and the PSRO activities which have

to do with the quality of services which are being provided.
                     I

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And, third, there is limited, very.limitad, recogni-

tion of the need to br! prepared to do something about what it i

you are discovering when you carry out this kind of a review

activity.  There is an almost reflex tendency on the part of

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the inexperienced dealing with PSRO to speak in terms of
sanctions against those institutions or individuals who don't

come up to the mark as though tha only solution if somb,ons


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e     1 does poorly is to cut them out of the system. This is clearly

         2  not our intent.  And it won't work in any case.

3        The real problem will be not only to develop effectiv
.4 'information systems which certainly have to include a revolutio

5 in medical records and standards of reference and comparisons

6 between performance and those standards, but some techniques

7 for remedying what is found wrong.  And the responsibility for

8 doing that will certainly include- Regional PIedical Programs,

9 not only in the kinds of educational activities with which WE

10 have sorts familiarity, but some organizational improvements, SOT;.:
    . .                                    .

11 manpower extension activities, some improvements which overcome

      12 the problems of deficiencies in services due to shortages or
e     13 maldistribution of health manpower. And of all of the

14 activities in PSRO, it seems to many of us that the remedial

15 aspects of this have been least attended. They will be address

16 not in th, 0 PSRO Structure,  but as broad issues which are

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important in any setting at the St. Louis conferenc.2, but I' hav

ths feeling tha t ~72 will do less wall on that subject than on
                     ,

a good many others that v-e are going to be considering.

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I think there is little doubt, for exampls, that

there will have to be'rapidly heightened, even above the pres=r.

pace, attsntion to sensible, logical, recordable, transferrable

medical record systems which can be used for audit purposes.

And this in itself is an undertaking of no mean proportions.
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So what is happening is a rapidly growing response


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on the part of Government to legislation which was passed vf;ry
late in the last session of Congress, but which must become

sffective by January 1.  So that the time involved is very,

'very brief.                               .

        DR. HESS:  I wor.der if you could commrnt a little bit

more on what is going on in the area of medical records because
this is of extremely critical importance in this area.

DR. MARGULIES:  Well #  in RNPS, but certainly outside

of it, there is a crssccndo of interest even above t~hitt it was

a year ago in the problem of orien%ed medical records.

Recently a conference that Nillis Hurst hzld down in Atlanta

had a huge attendance or? the part of psople who realized that

this may very well be the best available kind of record system.

We see growing svidencc. * around the country of hospitals, of

groups of peoplre, beginning to recognize the fact that thsre

must be a rapid change in msdical record systems.  I don't

believe that this agency or SSA has r.ecognizzd a nEed to put

official pressurV 0 behind the development of that kind of a

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medical record system, but it would not surprise ma if that

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kind of thing should occur.

    I know that'Rsprssentat.ive Rogers has been strongly

tempted to introduca legislation requiring that kind of a
medical record system which I think would be most unfortunate.

I would prefer to se2 the profession reach in that direction.

We have not, however, and this concerns me, been


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able to reach a conclusion in this agency that we should take a

position and promo,-
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??*? o  I am impatient with the tendency to continue to research

and wond,sr and study on something which at least is well

enough established so that it would be a vast improvement over

like to see us corns to the conclusion saying this or that.

I don't know if anyone is going to have courage

enough to require under PSRO at the central level a medical

record system of a specific kind, but I rather suspect that

a good many of the early dsvalopments in PSROs whers the

progress has  alrea dy  been great are going to come to that

conclusion righ t.at the'beginning this will be the only medical

record system acceptable.   But the action is general and not

coordinated.

mention all the names of people involv.ed in this planning, 'but

are allied health groups or nursing groups involved in this
                     .

initial planning phase?  -.

.        DR. HARGULICS:  You mF?,an within the Department?

        IJISS NNJDERSOP?:  Well, planning for this national

council.  You talk about the A2-m and Hospital Association and

DR. MARGULIES:  Well, the question is how extensive


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has been our involvement in bringing in groups to work with us.

We have only just begun.  This particular PSRO activity is no/t

more than 6 or 8 weeks old.  And so ws have actually bean

responding initially to those who have come to us with some

interests of their own.

For example, the QAP of the American Hospital

Association was of immediate and early intersst as has been

the Social Security Administration.  And we had already besn

working with the National Kidney Foundation.  'But we will

certainly find it nacsssary to work with those other kinds of

professional groups like nursing associations, allied health,

where there has  been developed an approach and some under-

standing or wh.2r.e thsro, is a need for it in establishing the

PSRO.

Even though it is keyed very clearly in the legisla-

tion around the physician peer review mechanism, it should be

self-apparent that PSRO as it is going to develop will requirs

an effective review for those who provide medical care which

means a small minority of physicians and a great majority of
                                -.

'others.

And I should mention one other thing that although

the legislation require-s PSRO in the institutional setting,

it dons allow room for some expcrinentation and some early

antries int:o the ambulatory care d%livrry system with the

implication that- as PSRO develops in the institutional setting,


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Now, that was a decision mad2 for practical reasons.

4 It is tough enough to do it in the institutional setting,   And

5 the feeling was we really aren't ready to try to take on the
6 ambulatory PSRO type of thing,  And in fact, if you reflect

7 Ii on it for a moment, the institutional setting sounds tough

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8 when you think of hospitals and agonizing when you think about
                                                 .

9  nursing homes.

10      We have somehow or other never gotten ourselves to

11  really talk seriously about PSRO in nursing homes.   I think

12 everyone is well aware of the fact that that is a very, vsry

13  difficult field:

14          DR. AI?CRUH:  Dr. Margulies, for the institutional

15  settings, isn't that only if they are involvad with reimburse-

16  ment for Title XVIII and XIX?  I am thinking about an instituti

17 may not want to come in.  Do they have that choice?

18         DR. I!ARGULIES:  This is based around the Social

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                                    -.

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21 party carriers fall into the pattern of what has been

22 through SSA.  So that it would seem to me highly unlikely that
23) 0th er methods of reimbursement would remain isolated frcm the

24 PSRO activity if it appears to be a method of giving warranty

25 of gcod quality care to the public which is being served.


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But it is a requirement only under what used to be

known as H.R. 1.

DR. SCIIKfDT:  All right.  Thank you.

Are there other questions or comments?

       Ygs, Dr. Drindley.

        DR. BRIfJDLEY:  Not specifically related to that.
This may not ba appropriate, but whare do we stand on HI"IOs

as far as Ri-IPS is concerned?        .

       DR. FlARGULIES:  The question is on HMOs. ::

      This is a great morning.  How do you think those

things up?

      Well, as you recall, the legislation for Health
14aintenance organizations did not pass during the last session

of Congress.  As a consequence, there is nothing officially

known as HI.10.  The RiJP funds which were used during the last

fiscal year went to some 29 HMOs which were in developmental

phase.  There is no more Ri,IP money identified for that purpose.

There will be no funds used for operational support of iII"JOs.

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There is a hope, of course -- and again Xr. Rogers

'has indicated his into-rest in it -- that the Health i3aintenance

Organization legislation will pass very rapidly.  There then

will be appropriations.  And in those circumstances, it will be

existing as a separate, self-sustaining activity in which the

RX? interest will be cnly as it is appropriate to the PJlP

mission.


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I think that the kinds of conduits which were used

in the past for this will either no longer bc necessary becayse

the i-IX0 activity fails or no longer necessary because it

succe, -0ds and has its own independent appropriation.

        DR. SCI-II?IIDT:  Other comments?

MR. TOONEY:  Dr. Ilarguliss, what has been considered I

in terms of the composition of the membership of the PSRO?

       DR. MARGULIES:  At the Stats, you mean, at the local

level?

MR. TOONEY:  State or local.

       DR. HARGULIES:  Nell, that is described again

rather loosely in the legislation.  It must include -- and I

dcn't know tha exact terms, parhaps someone elsz here does --
physician representation which is not limited to ?I.D.s. We

are talking about I.I.D.s, osteopathic physicians and other healt

care providers.  It cannot be designed, for example, around a
county medical society because that is a selected group. If  I

you have to be in a county medical society to be in the PSRO, I
then that is not'an acceptable PSRO arrangem.ent.
                                 -_

.        On the other hand, members of county medical

soci&ias can make up.PSROs as a separate activity.

       The intention, as the language was daveloped and as
it was understood in the Department at that time, was to give

the PSRO g&v?rnancz a very brbad bas.2 which would mean that

.it would represent quite frankly ths best description of a fairl:


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characteristic PSRO base as Dr. DuVal was understood at the

time it was passed was a good regional advisory group of a3  I

5  really a consumer-oriented thing.  It is a provider-oriented,

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4  institutions, allied health, and some consumers.  But it is not

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And in the final analysis, it is the physician peer review

And as I recall,  the National Council is an all-

physician group.  Is that right, Bob?

        MR. MORALES:  There is a requirement to include other

providers such as nurses and that type of officials.

DR. HARGULIES:  It was dssignad in such a way that

it would not become the private fiefdom of physicians.

MR. TOOHEY :  Will foundations be able to move in as

board itself?

that the foundations will very likely not only be able to move
                                -.

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in, but they are likely to b e early beginnings in PSROs.

      I suspect that a good many of them will have to

change their structure in some way because they tend to be

restricted to physicians and will have to embrance a larger

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written to to identify.  And I could be wrong on that.

       DR. SCIIERLIS:  In its broad phase, can this get

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involved initially with categorization of facilities as 1,.

sets up professional standards or is it looking at individual

rather than group service?

      DR. MARGULIES:  The question is could this get

involved in categorization of institutions.  I think the answer

to that is probably yes, deponding upon, again, interpretation
                                            .

and regulations.  But one of the aspects of the PSRO is

institutional quality review which is again almost self-

evident. One can hardly expect a group of health care provider

to meet a standard of psrformance in an institution which does

not.  And certainly, if a hospital is to be utilized, there mus

be evidence that it meets some kind of quality criteria for

its own diagnostic and care facilities.

When we began to think about our own Section 907

activities which I will remind you of in a moment, we real&ad

that these needed to be moved into the PSRO environmsnt for
                     ,

our own group to look at.  And we are going to be doing that.
                                -.

Now, the Section 907 activity is one which has grown

out of the original legislation through which RiJP was establish
You may'recall that it is a section which says that at that

time, the Surgeon General, now the Secretary, will publish

a list of hospitals which have the most advanced facilities

                                                                           .

for health disease, cancer, and stroke, and then later kidney


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1 disease was added.  We are currently in the late phases of a

2  very vigorous contract carried out with the Joint Commission

3 for the Accredi. tation of hospitals to establish some kinds of

4  criteria which conform to the currant intent of that section.

5        What has been done is the distribution of a very

6  cornplate questionnaire to hospitals all over the country with

7  a remarkably good r3esponse which will allow us to identify
8 hospitals in accordance with their capacity to deal with
9 hsart disease, cancer, stroke, and kidney disease.

10         It will also allow us to establish a kind of tier

11 of quality which could roughly,
II                    depending upon how it finally

12  SVOlV%, identify instituLL
                    &ions which are able to do the most

13 sophisticated referral type of activity, a good example being
14 transplant of kidn,eys or chemotherapy which can be done only
15 under very specialized circumstances for patients with cancer

16 and so forth, the so-called tertiary institutions.  We should

17 be able to identify th e criteria and pizrhaps the institutions

18 meeting those criteria for tertiary care, for sacondary care --

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19 that is, institutions which are able to accept referral

20 patients, not necsssarily for tha most advanced, but for scme-

21 thing which rtquirss referral -- and other hospitals which are

22 adequate for primary purposes.

23          NOW, if the PSRO is designed around the medical

                                           ,

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30 some kinds of things and apparently not to do others would 1:
of real value in trying to set up criteria for performance and
in trying to identify where therapy, where diagnosis and
treatment should be carried out and what the resources are for
better teaching and for systematic regionalization of health

care delivery systems.   This,  of course,  would mean that

they would be linked in closely with planning agencies.  And

we propose to utilize this list of criteria in hospitals so tha

                                   .

planning agencies will be able to take advantage of them as

                                                                   -,
well.

        I rather suspect that PSROs could if they wished to,

Len, use this kind of thing and decide whether they.want to

snter into that kind of definition of where a particular sorvic
should b,e provided and where it should not. You can easily
appreciats the hazards which are Fnvolvod in that decision, bud
in some cases the hazards would certainly not be great.

It would not be difficult for a PSRO to say that thic

institution is not prepared to take on open heart surgery and

this 0n.e is.  The gross distinctions would be relatively simpl:
It may get a little tougher if you try to make decisions about

where you can manage a patient with an initial infarction who

is already in congestive failure or something of that kind.

It is a little bit more doubtful.  But you have no difficulty

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in dis,- ";nguishing bet5:leen a small primary hospital and a

secondary referral hospital in that case.


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      I would suspec, + they would want to take advantage of

it if they are   imaginative and aggressive.  But the

lecision will be theirs.

       MR-. TOOPSEY:  I believe the legislation also said

:hat if you have an adequately functioning utilization review

:ommittes within the institution, that this can act as a PSRO.

2s your group given any  con sideration to this particular

situation? And what is an adequately functioning utilization

review committee?

         DR.  XARGULIES:  The question, if you couldn't

hear it, is related to the fact that the legislation indicates

the accaptability in hasp-,. ;+als of existing utilization review

activities.

When the Administration was preparing its own

position on H.R. 1, it expressed its skepticism regarding
existing utilization review activities throughout the country.

There will be no objection to the use of existing UR activitis:
but there will I.JE considsrable doubt about wh~ethar they could
do t.hz PSRO kind'of activity if their performance with the

                               --
utilization review is a criterion of what would happen under

PSRO'.

     I think as a matter of convenience, what they are

saying in this is there will ba increased attention and demand

to both utilization rnview and PSRO.  And since they will be

dealing with the'samr patients and same kind of information


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But I rather suspect regulations will require something more I

than what has been established for utilization rEvi% up to the

present time.

it that the use of the utilization review mechanism might tend

to restrict what happazs to utilization review rather than

really get into issues of quality which are not the sam,e
                                             .
issues.  I think that, however, you have touched on something

which-is as likely to be a difficult issua as any in the whole

process.

MR. TOOXBY:  Because there is a tremendous opportunit

for conflict within the medical profession itself.  Of course,

the American Hospital Association is pushing its QAP, Quality

Assurance Program, to be mnld$d'into the utilization review

simply to allow for the physicians who are using the institutio

to continus not only to evaluate the quality of care, but also

the utilization of the institution or vice versa.

     DR. 1tiRGULICS:  I think it would be unwise where ther

isan effective utilization review activity to sot up another

and parallel activity.   That should be the core of it. But it

should not be restricted to that core.  That is the problem.

MR. TOO:lEY:  That is why they are going into the QAP.

DR. J."WIGULPL:S:  I think the QAP makes very good

s3x.5~.


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        MR. CHAMBLISS:  Does this not, Dr. Xarguliss, require

the expansion of the review utilization committee?  It has been

pretty well. a hospital-related function.

       -DR. MARGULIES:  I think so.

        DR. JAI*lES:  14ay I make a comment along that line?
When you mentioned earlier regarding standards for hypertension
in terms of perhaps the nation has come to the point now

where it could set up standards for the adequate treatment of

patients, I think that is the way I understand it.   It seems

to ma like while we are talking about utilization and quality

control, where are thn, standards for good mrdical care as you

would see them related to the total program?

        DR. MARGULIES:  One of the responsibilities of the

Departnant will be to guide the way toward the development of

what will be effective standards.  There will be two issues.

     One of them is the creation of acceptable standards

which rspresrnt a professional output like those that we have

done, say, through the IntEr-Soci3t.y Commission on Heart
                     ,

Disease Resources or thrcugh tha National Kidney activities,

the things we are doing with strolr= and so forth.   And there

aren't enough of them.  NE need more
                                       - I    of them.  And we are

bevaloping some contracts in RXPS and also in IISI4HA to move in

that direction.'

     But the othrr and thcrny part will be to s.?e what

the relationship is bs;tweEn those kinds of general standards


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and local concepts of practice.  The PSRO, I suspect, will be

asked to develop its criteria, but it is going to ba looked at

very carefully to see how it goes about that.

    . Those who are being critical of the profession are

afraid that a development based upon local standard setting

will be established at a point of kind of mutual self-protectior

instead of aiming tow2rd high quality.  I think people who

say that are being a little foolish.  Our experience has been

that those who step aside from their practice to work toward  I

                                   .

the establishmant of criteria which th2y think they should

meet tend to set them too high -- actually higher than they

can achieve.  Because when thay get away from day-to-day

practice and say, "What should I be doing for the identification

of a petient for a tonsillectomy or eye surgery or whatever,"
thsy tend to become a little textbcokish rather than practice

~ oriented.

But the real question, and I think the prof,ession is

going to have to play a very, very alert part in this, is the
                      ,

translation from national standards to local.practice or 10~21
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circumstances.  And I would like to just say on this subject

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22 profEssions to meet a responsibility which is probably the

       23 mo.st important individual responsibility they can possibly meet,
                                              .
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England to compare the health de livery systems of the United

Kingdom, Canada, and the United Stat,as.  And one of the issues

we dealt with was quality assessment.  And it was apparent that

when other countries, including Sweden and some of the eastern

they agreed at that conference, the people from the other

countries, that we do far more at the pres.ent time without
PSRO, without utilization review and so forth, to measure the
quality of mcdical care than do any of the others.  They don't

hava tissue review comiiittees, they don't have record review

committees, they do relatively littl, p both in Canada and the

United Kingdom, and that includes SwJeden 2s well.  t?a are well

ahead of thrm.

    But now they ar'3 looking to see what we are going to
do, what the profession is going to do -- and this is really

a professional issue -- to prove its basically conservative

Now, there has--naver bean within the profession any

dissention over whether this is an acceptable and basic purpose

in what wz do.  In fact, the whole issue, everything we talk

about in the Federal Governmsnt and outsids of it, comrs down

whether you are talking about the ho;?r many people or what is

done with the individual.  And this is ths time when we could


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not only evaluate practice here and make a difference in the

whole professional environment, but set a pattern for the whole

world.   Because  if what wn, cm achieve can be done effectively,

it will influence the practices in Canada, in Western Europe,

in Eastern Europe and, of course, throughout the rest of the

country.  It is being looked at with great, great interest.
And as it develops to a higher lavel, it is going to set the
                                                           -.

pace for generations to come.

If it fumbles, if it is'not done affectively, somabod

is going to come along with some kind of further regulation

which is not as good.  I think it is an exciting time, but I

.think very  few people realize the full involvement, the full

difficulty, which it prssznts.

        DR. SCHMIDT:  I think you have given us a logical

break point.  The next activity will be to synchronize watches.

     It is approximately 25 minutes to 11.  And we will

now break and reconvc;n 2: not later than 10 minutes to 11.

       (Whereupcn,  a recess was taksn.)

          DR.  SCWIIDT:  We still have a couple of items to

                                -.

cover.  We have talked a little bi t about revanu,a sharing and

thz 'subject of sharing of authority and responsibility is

som.zthing vary much bain g discussed in a number of arEas.   Fle

mentioned the sharing of decision-making and priority-setting

and so on that will t;;, going on as part of future developments.

;ind the next agenda item raally kind of can be umbrsllaed by


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definitions and certain rrquir%ments in this area.  And the key

issua was to have the regions abide by csrtain standards that
would make for overfunding decisions and having to do with the
technical adequacy of proposed operational projects and also'

those activities which were fundod within the approved amount

'of the grant award.

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criteria and program priorities, on staff assistance, on CIIP
revigtring comment, technical review, project arranging and

funding, feedback, ax! appeal procedure.

69

that general topic.

     We all have been told from time to time and have

been briefed on the activities having to do with the
individual IUdP rzviaw process and what have been called verifi-

cation visits to ragions, looking at specifically their review

and decision-making proc,essss.  And 1%. Chambliss is going to

tell us a little on how that has bean going.-

         14R.  CHA.I4BLI SS :  About a yaar agb, RXPS dcvelcpsd a
                                            .
document in rospons& to recommendations from the FfAST Task

Forc,e,  entitled "RXP Rsview Process Requirements and Standards.

And this document set forth the requirements for the dscentrali

zation of project review and the decentralization of funding

authority to tha XilPS.

A handbook was produced setting forth certain

There ware minimum standards set forth on review

Now, during the past year, the Division of Operations


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and development staff has set a goal of visiting to certify

or to review the varification processes of all of the 56 RFIPs.

During the year, then, 51 of the 5G XiPs hava in fact been

visited.  Five regions were not visited, and those five regions
are California, Arizona, Northeast Ohio, South Dakota and

Delaware.  There were specific reasons why these regions could

not be visited within the sp=,cified time.      _

     In t.hc case of California, there were tremendous
                                             r

lcgistical problems'that you could well imagine there.   The

staff is now planning to make that visit soon.  As you can

appreciatz, thare will probably be a period of two weeks that

t.hs staff will have to b e in California looking at ths 9 areas

of that LRM?. I

There were ether technical problems having to do with

Arizona,  Northeast Ohio.  And in the case of South Dakota and

Dzlawara, those two regions are still in their planning stages.

      Now, cf the 51 R.2gional Kzdical Programs .visited --

and I might say it has taken a yeoman effort on.t.he part of sta

                     .
to gat these visits in within the prsscribod time -- there has
                                -_

bso,n unusual staff cooperation betwsian the compon&.s of NIPS
and 'I should say here and now before thz committee, before t.hs

staff and the public, that the support. given the Division of
Operations and Development by Planning and Evaluation and by

                                      `
-th? Division of Profzcsional and Txhnical Dsvslopmcnt has

been very noteworthy.  Of the 51 regions visited, and I might


71  I

         1  say that thsss regions are, as you know, organized along the
e-   2 desk structure, the Eastern Operations Branch having 20 regions,

       3 the South Central Branch having lG, the Mid-Continent Operations

       4 Branch 14 regions, and the Western Operations Branch 6 regions,

       5 including California -- that of t.hz 51 visited, 36 regions

     6 have been fully approved or certified to date. There are 15

       7 regions which have b%en provisionally certified or which have

       8 been disapproved duz to substantiva shortcomings in applying

                                                                .
        9 ths standards.  And as a consequence, staff is'working with

        10 thos2 regions very clcsely in sesing that whatever the

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11 defic,; ;pncies or whatever ths bases for disapproval are clEared

12 .up.

13        You would like to know that most of these visits

14 have been made in the last six months, and the nearest being,

15 of course, Xetro Washington and  th e furthast away being Hawaii.

16 And I think you would like to know that one of the visits was

17  made  at 27*  below O*.  So you can get a vision of the zeal and

18  enthusiasm that our staff has had in carrying these out.

19         But in som??, we would say that we proposed to finish

20  up the remaining visits within tha next two months *and will

21 give. you a report on that activity later.
II

22           DR. SCIEIIDT:  I am sure that some of the visits must

23 have generated some heat.
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;iR. CIX~IBLISS:  They did indeed.

DR. SCIRUDT:  The general topic, though, is kind of


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in interesting one.  And I was musing'in the last few days
~.s to whether or not this report would generate any discussion.

;o now I am going to find out.
    -1s there any discusion?

       MR. TOOi.IEY :   What were the shortcomitigs you found?

       MR. CIIAXBLISS:  The shortcomings?  We have undertaken

3 study of this, but many times-  the application may not most

5hs criteria set forth in the standards or maybe there was
                                             .
impropsr or incompl-t-
          Q e review and comment by CHP agencies.

                                   0
Xany times, the priority ranking system was not adequate to

ensure that the proper funding decisions could be made in

keeping with the criteria.  Occasionally, we found there was

inedequzte feedback to th? applicant who had not been successfu

in having his proposal funded.  So there wore a number of

reasons why they did not meet. the rrvi%w criteria.

       MR. TOOXEY:  When you disapprove them, what happens?

        MR. CHAl:I3LISS :  Gtsnerally, tha region is told what. th2

basis for the disapproval is,  It is itemized.  And then if it

is a technical disapproval, w2 attempt to tive the region a
                                -.

tims in which to meet that particular standard.  And the staff

usually works vary closely with the region in trying to ova,rcom

that. -

I4R. TOOi*IEY :  IIave you had enough time to see how

quickly thry attack ti1g-e short.co:nings that. you have pinpointed?

XR. CIiAMBLISS:  I&? have been most pleased with that.


73  I

1  Just. this WOE;, we had three responses from r,egions saying that

2  the technical basis for the disapproval had been overcome. SO

3  they are closing those deficiencies as much as possible.

4       .Now, there are some with more substantive bases for

5 disspprcval.  And the staff is working with t.hsm much more in
6 detail. '

7            HR.   TOOHXY:  Do you find at. all they will disagree

8  with your judgment?                     I
9 _        MR. CIIAMBLISS:  This has been a very interesting

                                        ,
10 phenomenon.  Nany times the region has said to us, ":*?a agree

11 with the bases," because it has given thsm an 'opportunity to

12 strzngthnn some of their intornel procedures. Occasionally we

13 have= had a region soIi\$blhat discgrse, .but in tht, procsss of

14 discussion and negotiation, thcsr- have bezn ovsrcomz.

15            DR.   LUGINUUHL:  Could you give us an e>:ainple of on2

16 of their substantive problems?

        HR. CIIN43LISS:  On", of t.hz substantiva problems had

to do with CUP relationships and revi% and comment and

                    ,
esp.?cielly in one of our regions undar ths iJi.d-Continent
                                -_

opzztion Dranch.

DR.  SCIII4IDT:  First, Judy, did you have a comment?

i4RS .  SILSBIX:   I was going to say in answer to I.&.

Toomey's question, our goal is to get all of these regions in  I

24 compliance bEcause thcs stat-d next stap would bcl 50 tak5 away

25 from the-m all decisions with rr-gard to what. the project


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technical review and funding decisions are.  And that is

somat.hing that we don't want to take back into Rockvillc.   And

so thR  incentive on both our parts and regions is quite great

to get these things straightened out.

        HR. TOO;*lEY:  What happens at t.h~, rank'lavel when

you point these things out.? Are these psople conversant enough

with your oparation to understand th- 0 deficiency you point out?

Do they have problems?
                                   .          .*
        HR. CWAXBLISS:  Dick-.

        MR. RUSSELL:  I would like to respond to that because

we have had on a couple of occasions going in'-- of course, we

do mset with representativ.%s of the Regional fidvisory Groups.

And as a result., when we have our fzzdback session, t.h*ey. sczm
                           .                               _

greatly relievad in some cases that this has bean pointed out

to them.  And in some cases, this gives the RAG the clout that

they perhaps have exercised in the past.  So they have been

very receptiv, 9 to the faedback.

        MRS.  SILS33EE:  I don't think any of us mean to

                    ,

imply the millenium is here.  Those are minimum standards.   And
                               -.

all of t.ha visits hav.2 poin t=d up need for monitoring and kind

of continued seeing how these are working out and whether thsy

ari3 following them.

        DR. SCII!~IIDT:  First, Hr.  Hilton and then Dr. Thurman

                            --_.      3 :
and Dr. James.

HR .  HILTON:  I just. had two questions or maybe


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comments.

The procedures manual that was r,zferred to earlier,

doss that go into this area of technical review to provide,

guidance so that when it is released, we know it is documented

somewhere?

MR. CHAMBLISS:  Yes,  it will contain these standards.

MR. HILTON:  With regard to the CHP, was staff able

to make any determination as to tha degree to which the problem
                                             .*

originated with CIIPs understaffing contributing to that and

the other  kinds of problems where the RNP might have tried to

make the prop-x co~mun, +cations with the accepted guidelines, but

couldn't?

        NR. CIYW~IBLISS :   Xr .  Peterson, would:you care to _
                                                                           ,
comment there?                                       I, ;                 

        l4R. PETERSON:  I think we might say two things about

the CUP review and comment procedure.   I think there have been

perhaps three levsls or three different kinds of problems we

have szen.  Some of them are essentially technical, but some-

                    .

timas they get beyond the tachnical problems leading to
                                -.
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emotional stress and strain.

There arc3 technical problems relating to a 30-day

requirement and what you give a CIIP and wh.ether som3 things

are being technically complied with.  I think in a few of
                             -. ._

the regions, at least, that I am aware of:', we hav2 sensed that

they really wers symptoms of lack of adequate cooperation and


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understanding, that they were simply thr- clubs that. were being

used in this battl?.

I think a more substantive aspect of this which real1

one in part ccmes out through the vsrlEicati.on visits -- and

I personally only participated, I guess, in thr& or four and

none within the last six months -- COKES to light as a result.

of an analysis that my office has done,J is in the process now

of gttting out, in the- way of a progrmJ analysis memorandum on

the stops and natur- * of CIIP comments &ring the first year in

which that was implemantrd.

We required as of the ;lay cycle, 19'11, that all RNP

applications, t.he oppcrtun,,.
                i6y for CIIP review,. a ccmment be

provided.  SC, we had a year's Exparier;ce as of this past.     ..,.

sort of the nature of those.  And I tZBlnk there are some striki

things that can be said in that. regard.                      

      First and foremost,  I think WC find that much of

                    <
the CUP comment is of a gsneral nature.  They commsr,t. on the
                               -.

application as a wholo or the X.lP.   ?md it t2 nds t.& be of the

Good HousEkssping Seal of Approval.  It do,zsn't. say much, and

I question it.

There is very little CfIP commt to date in terms
               -.

of specific activitF2s being pro;:ossd -- this home care project

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17  khings that can be said in that regard.

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understanding, that they were simply the clubs that were being

used in this battle.

I think a more substantive aspect of this which real11

one in part comes out through the verification visits -- and

I personally only participated, I guess, in thr.ee or four and

none within the last six months -- comes to light as a result

of an analysis that my office has done, is in the process now

of getting out, in thr way of a program analysis memorandum on
                                            ,
t.h e scope and nature of CIIP comments during the first year in
                                   .

which that was implsmsnted.

We required as of the iiay cycle, 19'11, that all IUIP

applications, the oppcrtunity for CHP review,..a co.mmsnt b's

provid.ed.  So we had a year's &xp~rFznc~ as of this past.     ..i

sumnler.  And we have baen trying to analyze to the extent that

there was written comment letters supplied with the application

First and foremost, I think we find that much of

,

rhe CHP comment is of a general nature.  Thsy comment on the
                               -.

;ood Houp- 3=kesping Seal of Approval.  It do.esn't say much, and

: quGsti.on it.

There is very litt.12 CIIP conment to date in terms
               --

jf spscific activiti?<; bzing pra?os~d -- this home care project

;r that EXS planning effort.  There is some of that, but on the


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77

whole, it is comparatively small.  To the extent it exists at

all,  it tends to be favorable.

    That may simply mean that there are Other forms in
writing in which they express themselves unfavorably.   But

certainly in discussing these findings with som, is of the CHP

staff here, I think there is a general agreement that what this
                                            \

points up is that in most CUPS, whether they are talking about

areatqids or State, but principally areawide, there really

aren't the kind of specific priorities or plans that have bssn

developed yet that psrmit them to comment in tarms of a
particular kind of activity or a specific proposal.  And I

think that goes beyond _
              thp verification visit.. *process, but

I think it has soms implications for CHP review and comm2nt.

      ',,a DR. SCIINIDT:   Dr. Thurman.            I.. ,           . '

         DR.   TIIURI.rnJ :   I am out.

        DR. SCHMIDT:   Dr. James.

        DR. JAN&S:  I don't know quite how to ask this

particular question related to what you are speaking of, but I
                    .
think you mentioned that primarily what was involved had to do

with the decentralization of the review process.

        &IRS. SILSBEE:  Ths t.c,chnkcal review, Dr. James, of

projects.

DR. JAHES:   At the  local level.  And I wanted a
               --..-

clarification on that so that S would br sure that I understand

the focus here relativ e to the largz applications coming int.0


78

1  this review committee or is the focus relative to applicants

2  at the local level in that the local RXP is following the

.

.3  guidelines?  I wasn't quite sure where the focus was.

4          MRS. SILSBEE:  Well, the background of this

5  particular verification was wh-?n the FAST Task Force which WAS

6 before your time, but it was an organization for streamlining

7  grant  operations and application proc-?dures and so forth,
8 whan they looked at the Regional Nedical'Programs and saw

9  what was developing out there -- and this was several years

10 ago -- it seemed to them that the national review process was

11  duplicating what was occurring on ths local level with

12  regard to looking at th.e individual projxts, looking at the

13 technical adzquicy of them.. They rxcmm~n~d%d, and *Dr.,..,,,.
I                                                                           _.

l/4 Plargulies implemented, the procedure that the national review

15 process would no longer do that particular thing.

16        Before your time,  this review committee used to take

17  a project and the applications came in wit11 the full material,

18  all the background information on a project, and go through
                         ,

19  th% project and look at it to see if they thought it was
                                    -_

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20  tp_chnically adsquate and whether the project itself should be

21  approved or disapproved.  This was creating problems since

22  the regions in many instances were doing this also and the

23  national review did not have as much information as the people
                                 --b ._

24  that were doing it at the regional level.  So the FAST Task

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And this process that Mr. Chambliss has been describing was

to verify that indeed each of these Regional Medical Programs

did have a process by which tne projects were looked at from

a technical point and other standpoints.

The national review then looks to see'what the effect I

of all of these activities is, what the composite effect is,

rath-cc than the individual projects as such.

        DR.JAHES:  Then, I can relate vkry well how you may

pick up in your visits the relationship of the' CHP agsncics in

that respect.

Now, when you get down to thz area of what happens

'as far as local applicants are concerned in the appeal

how are you able, to sift that. information out?          _. x. ._ 2. .._

        MRS. SILSBEE:  The process by which the team looks

at this is to look at the documentation that has occurred in

the local review, .to 1003; to sse what the records are, to see

at what stage a project proposal gets stopped in&e process, I
what thz feedback is to the procedure, whether the Regional
                    ,
I'idvisory Group -- what kind of information they have about
                               -_

.

these ideas that they haven't been ask.ed to act upon.   These

arz 'all stops in this review process to make sur;zI that someone

who has an idea gets it considered and,knows, if it hasn't

been considered and approved locally,why.
                            `L1-

DR. LJARGUL,_'.ES:  For example, there is an effort mzde

to interview unsuccEssfu1 applicants to see how they perceive


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        1  the process, how they  go t involved, what occurred when they
e      `2  were turned down, if they had an adequate explanation of why

    3  it was rej,%cted, whether they feel the process was fair and so

   `4 on.  So that they try to get verification of the true dynamics

   `5  of the review process.

    6            DR. SCIIIKLDT:  In previous discussions of this in the

    7  review colmmittee, we have gone back to something that we are

    8  all vtry familiar with.  And that is the 'project grant type cf

   9  review conducted in NIN where, indeed, the technical review of

                                                                           \
   10  a research grant is  carr Fed out by the study section on a

   11  ons-by-on% basis.  But within :?IH, thare are developing

.' ,,  ' 12  ..centars.  The so-called cznters of excellence approach, for

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        13  exaEli21-5?,  is one in which IJIH will fund a center and then the

  ,.I :< ,   14 ; center locally can fund research grants.  And, they must have

15 /I  the ability to do technical reviews then of the r.ssearch

16  projects within ths canter locally.  And then the study
                 

?7   section and the Council really serv, * to accredit thz center to

do this job.

      So th%n you can translat- ~3 that to Regional I,ladical

                               -.
Programs wherein the function of a review committzc at times

21   we havs said is to accredit the region to do this jcb that as

22  Judy pointed out used to be dorm by the review committee, in

23 I/ many caszs not as wall.   And, finally,  the people who we do  I

-- . . .

it with come from rtlgions anyway.

25

And when you play with this a little bit, you see


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that in the kidney r&vir;ws, for example, recommendations have

been mad2 to get expPrts from without the region.  And all of

these sorts of things get into this.  The triennial review
and this sort of thing becomes an important aspect of this

5  also thare.

6

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      First Leonard end then --

       DR. SCHERLIS:  I think your analogy as far as
cantP,rs of excellence is an analogy, but not, I think,
paralleled by NIP type of organization bscaus%'in each region,

10 you do have an J31P. And in each region, you do set up a

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verification system.  You aren't saying that is a center of
rxczllcnce which really has all of the n2cPsssry t-zchnical

skills to dscids. about each individual project.                  .' ~.
    If you select the centzr of excellance, it is.in

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competition with many other csntars.  And you are selecting

       . . '.
from a large pool in d,, =*&mining which ones do have over a&l
above a system of rsvizw ths basic ability, talent, and n-3c.zssz

18  rzvi%d officers in that ersa who can look at it technically.

19

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What I am getting to r.-& =-lly is that I still believe

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that within this committcz, WB have a right to decida th%

quality sf a program z.ubmitt.ed by a sampling mechanism.  And I

find it invaluable in raaching a cor,clusion about an area to

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1oDk at a project or two in order to dc,termir,e whethzr they arc
                            -. . .

just forwarding up to us some what otherwise would be very low

priority items.  Ar.d we have the decision and I think, indeed,


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the responsibility to determine by such a sampling mechanism I
whether or not the overall grant request is a valid one.

I would like to interpret the results of whatever

this discussion will be that you are not removing from our  I

responsibility and purview the right and indeed-the responsi-

bility if we chose to look at individual projects as a sampling

mechanism to determin- m our overall reaction to the entire

request.  Will you comma-nt on that, please?

       HRS. SILSBEE:  That se2ms like a very reasonable
                                    .

approach.  And in order to answx some of the questions that

are asked in the review criteria, you would have to do this.

But it doss differ in that you don't go through each one and

say this on5 is approved and this one is disapproved. :_ ,. :..

1.       DR. SCIIXIDT:  I agrae.  What you have done really is

described how we have been operating in thr! last year or two.
And when you gst right down to it, th2 program is a kind of

a nebulous thing that is some?., &hing more than the projects,   But

what you have in hand to look at rsally are the projects . And

as we all know, even now-regions are not making some decisions

thzy should, but booting them up here.  And, of co&so, what

1 this'means is that there is something wrong with that process

and we have to continua to work with the region.

Dr. Florin.
               - . .

DR. ??LOI"II;I:  I nicjht reyoz-t on a recent visit. We

thought our review process was quite adequate.  It. was pointed


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6  review visit was that those applicants be informed of their

7  right to appeal to the Regional Advisory Group at any time

8  even though decisions have been made at a lower level before

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out in the Regional Advisory Group meeting some of our short-

comings.  And it was accepted with understanding and with

appreciation.  And WI have since modified somo of our

raviow mechanism to do it.

that time.

I think also to comment on another statement that was

made by Dr. Scherlis, as funds bsco,me more comp&.itive, the

problem within th e Regional Advisory Group was one.of fairly
                                                            _'

good reviaiq in that they tried to cull through ,ths ,project.s

allowed them to corn? up that far, they would be eventually

filtered out by the Regional Advisory Group.  This isn't

always possible, but I don't think the undue influence of

                    .
tainly  in cur areas.

DR. SCIILIIDT:  There was a comment along this side of

the %able.

IXtSS AiJDEKSON:  I think I` was yoing to comment on the

fact that the site rav iew teams have an opportunity to see
                            ---...
soma of ths proposals in dnpth znd bring it. to this review

committee for discussion.


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        1           DR. SCIIIJIDT:  The comment for those who may not have
e    2 heard it was ths site review teams certainly can and do look

3  at projects and use this as an entry point into the survey of

4 the local decision-making process.

5      One question I would have is what are-the plans for

.6  some kind of -- wall, let's say, are the forthcoming site
7 visits then as part of the triennial review the mechanism for

8 looking at compliance or does staff intend to 90 back in a

9 year or what mechanism of seeing to this process have you

10  considered?

11          HR. CIUUIBLISS:  This will probably be done in a variety

12  of ways.  The staff is making regular visits, technical

o

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13  assistance visits, to the regions.  And they will be monitoring

14 and checking throucjh with the provisions of these the

15 verification as they 90 to se2 how they are being maintained
16 and what the status of the region is as it relates to this

17 decentralizing process.                                            

18          DR. SCIIXIDT:  Yes, Ur. Toomey.

19       MR. Td&EY:  One of the things that bothers me is

20 the  number of times that one of the Regional ;,ledidal Programs --

21     DR. SCIIXIDT:  I am sorry, let mo interrupt and ask

22 you to talk into a microphone because thsre are paopls in

2.2.. 23 (1 t$e baclk ry. _

      24          MR. TOO:lEY:  Or.5 of thz th ings that bothers me is

eraI Reporters, Inc.
     25 the nutio_r of times that a region is visited and the number of


85   I

1 purposes for which it is visited and the number of reviews' that

e..

2  a region has.  I know the last time that 2 visited as. a site

3 visitor, I think that within the period of four months, there

4 had beEn a management assessment report, there had been a field

5 trip,  a technical review.  And it just seemed that there was

6 almost an unconscionabl e amount of visiting to that particular

7 region,
I/      although I am sure each trip was justified.  And we did I
8 gst a report on it.

9 .    But the th'ing that bothers me is the fact that when

10 we take the rating sheet, the review sheet that you spoke of,

11 Judy, it really doesn't reflect the number of visits, the kind

12 of visits, ths results of the visits.  It doesn't give the site

13 review team real specific knowledge about what was found, what

14 wasn't found.

15        I am not saying it righ t because really this discussion

16 has brought on something that bothered me. And I am kind of

17 struggling for the words a little bit. But in any event, it

18 seems that there should be a more specific kind of indica.tion.
                                                                    .

19        I know'what. I was going to say.  We do get the problem:;

                                     -_
20 Tlow, this is for sure.  We get them at the RAG level, the

21 program development level, the field level, the staff level.

22 We get. the problems.
II               And then you use another sheet to provide

23 a II   rating mechanism for what has gone on.  And sometimes the two I

241d~n't jibe actually.

'

25

And as a site visitor who attampts to prepare himself,


86

        1  I look at the problems.  And then as the review mechanism of
m      2  what has gone on, you don't focus on the problems, you focus

        3  on process, performance, program, and some other things.

         4         And this whole thing, the number of visits, the

5

6

10

kind of visits, the purposs of the visits, the results of the
visits and then the result of the site visit, don't seem to

meld adequately.

        DR. SCIIMIDT:  Let me ask for clarification.

       HR. TOOMEY:  I would ask, really, if' anybody else

has had this same kind of problem in bringing all this

11  material together.                                    

'12           DR. SCIIHIDT:   Let me ask for clarification of one

13  thing you said that I didn't undsrstand.  I recently mad2 a

14  site visit to a region that had been visited a number of times.

*

15 And each group that went in pointed up the same deficiencies

16 and the same problems.  And we did, indeed, I thought, concen-

17 trate on their problems.

18       What did you msan when you said that you go in and
19 really don't concentrate on the problems? I missed your
                                    -_
20 * point.                                                         -

21      MR. TOO:GZ:  I think the point is that you do concen-

22  trate on the problems, but the problems that you find as a

23  result of one are the problsms as a result of three visits,

And you actually hav.2 made a num!.xr of visits for a number of

25  different purposes presumably, and they all come out the same


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way.

     And then my last point was that the assessment, the

in-depth assessment, that starts with process and parformancz,

these questions do not always relate to the problems that have I

been identifie d by previous visits except by indirection.  I

        DR. MARGULIES:  I think that is a valid problem, but

I think that it has little to do with a sort of an accident in

timing, Mr. Toomey, although staff may want to add to this.  I

We have had an excessive concentration of necessity on two kind

of visits -- management assessment and the review process

verification.  These wsre necessary because we had undergone
a profound change in the way in which we ran our affairs.   This

has meant in some cases a deluge of visits which include not

only the regular visits, but the specialized ones for managsment.

assessment which we had to have and for review verification:

process as well.

I think in the future, there will be less of this

kind of specialized attention to programs and a better

opportunity to integrate them.  I am suggesting that this is  I

-_

'an erratic phenomenon rather than a consistent one -which moved

us from where we were,to where wo need to be.

     Mr. Chambliss commented a moment ago on what we would

b.2 doing in the future.  What we would like to be1iev.e is that
                             -*.
this intensive period which we could not possibly duplicate

as we could not duplicate management assessment visits sets a


88 I

        1  plateau from which we can qerate with attention to what comes
e      2  up as a variant from the norm, but which we will then have to

3 /I re-examine at some point to see if anything more intc;nsive

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In fact, the responsibility for the ttro kinds of

processes restad in different parts of the Operations Division.

And we had our own difficulties in bringing tham together becau:

they did put a great strain on RXPs and added an amount of

information which was not nscessallily a part of the regular

review process, but was rather a buttress for it.

DR. SCEIHIDT:  Of course,  the revisw'criteria and

that kind of a laundry list and form for site visitors and

so Gil was  cl sarly intzndc-d to be a guids and not all-inclusive.

And I know that many site visit tsams have gone far beyond

that guid.o.  That was not intended in any way to raStriCt Site

visitors or the review committee or anything else.  Of that,

I am sure.

Judy.

         MRS. SILSI3EE:  I was just going  to say to Mr.
                                -..
'Toomzy in terms of trying to plot out these visits *where th,ey

could be combined,. the verification visit and managcnznt survey

  ware put together.  And the strategy within staff was to try to
23 do that enough in advance if there Wr-3 going to be a triennial
II                     I

II                               --.. ._.                                      I

has to be done.

      24  sit.2 visit so that th2 region would have the benefit of the

era1 Reporters, Inc.

25 observations and recommendations and an opportunity to try to


89

1  correct some of thrse things before their three-year funding

2  request got considcred by the national review process.  This

3 didn't always work out.

4       DR. SCBI~IDT: O.K., any other comments, then, on

5 this subject?

6           MR. HILTON:  I just need to follow I&. Toomey's

7 comment for just a little clarification for m.3.
      From what Judy was saying, as I understand it, these I

9  visit.s , management, technical review, etc., etc., are they
10 deliberately thrzn timed to precede a visit by the review

11
11  committee, Council,
  committee, Council, that kind of mixture, so that we in effect
             that kind of mixture, so that we in effect
'12 follow up to assure
'12 follow up to assure  that what has been discovered in the
               that what has been discovered in the

13
13  earlier visits has begun to show returns?
  earlier visits has begun to show returns?  Leave the verifica-
                                 Leave the verifica-

14
14  tion for staff?
  tion for staff?

15
15          MRS. SILSBEE:
           MRS. SILSBEE:  The thought behind that, Mr. Hilton,
              The thought behind that, Mr. Hilton,

16  was that in some instances, this would relieve the site visitor

17 of having to go over that same old ground and be able to

18  concentrate more on the program and the activities and the
                         ,     1

19  effactivsness of those activit ies so that tho,y wouldn't have to
                                     -.

    .                                                                    *
20 focus on the organizational structure so much.

,c . .,

21      MR .  IJILTOiJ':  Is that to say, then, as this develois

'*
-.T

22 there would 133 no need for us as we did, for example, to ask

     23 them to go through projects, that we are sure that the process%
e                                            '---m.

       24 is legal and that kinti of thing, we won't have to be bothered

Ice-Federal Reporters, Inc.
        25 with that?


                                                     90 I

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1           ??? o  SILSBEE:  I don't think that is indicated    I

2  think at any point in terms of the perspective of the applica-
3 tion that these things have to be checked out as Dr.

4  Scherlis was saying.

5         DR. SCHMIDT:  I would get alarmed if 'anybody thought

6 in any way they shouldn't do anything that their brain and

7 II tummy told them ough, + to bs dona on a site visit.  And you know

8 you smell somV4 e+-hing, you go right in and find out what smalls.

9 `   I think the thing that bothers me about this is as

10 tiill corns out in our discussion of regions in the later part

11  of the meeting, why is it that ther, 0 can indeed be a series

`12 11 of visits all pointing up the same thing?  And what is wrong  I

13 I
I that over a period of even two consecutive triennial -- do we

14 have any two consecutive -- the same things are there? And
15 there is a csrtain obstinancy sometimes that one needs to

16 change.

17       Well, fine. Bill.

is /I

DR. TlIURiJAX:  In no attempt to match .th,e wit and
       ,

19 rloquznc-
/I      Q of our chairman, let me point out Mr. Nixon's

20 statemsnt was the carrot-and-stick procedure was designed for

21 the 'jackass.

22       (Laughter.)

         23          DR. SCIIXIDT:  I think WD, have to take a recess to
                                       . '-s _.       , ;
e     24 figurr3 that one out.
ice-Fedetal Reporters, Inc.
          25     I did hear a marvelous line, though, the other day


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                              1
e   11  that came from Congress.  In talking about this congrassional

    2 budget buresu and so on, one Congressman said that the Congress

(3

4

is fiscally irresponsible and if you added up the monies that
Congress appropriates and spent that the country would obvious1

is /I  be broke.  And one Congressman described Congress as a fiscal I

6

junkie which I thought was a great line,
     I will use this for transition into the n2xt subject.

7

8  Those of you who raad what I think, Dr. Nargulies, was a very

$9  in&resting and informative summary of the  Council meeting --' I

I hop3 that Review CommitL-..
              +-a= members read the Council highlight   -

you will recall there  was reference to the d&velopmental

e
I.

`12  component including a little bit peculiar fact noted by the

~13 R,zview Committee often.  And that is the developmental componen

14 was often most needed by th- 0 region that didn't merit it.  And

I
15 for this and other r,oasons, the developmental compon",nt has beer

16 under serious discussion by the Council.

17

I i;

And Judy will review this for us and get`us up to I

18 date on the status of the davelopnental component.
                         ,

19      P4R.S. SILSBEE: _Well, we were talking a little earlier

20 /I about tha fact that this review ccmmittee used to be involved

21 with'project review and th? developmental compcnant was            ,

22  introduced as a tool to help regions about the same time that

23 W'J wsre trying to g&. regions in the habit of submitting an
                                  - . .       :
24 i application for funciizg once a year rather than every tima a

qce -Federal Reporters, Inc.
                FIc II yevim cycle came up.  And the developmental componant was at


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that point, which wasn't tco long ago when you really get back

.

and look back and see what actually happened -- it was In

1970 -- a revolutionary idea that the regions would request
funds for projects and at the same time would request funds

for activities that they didn't specify aC, tile time excspt in

terms of the areas in which they would want to develop programs

And at the time this committiW
              +ne and Council considered the

developmental component, they decided that there had to be
certain standards for those regions which were to be approved

~ for the developmental component.

And in practice, this became a way-of sifting out the

regions which had Regional Advisory Groups which were-able to

make decisions, withstand the local pressures of some kind of

technical review.  There were a number of different qualifica-

tions.

And in terms of thu * way this review committee

recommend-cd the regions receiving dsvelopmental components,

looking back over the past two years, it sifted. out pretty

well. If we look at the regions that are roughly in the A
                                -_
category and the B category and C category, in the-A,  most all

-- and one region had not requested a developmental component -

of those were approved for developmental component.  In the B

area, I think of 26 -- and when you do these categories, it

,

depends on what point in tim2 you are doing it -- 20 of them

have been approved.  In the C area, only one or two.  So in


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,terms of a way of sifting out regions, it 1~1s been effective.

         But since the developmentaX component was introduced

and has been utilized, the regions i:E~~Ernselvas, the ones that

have decided to allocate their funds in this direction because

we have never actually given additioirzal money for that purpose,

we have had a number of other things happen.   We have decsn-

tralized ths project review.  The RHP review processes have

b.een studied.  This triennial system &as been inaugurated.
We have the RAG grantee policy which &.ates very clearly what

the I?egional ADvisory Groups' role is in a more succinct

fashion than ever before,   And we have the policy for discre-

tionary funding which provides the opportunity for a region -

tc do everything that the dev2lo>mentel component allowed thsm

to do if they ar2 approved for t.rienr&al status.  And then rogic

have the opportuc-,
           icy to shift funds t.E;T initiate activities

within one application time to another.,

And at this point in time, it seems that the

developmental component as such, a request for it as such, has

i9 /I
  served its purpose, and it is no longs.- a necessary part of

                                                     -.
     2. this evolution into decentralization.           -=a?- .

        21 .     In looking at the results, there are a number of

   ,..
c I       22  regions that hav e requested developncn&al components two or
   __..,.
      23 thre2 times and been disapproved each &ime.   So as a mechanism

      24 for getting them to do ths thir.g's that--. Ilr. Toom~~y says he keeps

;e    al Reporters, Inc.
         25  seeing coming up in every rE2'port, it Cdn't se.em to be effeCtiVE.


94  I

1  nnd at the same time, there seemed to be for those regions

2 II that. needed to initiate some new ideas or move in different I
3 directions, they were using their disapproval for developmental

4  component as -- they interpreted that action as disapproval of
5 the type of activities they were going into rather than some
6 difficulty with their decision-making and local review.

7 /I     So at this point in time, staff feels that the   I
8 developmental componen, + has been a very useful device.  It has

                                                                         .

9 served its purpose.' Regions have had ample opportun1t.y to
10 request it and that it might be better to eliminate that as a

11 special thing -- not eliminate the d.evelopncntal idea, but  I
12 .to eliminated the con;20.,, n-?nt as such which has created some     -._
                               I

13  i>r3blZEIS internally.

14         DR. SCXlIDT:  I think that is an excellent review.

15 And, of course, the existence of discretionary funds really is

16 to me what renders the developmental component a little bit
17 unnecessary now because the developmental component was
18 intended to provida, indeed, discretionary funds.  It got to

19 bz sort of like'ths stamp on meat, unfortunately.
                                     -_

20

I forget what the current grading ???now;  But. if

21 ycu 'got t-h2 develoi>mar?al component, you were stamped choice

22  or whatever tha top grade is which is sort of ridiculcus.

23 II        MR. ClIXlULISS:  Prime.          I

         DR. lJARGULII:S:  YOU have forgotten about it because  1

25  it cost so much.

tee


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5  than any reaction to your comments.

6

7

o ?

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11  AS I have understood the use of the developmental component,

12 .this has been some funds that they could use in a variety of

m

13

14

DR. SCIMIDT:  I am on the verge of forgetting

about meat because it costs so much.

Dr. Scherlis, you had a furrowed brow at several poin

DR. SCHERLIS:  That is a lack of good vision rather

(Laughter.)

DR. SCi-I!XIDT* .  Then put on your glasses because we
                                              -
                                                             \

need your clarity of vision on this committee very much.
                                         .
       Joe. '

DR. HESS:  Just a question for further clarification.

ways.  Iiow will that be requested now in the future in

applications?

MRS.  SILSwx:  At t.11: present time and through idarch,

15

16 it will be requested just as it has been. But if there are

17 some revised instructions, it would provide an opportunity to

18 put that in the program staff budget as developmental activitie

19

which is where f5ey have been putting some of these funds  anywa  .
                                -.

20 'In looking at the situation right now, regionysomitimes are

2' II requesting a devzlopmantal component, then under their program I

22 staff budget, they are requesting money for feasibility studies,

23 1 thzy  are requesting money for contracts and a number of things

24 which have the same pL!rposc.   So we thought if we could get

25 it, it would be tighter if w? could g&t it all in one place.


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        DR. SCKIIDT:  \1hat will be interesting is when we

arrive at the point this afterncon or tomorrow morning when a

region has had a review verifica,.
                   -'-ion visit and has had this

project asproved and the recommendations of the site visit

team will be in that region that they do not merit a develop-

mental component.  And we will see how that comes out.   I will

predict we will have that situation.

         Nr.  Hilton.
                                            

        MR. HILTOX:  Such terms as aside from developmental

                                   "
component, growth funds, rebudgoting or budgetary flexibility,

discretionary funds, I am assuming there is no substantial

difference between those terms; they all are really saying t.he

SX?lE: thing. I am surprised, however, to note that I have

seen at,.least one application in which more than one term is

used for one application.  And so they ar-. 0 kind of doubling

up on flexibility..

    How many different ways do you provide incentive

and bw much of that do you tolerate?  I guess I am seeking
                          , .
                    .
guidance.

        MRS.  SILSBCC:   I-Ir .  Hilton,  this has ""t een'a concern

and is part of the reascn why staff lookEd at this whole area

of developmental component.

        In terms of the discretionary funding policy which

came out about the s,zrle time as t.h.2 RIG grantee policy, it

again puts a burden both on our staff and this review committ6c^


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of looking at the results of a lot of flexibility after they

have already initiated it rather than before.  And in looking

at the ways in which regions have usod developmental funds, the

have been very exciting things that have occurred.  And there

have also been some of the othrr kinds where they have put it

all together and started a project.

So we have to monitor this very carefully.  But if
                                              --

WE could put it all in one spot., we thinkit will be more helpfu

HR. HILTOk:  So you are saying if we get an applica-
                      .

ticn like that and they are asking for four different kinds of

flexible money, we could easily disallow'three out of four or

-scmething if that seemed to 5.1 feasible.

IIRS. SILSBIX:  If it seenrd like an undue proportion

.without .any .kind of
..:'     . . . . . . . . . :.-. :..    ._   . . . . . jus.ti.fic+$ion., . And .this is. certainly.. . . ,
within the line --

HR. MILTOX:  This whole question of degrees of

extra money like everything else.

DR. SCHI4IDT:  All right.,  let me seek out now any

commsnts from anyone around the table, anyone who is here

                                                         -=e -

as representative of the public.  Are therz any general comment

or qUzstioI:s not. necessarily directed at the last topic frcm

anyone in the room?

(NO response.)

       If there arr: none, th?n I think that we will declare

t.hat this section of the Review Committee meeting iS closed.


98  I

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         15

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18  hard this aftsrnoon and do the most we can today with this so

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25

We will reconvene at 1 o'clock in then the first of the closed

sections that will be devoted to prcgram r.?viPw.

        Leonard.

DR. SCIIERLIS:  I have no comment except an inquiry.

Have you dstermined who would or would not be here tomorrow in

terms of making sure that the review can be done today?

ffas this been taken care of?

DR. SCIINIDT:  The information I have -- we can do

this little bit of housekeeping right now -- is that Dr.  White

will be here this afternoon only; that we must do today

Alaska, Connecticut, and North Dakota in part because of your

.schedule.
                
       Is there anyone elss who is  involved in a conflict?

       HR. .HILTOIJ:  .Yes, Mr.  Chairman.
             . .
      . . ,' . I                     '.
.-. :                                     .. :... .   .Unfortunately, I,
                            i. .'                ..-. la..'      .  : . ., : : . . .
                                                                           . .
.
too, will only be abie to be hers this afternoon.

DR. SCHMIDT:  All right, we have got Washington/

Alaska scheduled also.  SO I intend to work the committee very

that we have the' benefit of  th E? members who mdy not be here
                                -.

tomorrow.  So eat heartily and have a good stzng cup of coffee

and corn= back with loins girded.

(Whereupon, at 11:55 o'clock a.m., the meeting

recessed, to reconvene at 1 p.m. the same day.)


99 I

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.l                  AFTERNOON SESSION

2                               (1:OO p.m.)

3          DR. SCXMIDT:  I think I will call the meeting to

4  order.

5       Let me first suggest an order, kind of doubling back

6 to the last topic.  And it would seem to n& that. -- let's see,

7 Phil isn't hxe yet. and will be coming about 1:30, I think.

8 And giving him  a little while to get here, it might. be 2

                                       -
9 o'clock. So I would suggest the following order:  \?ashington/

10 Alaska first, and then Louisiana, then Connx%.cut and North

11 Dakota, then Eletro D.C.
II                                                             I       I

12         NOW, those seem to mp, to be the musts this afternoon.

e

.I  . ;: .; .

13  And if we go on beyond that, it would be good.

   14
. .  . . . . :;
     . .
   15

.    Is that pcc%ptable? Have I lT,ft. pvt s0m.e imppratiyn?
                 ::
            .: . .  ,:.... ."    : *. c  . . i .- :. .    _. ._..   . . ._ . . . . '.,. ,i ;    :.:. ,. . :. ,.  :
: .                                                 . I

(270 response.)

16

17

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20

     If not, then let's start with \?ashingt.on/Alaska. ,
Ths primary reviewer is f.Ir. Hilton and then Dr. Luginbuhl is

the secondary reviewer.

      Oh, y&s, I forgot to bring to the attention of the

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review committee the conflict of intarest statement. and the

     21 confidantiality of meeting statcmsnt. You know that we cannot

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       23 interest.  Committee members will absent themselves when

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         25        I don't have to read this, do I?


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14RS. SILSUEE:  IJO, since everyone has it in front of

them.

DR. SClILXIDT:  You all have a copy.  Th.$ is a rcquirs

mant of ma&.ngs.

Then, before we do start with Washington/Alaska,

Xr. Chambliss will inform us as to the Council recommendation

stemming from our last review meeting.

MR. CIIX~IBLISS:  IAs a result of the September-October

review cycle at which time` 13 regions were reviewed by this

committss, 9 of which had applications in for the trisnnium,

3 anniversaries prior to th.e triennium, and one anniversary

within the triennium, ws certainly thought the committee would

like to know that all of the committee recommendations were

;Pcceptecl by the council with the excEption of one.  And that
                                                                     :        . . .
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             .   ;., . _.. i.' :;          ... * '.   5 . .                                  ,. . .. :
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                          *. .;i             /  ..:*:,* .`!.y...- . . . . . .: . ..*. c. ;'> .:;. .:' : *., ..,,. <. ':';
' ;;la&'&ca 'case df 'Ne$J ]+l~x~*CO;                                       . .
                                       . . .

In the iJew Mexico application, there was a site

visit recommendation of a funding level of $1.3 million.   The

comrnittca recommzndad $1,150,000.  And Council upped that

level and recommended a level of $1,250,000 which was $100,000

above that rsccmmendfd by- this committee.     - .

DR. SCCERLIS:  T?as there a reason given?

ilR. CI-IAXtiLISS:  And I simply thought. you would want

to know of those proceedings.

*
Thank you.

DR. SCiii4IDT:  Let's take Leonard's question.   What


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16  and they should have a little bit more in funds and not in

-17  flexibility.  The actual amount of funds awarded, however, was

48  more in line with the committee's recommendation.

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     rxcss KERR:   I notice on the summary she& requests,
                               -.

it is  footnoted No. 3, Review Committee ratir?gave Connecticut

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23          I wonder if you could giv-e us the reason for that

was the reasoning behind this?

~4R.CiUAXBLISS:  The qu.zst.ion is the reasoning.  And

would you speak to that, Mr. Posta?

MR. POSTA:  I might pass the ball over.

IIowever, actually, Dr.  Kamaroff was on the site visit

felt perhaps they did deserve a little b&t more ,what we used
I

to call until this morning'developmental component funds. And

that was the primary reason for it to be increased in a slight

amount.

Is there any ether ccznmznt?

.:. ..:..  ,...'{ .*,..c '- MR. ZI'ZLAVSiCy.:..: _,
       ,. -;..:.." '...I. .;,, ;;" ..I.   An additional comment, Dr..Kamaroff
                                 . :' _: , _.        '.
       :. .                   :: .           '- _. .,; , :..,
                               , . . . . '... .         .'. : . . .-*.. . ..y . ;; : 1 ., ,.   .  . .   i .:
   

who chairrd the site visit felt it. was a little bit stringent

312 which would plac= it in thn B category.  And it was changed

by Ccuncil to be an A region.

or why this was changed?

HR. CIIrWi3LISS:  Let's sze, 1-W.  Nash !gho is the Chixf


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of the Eastern Operations Branch -- Miss Kerr raises the questi

on the rating for Connecticut.

         MISS KERR:  The rating changes for Connecticut from

B to A.

        MR. NASH:  That was raised by Councii itself.

        &IRS. FAATZ:  That was a year ago.

        MR. NASH:   It wasn't. here.

        MRS. FAATZ:  We are reviewing Connecticut again.

        MR. NASH:  It was a site visit, by thk way.

         14ISS KERR:  17311,  I notice it was on this sheet.

        DR. SCWIDT:  We will be doing Connecticut so maybe

we can hold that off, then.

Are th5rs any other questions specifically directed

toward the Council ac:tions?     .
* :- . . . . *. .1 .         . : . . : :    " . :.. :. * ,. . :.. ,:
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(No response.)

     If not, then I think that do5s bring us to the
            *. '
program reviews.  And for those of you who have just corn'", in,

the order will be Washington/Alaska, Louisiana, Connecticut,
                    .
North Dakota, and lletro D.C., b?ginning with YashingtonjAlaska

                                                       -z?- *
and Mr. Hilton.

(Dr. Ancrun absented herself from the room.)

14R. HILTO;?:  Ted Xcore from the staff will prcvide

a'few minutes of introductory information using the audio-visua
                             -..

and then we will go i,:lto our r.zport.

DR. SCIIllIDT:  We will have audio-visual prrssntations


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on Washington/Alaska, Louisiana, and Intermountain which we

hopa trill be helpful.  And onto again, we will want your

critical evaluation of these presentations.

    MR. ~IOORE: ' We don't have a speaker, but of the

3.5 million people in the two States.

      (Slide.)

As you can see, this is Washington State. IAnd the

3.2 million p-ople in the population areas of Bellingham, Seatt

to Tacoma, 80 percent of the population resides'in this area

                                   *

hero surrounded by the Olympis :.lountnin Ranges and the

Cascade, Xountain Ranges.  The rest of th? State, is flatland.

And the other 20 portent of the population is in Spokane and

      One large riveq,. t.h-c Columbia Riverc stretches 15cQ,.
    . . . . . .._. .-.*, .   :*. .    :. . . .-   -.  .'.';j.    . . . . . . . . . .', : _I_. .,     . . . . .
                                                                  . . .     ..:'..
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      :.
mil2.s into Orogsn ar,d.

Next slide.

(Slid%.)                                                  

Alaska has 310,000 population.  Population bases arQ-

locpfsd llzre --"
    ^..,I       capital at Juneau, Anchorag%, t.h? largest city,

Fairbanks in the central part with a scattzrLFg population on

the coastal regions.

, You have the Brooks ;4ountain Ranges in the north and

thp_ Alaskan Ranges in t.hz south with X.. ;-icl<inley's 20,000

Next slide.


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(Slide.)

The region encompasses 700,000 square miles.  As you

zan ~5~0
   ;-, it is approximately 0nL a-fifth th? land area of the

Jr,i.ted States.

Along with the siz5, the terrain d2nsit.y of populatio

,eat.hlr and so forth, you can S--
                    se wh2re this would add problems

to health care planning and hsalth care services.
                                                           ..-

Next slide.

(Slide.) .

These are air mi3.E distances between the larger

cities in thz aree of Seattle, Portland, Spokane, Fairbanks,

and Anchcrage.  As ycu can see, it is quite a problem to travel

allow52d for such we+-ng.s..          1 .     . .,
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  .;:   . . . . .y L.'.  '..;. ::._ \     ,..    .., :    . . . .                         _... f.': '.:. I
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                                   . . .
       .  It is veri. hard to consider that. t.hF time  that we

le.Ive National Airpcrt in SJashington, people are leaving

Fair&r&s to attend the same r&?c,5ing in Seattle.     _

        With the isolation that. contributes to the goals of

accessibility a6d evailability of car2, however, the pecple

                                -.                          -=a?
were able to si?~ t.hs Super Bowl via satellite commtir~cations.
                                                                     .-

xext. slid?.

(Slide.)

This is a view of Bethel, Alaska.  It is i-lain St.rc-et

Uothrl, 1530 populat.Fon, in scut.hwcst Alaska.

Next siide.


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Reporters,

(Slide.)

This gives a population percentage breakdown within

Washington and Alaska.  In Alaska, of the 310,000 people there,

you have ground 9,000 blacks, you have 52,000 Indian-Eskimos,

2,000 other, and the remaining is 79 percent Caucasian.

In Washington, you have 3.5 million population.

71,000 blacks, 53,000 of Oriental ~xt.raction,_~Indian population

33,000, remainder Caucasian, or 95 pzcwt.

In Alaska', there is around a 40 percent shortage of

primary care physicians.  They have a total of 320 p!lysiciar,s,

half of whom are military or PliS physicians.

      In Washicgt.on they have a little above the national

av5rag.z of h5alt.h rnanpowz in terms of physicians and zurses.

        IJext slide.
-.*,   _: . . . .  -
          . . . . .  . : ..  ..'..\l.. . . . : .  .:J.. .    .:   . . . . . :.    ; . . * : './.

        (Slide.)

These are the araawide planning agencies.   There are

7 in the State of Nashington.   Thare  is on3 in Alaska in

hnchoray.

                     .
       As you can se?, thr- shaded portions are covarsd.

                                                       w
The ur,sh=,deJ prtions are not covertd by any Pzdcril or State

planning hn.alth ngsncy.

a ?Jext slide.

        This is a ccm~osition of t.i-ir-S various cormit.tees,

Xashington/Alaska committ5es.  Son-; are technical and others


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ara on the broader committee functions.  As you can see,

around thE populated aress, you have rzzpressntation in kidnsy,

continuing cducztion, Cxniun+ty IIealkh Serviccl, htart,

cancer, and health care tzchnology.  So repressntztion flows
with the pcpulstion bases centered around the university.

Next slide.

(Slide.)

As a result of some of the earlier planning -- this

is thg tot.21 RAB me&bnrship.   Tho,rs are 46 members in the State
                                   0
of Washington.  This givas a gbographicsl distribution of ths

msmbxship.  Advics given by thz manageAm";isni; assessment t.r?am in

.February v -f ~CI indicatsd that thay nrzdsd a largar geDgrashica1

spread, proftssicnal sprsad, ccx1sumbr and other groups on the

MB. . ,. And this. shows, ,the gcogrzphical-.spre?$. .    . . . .        _. . .
. . . . . .     . .   .                               . *

Also,  of the 4 6, 8 membsrs @rz frcm Alaska.   And

tilers are around 3.consumsrs on t.hs tots1 Regional IAdvisory

acard.

Next. slids.

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(Slide.) __
                                        Qe- .
This is the Alzskan Advisory Com~ittcc- ccnpxzd of

22 msmbers.  Th%y -
             2SS"SS the hEalth nl;Eds in Alaske.  And this

is a col5munication dsvice into the FLAB.  Eight of thsse 22

mgmbers ars also RAB   mrmbers.

Jext slidn,.

(Slide.)


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As a result of some of the earlier planning -- this

is the Providence Hospital in Anchorage, Alaska -- prior to

1969, there was no super radiation therapy available to the

Alaskans.  Xany cancer patients had to travel 3,000 miles to

other States for their radiation therapy.  R'.IP purchased the

cobalt unit and the community provided the financing and built

the facility you se? hare.

-

In its first year of operation, 135 patients complete

therapy at the unit' which was twice as much as had been expects
Today, 300 to 400 patients'rzccivs cobalt treatment at this

center.

This is one of the first successful l?JlP projects

which,  of course, have bszn taken over with other resources.

       Let's have the transparency.
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        Xr . Hilton, would you lika to present the planning

process for th eir triennial application?

        XR. JiILTOiJ:  I think probably, Ted, we can hold off

OP, that planning process  slid 2 unless questions arise.
     Is that the one you are about to show? We will hold

up on that one.                                -SF .

      Here is an additional audio-visual aid, and I also

have a handout to share with you.

      Basic.ally, our approach to, the Washington/Alaska

region was what. mig!le by? qualified as a --
     DR. SC&IDT:  Could you kind of cozy up to that mike


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a little bit?

MR. HILTON: O.K.

Our basic approach to th e Washington/Alaska region

was what might be described as somewhat negative in that we

sought initially to identify what tail? problems were, what was

wrong in the region, understanding from the 1it.eratur.e that it

apparently has a rather good history, that it is really very
                                                           ---

highly rated by staff.  Still, there were problem areas.   And

really, I guess we can probably break them into two types --

                                   a

what might be called minor league problems, problems, for

,exampla, revealed in the management verification visit, such

.things 2s not providing adequate feedback to applicants.   And

thars was a qusstion at one tine about 21% number of vacancies

on staff and thr; lack of an evaluation director and a number..of
.*.: .,.        .     .-. I     . . . ':                      . . :               . .
                                            .                       

othrr prcbl~.:ns.

There wsre also major concarns, some of which were

not entirely resolved as of our site visit.   And we have some

rsconunendation as to that these perhaps ought to be watched.

     Axaocg'the major concerns as I have characterized
                                -_
them, there were really fiv2.  One question t?Zt arose was with

regard to the future of the cosrd;nator or director, r)onal
                                            L.-b.

Sparkman, of the Alaska Regional ;I?dical Program who has been

apparently a very strong leader in th2 region since it bo,cam9

activ2.   115 is apsronoh ing retirrmcnt. age.  He has indicat.ed to

us that it is an option that he is not going to pick up and tha


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he will be able to continue to provide leadership.

Part of that whole package in terms of leadership,

of course, depends on the appointment of a rather strong

deputy direct.cr.  And we have received assurances that this,

too, would be done and that such a psrson is pr&.sently being

sought.

There was a legal concern raised, legal in terms of

RLIPS policies and procedures, with regard to the memorandum of

understandings t~hich the  RN. staff have been dratin up with th!

                                    .
grantea organization, Univsrsity of Washington Xedicel School,

in that the memorandum of understanding includes a stat.emont

which in effect says that the RAB  can overrids the grantee

should the grantca decide to fire t.ho coordinator,

. . . . . .   .And staff .cqllzd. tilat to
      . .   ..          : . . .      the at.t.eqt.ion of the ..Ri'B,     i
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it is cne of the things tha, + should be called attention to in

the advice' letter. And staff should look again at that at some

point in the  rot too dis tant future to see that it has bean

corrected.

Thar "
    e were reports about a possible degree of competi

--                           eei?

tion between two heal.5 education type activities in the

Washington/Alaska region.  One of thxt, one that was establishec

first, called the WAXI program -- that's W-A+-1 which

stands for ~?ashicgton/`~laskz/~~ontana and Idaho -- is a coopera-
                             -s . .

t.ivc- progrzm in which mEdica students can corn% to th2

University of Hashington for Part of their clinical training an

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then go back hom2, and the whole idea bsing to sort of centrali

this kind of activity on thz mEdica sfudent.

Wh2n the 10~31 KllP cams up with another IISEA program

a little J.ater on and sought cooperation of the grantee, there

was some difficulty thEr%.  There rsmains some uneasiness on.th

point, although wo, were confident after talking with Dean van

Cittars of the i42dical School and thg staff -z we had, I think,

some very helpful open and frank discussions with him on these

9 problems -- that it wasn't a problem that couldn't be resolved.

                                       a

10 There have apparently b oen very good relationships betas%%

11 the grantee and the IGiP.

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This stems to have beEn the only problam that can be

e .   13 rsally regard-?d as a significant problem that has evolved in

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                                                 '              And it..,j,s not

15  one t.h.2t wt nxessarily sze as jeopardizing the r,slationship

i6  at this point in tims.  But again that is something staff

ought to bs awar of and be mindful of.                      

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There was a concern about the degree of planning

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input that was being rx?ived from thz CHP zgnncies.   And

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considerable discussicn car,tz!red on this point.  Rkpresentation

from thz Region 10 office was on hand,

j Apparently th, 0 blame for the problem rasts in both

parties, both the lXG? and CiIP.  Th9, CIIP has not bsen responding

making appropriate n:~.ningful kinds of cc;mments on mzterialo as

th-sy come to them fcr review.  And the N.IP has not felt it

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or respect on their ccmmzntary at all.  And there has been

this kind of emotional friction between the two.

     Again, our feeling was that an advice letter to the.

R%fP or an item in the advice letter to the Rf,IP, on this matter

would help to resolve the problem.

     It was also my feeling that some similar step
                                                           -
should bo taken on the other side of the confrontation to gnt

cHP's coopsration a' little better.  And staff assures us this

will happen to Region 10 staff.  It is going to be resolved

11 that way.

12      Anothz kind of major prcblem we got involved with

13  the Washington/Alaska prsgram cclnters was on the lack of any

14 rz+l comprzbenslble system of arranging opsrat.ional requests,
                                                                           . .
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16       Now, apparently prior to the visit, some serious

17 thought had been given to t;\is bPt.ween the time of the

18 applicaticn and our actual site visit.  And some more thought

19 had basn given to this.
                                      -_
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21 a sy.stem was described to us. And admittedly, it was a new

22 system,, somewhat complica ted in scmc respects, but nevertheless

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II        ;dhether or not it is workable, will bo workable,  I

     24  is SOi~~~lli~CJ ",O b% pzovc,n in time.  llnd again w, Q are advised

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      25  t.hat this is somsthing that staff might look at.


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18  good region as far as we could determine in our investigations.

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      These were th% major problems.  The other problems

I mentioned that evolved from the management review team,

problems on feedback letters to applicants, problems on thG

structure of the review bodies, etc., were for the most. part

to the best we could determine -- and we sort. 0% subcommittood

ourselves to deal with th-ese issues -- were resolved by the

time of our meeting.

th.5 site visit team ranked this particular region.  And most

of the site visit members, by the way, had not had the

opportunity to do this before and had not had.any in-depth

background information on the region. And even so, from our

with staff and others who had been participating with tho.,fll!P,
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we ourselves came up with a pr5tt.y high rating.  And in talking

little bit. lower.  But neverthsless, this has been,a pretty

\

06, 07,

materia

it.

They are requ esting funcling for a triennial period,
                    _-

OS years. Their requests arc record-Ton some of the

.ls here .  This document has a good brief statement on

For the 06 year, $3,173,000.
               --S..          
07,  $4,480,300.

08, $4,421,000.


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       Our recommendations are that for the first. year,

06 year, $2,500,000.  $3,000,000 for each of ths subsequent

y33rs.  end we have not involvtsd ourselves at all with the

II 910' application centering on the Fred Hutchinson Cancer
Cantsr there and have accepted their requests a&.-they stand..

I can best proceed from here on t.ho, basis of

questions which you might want to hold until after Dr. Luginbuh

has made his comments.       I

By th,e way, the handout I gave you tends to break

those figures down and make it mores easily assimilatabla.

Did everyone get on--z of thess now? '

        DR. LUGINUUHL:  I followed t.h3 instructions laid

down by our chairman, and I went. out trying t.o smell out the

prob.ls,ms in this program. *And in looking over thc.mat.?rial in
                                          .                                 .

the meetings prior to meeting with the group cut t.h8re, I made

a list of areas that. I thought we should dig into.  And they

included program management, planning process, progrem evaluat&

and thz budg&. I will comment briefly on each .of thzse and
                    ,

try to bs quits brief because I think you did cover tA~m, too.
                               -_                         ==a-

    As far as progrem management. is concnrnei, Dr.

Sparkman is due t.o rstirs.  And he was allowEd to stay on one

year on the ba,,
        r+s of a waiver by the university.  And the head

of the RAG and Dr. Sparkman seems to f~,el that ha would by
                            2`-.       ,
allrxcd to stay on ix<.l5finitSly on an annual r%vi~w basis.

        I did hav? t.hs opportunity to discuss this with ths


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doan of the medical schocl, and he told me that it was with

some difficulty he got this clearance.  And I think this is an

unresolved question therefore and probably should be addressed.

There was also question of the continuity of leador-

ship in the RAG in.that the chairman appears to be a very stron

individual and v,zry capable, is up for reappointment.   And I

think they have a limitation on rzappointmant.   He, however,

felt that there were other people that would provide continuity

nnd ,  indeed, there is a waiver provision so that he might be

reappointed.

Hy impression was that it had been a very strong

group and there wsre a numbor of individuals who were very

important to that group.  BUM, there does appear to bo.the

potsnti.al fpr continuity. .

.

The planning process, as 13ill said, w% did pursue in

some depth.   md I.think none of us were completely convinced

that the planning process is as well coupled to the program

goals and priorities as we would wish.  I for one got the

                     8
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                                                           -se
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it comes to approving projects, they do this and then sort of

rr-late them back to the priorities after the fact.

1. feel that is an area that dces require continued

attention.                 ----.

As far as  e\-aluation is concerned, they have put a

lot of effort into evaluation.  I don't think they have solved


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the problem by any manner of means, but I was imprassed they

were making some real progross in this area.

      Do you want me to talk about budget now in more

detail?

MR. HILTOH: Yes.

        DR. LUGIi?BUfI:,:  The budget for  th e three-year period

as submitted was a total $12.1 million.  And the first year

was $3.1 million, the second and third year were each

approximately $4.4 million.  The budget in the current year is

$1.8 million.

        I for one and I think other members, felt it was

virtually inpossibls to adequately analyze a budget of this

magnituds in the. tier allott.c;d.  I3ut WB did the bcjst. we could,

I;?e really felt that we would have to almost d$lve
                           .

into sorn2 of the individual prcjects and review some staffing

and staff assignments to t&l wh,.
                   o+.her that is a logical budget

or not.  And WC just simply couldn't do that as you all can

well imagine.

. ,

We reviewed the proposed n%w positions and reached

'the conclusion these might be wall reduced, specially consider

ing the number of unfilled positions.

We also felt that funds could be cut from the

proposed d5vslopmsntal aspects.  This conclusion was reached

                             - -.

i in part by 'the realization &at t.hnsd_ developmental activiti,os

were designed to yield an increase in the second year of


$1.3 million in new project activity. And this could almost

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certainly not be funded even if developed.

     And we did review their ranking of projects.  And

some of them had a low priority.  And we felt that they could

well be reduced.  And therefore, we made a cut in that area as

well in our thinking.

Using this approach, the budgot for the first year

of th? triennium of $2.5 million was recommended and budgets

of $3 million for the second and third year w,era recommended,

rscognizing these latter years would b3 subject to additional

review.

The increase of approximately $700,000 between th-2 .

current year and. ths coming year was thought to be a gene.rous
                                              . .
                   . .                                       . .

award and  one that would tax the capacity of the program.
                              .

In summary, I thought it, from my limitsd sxperisnce,

seemed to be a pretty good program and deserved encouragement.

The strength had b-t
           3-n because of the staff and the leadership

of the. board.  There were deficiencias, and it was impossible
to really deal with effectiveness of individual projects.

.     We did fesl that they could handle??8ditional funds,

but, certainly not tha amount that they requested.

' HR. IIILTOil :  I guess we could hold staff comment and

handle questions.
     UR.  sc1I:XIX:  Let's go ahead, then.  Arb you prepared

to make a motion at this time t.o g-t something on the floor?


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9           DR. SCI-IKtDT:  It does includ? t.hz d.zvczlopmental?

10           DR. LUGIN3UiIL:  And tha renal.

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16        I will do three things v"ry quickly.  I want to remin

17  thz committee- of your rating sheets, these big long things.

18         The other one is to welcome Phil White.

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        MR. IIILTOiJ:  I would move then our recommendations of

$2.5, $3 and $3 million for those three consecutive years.

DR. SCIIHIDT:  $2.5, $3 and $3. HOW, this is c,xclusiv

of the 910- -prcjacts. .That is not a part of'it.

         MR. HILTON:  Actually, it includes the 910.,

projects.

        MR . FIOO?S: :  No, no.  It includes th,e developmental

component and kidney projects, but not the 910.

DR. SCIil'iIDT:  And renal, but not the 910.

MR. HILTOX:  Not the 910.

.. DR. SCliIlJLDT:  Then, you.are seconding the motion? .

DR. LUGINBUIIL:  Yes, sir.

DR. SCHXIDT:  So that we do have a motion on the floe

                     *
      W&corns, Phil.  It is nits to sze your face in the
                                -.                          Qs?e
boom.

The other one is just for the fun of it.  I spent

part of last week with Dave Rogers, a good friend of RXP.

you who know what he is doing knots why we had him out as

visiting Professor of Xsdicins.


118

1         (Laughter.)

2         And we spent a  f un evening drinking and talking.   IAnd

3  a good part of the conversation revolved around what I think
.4 has become a kind of a legendary site visit -- the first one

5  in Washington/Alask a where Dave went and i~lartha Phillips went,

6  and I was there.  And this was a magnificent. visit.   I still

7  start shaking when I think about it.

8       But he spent-. a great amount of time talking about

9  Washington/Alaska,  that visit and RMP.

The floor, then, is open for comments or questions.

Joe.

DR. HESS:  I would without knowing a great deal of

13 detail about the.progsam, but. accepting your Evaluation as a

14 quite good one, concur that the recommended increase of

15 $700,000 a ysar is a fairly genzous one. And I am wondering

16 about the further incremen t. of another half-million dollars in

17 the second and third years.                                      

18            It seems  to me that is a rather substantial escalation

                         , .,
19 for a region who though it has problems probably is at least in

                                                               =xzze
20  'tha  middle range as you look nationally of resources and

21 geographic and other kinds of things which get in the way of

22 delivering health services.

23       And I wonder if you might comment a little bit more

   24 on your rationale for that steep an escalation.

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I think, of recounting much of the thinking of the committee

ZS  we struggled with this item of budget. in terms of some of

the elements he mantioned -- reasonable projections as `we saw

them, really looking at what thay wanted, really looking at

t.hs?ir  ranking systems, and in effect in terms of our, for

example, projects budget., working with thair recommendations

and shaving that back somswhat.

       You mentioned the cost element becauss of the resourc.

I think it was very much impressed on many of us that t-his

    .
region does have some pretty excessive costs bfcauso of the

broad axpanse of land territory.  And thair emphases are upon

not only accessibility which I guess would account. for a grsats:

-- in fact., which does account frzr the greatest portion of

th2i.r budget, but they also havr taken into account. accsptabilf*
                                                              .

of haalth care which becomes very important in terms of the

diverse kinds of populations thsy are trying to serve in Alaska

and alsewhcre.                                                       

     And they do have soma considerable extra costs. It

                    `

takes tham thrr=,& days travel tina to corn? to.a LRAB maeting, for
                               --                          -ue+ .
example.  Thay don't have as many RAU mambzrs from Alaska bscau!

of 2~ transpcrtatlon' problzn lergaly.

      Those kinds of things in addition to as careful a

study as VJ~, could make in tima, although thair projects and

thair staffing raquirsnznts rsally lzd to that kind of --

        DR.IIESS:  Fly question is can you justify a half a


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half a million dollars a year furthor escalation for those

kinds of things?

       DR. LUGIXBUHL:  Let me say at th, 0 outset I really

don't feel that I could go through this budget either in the

first of the three years or in either of the subsequent two

years and justify it in the kind of detail that I wish I could

give you.  I simply don't think you can take a $12 million
program and in two days break down a budget in the kinds of

detail that I would like.

      I think that we conczntratsd on the first year.   And

we did make a v,ery concerted effort in the time allotted to

build that budget up by looking at the staffing pattern, by

looking at the kinds of projects that they had ranked, and those:

that we thought could be eliminated, what they might reasonably

be able to expand, and so on.

      They were very ambitious about expanding that program
            :

and they felt tha t they would put a grzat deal of effort into

the development  of new projects in the first year and then
                    3

ask for money to carry them out in thz subsequent two years.
                                                       e *
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       I would say that our $3 million figure, the half-mill

dollar incrzasz, is going along at this stage with their hops

thsy can expand their activities.  I would regard it as a very

tentative recommendation.  It is one that I certainly wouldn't
                             --r. . .

   24 want to havs firmly szt at this point in tim?.

Reporters, Inc.
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with the understanding it is going to be reviewed.  And I thin;:

when it is reviewed, particular attention'has to be given to

what kinds of new projects they develop that. they then want to

fund in the second and third years.  I certainly don't. feel

that that should be a firm figure at this point in time.

DR. HESS:  We ought to do something about it becausE!

that recommendation is a firm recommendation...

DR. SCMIDT:  John.

DR. KRALC\7SICI:  I am concerned over that budget also.

And I was wondering if you might provide us with a couple

other pieces of information that might help to evaluate it.

One,  I would be interested in whether or not they

                                                                           .-

havt soma unexpahded funds for this year that might be carried

over.

Two, the question over their core staff, the, vacancie

they now have.  Will they be able to fill those and will they

be able in your estimaticn to than add the people that they

ars hoping to add to expand it to this budget.?
                     .
       And then,  numbar three, their rc-cord of phasing out

                                                          e
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PrOjECtS.  Are we funding her-c projects over a long period of

.                        .            .
time or are they phasing out tn-z projects or arz  thesa now

on2s?  And are t.her% a large amount of new ones and are they

all solid projects?

;IR. MOORE: Yss.  In answer to the first question, V:::

were told thsy would be zero balance,  They would not be


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carryover funds.

DR. KitALE\ !%I :  ROW can there be with all the

vacancir-s th?y have?

DR. TIIURilAX:  They rebudgeted.  That is what Judy was

talking about all morning.

DR. SCilERLIS:  They knew you were going to ask that

question.                                                -

NR. RUSSELL:  Historically, this program has managed

their finances extremely wall and have because of discret,ionary

funds the flexibility RNPs have who have very consciously and

carsfully budgetsd their unexpended funds which because of

.their gcod management processes, they have been able to look

dcwn tha road and see what was going to lapse when and where an

plow that money back into the programs. .

i4R.  HILTON:  On the question of phasing out, they do

have a pretty good.history of gathering continuing support.

We had ona yusstion about one project, iJo. 5, which apparently

has barn or will be by a set date in fact. effectively phased

out..  WE had some quas,,-
               +icn as to some of the resources that
                                -._                          e

*might s!low up in another project further down the road.

But they have be.an pretty successful in getting

continued support for projects.

     You also asked a question'about core staff.   And as

I recall our delibsra5ons on that, I can only say that I

would imagine the site visit: tsam was confidsnt in the abi1it.y


123 1

        1  of the leadership +dlzre to fill the position.  We didn't give

    2 them as many positions as they wanted. We werI- reasonably

        3 confident they could fill the. ones wz allowed th%m to have.
_

MR. RUSSELL:  There are a number of candidates under I

5  consideration now for the deputy position.  They have been

6  actively recruiting.

7         DR. SCII:,fIDT:   John.

8          DR. KRALES'JSX<I:  Can I follow that with one question?

9      Undsr your plan here, then, how many positions would

10 they have to fill this coming year?

11          MR. 1400RE :  We were told that within two months they

.l2 would have the depty director,
II                   the director of professional

13  education, and the director of medical services.   So there

`14 would be three positions, top positions, filled within two

.15 months.

16         DR. KRALEVISKI :  How many additional positions would

17 be in this budget?

18

MR. MOOI??:  The additional positions below directors
       I

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                                                    .
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t.0 b% above those subregional offices.

DR. SCIIXIDT:  Dill. '

DR. TIIURlAX:  Could you give us just a little bit of

a rundown on ths relationship of the Prod Hutchinson Cancer

Center?  I think the only reason I ask it, and I think it iS


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pertinent, is that over a quarter of a million dollars and

going up each year of this budget is for relationship to it.

And probably more than that if we really knew.

      -MR.  MOORE :  The direct relationship to it is the

910  application which is $GG,OOO which would provide the
Regional Cancer Council --

         MR.  HILTOX: Are you asking about the background of
                                                            --

the center?

      DR. THURZAN:  No, box this relates to it.   Because

                                    (I

I think if you look at several things down here requested for
OG, 07, and 08 and add them up, they are half a million dollars
-which basically is going to go into the Fred Hutchinson. Do

ws understand ho721 that is going to work cr is that just down th

pike?                                 . . .
      . . .

       DR. LUGIdBUIIL:  Dick.

      MR. RUSSELL:   The  910 figure shown there represents
the support of th6 Regional Cancar Council whic!l will cOv%l
more than just the State of Washington. We advised the
\L7zshington/Alaska IVIP that we did not think it would be

                                                          e=ie
appropriatz for the ~~~ashing~.on/Alaska R.!.IP to support totally
ths Fred Hutchinson Cancer Research CEnter, that Regional

Ccuncil;

     Does this help any?

       DR. TiIUI?:iX~:  It hslils somzl Dick, but there ar9

other things like Project 52 that really basically are going


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to be Fred Xutchinson Cancar care.  And they are worth a quarts

of a million dollars right there.  Yet we don't have a building

yet, do w3?

     _ MR. RUSSZLL:  NO, not yet.  The status of the

building is that wa funded the ona phaso of it which is worth

$5 million.  NCI has just recently approved, and their award

is axpacted scan for the rest of the building_,

       So, no, it is not up yet by any means.

     DR. LUGINjUIiL:  Could I ask a qu,estion?

                                   .
        DR. SClIllIDT:  Are you asking what the relationship

is  of the IXIP program fun&d projects in cancer?

        DR. TIIURMW:  Related to the Fred Hutchinson.

        DR. SCXlIDT:   To thzt U~COKiiRCJ c5ntzr.  In other

words, is a good part of the dollars going to the Washington/
         . . .            . *       .                                           .
Alaska Regional Hadical Program going in point of fact to be

spent in that center?                                  

         DR. TI1UlWAl~:  Right.  And that is why I think it is

pertinent.   Because going back to Joe '8 initial question, they

are asking, and we are proj-acting, a very large slug of money.

                                -.                          ==a+
And yet we really don't have any bricks and mortar'on which to

spend the money.  That is a little bit nebulous.

      2 DR. SCHMIDT:   Those are now projects that you wre

DR. LUGI;U~UII;:  I don't think it is correct to say


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we are projecting funds spscifically for the Fred Hutchinson

Cancer Enter in tha t we simply gave an overall recommendation.

nnd I would poin t out that. we did cut $1.4 million out of the

second year and the same amount approximately out of the third

year.  That was obviously not a categorical cut; it is a

general cut.

        I would like to ask a procedural question and that
                                                           -A

is if we approv- 1 tentatively a $3 million figure, what is the

,further review that will occur?

        DR. SCHI"IIDT:  I &as going to make this point in a

minute in regard to what Joe is saying.  The dollar figur,e that

we put on is in Effect a ceiling.  And unless Council would.

override our raccmmendation, the $3 million for the subszqurnt

two years becomes a ce.iling which th8,y. could not exceed.
   . . .*  .' _.C      :                   .         . . .    *a .         . :
                                                                           . .
        DR. LUGIiJl3UIIL:  It is a ceiling or a floor?

       DR. SCIIP!IDT:  It is a ceiling and not a floor.   There

is really no floor.  The floor is set by the availability of

funds which is the first one.

And f&En, secondly, when this comzs up, there will be
                 -.                          e

a staff anniversary review of the application.  And staff will

make' a reco,mmendation.   And we have later on some recommenda-

tions coming before the committee.
    And staff, of course, is guided by the instructions

given from the sit:; visits end r-aview conmittae- and is guided

by thp_ concerns expr-?sssd by thp, committee during this discussic


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       DR. HESS:  Just as a matter of further emphasis, I
don't think ~7~2 ought to take that ceiling too lightly.   Because

what it says in effect is that if there is enough money to go
around and do everything that they could be funded up to that

level.  And I think the question that we have to -- or one
question that WC have to -- be concerned with here as we are
trying to look at the country nationally is not just do they

have a good program and would th.ase things be worthwhile doing,
but in relationship to all other programs countrywide can we'
justify spending this much mcnny for this program?
      The site visit team goes in with a narrow view, and

W-2 should take the broad vie>? when it comes here to this table.

And it is from that base that I have some serious reservations.

   . .  ,. .DR. SCXIIDT: . ,.+ .
          Th-re is a. real trap here, tho.ugh, and
that is that the committes must act consistently.  And I will
listsn vary carefully for the committee's actions over a two-
day period because if the committee looks at on, 0 region and has
that in mind and then tomorrow morning after a night's sleep
and so on nakcs judgments withcut the total nurnbzr of dollars
                                                                           .
                                -._                  - .

available for the country in mind, then raally there is an

inconsistency in ths committee actions.

LAnd the business of rsvizwing and making judgments by

                                    . .

merit kind of irrespective of availability of dollars is
                                      ,

scnsthing that Dr. I4a~~gulies talked about a littl?; bit this

morning .


128

The decision as to tile  allocation of what funds

0

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.3 th? Council. And there is some, balancing here betwesn regions,
#4 depecding.on availability of funds.

05          DR.HESS:  I don't disagree with what you are saying.
;fi In most respects, Nat, wa don't know.  We won't know tomorrow

7 what ths availability of funds is.  But I think there is a
8 kind of a general feeling or balancing that. we n,ssd to try to
9 do here in terms of'looking at both the quality of the iil4P staf

10 and the elements that go into the program, the needs of the

11 rzgion, the relative resources which they havs, and so on.

12        And as a general practice in order to bo consistent,

13 I think ~$2 ought to be trying on a nGu -+-ional basis to channel
j.4 the most help to the regions which have the greatest number of

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problems.  And it is that kind of balancing and consistency
which I am arguing.for. And I certainly agree that we ought.
I
; t.o b- 0 consistant, but I think consistent with the broad   I
picture in mind, what the overall goal is.

        DR. SCfIilIDT:  Nzll, let's ses -- Leonard.
                                  -.

       DR. SClIERLIS: I was intercst?d in?%o p&ticular

projxt -- the patient car2 appraisal and continuing education

one, Because over a thrse-year period, that absorbs well ovEr

$1 million. And although I don't like to review small projects,

   24 I think in view of our discussion earlier today about peer
ze    1 Reporters, Inc. 25 review and quality control, I would be very interested in this.


1' It is sponsored, I think, by the medical society.

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2        I was wondering what sort of a progarm it is. It

.3  is a million dollars, and I think it is worth spending a little

4 time on.

.5           MR. EILTON:  I think we broke ourselves down into

6 .
  committees,  and it seems to me we had some discussion on that

,.7 patient cars appraisal.  And I am not certain now, Bill, in my
                                                                 -.

8  memory, who handled that.
                                        .
9.      DR. SCIIXIi)T:  Ceci.
'10           MISS COXRATH:  This is the implementation on the

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statewide basis on a program that has bs%n going on for about
                            ?
.thras years.  This is the plen ground approach,.tha tri-cycle

approach of phy.,-
            ~4 cians within an instituticn dstsrmining what

criteria,they are going to use for qualj.ty of care, looking at
` .

15 records and determining deficits, implementing an educational I

16 program and evaluating results.

17        The State medical societies became very much

18 in it and has undertaken this as their major activity.

19       About`two years ago, they passad a resolution for

-_

20 assessing a portion of the annual due-s -- nazy, $10 per

21 II member per year -- to help underwrite the. expanses of a    I

22 continuing education program that has as its goal improvsmsnt

23 of patient care. .And this is their major program thrust.

                                                I
          24          This is prc3ably th.e most ;;xt-znsivG program in ths

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plen grcur,d approach in community hospitals throughout the

State.

Alaska is also int?rost.ed in this and plans nrxt year

to impla,ment it.  They hava a core of faculty;   they have

probably one of the most thorough con~~unity organization schoms

in the country to really test out the prir,ciples of this

approach.

DR. SCHMIDT:  Leonard, do you want to push that a

little more?

0

DR. SCHERLIS:  Only if any other informztlon is

available.  Perhaps you could comment in the visw of our

discussicn earlirr today how this fits  in with H.R. 1.

DR. SCHMIDT:  Lst's S&E, do thoy have plans to extend

that or relate, that to what must car?? along 1n pas,r r3v1EW Or
                .                                          . .

PSROs?

HISS CONI~TII::  This is the first cut of psar revkw.

Itis a seer revisw apprcech.  And it probably msans that

Wshington would bz cble to move, depsnding on how PSRO
                     ,

zvolvss.  They will have-- a cadre of people wh:, are more

                                                         ca$p .
sDphistice,-
      +cJd in terms of peer r%vi%l 2nd also in terms of

criteria setting than is true in cthsr placas.

DR. TIIURXAN:  Ceci, do they have an EJ.iCRO in addition

td that?

llISS CO1JRATL'*:   I don' t. ;;r?oVi.  I don't think they do.

This is the culmination of about three years of work


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with the State :Iedical Society, the, School of iisdicin=l, and

RI4P.  Thxe is a film on it that has bezn used, I gugss, in

about 25 StatEs -- on the patient care appraisal.   We saw

portions bf it.

        IUSS ZtiDERSOiJ:  Does it include the other health

professionals, Ceci?

MISS COXPATII:  They are beginning to in the last

six months through Larry Hulbzrt and the,group.  Both nursing

And allird health arc invo&ved and some other projects --

namaly, the laboratory projects -- havs long-range plans to

interfac? with the proj2ct.s.  At the moment, it is physician

oriented, but the continuing education progrern in nursing is

patterning its approach on this particular program.

. I. ., . ._.
*.. :. QR&. . .S($i.~~DT: : i;Irs. :Flood',- . *:- :  .:. . t  ., * . t, : *. . .* .. *I . -`.*

        MRS. FLOOD:  I have a quastion to ask in regard to
that particular project, too, ,with resp^,ct to ths $3 million

within a three-yezr period.  Have tho,y dnvelopzd a mechanism

for the continuztion of thz program without RM? support?
                     I

MISS COJRATII: --i?amzly thrcugh the Washington State
                                           es+

i\Izdical Association throughthemetiarship duzs.  How this is

going to work out, I don't know, but it has already got about

$35,000 ayeargo&-. ;ng in through msnbzrship dues about the last

year znd a half.  Ike: it goss in from ?his pcint on, I don't.

know.


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MI&. FLOOD:  up to $375,000.

        DR. ELLIS:  That is just about one-tenth of what they

need to operate in the year.
     MISS CONRAT1I:  This is the beginning.

        DR. SCHI,IIDT:   Joe.

        DR. HESS:  I have a process type question.  And that

is how did  they through their goals and priorities arrive at

a project of this type funded at this level?

        MR. HILTON:  We took them through th& process on a

coupla of projects, not this particular ons.

     Would it be of help maybe if w went through the

process as they do it generally?

DR. HESS:   30.  I ws just curious.  This is a very

exp%nsive project for this kind of thing.  I am not arguing.
                                                                           . .
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I. believe it'is. a very excellent type of thing to be doing.
I am just questioning the amount of money that is going into

it.  And I am wondering if this in relation to all their other

problems and needs is the most effective way to use that much

                      .
money.                         -..

.      I am trying to use this as an examm of'thsir

decision-making process to see how they arrived at a racommnde-

tion of that nature becausa to me it ssems a little out of
balance with what I would expect. And I just wonder if they

had good justification for it'.
     DR. LUCIHBUIIL:  As I said, we really did not try to
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r?viaw individual projects.  We did go spend quit.e a long t.im%

with them on their ranking, their mechanism of ranking.   And

once again, as I said earlier, I for ant? was not convinced that

they had a sound coupling of their projacts in all cases to

their priorities and goals.

     What we did with the projects, as I recall, is lock

ov-zr the list.  And our fs%ling was that there wer8 a numbar

of ?rojzcts that were either of 1owEr priority or w3re vsry
larg? in the amount of funding raquest.ed.  And rather than

try to make recommecdations on them individually, WB mads an

overall cut..  Ar,d ths overall cut was about Si.5 million p?-r

year in the second and third year.

      But onc8 again, I rsally don't. fe$l that. I csuld

bui.1.d .UP .z. I+get. for $3 miJlion..any mor'P,. logi,cally, than, I .
          :                             

could build one up for $3.1 or $2.3 million.  I am sorry, but

I honestly don't think I have-, the kind of confidence in this

figure that I would like or that you would lik,s. '

And I don't. know how you can do it giiren t.he.nat.ure

ofthe rsviEw process. L                          -SF- .

        MR. HILTOH:  I am a littlcd confused at this point on

one thing.  And, again, in the area of process, we talk about. aI

ovsrall, and it. was indeed as Bill szys, an overall cut.   It is

true that w9 did look at SOIX particulars, but. generally it was
                             --          

a figur; that WCS shaved out..  And we think wr` built in snough

flsxibility for the leadership of t.h2 program, looking at


      1 program primarily, to handle.
o ?     2         With regard to any single project that appears on the

       3 printouts, there is no specific guideline. We could have had

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        But we can't really say that this projsct, in other

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  words, is going to cost that much.  ide didn't say specifically

-and have'not made it known to you or to them that we are sayin
: 12

13  only 50 parcent of their pat.io,nt appraisal.  1Iayb2 they will

we the time gone down project by project and shown what was

cut out or what percentage was cut out.  But as long as there

was an overall cut and as a percentage of one million plus

dollars are extractc;d,  I don't know what the decision of the
                                                           .-

leadership would be in the face of that.  They don't. know yet

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           DR. SCHERLIS:  One or two questions.

is       In your fasdback session or during your actual reviow
i9 site visit, did'you have occasion to ask their leadership if

elect that the million,or so we cut out is the patient .
                                         . .
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appraisal.

DR. SCIIIUDT:   Leonard.                           .
                                                      n

--

they had set up a priority rating so if they%t. $1 million

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instead of $10 million or whatever the sum might be, that

they were able to delete certain projects?

FIR. IiILTOiJ:   Yes.

DR. SCXERLIS:  Did'you havo presented to you that.

priority?

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-1         MR. HILTON:  In fact, we raised that several times

2  because if you look at the application, it is somewhat confusinc,

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there.  Their explanation which involved a system of attaching

if I recall correctly numbers, weights and values --

        MR. MOORE:  A, B, C, high, low.

      MR. 'HILTON:  A, B, C, high, low. They have a system

,7  which they explained to us, and we asked for a sample of what

8

would happen.  And I do recall in this particular area, there
                                  .

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were suggesting what the budget might be.  And we tried to

point out we simply wanted to see them go through a dry run of

the project.

about a project?  And that is Em2rgcncy Medical Services which

looks like a good system except it seems to be sponsored by the

Tacoma Community College.  And it isn't just training. It

talks about setting up a total system, grading emergency rooms

and so on.

,

And I was just curious, having had.experienco looking
                  -_                          Qee -

at various sponsors of ECIS, this was unique, having a community

coll.zgs beir,g spomor.

     DO you have any details on that?

        MR. HILTON:  What woject number is it?

                         
DR. SCiIERLI:;:  64, 064.

DR. SCHMIDT:  l.liss Conrath?


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DR. SCHERLIS:  I don't want to belabor the point. I

just asked as a question of curiosity.

MISS COiJRATII:  I dcn't have particulars on that.

But the .plan in Washington is different than in many other

places -- namely, the community college is a recipient for

                                                       . .      .       .
many ccmmunity programs which are not training in whxh

the community college system in the State of \?ashington under-

takes wide, broad-scale community activities way beyond the

-usual. And in this case, I think this is probably what. is
                                   .

happ,ening.  They serve as the sponsoring agency.

It is a much strcnger community force than is true

in many other parts of the country.

DR. LUGIiJJ3UilL:  I think the most. serious question

about this program is a ques,- '-ion about continuity of leadership
                                                      .
      . . .                             .

                                                                      .       .
And if indred Dr. Sparkman does retire b-2cause of unxvers2t.y

regulations and if indeed thsy do not get a replacement or even

now a qualified deputy for him and if there is a significant

turnover in the leadership of the RAG, then I would be very

concornzd about the lovol of funding.  I frankly feel that

e .

the level recommended would be too high. :

If these problems are not solved as we were told they

would bP solved -- we identified the problems, we discussed

them, we were given assurances that they werl * being addressed -

if in fact they are n&z addressed and these basic problems are

not solved, then I would f,, ~01 very strongly that the funding


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should be scaled down in keeping Qith their capacity.   Because

I don't feel that without continuity of leadership, they would

have the capacity to expend this amount of money.

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     But once again, I visualized it as a ceiling, but

certainly not as a floor.

      DR. SCNIKCDT: Joe.

DR. HESS:  Primarily with concern for consistency

'8 with what we have done at past meetings and what we are

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probably going to do in the future based on past ,experience,
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I would like to offer a substitute motion for funding for this

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region, something which I think is more in line with what. we

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similar needs as best. w^; understand them under these limited

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circumstances.  And that is for the first year, the funding be
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$2.3, for the second $2.4, and for ths third $2.5.

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That gives them a half-million dollars increment

17 over their current level of funding which I think is a fairly

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generous one and a pratty good vote of confidence in the
~ program and also givas them a gradual increment of dollars
                                 -.

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$100,000 a year over the next thr-3 years toy?ovidz for some

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expansion.  Within those funds, t.hcy still have the flex&blllty

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for reallocating mcniss as they see fit.

So I ,would just like to offer that as a substitute.

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DR. SCIII'IID'j!:   'I'!12 dsan her> h.as a great ploy.   IIe

i just whippsd out a slide rule.

137


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     I installed a computer terminal in my office.   And

&enzvsr I rEally don't know what to say, I whirl around and

start punchixg my computzr terminal.  And usually whc,n I whirl

2ack, the person I am talking to has turnsd absolutely white.

       DR. LUGIi?I3UiiL:  We can't afford that.'

to anything, it is just. a computer terminal.

(Laughter.)

~a have a motion on the floor, thsn,' which I will

%cCa-pt as a substitute motion.  Is there a second?

       MISS AHDERSCX?:  I will sc,cond it. '

DR. SCHMIDT:  All right.,  there is a second so we are

?GW discussing G subst.it.uts motion of $2.3, $2.4, 2nd $2.5.

tid I do two things in this case.                               . .  . .
       .     . . *        . *.        . . . ., . .;*..

      Assuming tha, + the site visit team has looked at this

very carsfully as have staff, I ask specifically if anyone

Ecels that there might. be some brEakagE or some damage dons to

                                                                .

Ls+, thz committz know about this sort of thing If they f,,
                                                   fiQ1

that this would 'do harm.

                  -_                          sraep
Mr. Dean, what. does your slip stick say? -

DR. LUGINBUJIL:  I don't t.hi.nk that the $2.3 recomm%nda

Lion for tha first year would producs serious damage.   I would

32 a littl2 more concerned about thus increzs? of $100,000 in
                             - . .
the next two years.  That, is about a 4 percent increase, th%x-

abouts.  And I th-ink that the escalation of costs would bs



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139

probably graa,-
          +ar than that.

Their increase in the first year is based in part on

a rather ambitious planning of new projects.  And I think that

if we gave them $2.3 and they then planned the projects and

had $2.4 the following year, they wlouldn't be able to carry

many of them out.

I would be happier to so8 at least tha potential for

a greater increase in the second and third years, although I

think the actual award should be based on an ass%smrnt on

how they havr dens during that first year and whether they have

indeed solvizd thEse po tential management problems.

DR. SCIII4IDT:  Again,  as we said,  there would indeed

be an assessment.  And if these if's that you talked about did

come .to. pass,:. th,en. th, Q staff.,review would surface these concern

All right, let me ask the staff if any staff has

comments on the substitute motion?

.L.

MR. RUSSELL:  I have been sitting here trying to

separate emotional reaction and applying it to rsality. I

would just like to point_out that this is a program that has
                                               - .

had, I think, probably on= of the strongest Regional Advisory

Boards in tht country.

The board has been deeply involved.  They do make the

decisions.  Through the review prGcess management survey,

wa hava found out thc;r do have Wry gGrJd management. reVi.EW

processes.

c
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     They have responded to cri,.,
                      '+icism in the past and have

in the last, I believe it is, year, Ted, they have really

expanded their community service organization.

      . MR. IJOORE:  Subregionalization.

        MR. RUSSELL:  And I guess I am saying I would like.

to see them got a little bigger vote of confidence.  But I do

think the concerns about this next year are valid, are real.
    But going along with Dr. Luginbuhl, I would like to
make a plea for grzhter movement in subssqusnt. years if their
                                   .
plans do materialize.

        DR. SCIltlIDT:   Bill.

        MR. HILTOX:  I was just going to say, Mr. Chairman,

I am following your suggestion and am not thinking about next I

ye?* +d I am ,yssuming .th.at i.s ,w&at. we..are, supp.osed to, to .in .
                 . .   :.

our review of all of these programs and to concern ourselves

with the information before us which I think is mor,a consistent

with what has been the case in the past before next year looms

so close to us.

       
DR.   SCII:KIDT:  If what you are saying is we should
                  ._                        e

not base decisions on a supposition of what might happen two

or three years from now, I would agrse.      I

NR. HILTO;?:  Exactly.

DR. SCIII~IIDT:   however , with the triennial review, ~8

must maks a recoinmand:tion for t-h.3 three years of funding.   I

NR. 1GOORE:  There are abGUt six activities which --


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DR. SCfI;IIDT:  Use the mika, would you, please?

MR. 1~4OORE:  There are about six activities which they

areplanning for 1374 which are not included in the first yezr's

request.  And thsss, of course, are patient car,o appraisal

in Alaska, rural health care programs, hypsrtsnsive programs,'

Emargancy Hsdical Services.  So these and also health service

education activities, they arc moving vsry slowly as you heard

earlier in the health service education activities.  But with

the first year's planning through various studies, they had

plennad to do soma of those things for ths second and third

year of tha trionnial.  Rnd these ars the things that really

-took up tha half-million dollars in the $2.5 and $3.0.

So they are moving ahead in thass areas for the

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sacond and third year.        . .
:       . .  _, ..   ., '.' '::' ..,..! :..* . .,     . .      . . . . . .   . *. .
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DR.  SCII,FIIDT:  I think we are drawing to the tim2

where WE must bagin testing sentiment of the group.   If someone

has son2 nrw point directed toward th2 substitute motion, thsy

may hav2 the floor.  If no one demands the floor, I will call

thz question on .thez substitute motion.

                                                          as?-
.         MR. TOO;IEY:  I would agrsa with the dean;  I think

if wi ar,c --

22           DR. SCIIZ4IDT:  Would you us? the mike, please?

23          I4R. TOOXEY:  I would like to suggest to Dr. IIsss

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perhaps he might chA:17c his funding from $100,000 psrhaps to

increase the two additional years to $200,000.


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       DR. HESS:  I would say at 5.5 percent incress annual
something like that, that might end up $150,000, somothing of

that nature.

     . 14R. TOOHEY:  I think that would be more reasonable.

       DR. SCIII-IIDT: A 5.5 percent annual ikcrenant is what
is usually calculated as the amount nscsssary to meet infla-

tionary   costs.  This would not give tham nsw program dollars

probably.

. .

MISS KERR:  That is what ccncorns me in vi% of his

statsml=nt in what they are planning in the ysars ahead that

it is  hardly enough room to move.

       MISS ANDERSOiJ:  Wouldn't they ba discontinuing soms

proposals?

  . . MR. T.OOi.IEY: Jay I .suggest the..5..5:p?rcfnt is :on. . .
                             .:
*.                     . .

wages? And if you take the whole ball of wax as thr Nags
and Pries Control Board has looked at it, you are closer to

7 to 8 as far as they ars concernad, although I don't,want to

argue about the 5.5, 1.6, or --

                       $2.3, $2.4,' and $2.5
   DR. SCIIXIDT: J7el1, ws have got ~
I won't accept another substitute notion.  I would accept an

amendment to the substitut<? motion.

If not, than I will call tha question.

MR, TOO;-lEY:  I would rb;command it ba amended to be
               A . .

$2.3, $2.5, $2.7.

DR. LUGIIWUHL:  I will second it.


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        DR. SCIIIUDT:  All right, I will accept that as an

amendment to the substituta motion which is proper parliamentar

Lqise.

Any comments on that, then?

(Ho response.)

I think it. is time to test. sentiment, then.   We are

voting on $2.3, $2.5, and $2.7,

All in favor please say, "Aye."

(Chorus of dyes.)

Opposed, "NO."

DR. KRALEWSKI:   No.

MR. HILTOEJ:   No .

         DR. SCHMIDT:  To my ear, the eyes clearly have it.

: ,,.. ,. ' -_'. ..; .I .qn .r.uMr)ing the motion thrsugh... ..I. think. we: are done

         DR. KRAIJXSKI:  NO,  that was the amsndmznt.

     DR. SCHMIDT:  Oh, that was thz amendment, that's

correct.   So now we are to the substitute motion.  That's right

Thank you.  Which is $2.3, $2.5, and $2.7.

.

All in favor of that, please raise your hand.
                                          aBE+

1% are voting now on the substitute mot.& of

$2.3, $2.5, and $5.7.

DR. SCIIERLIS:   You have thoroughly confused me.

You control your faculties obviously by not letting
                -..

them know what. t.h%y a:? voting on.

DR. SCXIIDT:  No,  I write the minutes.  That is whsrr;


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I control them.

      (Laughter.)

     The original motion was $2.5, $3, and $3.  We then

had a substitute motion which was $2.3, $2.4, and $2.5. We
then successfully amsnded the substitute motion to be $2.3,

$2.5, and $2.7.

We will now vote.  And if we adopt the substitute

motion, the funding levels then will be $2.3, $2.5, and $2.7.

Is that clear?

DR. SCIIERLIS:  Yes, sir.

DR. SCHMIDT:   Is it corrsct?

(Laughter,)

DR. TfliJRUW: Dr. Scherlis is suggesting you ought to

hook up .the c,ornputer .                                             . .
                                  .

  *.'. .               _.   _. *'. .     . . . -. .: .:. . ..'.
                                :. . . .            . . .  *.. . *..

        DR. SCWIIDT:  The chair declares that out. of order

and what I said to'be correct.

Doss anyone wish the floor before the vote?

       (No response.)
                     ,

       If not, all in--favor than of thz substitute motion

.                                                    6%3+ -
as amended please raise your hand.

(Hands were raised.)

It is nine ayes.

Opposed, no, raise your hand.
               -.
(Pour hands were raised.)

/         Nina to four vote.  The motion carries.


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      The quEstion is do w8 need a special action on tie.

910?  Who can answex that?

        MR. RUSSELL:  It is being considered as a separate

application. Yes.

        DR. SCHI.IIDT:  All right, than, we have a separate

tiing to act on which is the application for funds under

Section 910.

DR. TI-IERHAX:   Move their approval. .

MISS KERR:   Second the motion.

DR. SClGlID'i':   Thxe is a motion to approvs that is

szcondcd.   Is thars wish to discuss?

(No response.)

If not, all in favor, pleas2 say, )IAye.'
                                            . . .
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                 .                            - .         _ ,,
                                   *. .                 . . . . .
(Chorus of ayes.)

opposed, "NC)."

.

The ayes have it..  You have your recomm%dation.

We will ask Phil to corn? up and join his old team-

mat.es at. th,e tebl~.  And WE will move on to Louisiana.

    DR. SCMXLIS: --Hr. Chairman, I wou?i?? submit if you

wer3 to haves a poll for that last vote that you just had, and

would urge you to ask that --

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DR. SCIiilIDT:   I have a gro:qing suspicion you are out

               -s- ._,

of order, but go ch2zd.

DR. SCiKRLIS:  No , I question very much whsthsr or


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not the people who _ voted  knew what they were voting on

with that last bit.  Would you please ask whether or not that

is indeed so.

      I, for one, abstained because I didn't know what the

vote was about,  Cculd you clarify what the 910 was?

Am I alone in that?

      (Indications he was not alone.) -_

        DR. SCIIfIIDT:  If I&. Hilton agre-s with you, we are

in bad trouble. '

     Would the primary reviewer please address the

question?

        MR. HILTON:   No.  I heard other questions like that.

        DR. SCXlIDT:  Well, I gave you all at. least two

seconds to comment.,.                                                      .
                                                     . .            .

        MR. TOOIEY:  Take a moment, will you?

       DR. SCH>l.IDT:  I will accept. a motion from the flcor
to reconsider that if anyons wishes to make such a motion.

        DR. SCIIERLIS:  I would ask for a point of information

first to explain what it was, that last vote.  I am not being

'facetious.   There  is some question hers as fFas Ghat it inclu

This' is the intent.

        DR. TIiUIum?:  Can I speak to that, Mr. Chairman,

since I made the motion?

DR. SC%-:IDT:   Please do.

DR. TIIUPJ4AX:  I think the move for approval of the


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910 application basiczlly relates to somewhere between $66

and $89 thousand that is floating around in refermCe to

organization structure and continuing communication for

dtivelopment of the cancer center concept.   It does not relate

specifically to construction funds or operational funds at .

the pres'ent time.  And that was the genesis of my motion and

the gist of it as well.

DR. SCHIGIDT:  Thank you.

                     .
Judy.

NRS. SILSXE:  xo, he stated it very wsll.   There are

two separat.e applications in from this area, ons having to do

with the Regional ;-ledical Program and the other a 910 ,baving

to do with this Fred I-Iutchinson Cancer Center that. is now

being constructed.

And in order to clear'our books, we n,eeded an action

on that request which is for the first year $66,402, the second

year $72,130, and a third year $75,346.

Our reason for asking for that is again shorthand.

The site visit iilzrn didn't make a specific rscomnzndation for

                                -..                         aa@
funding with rsgard to this application, although they looked

at it and talked about it.  And we nseded this action in order

to clear our books.

DR. SCIIERLIS:  And this is  not in violation of the

Council's statement rz:lich said in addition escspt as outlinsd

in discr.etionary funding policy, no special approvals are


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required by an RXP program to carry out activities authorized

by Sxtion 910?  This  is not in violation of that?

PIRS c  SILSi3EE:   fJ0 .

     . MR. HILTON:  Judy t  I have a question.  My figura for

the first y%?x, this 06 year, for the 910 was higher I got out

of SG~P of the documents here.  I havs a $86,,000 figure.   You

said $66,000?

MRS. SILSXX:   You are probably talking about total

costs.  I am talking ebout dirxt cost.

                                   .
        MR. HILTON:  oh, I se=.

filRS. FLOOD:  TJO *  there  was on3 copy'with $86,000, but.

that has besn correctsd.

XR. RUSSELL:  led, wasn't that budgst reduced after

submission of the application?

MRS. SILSBEE:  PJhsre is Mr. PIcore?

         XR .  t.lOORE :  Yes, it was reduc2.d hclf-time, salary for

Dr. Spi5lholz.  So there should b= an amsndmznt in hsre with

thtt $66,000.                                                  ._

DR. S&IDT:  Th.2 figure is $66,402.

                                          eze

DOSS that givs you t.hz information required?

Really, my reading of this was this was som.2t.hing

in a way we were at least politically com..itted to.

      All right, we will move ahead thsn to Louisiana, Dr.
                             c-- . .
Urindley.

DR. E3RITJDLEY:  Louisiana, the region encompasses ?.ho,


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.l  entire State of Louisiana, a population of 3.6 million. They

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have threz madical schools.  The average income is considerably I

less than ths national average.

*It has been an interesting complex to study.  They

made the caciginal application in June of 1966.  It was denied.

They had planning funds in Decl;mber of 1966.  They asked for

operational funds in 1963.  That was denied.   Thz second

operation application was approval in August of 1969.

I -

In November of 1971,. we had a site visit.  Dr. White

.

was chairman of the site visit and will discuss that some a

~ little bit later.

They related that th2y wzre impressed with the sound

data base anil that the p1annir.g framrwcrk was excellent but

there wzre som2 deficiencies that we would like to show or: the

screen a littlz? bit later.

figure is $40,233 above the Council approved l~_vp_l for the four,l-

year.  And although the-y warp, approvstd lzst year for $1 million,

                     .      1
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                                --                   - *
projtcts.                    I

       However, in addition to that, they also were awarded I

$705,963 in earmarked funds for three f;z'AS projects and four of

the IISEA and a pediatric pulmonary project.

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this yaar.  They have indicated that. they probably will apply

for triennial status n*ext year.

      They did have a certification visit to the Louisiana

Regional Fledical Program.   I have a  let ter of January 12

about that.  The visit was nads on December 14.  I will give

you a 12-word summary.

They thought evzytiring was in good shape, and they

recoclinendsd that it be approved.  We can look at the details

of that if you wish to.

A management survey visit 5 \as performad on Hovembsr 7

through 10 of 1972.  A& a number of their items, we would like

to discuss as we project some of these on the screen.  But in

ess3.nce, managcm%nt seams to bz good.

      There does seen to be som? room for irn$rovemsnt as

far as program direction is concernccd and perhaps in planning.

But the management seemed to be good according to ths survey.

Now,  if we migh, + show some of these, please.

(Slide.)

I hav& had a question about~~~lot.he,grantse was, and I

will just mention that that in Aarch of 1970, a noriprofit

corporation of LRXP, Incorporated, raplaced the Louisiana

State Department of Hospitals as the grantee,.   There  were some

problems related to that,  The corporation was governed by a

9-msmbzr board of trustees.  They wsr.s not RAG members.   And

according to their bylaws, thoy seensd to pretty much have i-h?


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authority of decidingwho would b, a on RAG and what the monies

would be used for.

Our first map up here shows the CHP U agencies that

can see here,  And we have four fundsd agencies -- iJew Orleans,

Daton Rouge, Monroe, and Alexandria -- and three operational,

but unfunded -- Lafayette, Shreveport, and Lake Charles.

Now, we will try another one.

(Slide.)

This shows the projects that have been terminated.

And largely the conclusion'is that it shows that the projects

have bean moved away from concsntrating largely on Hew Orleans.

Actually, nearly all of the projacts  were in the New Orleans

area.

Next.

(Slide.)

Here are the ongoing projects thatyou can see.

What is   more,  now we are becoming much more regional in dis-

tribution.

we have only one statewide project, but 7 subregional

                                            eis?s

projects have botn added.

Now, can we show the chart?

,  (Slide.)

    This emphasizes the new projects.  It does show the
rsgionalization much better than we have had before.

       Jext chart.


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(Slide.)

NOW, Dr. White will prcbably discuss again in a few

ninutes some of the recommendations of their site review

:ommit.tee.  But to relate to some of these as we go along, the

Eirst one, improved RAG involvement, Dr. White's group found

that. the RAG was not very much involved, that the grantee

organization at that time was largely calling t-h% shots and

deciding who was going to actually be involved and mostly how

their program might develop.

After this  recommendation and after staff had boen

"here and related these suggestions to them, three fundamental

committees of RAG had been appointed -- program d.evelopment,

evaluation, budget and finance.  There are a number of other

subcommittees that have bean developed also, but these major

committags have been appointed.  And RAG has become much more

involved in the direction of the program.

The site .
     committee did reccmmend revision of the RAG-

grantee relationship.  As I mentioned a while ago, this was not

very tenable.  The grantee group and especially the executive

                                -.

committee was largely controlling the members%p on the RAG ani

the direction of the program.

i4ow , the grantee bylaws have been altered, and they

have removed this restriction.  And the RAG has become much

LIOK 8  autoncmous.

As a mdtter of fact, the evaluation groups that have


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1  been there have said that now RAG does seem to be the group

2  that is determining the direction of the program.

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And in our mar,agemzr,t survey that went. thsre, they

felt this was even so good that it might be considered as a

model, demonstrating the relationships between the three groups

     Dr. White's group suggested we should have increased

minority representation.  And it was not very good at. the time

that  this group reviewed them.  Thsy have improvsd this.

Thsre now are five mc,mbers of the mir.orit.y on RAG and one on

staff.  And they have increased the assistance to the ager.cies

serving the minorities.

There is still room for further imprcvemznt.   We do

13  not have encugh 'either on staff or on RAG, but they are moving

14  in the right direction and do show a recognition of the Fmporta

15  of this and of the intent.

16      They have recommended that they clarify the RXP/CHP

17 implementing and planning agencies.  Initially,  there were not I

18  many funds in CIIP and RiG took over the important planning
                         

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                                                           -se .

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    It. seems important now that that 1argEly b2 reversed

and CID? would go more into planning as indicatsd and implenenta-

tion be done by R!1P.

       RIG? has inckcatcd that it wished to take on this

function and CIIP actually has agreed to it and is ccopsrating


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'with them.  They actually are the sponsors now of some of the

projects.

Next.

(Slid=.)

One of the criticisms was that it b,ecome more

action oriented in their program.  They had more planners than
t!ley actually did people who were dsveloping-on program.  And

that they needed to stimulate funds from other than FCIP sources.

      In improvement, -we havs noted that the staff now has

four project developers and three planners.  They have secured
$131,000 of outsid support, and they have assisted other
agsncizs in gaining another $G12,000 in Federal support which

is a rather remarkable achi.evensnt.

     It. was indicated they need to refine their goals

and objectives.  The goals they' had first were large.  They

did not have many subgoals.  There were very few means of

evaluation, time of achievement, how much was being accomplFshsc8

     They have five pages of goals in here which I can

read to you, but they now are relevant and understandable.

                                --                          eeapT
Th.ey do have systems of recognizing priorities.  There is a

good. criticism there that there is no time frame.
    And X think one also might recognize the deficit

that there is not a good method of evaluation of program.

      There are projects, but not too much of evaluating

progress or program.  However, it seems like nearly all ?&MPs


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c / r,alevant action plans.  And in response to this, there has been

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we review have that deficit, too.

Criticism was made they needed to develop more

a reorganization of the committee structure and staff.   About

five more ccmmittees have been appointed.

The action plans now are developing in primary care,

relevant projects.  Those are a little bit superficial.  They

arashowing intent to move into those areas, and they do have SOT

       Now, in improving RAG involvement, the orientation

is planned for n6w LRAG members to include a new group orienta-

tion.  The criticism was made that the group really needed to

16 could relate to them. So they ar e having an orientation

17 program and a site visit by ZAG going to the various projects

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and programs and evaluating their progress.       .
    They h&e added more CUP and consumer and minority
                                1.
representation.  I told you about their formiz -
                                          threz new

COmIrlitt.eES.

In the $612,000 that have been gained in Federal

sup;lort, these were related to the New Orleans arrawide Council

                                       '
on Aging, th9 IJew Orle,:ns Sickle Cell Anemia l?oundatkon, the

iJ-?w Orleans Health Development in Charity Hospital to develop


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a statistical program.

       And th'3 morz rr-levant prcjects that they havs

developzd, some examples of thosn,, are the homsbour,d rehabilits
tion program, thg continuity of care demonstration, th2 extsnsi

of the Lallis Ke,mp PPdiatric Outpatient Service -- this is a

nurse program -- a family nurse, practitioner program and a
hypzrtsnsion surveillancs program.               -.

      One of their w9aknY33r
               aeras is that some of their
                                   .
projects really don"t fit into their new emphasis of their

pl.sns that they  hav e outlinsd themsslvcs such as ths training
progrsm for CCUICC nursing ?srsonnc-1, the outrsach cD,unssling

-program for diabetFcs, ths care and transport of high risk

n~onat.es and ths Louisiana Drug Information CE;ntzr.
   They justify t.hEse as seeing that the peril of the

high risk neonate is a very first priority.  And if th5.y can

zcconplish this, it will not only relac.-
                     &+ a numbar of hospitals

charity hospital systems togath"cr in providing .what they

csnsid.zr to 59 a very scarce service.
    you have, had a staff analysis.  I Zed Ikna if

Sh2 -could hr,lp t-211 us about how th?y arE going 2.0 pay for  I

th2s.e programs af t"r WP support is concludad.  And sh% has

23 /I giv2n rnz thsse impressions.
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funds ir, Fsderzl third party payment. The Louisiana Health
Date Information Cxtar prcgram, Skate Health Officer says
his office will assurn~ this resource.

   Tumor registry coordination and assistance -- Well,.
I won't read all these to you, but they have means of providing

.nc

suppcrt for most of t-h-. air programs at the conclusion of RNP.

And they have s!lown recogciticn of the import_anc2 of this

and the nrcessity for having sox~one to pick up th- a bill. A

I have all these documented if you wish to look at them.

     The Louisiana Sgional Xedical Prcgram does have
two kidney disLasa activities that are included in the staff

rm7i.w. or,% of them was the i.iet.ropolitan Naw Orlsans Organ

Prccursmrct Proyrzxn.   And , this Is a lccsl organ prccurem,ant,
program centered around NEW Orleans.  And it largaly relates
to their renal transplant service.

1

   They are, requesting $23,235 of direct costs or
$41,344 tot21 cost for their final year of support..  And the

review committee that saw them that was headed by Dr. Jimmy

Rgb3rts, the hei1t.h consultant, t.hought this was a good program
                               -.                     w&e I

and that it probably w:,uld be worthy of suppcrt.

They did m&e t.hEz criticism that no significant

                                 cment for the
effsrts, had been made to get third party relnburs-

The ot.h~r ~22 t.hzt t.iz.2~ have is a feasibility study

on mass scrcsning for renal and urinary tract diso_zsp_ usxng


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low radioactive renal scanning.  And this is for $19,500.   And

th= consensus of opinion is that this probably was not too

.

good a program and perhaps shouldn"'t be worthy of our support.

    . That is included under core and $19,500.

       Then,  I have from Doria  -- I asked her what. they
plan to do next year, and she has given me these promises for

us to look at.                                          -

     (a) They plan to dernonstrato extensions of primary

care services in mahically under-served areas.  And thsy have
                                   .

underne.at.h that five ways .

      They plan to have nurse extenders.  And those are

going to bs, research models of use, in private care sector, in

deprived rural clinics, and in urban n"eighborhood clinics.
They are going to work with private care sectors, especially
pediatricians, and they plan to have an outpatiant ambulatory

care in public hsalth clinics as an extension of the Charity

trospit al outpatient service.

     They have access clinics around t.hs parish health
                    .
unit., and those would be related to the northeast Louisiana
                               -.
tri-parish model.                                es+ .

     They plan to do:nonst.rat.e ths use of a Charity I1ospit.a:

nedical~school residant in outpatient care in underutilized

cural hospital..  And that would be in April of 1973.

     .?.~obils h-=,al",h clinics in I'l~gust of 1973.  And t.hey

1ave specific ways in which they hops to accomplish that.


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And (b,)  -- that. is t112ir second major category --

they plan to demonstrate impact. of expanded third party

payer such as mdicaid.  Ar,d thsy have PAR study, a State

Department of IIospitals contract, contract with the Calcasisu

i-Isdical Society, and t.hen n.ext to thz last in primary care

strategy, they plan to look into program ar,d develop a strategy

for t.hz care of the rural and undrrprivilfged.   They have the
                                                           -A

men indicated that will do this.   That will start in Dzccmber

or,January.

And quality assurance, they have both the project and

the  wJorkshop that thay plan to usa to try to WalUat2 quz1it.y

assurance and guarantee it improvement.

As a 12-word summary, it semcxl to In% that this is

an area that does have great need, that has made significant

improvemsnt, that has respcnded'to each of the reconmzndations

of the site review tsam and is worthy of support.

Th.ey have requested $1,040,000.  Council approved

last year $1 million.

        I do h'ave a suggestion to make as soon as w3 have th?
                                -.
other comments.                                        etze *

Phil, do you wan;. + to talk now or after Dorothy?

DR. WITE:  Why doesn't iliss Anderson go along?

14ISS AHDZRSON:  I think you covered it very well.

I would just like to msntion the things that came to my mind

while I was revi&ing the material was their relationship with


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CHP .  &d it. sesrns like they are working a little bztter with

Clip rather than taking over CIIP's responsibilities.  And their

&SEA has bnen developed in cooperation with CHP.

Another area when we talk about minorities, I was a

little sensitive to the fact that there are so 'f.sw women on

the RAG and so few women on the staff.  And I think this is

another arsa where they reed to concentrate.

The projects are very good.  Fifty-fifty.

DR. URINDLEY:  Did we mention the extra monies they

got for the other programs?

L~ISS ANDERSON: No, I didn't.  Go ahead.

DR. BRINDLEY:  Phil,

DR. SUITE:  I think I must be here mainly to lend

some perspective to the Regional >ledical Program of Louisiana.

Your reviewers have given you the details.

      I would like to give you a recall of my visit, I

found myself -- and ths other site visitors, I think, agrssd --

in sort of an encrusted reactionary atmosphare rather than

.

just a conservative one.  And I think this is important to
                                -.                          asi@ .
. undErstand because it gave rise to some difficulties in the

gc-nesis of the Louisiana program to bagin with and continues

to givs ris.2 to sompI problems.

        These comments are not want to denigrate the State
                             -- -..

of Louisiana.   This i:; just the way things were.

     I think that Louisiana Regional !ledical Program was


161

1 looked on with suspicion from the very onset. and barely got off

e

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-2 the ground. And I think Dr. Sabatier is probably the Christ

,3 figure for the Louisiana :&gional rledical Program.  IIe was the

`4 savior . indeed and was acceptable to the professions and
'5 providers of health care at that time.

'6 II     But, even he was not stalwart enough to plunge into I

'7 a great deal of ectivitqr.  He felt that it was not wise to put

8 too many burrs under too many saddles at the beginning and four,

9. an acceptance for Regional Hsdical Programs by casting it in

10 the image of a planning agency, a data collecting agency.  And

11  he procz;rdsd to do this.  And by virtue- of that, I think he

II
12 was no,. --t.hreat.ening in that area and therefore did indeed

15  of the Rzgional Advisory Group had b)c;gun to recognize that it

16 may not be playing the role that it should.   Nr .  Smith was
17 the head of a committee at that time analyzing what the role

18 of -the Ixsgional Advisory Group should be.  llnd he is now the

19  chairman of that' groq and I think will indeed implement the
                                    -.                        WE?+ -
20  changes which ar& nrcessary.

21
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At ti12 tin2 we wxe thtre, them- was sort of a   I

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22  nsbulous shadow-like multiple-headed creature in the background

23 which we finally came to identify as the Regional ADvisory

c    24 Croup. -
                      \$.a 2x2 not, sure tliey 3x5:.: wh3t their role was.  And s-la>

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162 I

         1 confounded on why thay w?re there at t-ho site visit at the tima.
*.     2           But Xr . Smith and a few others have taken lsadership

-3  and at least from the written comments I have available to me

4 have made substantial changes in the role of the Regional

-5 rAdvisory Group and I think are taking lead.ership.

6      I think their new structure clearly points out that

-7 they do have some dedicated mc,mbers who will.part.icipate in
8 the establishment of the program and hopefully evolving in the

9 evaluation of the program eventually as well.

10

There is no need to dwell on the grantee relationship. I

11  This cams out clearly in the site visit at the time.   The
12 -grant;22 was sort, of a patriarchal group that deigned t.o let

e

13 II the Regional Advisory Group meet from time to time, but nOfI.

14 do too
. /I

much.  But this has been corrected, I think.

15     Minority reprssentation -- there were some token
16 representatives there at the time of the site visit. This, I

17  think, has been improved and cert.ainly needs improvsmant more,

18 I think no t only because 1, '+ would be helpful to have their
                         *
19 input., I think it would be helpful if Sam2 of these non-whit.e
                                                       - .
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20 mat on some of these groups and found out the problems that one

21  iS cjnfronted with in trying to get. the changes made in the

22 existing systems that occurred.

23     I recall my own amazement. and consternation when I

24 moved from a simple f;,culty member to the dean's office and

25 began to recognize that maybe the dean wasn't th- 0 all-powerful


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figure that we all thought he was and that he couldn't wave I

a wand and create changes overnight Even though he thought he I

cculd at times.  But I think it would be helpful for minority

groups to sit on a Regional Advisory Group for that purpose if

for nothing else.

      It was interesting, as we discussed the role of the

R1.P and CIIP on that occasion.  IJeither group really knew what
                                                           4_.

it was they were supposed to do.  R?iP had effectively filled

thf+ role of a CHP, 'filled the vacuum that existed.  'We queried

a number of visitors who really felt. t.hat. this was the proper

role for RXP, and they weren't quite sure what the proper role

.for CBP was.  There was just. no clear understanding of what

this was all about or what tha relationships should be.
     Apparently there is still some confusion existing,
although a coordinating cont?lit.t&. is in existence which will

help clarify their respective areas of activity.

        I think Dr. Brindley and PIiss Andsrson have fully

rslat.ed to you the change in dir'sction that has taken place.

Their projects now are; indeed more action oriented.
                                -.

I did not rrcell with great clarit.zhat.the goals  an I

i objectives VEZQ, in the original application prior to the last

sit.2 visit, but on page 39 of the present application as was

pointed out, thhsre are a number of psg-s beginning on pago 39

which outline their goals and objectives.  I think they are

clear, undzrstandabls and quite pertinent to the needs of


164  I

1   Louisiana.  And if this does indeed form the framework for

e       2  their action, they will forge ahead.

         3.      I think also that es they have reviewed their own

         4  projects, they have taken seriously the comments made in the

         5  advics letter and in other cral communications,  They have

         6  clearly looked at each of their projects to determine whether

         7   or not they are relevant to the comments that are made in those

       8 letters and in subsequent advice.  So they have taken to heart

         9  what was told them.

                                                       .
        10       I think that perhaps we could be a little impatient

        11  with how they havs expedited thesa suggestions, but I think

      12 the atmosphere has not changed that great.  There may be a
8'
e      13  nEad for them to   kind cf subtly invade +the care system in

        14  this State still and that perhaps a neonatal intensive care

     15 program of some sort will provide that without general

16  threatening attitudes of any kind.  Perhaps a drug information

17 szrvics will provide that and certainly the extension of the

'18 pediatric clinics, the nurse practitioner and so on will.

19        So although there may b- 9 some quc5stion as to the
                                      .--                          aIs+
20 total relevance of some of their new projects, I do think it is

21 a mechanism from w!lich they can enlargol.

22       I guess the only exception I would take as to the CCU

23 coronary nurse training which is something that. you have besn
                                  2- .

24 dealing with for years and years,  and it doesn't seem to ever

25 want to phase out, so perhaps somebody has to take the bull by


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the horns and say no once in a while.  And if that were so in

this particular casn, they wouldn't need that extra $40,000 more

than they requested above the c2iling Council suggested and

they could get by on the $1 million.

Those are about my only coxmznts.  I 'would 1ik.e to

state that I have enjoyed being here today.   I used to look

forward to these meetings remarkably well, not because I enjoys

all of you so much, but the trips were always kind of exciting,

theairplane rides.

One time I had lunch with Diana Ross.  Another time

I met with a i3r. J. C. Agergani who owns racing cars at the

Indianapolis speedway.  I think it. was t.imG before last I came

in on one engine.  And this time I was with a bunch of

apparently Dsmocrats for i?ixon from Texas.  And they were all

coming for t.he inauguration.  And there was a very festive

plan= ride.

The only difficulty was I happened to be sitting

behind a rather generously proportioned lady who did not join

into the fsstivitizs.  And she promptly put her szat full back
                                -.                          am
'into my lap.  And I was kind of sitting t.hern unable to er,joy

mys-?,lf or the festivities and was thankful when we landed

finally and  sh e was able to put her suL
                        n?t back up and I got hera

It is nice to be here.  Thank you.
                -. .

DR. SCIi;.IIDT :  It is nice to have you.

The planes will probably bs empty going home, I would


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guess.

      I am watching the clock because -- let me test the

sentiment of the group on a very imp0rt.ar.t issue.  How many

fez1 like they must have a cup of coffee in the, next little

w:h ile?

       (Hands were raised.)

      All right.  Then what we will do, let's go ahead and

get the funding le,vp,l to meditate on while we go gst coffee.

I would  sugg'ls t that committee msmbers g& their

coffee in cups and bring it back here and we k,eep working.

         Dr. Brindl3y.

DR. BREJDLEY:  We would like to recomiend a level of

$1 million for on2 year.  WC feel that is a considerable

improvqent over w:lat was..actua.lly granted to them last year.
                     . .                                . .
. .         :
It is only $40,000 l,sss than they have requested.

And then, they intend next year to ask review for

consideration of triennial application.

So I would move that we r,scommend $1 million for them

for one year. "           -_

         DR. SCIIi~IIDT:   IS there a second?

KISS XJDERSON:   I second.

        DR. SCXIXfDT:   There is a second.   Is thare a wish

to discuss?

      I
DR. kRALI3':'~;;
             h.  I:  I have one question.   Thz

supplsmzntary funds that were given to the rrgion this past


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I year was that just a one year?

         DR. BRIXDLEY:   Those are earmarked funds, one year.

         DR. Z';PALC%iCI:  They will not have a nesd for those.

funds this coming year?

DR. BRIXDLEY:  They did not say that.  They indicatsd

one of the programs -- 1 bslievs that was the pediatric
pulmonary program -- that Tulane University intends to apply

for funds.  And th% Health Service Education Programs when

funds bscomz aveilabls. And then they may try to apply for

fZhOS!2.  But that is not part of the application.

        DR. SCBFIID'I' :   The earmark was a one-shot deal, and

'they knzw that.  So that this application is to cover that.

DR. BRILJDLEY:  Thsy are not applying for any m0ri-E

$~nds..~ A..... .C . ..: ., . . . . . ... . . ,.... .. . . . . .,. . . . . :. . . . . . . ,- '              . .
      -. . . .                                                                .

         DR. LUGEJUURL:   I would liks to ask about. thz laader-

ship of this program.  They have born active since 19GG.  They

I

~ still do not have triennial status.  It is obvious that tharz

hav= bc-on problems with this program from r-?viewing tha

I
material.

.

,

The amount of money they arorrequcsting is $1 million

for .a population of 3.G million.  WC just approvad tha

Washington/Alaska program of comparabls population at a much

higher 1~~1, obviously a much more dovslopsd program.

In short, I am concern-d that this population mzy

not bo, adsquatcly served by tha organization as it now exists o


168

        1
e       Is that actually the case# or are there reasons to believe that.

      ?  this will develop into a program that will really adequately

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something of that sort for the new projects, now are action
                             -..?

orientsd projects ra!-lier than data collecting and planning ones,

nce - Federal Reporters, Inc

25 But
II

serve this region?

      . DR. SCIIMIDT:  Phil, let me ask you to field that.

        DR. WHITE:  I was hoping to clarify that in my

remarks that there has indEed been difficulty with this region

because of the attitudss that existed.  It has not been a

lack of leadership, I don't believe.

     Nell, partial lack of leadership.  Let rn5 put it that
                                   ,

way.  It has been a lack of leadership by th.e Regional Advisory

Sabaticr has been a good leader.  I think the staff members

that 11s has around him arz good leaders, good in working with

ar,Ba.

But there has been a lack of leadership.   It has been

extent at tha grantez level, too, and perhaps even to some
                    ,

extent at

the. medical school l.evel, but not at the staff level. /
                  -.

                                            aEzs?F -
I think that this is t.urning around.  Clearly in my

mind;  it is.   If we ware to deny them what they have asked for

particularly since the additional sums this year, $368,000 or

they would question  cur understanding of their problems, thf


169 f

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.

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would question the seriousness of any advice that we sent them

they hsvs indeed done what we told them to do and now we do not

reward than by giving them substantial sums to do what they

nwsd to do.

DR. SCIIIXIDT: 0.1;. ,  I see there is a need to discuss

this, and I don't think w,e would be too well served by trying

to jam this many people into t.h.e coffee place as they are tryin

to slam the doors.  So we will adjourn now for going down and

getting coffee.  And I would ask the committee mcymbers to gst

it in a cup with a cover on it and bring it back.  And ws will

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try to rsConv.ane hsrgz in about 10 minutes.

      (Whereupon,  a recess was taken.)

        DR. SCII1IIDT:  All right, to recapitulats, then, we

are talking about Louisiana.
.                                       * :  .        . .      . ,' I_           .,   . . ..I
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      We have atition on the floor for funding levsl of

$1 millionibr one year.  This is essentially exactly what the

Ccuncil rsccmmanded for this year.  It is $40,233 below their

rl;qusst..

     Dr. White pointed out op.5 $40,000 projzct in there
                                -_
that wasn't all that exciting.                  aai+

We were discussing the funding l~,vel.  And the

question has b,,
        con raised as to the leadership.  And the point

has besn mad2 that the program leadership was really quite good

      24 It was in a vary conservative, more than conservative,

.ct?    al Reporters, Inc.
        25 atmosphere, meaning the problems went much bsyond the prcgran


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3           XRS.  FLOOD:  I hava some concerns about the minority

4  and really down to earth non-knowledgeable consumer representa-

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16  also no constituency to coerce or -- I won't use the word

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staff 1zad.ershi.p which has beon quite good.

Yes.

tion in the davrlopmznt of these great fiva pages of -

objectives and priorities that they developed: Zind whether

ths obj%ctivzs and priorities are! valid is probably not

questionable.

Dr. White'has assured me they are valid, and they do

Y

give a trut picture of what need to be done in Louisiana.   But

my concern  is then that the emphasis in apportioning funding

to projects is questionable that it answers these neads that

thsy hzve so well documented in their many years of data

gathering,  And if there was no input from mil?orities,.and,,....
::* '.-: *. .
      ..:. :*   . i -   ., , I_. *. . . . . - . '.
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consumers into the devslopmsnt of the objectives, then there is

"coerce"  -- to encouargz the Louisiana Regional Xedical Program

to spend their project dollars to answer the wall-documented

needs, especially in the urban poor,  And the rural poor, too.

        DR. WIITE:  I think %qe point is a%lid.one.   It. was

poititsd out by our rev-,
             iowers there was at onn time practically

no minority representation at all.  These data were accumulated

Thsse statistics were compiled at a time when this was an

end in itself, I supijose.

There have been some actions taken to improve this,


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I think, Xrs. Flood.   There is at least some minority represent

tion at the present time.

    I think kegardlass,of that, the most encouraging thin
to me at least is it is no longer the staff of the Regional
lYladica1 Program which is defining what needs to be done, but

indeed the Regional Advisory Group.

     Now, as I was saying, it depends upon your definition

of consumitr, I suppose, as, to whether you feel the Regional
Advisory Group is consumer oriented.  I think thare are 17

clut of 44 that ars physicians, and the rest are in a variety

of walks of life.  So perhaps there is some consumer input at

least to this.  Perhaps it needs improving.  And I wouldn't

deny that.

.'  . . . . . . . `.)..            though,$hat t&sepeople.
                                                      .
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have been rather busy this year.  They were attracted by the

earmarked funds, and I prasums spent a considerable amount of

time developing what were presumably first rate programs becaus

they were fundc,d for those funds.
                     ,

       At the Sam3 time, they wp,re trying to rsorganize
                                              -?sas.- .

their Regional Advisory Group and have substantially done that,

but heed to do more.

      So that perhaps the projects which they are now

presanting to us may have suffered from a lack of time and

people in devclop~ing them as fully as wz would like to see.

_. .- T  Jrrn tt t.hink this should persuade us they can't. do it in


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the future.

     This is the beginning, at least.  And I think a

fairly decent beginning in view of the circumstances 'that

existed. .

        DR. SCHXCDT:  Any other comments or questions directec:

at the funding level?

      (No response.)

If no one wishes the floor, then I will call the

question.                               .

,

All in favor please say, "Aye."

(Chorus of ayes.)

opposed, "No."

(x0 response.)

           .
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          Joe.

DR.HESS:- I would like to suggest that along with

this reccrxmended funding level that we include our hope that

there will be further vigorous development of programs which
                    

are  more effectivsly addr-,
                  firsed to the health nasds of t!!e

people of Louisiana.

I reviewed the yellow sheets here, pages 10 and 11,

things tha t were pointed out a year ago..  And there.has been  I

23 rilatively little movemc,nt.  And perhaps that needs some

24 I reinforcznsnt along ~5.th these rEcozz.andations to try to move

25  the RAG and the other forcss there that may be tending to


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173

1  resist what Dr. Sabatier may indeed like to do, but. cen't

2 becauss of t.h~ internal forces.  And perhaps this would help

.3 that process along, try to bring this region up to a level of

j4 funding and the kind of activities they really ought to be

-5 engaging in.

'6          DR. SCIILXtDT:  All right, that. is approval with

7  advicE about tha act.ivitiss.

8           Dr. Ancrum.

9       -DR. AI\JCRUI,I:  This is not rzlatzzd to the funding; it

10 Ii is somewhat related to what. iIrs. Flood, I bslieve, said.

11        I don't. think RllP has dofined what they mean by

12 cc>nsum.zr for this group.  And I think frequently it means

13

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surz.t.h-3 cxnsumer might somztim% ha a provider.  And it

anybody whr, is not a physician 3r SO;;~Z health prafGssion.

-*     And. one definition $  saw for anoFhz.T.- p,r.ogT$m was..t&at,
-
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a consumer mzznt people who wsrh eligible 'for the szrvxzs.

So that maybe this might make it a little bit better.  I think

shz is speaking mors of grass roots consumar rather than having

a retired banker who is not a health profsssional, but not t.hr-

type of consum& she is talking about.

                  -_                         msxe
DR. JANES:  I could carry that one step further to bf

22 drpznds.whzt roll
II            hs is playing in the community.

23      DR. S.CIIERLIS:   I think the best. definition I h%ard

    axclud~d provikr was that by Dr. Sp2llman.  I think you

25 rscall that.  lip_.said 2t. best. a physician really can't be a


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consumer.  At best, h3, is 2 sick provider.

        DR. JXL'IIES:   In one of the programs that is included

here today, I think there is a description of providers being

consumers.  That is in th= role that they are playing on the

5  RAG comiiittaa.  And I think that often as I have looked througf

6 many of fizz programs in regard to minority interests that if

7  it is a gsneral opinion that the consumer who reprsssnts the

8  minority must be a grass roots level who is not knowledgeable,

9  -1 think that tha RAG committee would be betto,r off not having

10  thzt consumer on the board.

11         But I would like to think that this committee would

think. in ixrms of minority consumers being those who are

knowl%dg2zbl? in ths field so that ?5lzy can best contribut.2.

. And that son-+?tim~s is a physician.  11% migh.t b.9 blac$ or 1~e
       :    : : .;'        . .;* ., .
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                                            _.         . .. '2.   , '. ., :    . ,. . . . f    .,; . .

might bs an Indian or ha might bz a Puerto Rican.   But he

ects in that capacity as a providar and can then support.

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DR. SCIIXIDT: O.K., I would likn, not to got too far

into a discussion of what is a consum2r for RPIP purposes.

       ,
All right, I will take one more coyn,nt.
                  -.

HR. TOOi,lEY :  I thick I would just lx-, t6 join the

crzs'car.do which is kind of a P.S. to th? action that has alrza

besn tak-;n and say in diffzrcnt words than i4rs. Flood and Dr.

Ancrum that with the known ncu=ds that exist in th2 State of

    * *
Loulslanz, with thtz ~~?portunl?.izs that. ara potential through

25

PZ~lP , that probably arn short-stopped because of the inadquacy


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of representation of people who are in need, that everything
I

1 possiblo should be done to encourage the Louisiana RIIP to
/ expand its services because its rate of poor people, people in

I
1 need who.are underserved, probably are as great as they are

anywhere in the country.

And I think as a P.S., there should be encouragement.

The encouragement should CG~E about in tarms of getting a

larger representation of people who can use the services of

Rw? .  And I think that it is a shame to say, "Her3 is a

million dollars, you are doing fine."

Perhaps it ought to b5, "Iiere is a million dollars,

                                                               . .

now go ahead and do the work necessary to expend the $5 million

DR.  SCiIi,lIDT:  All right, I will accept that as a

vgry .val~~..:~.St.,,~to. wh?.t..?.oz.- . . .:
.-.                             _.  F said.-that this is,.appr~~~~.L,,9E.:~~:~ ~ . . . .
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funding level with advice.   And the cornrnittae has been

discussing a number of points tha,. + should be conveyed to the

region.

Thank you very much, Phil.

       .                                       k ,.*
DR. WHITE :  14~ pleasure.
                  -.                        -is!?
DR. SCIIFIIDT:  b7@ will move on way up in the northeast.

part of the country to Connacticut.  The reviewers are Dr.

Scherlis and Dr. Ellis.

Dr.  Scherlis.

DR. SCIIEiXLIf;:  First of all, I should express a

certain note of thanks for the various site visits that have


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been arranged for me over the years.  I think I am batting

about 80 pcjrcent replacement of the ccordinators after I havl

been in th2se areas.

And I guess among t.h notches that I have on my      . .

site visit sleeve would go 2Jort.h Dakota, Oklahoma, and as of

Chis `wesk, I guess, Connecticut.  Ti'hxe is one I have missed,

but that fortunate coordinator was bzt.t.er than you all thought

so hs stayed.

        The visit to Connecticut was or-e which was really

cions with a grsat dzal of fa,ar and trepidation by some members

of our site visit grcu?.

DR. SCII:lIW':  Pardon m3, can ycu h2ar in the b.ack

of the roci-13 .  If you ever can't hzar, stick your hand up.

       You have to kind of get within four or five inches

.: . .      . .                             . . .       ;. ..*     *.: * I... ;. :   f- .:: :
       . :.     .,.. .: - '_.    ,       . . . . .
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of 'that mika.                         -a.... *  . . . .    .*   . ,,...
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DR. SCIIERLIS:  Thz members of our site visit group

ineludEd 1-W.  hircto from L.A.  I had thz plaasure of bGing

with him on another site visit previously to Hawaii.   xis s

Jackson, I3r. Noroian; frcm staff Xr. Van Nostrand, Xiss Faa:tz

who is Xiss Connecticut of 1972 and 1973, Xi???\Joody end IQ.

:ici;?nna.

!ihe visit itself was a very interesting one because

the Csnnscticut progrzn is a different program and not just

by evalusstion of out>;?-ders, but c.%rtainly from the point of

vi5w of the group in Connxticut as wsll.  And let me begin by


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       saying thers is a grsat dzal about the Connecticut Kagional
e-    2 .
      Azdical Pr=,grarn which is excellent and dcsErves a great deal

..3 /I of ccmm%nd~tion.

.4 /I      On the other hand, there were some aspects of it whit

5

had been subject to a great dzal of discussion previously for
6 '
  reasons that I hope will become apparent as the discussion goes

7   on.                                                         -

8       A little rzference was mad% before about. some of t.hs

  problems with Concecticu?..  And I think you noted its rating

                                        .
10  was bumped upward at. .S Council meeting.  And this, I gu8ss,

11 baspzaks the fact t.1~sr.s are difficulties in Svalueting thf

12[iConnocticut program.

W.2 w&r4 there undsr rather unusual circumstances to

. . . _,  :, .*. ..!:f  beg.+ with.
                           : . end that
                                              . ,$ eat .the.y are op";r&t.ing wifbin. ,J-, :
    . .              .                                                     . I..           : ..'*
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15 triannium period having bssp, approved by t.h=, Ccuncil for

16 roughly $2.0 million for thz fourth year, $2.3 fr,r t.h? fifth

17  and $2.5 for thz sixth.  And they rsquzsted an incrzas? in t.hz

Council-apilrovod 1~~1s for the fifth ar,d sixth years.  And

19 thersfora thz sit-? visit wzs m-?dn.                                  r.

                                    -.                          aal+
20     Th2 s%t.t.ing for our visit was t.h? i~sw IIav"ln Lawn

r .*

21 Club,'.  Ths f acilitizs wzr?-s!  axc=llact o
                                            o?      1.1~ wQre told as the

22 visits began that we wzre there at th? invitation of the

?3 Connecticut Regional i-lsdical Program and WB wp,rc tho,re bscaus=
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t.h2 fact. that t.h?.;/ wantrd to cr:largs their program alcng

25 t.ixt levsls that I hav+ indica%d.


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It also request- nil a developmanta component. that I

will get to.

And early on,  we were reminded that the Connecticut.

program has, and these aren't words of my own -- these zre

words that the staff and the coordinator used in describing

the Connecticut program -- that we were there because this is

the  only program in the country that. s.et a grand design early
                                                           -

on and that. this grand design was really what'was being

prasentsd to us to 'enforce by our approval hopifully of

increased funding.

        And this thx was the import of the meeting to either

.approvs or not approve the grand design.  It became apparent

vzry early cr, --, I just want t.o get SOX3 highlights bzfora I

got into the d,etails -- that there was some disagreement in t.he
                              .     : :,      . .
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State of Ccnr,=c+;cut. as
                AC v-     far as the acceptance of this program.

The State Hedical Society wa.s represented by an articulate --

1 won't say an official -- spokesman, but certainly an

art.iculatf= spokesman who when he was scheduled came to the

head table with 'a suitcase.  And there was a tape recorder.
                                -.
'And hs opar:a,d the suitcase to indicate the w*zt.h of material

which is circulated by the Connecticut Regional :?edical Program

And this was quite a large suitcase.

     And then he put on his tape recorder to indicate that

he would use the tap2 recorder for his presentation.   And I

~ questioned whethkr the taps recorder was to be his speech or to
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be a rxording of his speech.  I reminded him if we were going

to listen to a speech on taps,  I was prepared to leave my tape

recorder there to listen to his taps recorder.

(Laughter.)

.

It turnsd out he wanted to document what. he had said

in some detail in case any questions arose.

Again, another representative speaking on a totally
                                             --

different project., the Emergency Xedical Service project,

at the conclusion ef it stated he wished to use the time to

make public his attitude towards Dr. Clark, the coordinator.

And again began a rGC.
           q&her strongly worded statsmsnt which I,

.using the prerogative of the chair, chose to stop, indicating

it was not schsdulsd for this, and we would be willing to

rrcsive any statement, in writing at the national office. I
               .                                                        : .

don't know whethar you have received this statamsnt or not.

He agreed this was thg prop% executive stat.emant for

the chairman to have made under the circumstances.
   We had equally strong stataments made.by Comprehensive

.

Health Plancing agencies.  There were two, each ons of whom
                               -.

made vary strong st.et.smr5r,ts t-o the fact that the Cbnnecticut

Rfgional Asdical Prcgram was not cooperating with them, had

not supported them, was not giving them an ear.   And these were

not just objectively given, but I think rather emotionally

25

It became apparmt., though, in questioning them that


180

.

at no time had they really evolved any plans nor had they

presented any plans to the Connecticut Regional ilsdical

Program and that they wore now bain g very wall reprrssnted on

the RAG group.

There were also just as strong statements made to

support the grand design of Dr. Clark.

      I am giving this introduction to indicate that people

arc not lukewarm in Connecticut about the Regional Pledical

Pr,ogram.   You are oithsr for it or against it.  And if you

don't state on2 at.t.itudc or another, then you just don't. know

that. there is a REgional Xedical Program in Connxticut.

        Dr. Clark has in his grand d esign divided the Stats

horizontally so that. on? part of ths  State is elli'zd with the

University of Connecticut, referred to as UCOZ, t.h:% cthsr
                                                            . .
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with Yals, &cl thatmost. of th? 'hospitals  in the Statc3 are now

affiliated with one or the other by way of full-time coordinator

Anti in discussing the SUCCBSS of t.hs program, Dr. Clark

ErumIrates that. over t.1~~ years the
  * d                     numbers have grown as far

as t.hs chiefs are conczrnnd and the hospitals are new approxi-
                               -_                          es+

matzly 55 and some 25 hospitals.  And that as he points out,

ths troops ara marching, the numbers ar,% incrEasing, and this

has bren going on progressively over th? last sewral years.

In terms of ths goals as set under the design, there

is r`,3 qu~s".ior: that. c::z would hi>v(~?  to indlcete that. t.!lnrr; hzs

baron an 'amazing success of this program.  The nu&xz of full-


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txne chiefs have indced increased, the number of fully

affiliated hospitals working with UCOlJ or Yak have incraasc,d.

And he us>d this, 2s he states, as a threshold of fulfillment

of local medical leadership based on community general

hospitals.

       And it is this program that he wished to have reviewe
that he wish-,d us to understand and become familiar with. lie
used community hospitals as becoming community health centers
and that the local leadership would be based on creating local
medical leadership by way of the chiefs in the hospitals and

that they would be the new level of medical lead,ership in

Connecticut.

       Ha describes this as r.wnarkabls linkag,? of the

univ.ersity and of the various hospitals.                         '.
                                                              .
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    There zre sequ-1s to our me.%ting. One is I havt?
rsceived letters from the Connecticut State Medical Society --

Dr. IsIargulies rcceivsd the original -- indicating Fhat the
words which were heard were, I guess, official .for the State

;Iedical Socisty'as far as what. was expressed at our meeting.

                              -=                          as+
         MR.  TOOiJEY:  I didn't hear that.

        DR. SCIIERLIS:  The Connecticut Medical Society

forwarded a ktt.zr to Dr. IlsrguliEs stating their attitudes

towards the Connecticut Regional ;ledical Program.  They have

                             --". ._,
fslt that. t!lo needs oZ the Stat.5 txanscnnd just thz ful1-tiixnf

ccordinators.  They felt there are local needs they felt.


         1  'obviously should be met and be given a higher priority than
e       2  what the program has been to date..

         3          Let me review our site visit. draft because I think

      -4 this will give a more coordinated presentation of some of the

     . 3  problems which came up.

         -6        As I said, the national reviewers have over the years

      7 been g,ensrally impressed with the concept of the grand dosign

.8 II as I have outlined it, although there has been some obvious

-9 disagreement at times with it.  But nevertheless certain

10 criticisms were expressed in the past, and this was one year

11 ago zt t.hE last site visit.

12            The suggestion was mad, p that increased attention be

13  givxl to the further development of outreach activities r-2lati.n

       14 to primary care.                                                    . .

-                                                                        . .
     15 .        Other sources of funds be pursued with long-term

16 support of university-based regional faculty.   I have alluded

17  to tilat..

18           That the core capabilities be strengthened and that

19 in filling staff po sitions minority r2prGssntation  in t.hs

                                    -.
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        21 net yet, by the way, he%n done.

  /- 'ht.
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k..&!       22        That the liegional Advisory Board and Executive

       23 Committee increase or change its m.zmbzrship to include active

                                                  -- . .

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183

vigorously to improv, 0 corzzjunication with the Connecticut State

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iriedical Scciety Comprehensive health Stat2 Planning perscnnel.

I havt, alluded to what has taken place over the y22rs, at least

as reflected in our meeting.

     That a system for organizing the full-time chiefs

be developed and that they pay increased attention to

craating positiv2 public relations.
    I told you the reason for our being there.  They

already approved Council l&cls for the triennial period.

Connecticut also wishEd this to be dor., to look at

12 thsir total program. We were there then to assess ths progrws

13  th-?y had made since the last sit2 visit and that. as I have

1.4 said we raview their total program.
                                      

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      The grand dssign has been their basic instrument

for affecting changa in the system of health care in Connecticut

And they vi2w their function as being essentially that of a

catalyst.  And there is no quest ion that they hav2 been somewhat

successful in this regard.

-.

Connecticut is divided into 10 hea??% service  areas.

And basically by R:IP, but this has now been agrsed to by most

of ths other groups such as CHP, Hil-Burton, and so on.   And

the key to undsrstanding th&ir syst.5.m is to understand the

                             --. -.
cormunit. y hospital vi..?,wed as th2i.r beso of entry into the

system of care.


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Over 40 percent of the basic program money is devotcsd

to the support. of  full- time chiefs and university back-up. So

this is a vsry heavily based university and community hospital

program.  It. is a partnership between th.3 medical schools and

the various hospitals in ths State.  And as I have said, the

State has been divided be;twesn UC014 and Yal,z.

In this Stste, unfort.unatsly, the Comprehensive

%alth PlaR-n.ing has blrn comparatively n:ew and is just getting

organized.  There is a wide disparity as far as the effectivene

of CHP.  And on2 of th-2 criticisms which they have made is that

they have not. besn given th-=i. documsr.ts to reviaw in time.

There was an argument. about th2 calendar on this.

Th 5 Rr.IP said yr3s they !lad, CIIP said no t.hzy hadn't.  And WE?

hava rzcsived a dossiar of some oxchange of correspondence

which I won't have th.2 temc-rity to judge as far as who was

told  what when.

Suffice it to szy there could be bEtt.ar liaison and

coordination of t.hEir fur,ctions.

They heve set up full-time formal affiliation

-.

zgrzzm5nt.s between the c0;XUni.t.y h?spit.als, FE universities,

2nd 3 ned Rot. remind t.hosc of yr~u who are dEans that this is

a  vpry significant support to univkrsity fur,ct.ion.   The

cadre of univ3zsit.y faculty+ ;cilich has bean developed is large-

k;hich would assist t.:::: affilia??zd hospitals.  And the attempt.

to s2t these, hospital:; up as centers of excellence is rsally


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ths key to Dr. Clark's program.

Twenty-nine of the 33 community hospitals in

Connecticut. are affiliated with univ2rsit.y contr=rs -- 29 of 33.

Saventeo,n with UCOX and 12 with Yale.  There were no such

affiliations befar the program.  Thare are now 30 full-time

chiefs receiving partial su?port. which is up t.0 $15,000 for

three years. The total number of full-tins chiefs has

increased from 6 to 50 since 1968.  And then these are usually

phased out after a &rcz-year period.
                                   .

        It. should bz emphssizzd that. this is not just c-n%

p-sr hospital.  Thsse inam instances gcyt to be 2, 3, or 4

-as the hospML.
       i+als facilities increzsr- and as t.hcre become

incrsassd ds;naEds for this.

       Now, we felt that in svaluzting this entire program,

                                                                           ,
t.il B only real evaluation one could giva is the fact. that thz

r.umbors zr2 incrwsing.  And thc,re are bits of anccdctal

informat.izJn zvailzble.  But there is no other evaluation which

3.23 can spz& t.0.  And this is, I think, trying to be obj?xt.ivs

                     .
zibDut it..                     -.                        es.- .
         The amount of mor.ey which has gone into the sys%m

is t?em?ndous.  In t.srns of sayir,g whzt. it h&s acconplishnd,

what would hav2 taken place oth.~rwis?, op,t? c;tn't say.

The a,ffiliated progr 333s do szrv2 the univsrsities

w--l1 becausz they do c_iv@ s&iitional brds, prsvidz for training

Df students, hDuss! steff, and by affFlizt.ion provide for some


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d=,grzs of ci2re on a strat.ified basis.   I am sure it improves

thz hospitals thsmsolv~s.

      Whether or no!: this can be thz prim2 mission of t-ha,

Ccnnecticut Regional Program is a significant quzstion.

      During t.hn course of the discussions, Dr. Clark did

indicatz that. h= thought that the request. for the remaining

two years of both ths ur,ivzrsity 2nd coa3unit.y components

w8re a.-& their peak levr?l in the nsxt. t.rienr.ium would see a

-gradual decrcas.2.   Thor% was smz quzstio!: abcut this, I
                                   .

t.hir.k,  in tsrms of how realistic this was in terms cf the

overall goals of the Ccnn%zticut Rlgicr.21 Ikdical Program.

Ninority int.zrzsts, I thin!<, on RAG, it appears that-

t.hers is somEwhat adequate reprcsantztion, but. certainly 20

evidence that therz is adrquat.e mincrity rapresentation'ein the

profzssioxl group, no ninoriti,zs in the professional prcgram

staff nor executive, ccmiiittra.  And only one of the 24-mrmbEr

review and evaluation commit.t.n,c=! is a minority mambcr.

      I don't rsgard womzn rzs bsing nambzs of minoritias,
                    .
but they arz also inadEquately rsprzscnted.  No inzdequatez
                                -.                      as+ .

p3rsc)ns of this ssx zre on that. co:.~z?it.t.21.
                                                        i

There is no quo,st.ion that Dr. Clark provides strong

leadership.  110, has a very devoted, although smzll, but. very

st'rong program `staff.   And Iir. :,lorrissey who works with him,

Xr . 13radley, thzse ar:? vsry, we thinl:, strong people,.

      ThE! statement is in the site visit. report that h is


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17  has not be-en a successful organizational accomplishment.

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187

grand design.  I would say that that is inadequately a weak

statement of his devotion to t.112 grad design. Dr. Clark

really views the grand design as being what should be the

model for NIPS.

      And I was told this before I went. there, and it

certainly comes across as pp_r his prasentatio-n of this.  He is

devoted to the concept..  He fcols it should be a model, that

this is what RHP is' all about,  and that. unless one understands

.

3s concept of the grand design -- and he was willing to come

to Baltimore and spend some time with me to make sure that I

thing mar?- except that. he is dsvot.ed t.o w;lat in Conrxcticut.

has proved to ba a very sffective link.  It. d'epends on your

judgment whether these arpI the primary needs of Connecticut and

representatives.   We were concerned about the r-lview process.

                                                 - .
Thare is a very, very, very strong review and svaluation

comii.ttse which scrzcns the prcjscts, performs site visits,

ccnducts technical and scientific reviews, detsrmines program

relevant-e and funding allocations and so well documents its
suggsstions that. by :Ilc time it g2t.s to L>G, I don't. t.hink

anyone would have the gall to dare differ with any of the


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188 I

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       And this  wzs discussEd in t.hz feedback szsslon
because I think it. is such a strong group and everything has
besn handled so effzctivcly and the documents are so

I imprsssivs, there is no way I think for RAG to.rcally bscoms

as mature as it should in passing judgment on making dscisions
as far, as whzt should go on in that area.

The grantee organizat.ic)n is Yale.  And apparently

this is satisfactory and in line with RNPS policy.

      I have discussed the nzdical sccizty in CUP.  This

is a vsry, very difficult relationship and ens which has not

bssn solved over the years.  I think Dr. Clark's attitude that.

thay clr& forrnlng a TiZVJ pcw%r basz through thz medical lsadzr-

ship of thz community hospit.als has to be taken as an att.it.uds
which hz has to express in tsrms of what. has taken place.

ThsrE were some projects preszntoud to us that.

concnrn2d us.   Thers is en ElS prcgrzm which is being formu1z.t.X
They have gath5rsd soms goad data, but in questioning the group

-a end Yale hasbesn vzry helpful as far as getting data for
many of th-ir studies -- it bscarne apparent. =?sYKat, their emergenc17

system is alinost purely trauma.

In asking whether or not -- and hrra my pzsonal

bias came out -- I askc,d what th3 cardiac input was to the

Emergency i!FCliCal Service program.  And thEra was a rnon~nt of

silznc-2.  ~.r,d thc?n they stated they zrc3 still in the planning


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St.agS, but along the lincz, sorn~whzrs they would get. some

cardiac input to this.

Is this your impression?

MR. ROSE:  Very much so.

DR. SCliERLIS :  And their stating that thc,y had

probably dons the bzst. job of anyGne in the country as far as
                            ,.(( 4: ,
svaluatf ng sErviczs in the emergency rooms a@ so on.

I asked two questions. One, if there had been any
                     .

fe?edback of any of t.hat date to tha hospitals.  And they were

thinking of doing that. and hadn't. decided if they would.

      They had gathered data and really hadn't baen able

to mzka use of it..

So I t.hiz:k they have a long way to go, but apparently

the peopls who are involved with thi? I think can with some

planning money move along in that. regard.

I should,say that one, of tha, CHP agenciss, the

South Central Agency, provided on.? of ths best r%vio,ws ws saw

providsd by any CIIP ago-ncy.  There is unevsnnes,s, but this

ag,., ancy was a v&y efftctive one.
                               -_

There is a peculiar 2SpzCt of their d5v~~iopn~ntGl

requast.  And that is that we hzd preO vented to us two projects

by two individuals which w:sre presented beautifully in terms of

what. could be 16okfd at as model types of programs.

      one for mUl?:ipls hoSpitd ambulatory pzdiatxic car8

systc-rn, th, 0 othrr forbsp-,.
              ;&al-based medical care system for th2


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         +=d excEllont outreach programs involving the

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,elderly by two extremely knowledgeably groups. Dr. Markowitz

was one group and then there was another.

       I am wrong.  I forget,   IWb-. theso two.  I forget the

two who presented them.   But both of these men were excellent.

They presented their syst",ms, and they have bean introduced as

presenting mcdel systems which the Connecticut Regional

Medical Program would then submit to all of the different
                                                           --

hospitals in the State.  And they would all come in and say

                                  .

whether or not they could handle it.   And there would be some

method of determination who would get the prograrns.  This is

      But in asking each of these individuals, it became

apparent that each was przs~nting something he was ready to do

and sn,t it up for his own area.  And they were both upset that

this was going to go out for others to bid on.

I potential and in many instancos good community support.  Thsy
I.                              -.
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' staffing.

      And it gets down to how you {define developmental

cornponznt.  We did not think these WEE drvelopmsntal componz

These should havri bzzn projects'which were ready to become

operational.


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We spent. two full days there.  And I think the

committee came away with, I hope, a full understanding of what I

the Connecticut Regional :SIedical Program has been and may very

wsll continua to be unless there is firm indication that there

is tinis to change from having 30 or 40 or 50 or GO full-time

msn in the community hospitals and having most of the funding I

go to t.hs universiti&s and that this is a time where decision

had to be made as far as changing direction of the grand

dr,sign of the Conn2cticu t Regional Xedical Program.

And we made several recommendations at the end of cur

m.%eting which included the following:

Number ens, they should reconsider the goals and

priorities in terns of dsvzloping rffcrts in com~~unity outreach

This sounds like what they said a year ago.  Although they

had developed an excollrnt network through thair system of

university-hospital affiliations, these should not. be
supported fur-cher as far as any expansion is concerned, but the

new programs were available as shown in both their supplEmenta

and davelcpmsntal ccmponants and that these should be supported

in preference to their expanding university a% hospital

affiliation.

That they have to set up some criteria for msasuring

the effectiveness of the full-time chief system.   I don't see I

how on? can measure i?, really, 'but. they have to at least try

to do something and get some data which they at least can say


means it has been successful or not,

That they needed a more affirmative action plan as

far as employman, + and training opportunities for minorities

and women.

     That. they should make their RAG more*responsible

in program decision-making.

     That. they should do and we suggested a task force as

far as Connecticut Regional Yedical Program and Connecticut

State Medical Society because this is a must if they are to be

                                   .
able to affect that area.

     And that their B agencies-have to.corne into some

agrezmsnt with Connecticut. Regional Medical Program about

details of logistics of reviewe  And that their evaluation

needed a better coordination.

      we suggested some levels of funding which I don't

want to refer to a,t this point.

      I do have to giva a follow-up which came to us as a

surprise -- namely, that Dr. Clark submitted a letter indicatin

that he wishsd"t.0 leave his position as of :.Iay 1st. and was
                               -.

willing to s5xve until that and to be an adv%%r after that

until they got. someone who could handle his position.

     I don't think this really reflects on any hostility

or animosity at the site visit.  I1e certainly did not feel that

                             -* . .

way.  W% think that i;l Co~~nsctkcut, and we ?.old them so, the

natwork he has set up is a most effective on2 for thp, mission  1


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that he had defined and thn, Connecticut Regional HediCal PrOgrz

had defined.

I can't help but feel that t.ho, obvious need for this

IIealth Planning, this probably played a role. -Of course, this

is no better off than it was before.  And at an open mneting,

it is embarrassing to hear the sorts of things that were said
at this meeting by both of these groups and by others who

-would havs liked to have been on the program to have expressed

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this.

        I would like to leave it here and then give the sums

;-liss Faatz;

MISS PAATZ: Dr. Ellis is secondary. .

DR. SCIiERLIS:  Oh,  I am sorry.

DR. SCIIMIDT: Dr. Ellis.

DR. ELLIS:  I did not have thz advantage of making a

IllilYbZ just really one.
                               -.

   I think that the grand design whic??cealZLy brings

tog&thsr the community hospitals with thn teaching services

doss provide the opportunity for bringing about institutional

change in the way health services are delivered to the pocr.
                            - -.

tizoause it bJi.11 only be by utilizing $53 community hospitals

that t!IZSP- kinds of people can b% admitted in large numbers


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3  one of the big problems in gztting poor psople admittzd to   I

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hospitals. is that you have no full-tima staffs.,  We have nobody

to take care of them.  Xedical education and health in general

ispoorly funded.   And so WE can't take them.

     I think we would all agrEe that this certainly'is

institutional< changs.  And what we ars simply szying'.is that

the grand dssign could and must be cxt.er,ded to do some, other

things.

       Now,  I have listened to the wonderful discussion that

Dr.  SchGrlis made and rsally can't.add much thr?re.   But I have

heard over and ovr? again that minorities.have not been involve<

in this program and in many other programs.  And it is one of

the things that I spent my time with every waak, at least.

.I think that maybe ox of the things that nesds to

be recommend4 in addition to what we have recomma,ndzd is

that there, be some special consultation on how program leader-
                    .
ship that is not lEadership of the poor or blecks or browns
                                        eszs?+ -
or rads or poor whites -- and we don't undzstand the culture --

on how we can communicate with those groups and actually find

out what. they are thinking and what their needs are.  I really

am not imprzss@d that @,c3 kind of communication which takes

place bctwxn the- groilps is done in a way that puts both the

laad-rship of the program and the people bzing servad in a


135

position so that they talk respectfully.

This is a serious problem.  And I tho,refore would

suggest thz use of spxialized people with special skills in

cross-cultural communication to b,, 0 brought in as consultants

to ths program director so that they ten immediately move in

    
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the right direction.

Then, the other *thing I thought it was interesting

Dr. Schzxlis brought it up, but he did not mention the kinds

-of things, you see, that we ars still talking about like thE

nsed for health education in primary and secondary schools in

the State.  This is the m.sdical push.

If you do not have ccmmunity hospitals to whom thesEs

children can be referred for services, you don't get anyplace

either. So it is just a constant up and down kind of thing.

DR. SCIIERLIS:  Lst me respond to on8 point which you

rais2 which was troublesome to me as well and to our'wholc

????? o  Imagine if you will that most .of the hospitals now arz

affiliated and indeed t.ilz full-time chiefs have bsen fundYed

through Regional Medical Program.  How wonderful this would b?
                                                  e#P .

if you cculd utilize that network.

      Wall, Dr. Clark had &out thrse of his full-time
staff there who were v:orking in ths various community hospitals

to discuss what th'3y d&d in t.hFjir hospitals.  One such person
~ spoke and o5viously 2 vxy ca;>ablz - individual.  And after hz
I

finishxl his prcsontation of how long he had be2n thxs and


1  what his hospital was like and how they had upgraded the lr-vsl

2  of c3E3  in the hospital, I said, "\?hat. is it. thrtt you do for

3  which you zre supported that reelly fulfills any of t-he

4 Regional -iledical Program aims in Connecticut?"

5      I would still be waiting for the an&r.  And it VES

6  anbarrassing bzceuse t-he silsncs was absolutely formidable.

7 I think it is the first. time 0 he had ever been asked what is

8  the Rs,giDnal r.?sdical Program in Connecticut about.  And this

9 -in many ways answers the question that you possd;
                                         .

-10          I think that. the relationship to the community

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12 I/ enywherr in the country for r%.lly affecting out.r.~ach by the  I

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                                             _. . . :.
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       14 thESP, hOSp itals to look at quality of delivery of care. It

15 hasn't. bsan den-s in this way.

16           Thes2 individuals in thair own hospitals serv8

17 sevzzxal functions. They attract house, st.aff. They maintain

18  training of house staff.  Students rot.zte through.  And they
                         I

19 help t.%ach ths students._- In on? or two i?sC,ances, maybe a
                                                       -es- .

,, -,,

20 fEw more, it. may even be beyor,d this, but tiler2 is no attempt.
21 to &en form thzse people into a cch%sivE group.

22 /I     He suggsstsd that. there might be an organization of I

23 /I such directors Warking with REgional :,!edical Program to
                                  -.          I

establish zn orgeniz-31 besis :*:ilr:E it would occur.   The

25 orizntztion isn't that way.  The orientation is to have more


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10           DR. SC%IIDT:  Eileen, do you have any gsneral

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chiefs in the community hospitals affiliated with the

universities.  And it is sort of t.hs university responsibility

to ss.zk out. ones to work with th2m.

It doesn't take too much alteration to affect the

sort of things you referred to.

        DR. ELLIS:  IJO,  it doesn't.  It really doesn't take

much.  It just takes an insight into how to program.   You could

pull thsse two things together very easily, I think, if you

conunents before we do g5-t in motion on ths floor?

        i4ISS FMTZ: No.
            a

DR. SCiiIlIDT:  All right, then, back to Dr. Scherlis.

DR. SCIIERLIS:  No comment, after all your years with

Connecticut?

MISS FMTZ:  NC, I think you covered everything.

DR. SCIIERLIS:  If pu differ,  I wish you would so

state.

                    3

IUSS FMTZ:  NO,  I don't.
                  -.                          am
MISS ANDERSC):'I: Dr. Scherlis, did th%y show any

ir,tei-est in bsing flzxibl? or adjusting their rolss from thz

old patterns?

DR. SCIIERLIS:  We had a feedback session.   And at.

               - .

the  feedback sessi.o:I many of +jle positive points were referrc-c!

to.  Ths success of the full-time chiefs, the increasing


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138

numbar, the good affiliation and acceptance: of the community

hospitals. This is an important aspect.  They do accept and

they do wn,lcomn, this.  There Zs no question they benefit as

wall as the universities do.
   But as we pointed out to them, 2nd I'headed this in

our sits visit, feedback as the dilemma of the site visit group,
wa, cannot discern any attempt. to set. priorities as between the
new programs which had been pr?sent.ad to us under the

supplemental development componant and getting more full-tims

gzt anothEr 30 full-time chiefs or would he dzvolop som% of

t.11 csz developmental conponznts or fund some of the onh,s that

had bT?n .pr~g~~-W!--.
. .'..C                       . And I guyss we;rea.J>.y ,do& t:..$:gw .Y$z~. Q@
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would do under these circumstencss unless thzra was some

firm indication.

he has enough chiefs.   B~~?causz those hospitals that have one
would lika to have two. And those that havs t.wo would lika

                    ,
t-o have, thras.  And those that hav-, thrse would lik? t.o havs
                               --                  - .
four.                                                   
    And the point that we mada vrry strongly was that.

as far as our rscorxnzndations are concarni?d, we felt. that the

point had now been rEached, and hz? was told this in th3 feedbac
                             -.

session,  that thz m~~!ical schools and the community hospitials

would have to find al,, +-crnz:t"u funding as far as any expansion


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of this program.

Now, as far as dollar marks, wo, have a dilemma.

Rsmembsr, I said at thz beginning WFZ were t.hErS at. his

invitation.   We were there to v&w t&r_ grand design because

they wished incrEased funding.  A lot of the iticrzaszd funding

could go to expansion of the full-tin% chiefs all thrown in

with thesr othc-r primary projr;cts.

         What we recommsnded is that they fund these new

projects, not as devolopmzltal, but as r@al projects including

the supplemsntary ones.  But they do this at. the expense of

th4.r full-tire chiefs.   so we rezommended no incrzzsed funding,

no developmental component, but that &hay with their Sam8

level fund tha projEct.s and n3 r,-orE: chiefs.
,. . . . .

     And I guass th? response, I 'guess Dr. Clsrk sensed

that in our discussion.  This may be the r3ason for the letter,

Dr. Plargulies.  I am not privy to ths exact reasons for it.

But I don't think wt should considsr that in our decision.

        DR. SCH!3IDT:   Let me b& sure  I understand now.   The

previous levels"that had bean apprcv& were going up.

                                -_                          Q?iw
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DR. SCI-IERLIS:  I,& me tell you the full fecommendatio

DR. sctI1:1~!: Yes, let's hauz that..

        DR. SCIICRLIS:  We rccommendzcd that for ths five years,

thsy r2eive $2,332,820 which is what ihad been approved before
                             --w. ._.

inst-sad of t-ha $2,737,000 thsy hsd rquestP-d.  r2'nd becausn

of t115! nature of.our recommendation that they be sita visits-d


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I did this knowing full w511 that the r%qucst might

j be that I would be on2 of those site visit crews. And that is
not a trip I would relish.   But und,sr the circumstances since

this doss require a complete change in their program direction,

we did not feel that they should have two years without a

sit.2 visit.  And so, therefore, th.? r.zcomqendat.ion was for

one  year approval and that we come back befors the sixth

year.

I don't see how els.8, we can move into this. Ths

grand design is there, but it has to be altered if there is

to be any change at all in direction of the CRJIP.

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$2,332,820 as you said.  And then the next. year $2.5 million.

DR. SCiIERLIS:  P7e are only going along with

$2,332,820 with the significant recommendations that we have

made as far as program change.

DR. SCHMIDT:  With then a site visit before the

$2.5 million year.

DR.  SCIIGRLIS: Yss.  I don't know??% e1.s~  we can

handla that.

DR. SCHMDT :  Is that koshm now?  They have been

approved for the triennial.
                           -- . .
     'DR. SCHZRLIS:  The Connzzcticut program is on.2 that

has excited a gr-,.
        .c;zt deal of interest in both the r,zvi.clw


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their rating gats bounced upwards at Council meeting.

201

committee and Council level, I take it.  The point that even

If we approve for two yEarsI there is absolutely

no indication in sight tha t they would not. continue as they

havs besn,  funding new  full -t.ims chiefs instbaci of getting

involvsd with additional projects.

If you havz snother mschenism to assure this, such

as a staff review, I would certainly prefer that to a site

rsviG7.   But now the fact. that they are also gztting a new

coordinator may make it raven more imperative they be sb,sn at

t.hs p,nd of this OP,B year.

I would like to have some direction on this.

;:,A;... - . : :  ,Xr ~.~.,,...SCii~~!.ID'i7 :
                         .._.   I j,ust want .
  ???????? ? ???? ??????? ???? ???? ??? ??????? ??? ??? ????????o ??     to .cl~sr..th.~..~,F?qjn~~. i;.2;.: _. . . .
                            ? ? ????? ??????????? ???? ? ?? ??? ???
                                     ? ? ??? ? ?           ? ? ??? o ?????? ??? ?????? ?? ??? ? ?        ? ? ? ? ?
                                                                           ? ???
??? ?

what he propos2s legit.?

MRS.  SILSBEX:   We don't hava any precedents for

th is.  But in relation to the rezscn the site visit was held

this y-Sar, Dr. Scherlis, in terms of tha fact thet. Ccsnecticut

raquc,sted developmental, that wouldn't automatically call for

a sit3 visit.  Th3 fact. that. they rsqu:zst.c;d mort monsy wouldn't
                               -_                      - .

-call for a sitz visit.

Actually, t-h2 reason the sit.2 visit was held was

bzczusz Dr. Clark r,equastad it.  And after much d?libsration,

WE dzcidzd --
                             -s -.

         DR.  SCI!;iID',?. Arz y;u going to stick with the word

"rzquzst"?


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        MRS.SILSBIX:  After much delibzrstion, we decided

thp_ only way ws could handle. this request, knowing about. his

program, was to sand a team up there to SEC whsthx any of thz

things that had been suggEsted in terms of change had occurred.

        DR. SCi-IERLIS:  Thank you.

        DR. SCIII,IIDT:  All right, DG. James and then Dr.

Luginbuhl.

        DR. JN.IES:   Thera is somMhing that bothars me in

regard to what. is efoot here.  I hear you statiing that there
wzs a meeting with repressntativss from the State M&dical

Sr,cisty, but hs was 11ot an official rspresentativs, he did

not represent. t.hz m.%dicsl society officially.

      I wond,er perhaps if thrirn_ is not in this grand d-ssigr
       *. .                    .i , .
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an area of threat to the private practicing physicians

rzprssented by thz Statz Nsdical Society that looks like there
might ba a town and gcwn takEover of th% private practice of

mzdicinl that possibly could cause some anxiety among the

Stata Flzdical Association p?opla.
    Yet, if what. you are saying that thy, grand design
do-,s represent an institutional changs in th??'%slivzy of healt:

services, what is it,all about?

     And r3lativz to a continuation of thz old, if there

could be some clarificstion of somsone hers today relative to

                            -we
what is th$ stznc2,  s-f--.-a-n-c-$, taken by the Stat.3 Medical
Association and iha CiIP agencies and the othz- agencies in the


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community, is it that the university and the community hospital:

who are for the first time moving into delivering a community

szrvice, something that should bs continued or is this

something that offers a threat to private practice of mrdicine?

        DR. SCilIlIDT:  If I might try to tackle that one
myself, I think from the beginning the grand design was somathi

that was held up by the Connecticut RI4P as a model.   And

certainly Dr. Clark who really kind of devoted his life to

this general subject of regionalization considered this to be

the best way to go in Connecticut.

     The I-ledical Scciety very early on did not necessarily

agree.  And indeed, they did look on this as a thr,eat.  And in

the past numbnr .of yEarsI there hav,s b?cl,n various number and

kinds of steps taken by the Nedical Society, including

telegrams in requesting there not be any action until they had

a chance to be heard.  There have been special visits of the

Director of Ri.IP to Connecticut.  There have b,een meetings

up ther and so on.

      And ai someone said, t.he NIP really did do the whole
                                -_                          Qz!e
'thing for the Stats early on.  And there was not a-CUP in

evidence.

     What has happened gradually is that peopls got used

to the grand design.  Thd_ fledical Society and RI-IP arc kind of

                            2*.

settling down into some kind of a co.existanc::.  The ;.lsdical

Society is awkward about stating its case.  And what r-ally


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'happened was that the official representative- didn't. show

at the site visit and the site visit team was a little confused

as to whether they worU 0 hearing an individual doctor and

chose to hear the doctor tha,. J- did come as an individual rather

than an official reprassntative of the 1.ledical.Soci.et.y ~CZUSZ

he had not been so designated and they were just left without

this official voice.

CUP is struggling, and the grand design in a way

umbrellas some of the things that ordinarily CHP would do.

I think that the site visit team is suggesting that

the F?i,IP must do some other things and not keep expanding this

grand design in the way Dr. Clark might.  And so we are

. .

obviously in the recommendation putting a stop to that., giving

them strong advice that they imp1zrxmt new types of activitiss

and do this with the funding th'at they might otherwise have use<

to furthm what indeed the Medical Scciaty has in the past

objsct2d to.

The question you asked could be answered with the

word "yes, I' but"1 don't think that anyon, c would necessarily

                               -.

imply by that yzs t'net the i4edica.l Socizty WL Fright. and the

P.XP Gas wrcng.

As I take a long view of the Connecticut situation,

it is that they ars kind of settling down and in a  little bit

                              --..
~ morT;, perhaps they will have 'sottlzd down into a relationship
that won't creat& all of the sparks and so on that it has in


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the past.

Is that an unfair statement?

DR. SCHCRLIS:   No.  I think to assume that you ara

going to change either the dalivery of health care or make it

more accsssible on the basis of the network that has been

described for Connecticut is an assumption.  It isn't set up

to do that.  The purpose is not to accomplish that.  And unless
                                                           .-k

the goal is altered, it won't do it merely because the network

'happens to be there.

    Being univsrsity'bassd, were I a dean, I would relish

ths financial support that lWP is giving.  I in no way should b

.assumed to be criticizing the valu, 0 of such relationships and

affiliations with ccrxmunity hospitals.  I think it is very

important.  I just qUES,.-
              +ion whethrr you should use 40 percent

of Regional I,ledical Programs money in order to accomplish that

when there are other needs.

So you know I am waring two hats in this as I am sure

the chairman is and others around this table.

DR. JAWS:   The only question I would have is there

                                         @ssF

any evidence wheri? there would be a takeover of the funds that

were initiated by 1<Q, say by the universities?  Is this

~ possible?  Or is it possible through any other agency? So

~ whers KIIP may have initiated this and certainly if there is

evidz-ice that further chiefs would be funded, there must be

evidence for additional health care needed in the communities.


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I wonder could you comment in regard to whether or

not there is evidence for continued support on the part of

other agencies?

        DR. SCiIDRLIS:  Two responses. One is I did indicate

that a certain number of these full-time chiefs  every year

have reached the three -year period of support.  And they get

sugpcrted through other funds.                    -
     The Dlue Cross re?ressntetive was there. We, of

patient in a community hossital the cost of a full-time direct

And ha said of course you can.  So there are other ways of

funding this.

And I think that whethsr or not such sources are the-r

is an issue.  Whatxver is done in the educational basis may

have to be support,sd through th.. Q medical schools affiliation.

And one could really question whether you nasd 29 of 33

affiliated with a medical school.  It may be wiser for the
                                                                ,

medical school to have a smaller nui2bEr and concentrate quality

in those.

                 -.                        aTi+
DR. SCIIllIDT:   Xr .  Toomey.

MR. T001IEY:  Yes, one= question and then a statement.

And let me ask the question first, please.

Did you have any input from the hospital 2nd of

this prcgram?

DR. SCiIZRLIS:   Yes.  \&en the various hospital full-


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       1 time chiefs were there, directors of the hospital usually came

         ?
o ? ??   with them.   There were re3r~ssntativss from Hospital Association
                                                     L -

      .? They spoke strongly in favor of this as you might gather they

         4 would.

5          MR. TOOi,lEY: Ths statement is really it is a strange
6 thing, but hospitals are changing in terms of  (a) moving

7 away frcm the community, (b) moving in an attempt to parallel

8  the chanqes in m&icir.n, which, of course, are more finite.
9 They ars greater, biqqrvr prcqrams, more equipment and this

                                        .
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11        The medical schccl is making a dual attempt as I see
12 -it at tha moment which is to move ahead in terms of research,
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14 care through their community practice programs.  Hospitals

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16 spectrum in which they are attEmpting to provid,e more complex

17 and conplicatsd services.                     ._

f-8          And I am rsa lly in aqrezment with you.  This is not

i9 II the mechanism td'ba used in order to get services to people

io in the community who are undsrssrved. Becauzthe-community
II                     I

ii hospital
II      is really now a mfsnomx in my opinion.

22

, DR. SCXJIDT:   Xr s . Flood.'

23        MRS. FLOOD:  %?ll, historically, this review body

24 has criticized and &.x~t st.ronq advice to other regions who

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part-time coordinators of categorical areas, etc.   And I see

really no difference in concept from the actual formal

university setting, medical school setting.

       And then, too, this affiliate health delivery

institution in the community hospital.  And I just don't find

any other comment to make except to firmly feel that they shoul

be urged to discontinue this and perhaps even sooner than the

--

        DR. SCWXIDT:  F7el1,  I don't know.  I think if you

look for firm evidence as ko what this sort of thing does,

you really get into principally the distribution of health

manpower issue.  And thsre arz data that would suggest that

this sort of thing might do something with the distribution.

If they are putting medical students and residents across the

State, then there is evidence to support the contention that

this will distribute health manpower and services across the

State.

      Dr. Luginbuhl.

        DR. LUGIXBUIIL:  What. about the effect on health care

in the hospitals, though?  Are medical studeE%? actually in

all of these hospitals?  Are these full-time chiefs of service

doing teaching of students?  Have they developed residency prcg

nre they delivering care to the indigent in their communitias

or are they simply sx;,>ervisiEg the quality of care that is

given to private'pationts?


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        What is the actual effect of these full-time chiefs

in community hospitals?

DR.  SCIIEruIS:   You are asking me the very question

that we would like to have information on.  I can give you

numbers.  I have tables here which show how many medical studen

there are in each one of these hospitals and so on.   In terms

of whether or not -- you notice, they are clustered around

whrt are the two orthreechief teaching hospitals.  But you
do get some distribution in some of the others.         '

                                   ,

In terms of does it affectthequality of care, I

would hava to assume that it must..  I would assums that. if you
                             ,

take a hospital and put in a kr,owlz+dcpabln individual who is

going to bz chief of mEdicins, he is going to ride herd and he

will attract hous- officers, he will get his own house in

order before ho gets into teaching students from the medical

school.  Once he does this, then he can be thinking about going

into the community.

The question that I raise is is this essent:ially the
       

goal of the Regional :Izd-ical Program to the exclusion of other
                                                         efie .
goals?  I thick it is good.  I think it is graat.  Being in

a mEdica school and nzading teaching bzds, I think this is

fabulous.   And if I could get funds from RJ.IP, I would be after

it.

I think, tilsugh, it is z ~~ues?.ion of the overall goal

and pricritiss of a Ksgional LIedFcal Program.  Should this b.2


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first?   That is the only point I am making.

        DR LUGINUUIIL:
                o         If this dces become first, let me

know very early on so I ten apply.

      - DR. SCXI~IIDT:  You nissed out because you had been

all the way back ~1,~ :&h Connecticut's grand design as one of the

early programs and get it established then.

       Of course, they defend it as vigorously on the basis
                                                           Lb
of ths planning of ths Connecticut grand design by a number

of committees and so on that they set up.
                                   .
        Bill.

        DR. LUGINBUilL:  It may be a very worthwhile program,
but I really must add my voice to those that are expressing

conc3rn over the appropriatcnsss of this being maintained in

the Regional Medical Program,  To me,  it is an anomaly.   IIerz

                                               ._ I .
        . .                  .
you have cne of the wealthiest States 0% a per capita basis
that has put $80 million in capital into a medical school, yet
the RXP is being asked to fund their developing programs

Fo the community hospitals.

                    I

And you couple with that on8 of the more affluent
                  --

private medical schools, and again we are berg asked to fund t.

development of community-based programs.

   ' They may be excello-nt progra;xs, but I really do have

a.very hard time with accepting that as a major thrust for a

I?agional I.!sdical Program and with maintaining this.  I really

feel it should be phas= -d down if not out and that there should


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be plans for having this taken ov.er by other funding sources.

        DR. SCIIi3IDT: Dr.  Thurman and then John,

        DR. THUW.AN:  I would like to ask Eile,en what she

thinks Clark's departura will do to the grand design, Do

you have a feel for that at all?
     What I guess I am really asking is are we joisting

with shadows?  Is this going to collapse when he walks out

the door?

         14ISS FMTZ:  I don't think it will collapse because

                                   .
many of the influential Rt\G members are not m.esmarizsd, but

they believe in it as strcngly as Dr. Clark.

        However,  I think it will be eesiEr for thr= program

to add different sorts of things,  pe. rhaps  level fund and then

scale down full-time  ch iefs in the universitie.s and do some
                            ..L. . . --              . . . . . ,..:
                                 . .          . :                            .._ .
'diff.er&t things.                              

        DR. SCiIEIIDT:  They may not b- * addicted, but they are

habituated.

        DR. SCIIERLIS:  Well, the question asked the chairman
of RAG by the pa'st chairman sounded very much like a carbon
                               -.                         esP
copy of Dr. Clark.  So I talked to the present chairman who

soun-ds likf the original.

      (Laughter.)

     Theyxr totally convinced that this is the way to go.

        DR. SCIII:I IX' -  I am sorry, John is next.

        DR. KRALE\~JSI:I:   I like your suggestion on the funding


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1  but I wonder if they will really do it or ccntinus the same

2  program they have now and not implrrnont anything else,.   As I

3  sit her?, it sc,~ms to m-3 tha.. + I have h%ard a good bit of this

4 conversation a year ago and a good bit of that the. year before.

5 And the progrzm is just going straight on in on3 direction..

6       And I think we had advice lct-tzrs to them with this

7  in it, didn't we, or didn't it get through Council?

8          DR. BRINDLEY:   We sure talked about it.

9 -        HOR PIOI??LES:   If I can interject at this point,

10  going back to previous rE?vi3w, as L%n has indicated and som% /

11)/ of th,z others, the diffc;rznce in p?rspect.iva in the reviewers 1

._        12 II

towerds  this program

has rradu it quit.'.~ hard for us to gain

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a consistent kir,d of V~ZPJ tward it.  Thz reviaw ccmmittse

                                                                           .
took on.3 positicn, the- Council took another posi!ion., And.It
.    . .   '.    .: . .                                   . . . .              *.
                 . .   .

was a ccmpiic atczid 2nd in mar.y ways an unsatisfactory rsview

prccass.

I think one c;tnnot overstat?, howC"vzr, ev8n with. ths

position of the Rsgional Advisory Group the significance of
                    .

Dr. Clark's departure.  Becausr hs describes. himsz,lf 2:s e
                               -
missioxery, and hs is. Iis bslirves tnd has Eliev-zd ~11 his

life in ~xacC,ly what has ba;--n sstzblishzd.

, r. -,
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i ,       22     The question mm and one that I think you are bsginnir:

       23 t.0 d331 W- ;+\ very effectively is w!lat zr.2 th2 possibilitiss
     24 of doing something ~:5, =ful with xhzt. has L,~zn dssignzd.

    Reporters, Inc.
            35       I was terriblv diszppoint2d son&zime ago,  end we


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discussed it in onn of thz review committzz sessions when

a proposal was mzda for supplementary funding for Emargeccy

14edical Services, and there was just no relationship between

that req!Est and the grand design.

Now,  if thers is to be z Connecticut statewide

Emergency Xcdical Sys,, +arn and ycu have an affiliation bettrsn

univsrsity health science centers and hospitals and b&ween

hospitals, one would think it would just drop into place      .

yf"ry nztturally and produce an appropriate c,ff,zct.  Or if on4

looks at somsthing like PSEO activities ir. which you have

linked togsthsr ins,.- +itutions with som%body in them who is

concerned with quality of care, it would appear to be a

vary appropriate kind of z scatting in which to rst.ablish thy

AHA approach to it or some othez kind.
                   '. . .    . . . . : . . . :       . . . . . . .  -.. . . .    *'. .*..
. . . . . .                              .         
     ~a' hav&. talked with them in the past.  This revi&

committe has.  So. has ths Council about trying to make the

hDspita1 now a part of the commwity and extend out so thet it

includes a way of organizing ambulatory services, all of which
                                                                .
                    .

ere potentialities.  l3ut I think that if thc?rz is to be a
                               -.                  es+ :
decision rnG.dz on what hzpp"ns in CR.J,iP with Dr. Clark's dzpartur

with this current review process, we are at a moment. wh2n WB

can be effective in making SOGIZ very strcjng advice to them

about jlst what exactly ought to happen.

       I thir.k it :,!ill be suscep~l!~ls.  But any time you

' spend on it is going to be of great assistance to us.  It is

II


1  the tinp, to take som8 kind of action.

2           DR. LUGIIJBUIIL :   Is thzrs a motion on the floor?

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                               070 will be z different

8  coordinator.  And I understand ths  selection committee has

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DR. SCIIERLIS :  Befor; I make a motion, perhaps I can

ask --  There is a motion on the floor, and the motion that

I made was that they be approvad at what has baen the Council

level for the next year; that strong recomnsndations go out 2s

@Iready been or is b2ir.g appointed for that representation from
                                   *
the Medical Society .  Acd that thz fGllowing year take into

account ths fact there is a new coordinator, there bs another

site visit.

I think it puts thorn v-r;ry much on notics they 'are

going to b2 looked at very hard.  I think ~2 drop down their
                                               . . . .       , . . .
                                          

funding, wz'& g0ir.g to bz in a positio; of a new coordinator

coming aboard ~7110 is going to begin by antagonizing half the

Stats by firing full-tims coordicztors.  Thsy ars'going to b.2

phased out anyway.  A group g5t.s matured every third year, and
                                                                 \
                    ,

thzy fall by thz wsysids.
                                ._                          63sJ5
        DR. SCKXLDT:  The question isn't maintaining those.

It is doing the rast of it by SO,EJ? ot:her means and doing other

things with XII? end R;lP nonz?y.  And thet advics can strongly go

So that the mction, then, is as hz said the 1~21,

no developmental CCIFI~CI~SI~~, the stro.rg advice, and the sit.5

visit in on'3 year.


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215

         Dr. Ellis, do you second that motion or not?

       DR. ELLIS: Yes, I would like to second the motion,

but I would like to make cne change if hs will agrse to this.

I think we  should have very careful staff work with them so th

they clearly understand th2 options ar,d ths things that they

c2n do.  Because I zm afraid that with the difference'in

feeling about delivery cf care, with one group feeling that wh

they are saying is decidedly different and doesn't relate to

what Dr.  Clark has done, it may destroy E very important base.

                                  .

And I think that the staff really needs to work perh

mom closely with this tha they have with other things

because it does have a very important facet.

As I said bzfor.2, there zre so mmy places whers the

community hospitals, community affili-lted hospitals, are not

. . *..-.
:        ._.. ..I. ,.      . . . . .     _...    . .  . . . _ . i
                                                                    _'
available to take Doer psopl& in.  And we htive 811 of t.h&

friction that we have in the large cities.  So it is so

important to krcp whzt has b-.+
                5-n built up and to relate it to

the other important aspzcts which we discussed hers.

     DR. S&IIDT:  I an sure Dr. Scherlis zgrEz_c;s wit-h

                                                      w
that.  It is conplem%tary to thz point Dr. ;izrgul'izs mad3.

And'it rsizlly is an assessnsnt of what they have created and

to build on that without destroying what they have accomplishs

tQ get at some.of the pressing health needs of the State.
                            'c1.

All right, Dorothy.

!JISS K:JDERSO:J:   I was wondering if meyb? Dr.


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Scherlis' suggestion earlier 2bout enlarging the RAG and

broadening the FAG might help make this change possible, if

that could be included.

        DR. SCHERLIS:  This is part of the recommendation

that they do.

        DR. SCHXIDT:   John.

       DR. KRALEWSKI:  Could you repeat the advice that will

go along with this ;rgein?  I am not sure I understand exactly.

       I would be in favor of some very, very strong
advice like within one year show us how this program is going

to lead into a broad program to improve the delivery of health

c2re to undersarvad, to tie in with Emergency Medical

Program that you are dEvalcl>ing, etc., down the line.

        DR. SCHERLIS:  Actually, these are listed in the sit.2
                                                    .    _    . . ._.,.    . . . . -. * . . . 5.
visit report on.pagz 27.  'I can refer to it very quickly.

    The progr2rn must reconsider its goals and priorities

in terms of devalcping efforts in community outreach and

delivery of health care to inner city 2nd rural areas.' -Althoug

an enviabls n&lork has bzn developed through the university
                                -.                        e+e

and hospital affiliations, the site team feels CWP should not

support further expansion of thsse areas.  Rather, the new

programdirections exhibited should be supported by new

program priorities.
                             -.

Over the nz;:t yb?arr there must bz dcvzlcpsd

me-lsurable criteria for an analysis of the effectiveness Of


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217

these full-time chiefs.

        CRm must immediately davelop and implement an

affirmative action plan which provides equal employment and

training opportunities for minorities.

       CRW must take immediate steps to restore to the

Regional Advisory Board its responsibilities.

These are list,sd in d'atail 2nd one or two have been

added ir, the discussion.

I think any new coordinator coming aboard, I assume,

would receive this full site visit report,

I assume  ho wculd know that he isn't going to begin

h is first. year by saying, "We are not going to follow ainythir,g

142ybe I m r\,aive in this regard, but I think if he

. . . .,  : .   : . . . . . . - . . . .:.    .    I.     * .-: *- .`. .".           * .  . . . .
knG;qs. hs is goitig to be sit~*visited in or-13 year, he is g0ir.g

to have to sh2p.e up and follovl these recommendations. He

isn't going to have the longevity of having bean there for

sevaral years and having built it up.

DR. StiIIMDT:   Eileen.
                  -_

.

MISS FrAATZ:  Wh&n the Connecticut %grti makes its

funding dscisicns, it very likely will not ham a ccordinator

or- board.  And I would like 2 point of clarification.   We bre

saying do Rot expand your  full -time chiefs 2nd the university

                            --...
countsrpnr~s.   flr2 w5 s2ying ~0 not
                     '7    expand thn nmbsr of

dcllars you put into this thrust?  Do not 2xpar.d the number of


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13           DR. JAIlES:  That wouldn't have anything at 211 to do

  14  with the influence that CRNP would have on encouraging the

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  15  universitiss'or others tb follow suit iti the deve1opir.g of

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people supported? Do net support any additional full-time

chiefs?   And let those who are now being supported phase out?

      You know, that is the sort of inform2tion that I

        DR. SCHERLIS:  May I respond to that?

        The intent of the group would be that no new full-

time chief be appointed.  In effect, this reduces the  number.

So if you were to accept that as a modification, no

new additional, no new full-time chiefs are appointed.

DR. SCIlXIDT:  In other words, they stop appointing

them.   If the case hasn't been made for the value of these

now,  it never will be.

Chi~CfS,  would it not?

DR. SCIIFIID'i':  Nzll, they have gone statewide with thi

now.  And I believe that csse~tially 211 of the hospitals 2re
                                -.                   we? :
'tied in.

All right,  ~?e have 2 motion on the floor then.

Ur,l5-s sor32one wishes the floor, I will call the question.

       The moticn is understood?

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All in fax!: please say, "Aye."

(Chorus of ayes.)


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opposed, IrNO."

(No response.)

All right.  Thank you.

MR. IIILTOiJ :  I probably should have made my position

cl.%ar earlisr except I don't like to bother th& committee with

such personal problems. But the IIiltons are expecting a baby

sometime in the next 48 hours, and I would like to discharge

my responsibility toward Washington today so that. I can get

back and be a delivery room daddy.

DR. SCIII~IIDT:  Then, we will move to Nstro D.C.

Joe, did you hava something?

DR. txss :   I didn't want. to prolong getting to a

vote, but just on3 additional comment or two perhaps.

       First, I think part of our ongoing problarn with       . I
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Conn%ticut has b&en 'that Connzcticut'has disagr&d with us.

I have bet-n hsaring the same thing.  This is t.h% third time

now I have heard Connecticut discussed, thp_ sams issu-s were

rais.ed.  And then the thrust of what we have said has seemed

to hav'e bszn blunted at the Council lsvsl and things sort of
                                -_                       ariP? .
'go on as they have besn before.

DR. SCiliIIDT:  Maybcj we ought to cut off t.ho funds to

Council.

meeting of the minds at that l?val.


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      But the other major point I want.Qd to address had to

do with t.h-? racommendations.  lZnd that is to actually strzngtha

what is stated here in the number two rocomm~ndations having

to do with ths evaluation of the effectivonass of t.he systsm.

      I had thought that Dr. Thompson and his group in

Connscticut were developing one of the b&tar data-gathering

systems in thr country and that I had assumed as WC ent along

that this somehow was going to  b 2 ussd by Connecticut RMP to

det~rminzz what the impact of their grand design was on the

hs l~h care of the people of Ccnnzcticut..

     And yet whzn I sea t.hs report there, is apparently

next to nothing in terms of evaluation,  I am rather appallad

when t,&re is tha talent: in that State snd in the grantee

ir,stj.tut.iOn that w,e know is thcro.  And what I am leading up

ought to got. if nscsssary morL 3 consultation participation of

the pzoplz who have that kind of capabi1Ff.y wi",hin their zgion

to help them strn,ngth2n that. evaluation aspact.

DR. SClIMIDT: O.K., staff.

DR. SCIIERLIS: -- \JC did. meet with t?????, and this WaS

ref srrsd to.

DR. SCIiXIDT: O.K., on to Metro D.C.

          DR. SCHIXLIS:   k&11, Mr.  1Iirot.o was with us.  He is

1                               --
~ on Council, ha strongly support..>
                   +p'the site visit findir.gs and

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would bs a voice 'to this group t.h.zre.


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I.31~. SCIII~IfDT :   John.

        l)!i. KltALEi~JSKI :  WCll, the I~I3t.ro D.C. arch, the zrea

is Dutlined in this briefing docummt that is included in the,

rni>ort hsre today.  It covers thz District. of Columbia,

ilontgomzry 2nd Print" G%orgS's Counties of Xaryland, Arlington

and Fairfax Counties of Virginia, and the City cf Alexandria.

      This is an area of a great many rzsourcEs.  It is an

ar2.a of about.  2.3 million pzople, sn area that. is rumored to

be. an area of high unsmploymsnt soon -- I don't. know about that

but. anyway it has a lot. of resources including thrz:2 medical

SCilCOlS.

Now, this program was sponsorad with tha D.C.

i.l~diC21 Soci5t.y 2s th.2 grant.rs.5.  And it 1~2:s had a very stormy

history right. from ths beginning.
    .   . . * . . .   . ,       . . .    ._ . . . ..-. .   : . .    . . . ., . .'. . I  .,j:... . . *.. :.a..:. ., ... :
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     At, the 'prkssnt time, 'now, they are 'in the t.hird y%r

of t.hzir triznnfum.  It. has not been site visitzd this year,

although t.hs program hss been sits visitsd for the, last. t.hrea

yaars.

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     A gr&t deal of advice has be=n giyzn to them each
                               -.

y5ar.   Scma changss haves been made as .z rrsu??of the advice i

but. 'prcgrsss is very slow.

     As I said, the-y ars in their third year of the

trirnnium right n3w, coming Fr; fcr an increase in fuRding, a

su>s?ant.ial incrsas-,.  end t.h2 &pp?.ication hes bznn reviewnd

by the staff heri at ;Gll?S, has b.zcn rrJviowed by SARP, and I


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          1  'reviewed the application.   13ut we did not site visit. th?
e-     2   program.

         3         Last year, they requested, as yc)u mzy recall, $2.1

          4  million.  After a grezat. deal of anxiety and discussion, we

          5  awarded them $1.1 millicn.  And they are now coming in with
     6 '
         an application for $2.3 million.  So it is a substantial incr?zas

          7  again for the, program.

          8         A bit. of t.hz history.  As I mentioned, it has been

         9  site visited many -&mc,s.  And each tima,, it, undergoes some

         10  rsorgSnizat.ion, some restatement of t.h% goals and objectivss.

      11 But they have a vsry difficult. tim E rr;ally getting the program

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.off the ground.

To start. off with, they had their staff disburssd

into many agencies.  What they  wer e doing was funding staff
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IW-nb~!r~S in hralth departm&t.s, 'etc., with thess individuals

supposedly thsn carrying on a specific role for an lV.IP.

Unfortunatsly, t.hey didn't have the strong cznt.ral

' 18 staff to handle that kind of activity.  And they never were

19 really gEtti.ng tiuch proclclctisn out. of these individuals.
                                       -_                         as-
20         The 13adership ar.d the corE program WTS,S not. stror=g.

         21 Dr. 1Jznt.z is a nice guy, and h? is plzlnsnnt t.o chat with, but.
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        23 staff WBS disbursed, as I mentioned, into a number of organiza-
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with him in the COTS building.  But t.hat. staff was quite

ambiguous ab.Dut their rolzs.  11'11ey didn't kr.ow who they

rsportzd to.  Thzr? wns a grezt. d2al of dissatisfaction among

them.  lAnd in gannral, it was just not a working unit and had

nEver really b--come a working unit.

Thars was a lack of minoritifl-s includad in their

ccr? staff and lack cf minorities on thheir Rz..ional Adviscry

Group.

        To make t.hings more compLe.y, given that sst of
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circums+ances
         CI        I  tha, grantra organization, the IIL"dical S=?ciety,

did not givs them a lot of support.  And as a matter of fact,

some of th2.r rzgulatiocs rcgxding salaries and frFnge
b?nzfit.s, ztc,, ov?r the yrsars wsrz Quito rzstrictivc and

hir.dc;red the real advznc2m2nt of a core staff.

. . ..:*...: . .  ;.i _. .I-;.. . .i                                       . .,
   .Sini.larly, they d-?&il=psd a lar*ge.Regional Advisory

Group made up of various health ag8znciss in the area.   And as

a result of thz large Iiegional Advisory Group and ,thz week st.af

thzy really wzr52 unable to gr;t. the group to work as a concise

                    
unit..

AS a rr;sult. of that., they had a lazz numbo,r of

RsgionSl ADvisory Group that didn't at.tsr,d th2 metir.gs,

ciidn't participate in s%t,t.ing thn_ goals and objectives, and
                                                            \

really in many cases w2ra unzwarE of them.  This is sll data

from the- pzst sit% visit.

To m&e thincjs further difficult, i-ha, program bEcan%


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1  involved in a numbx of subcontracts.  Again, while ycu can

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2  carry out subcontracts to groat advantagft, you can't unless

3 you hav$ a real strong central staff to initiate the contracts,
-4 d.zt.ermine what they are supposc,d to do for you 2nd to monitor

.<  thTm.  And, again, t!lc-y just didn't have, that..`

6       So again and again the site visits come up with thp_s?

7 II difficulties. And again the program would sit down and record

.8  thsse suggzstions from the sita visit teams. They would bring 1

9 their tap.3 r?cordars along to tha mestings.  Thay would pay

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And in a way thr?y kind of remind ma cf soms of my

graduate students who hava this postor that they bring along.

lindwhs Chsy talk t,hsmsslvss into a corner on soma issue, thay

have this poster thr-y put up.  And it says,  "I am not sure that
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you und2rst.ar.d what I mzan because I don't know what I am

saying."

This is the kind of thing we havE betwaan thr

. 18 Regional Advisory Group and our Raview Cornmitt.% hsra.

19       Anyway, follcwing last year's review, wz suggsstod to

20 thsm that, nunbor one, thay bring their staff together in on?

21 cohesive unit physically if nothing else.

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And then, number two, try to reorganize ths staff

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somewhat, has not b$sn cut down,, but rather has b!"" expzndzd.
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It has bszn sxpand.c,d in an attrmpt to bring som? minority group

16  into it.  And I think that is a plus,  although now they havs

17  a larger group to handla and mora problsns organiz~tionlly.

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DR. SCIIPSIDT:  Nhat is it uy, to in numbers?
       ,
DR. KRALEWSI;I:  Sixty-thrzs, I bzlizvs.
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                                     ,C       it is around 120

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DR. KRALE!`JSKI :  They !lave primaries a& thzn they hav

altsrn;rt.zs, but the alternates only comi~c" if t.h9 primary dossn't

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I'think 63 is their pri!nzry.
                             4.

Thsy have 1~;:ought t'rlrir stuff tCgt3_Lher in one SP,tt.ing

2nd they hava lost a f% staff rAembers in thn process. But

and get a lzrgs advisory group involved and make sue some

minority members g?t involved in this whole process.
    Again, they rc,mind2d us of the difficulties of

.

some available in ths area and mad% sornz phons 'calls and

brought them in that aftarnoon a, + our site vis:it and so we put

thsm in contact with some of tho,ir minoritiss right th%2re that

day.  And te hzd hop,zd t`nat that wculd grow into some kind

of mutually agreeable.arr~ng~nsnt.

     Well, we hev~ now had this application.  And as I

mSntion533, they arr asking for about $1.2 million incrEase.

And tha situation is this:


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the onss now that t.hr,y have arz in a closer unit..

The coordinator has resigned, Dr. Wsntz, and has

laft.  So thsy have now an acting coordinator, a fellow by the
name of Choatewho was thsrs before as a deputy.  And ha is

a pretty good guy administratively. IIe is a pr5t.t.y good guy
in terms of intarnal administration.  That. is where I think

his abilities lid_.  And I don`t think hi is going to dc much

in terms of taking th2s2 goals and objn,ctives and doing some-

thing with th3 program for thz community.

The Rsgional Advisory Group looks 2s though it. is

bttt;l;r organizad than it was in the past..  Th?y hav? more

committres formed, and they have minorit '-4s on thoss com!!it.t.s%

so It shows som.3. I3r+s2.

     And they have b-a..
            c n able to bring more minorities
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into t.h&r cars stzff with some changeover In,  I beliovs it

is, at the secretarial lev~~l, howsvar.

They heve rsvisod th2i.r goals and obj?ct.ivss, and

thay revision looks as though they are making progress.

The wgy Dr. Wentz chose to do this,aft.er he, rxeived

                               -_                        QzF-
our advice 12ttW ~2s really to turn it. over to XAG and form

subcbmmitte.5s and .g?t th%~ involved in th? goals and objacti.v?s

And he started phasing himself out of it.

I think t.hzy are at. ths point now where they hav?

t.rixl to lock at. t.hc1~;4, thcsy hav-? tried to pick out a couple

of arcas they want to d9-11 with.  And what t.h-y nc(s-d now is som


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227

kind of leadership to put the whole thing back together and

make it work.

     This is kind of how they sit today.  And it is the

kind of program you would like to put into receivsrship in a
way, but thers is no one that. wants to receive it.  And w,e have

invested a fair amount of money in tha program.  And the

question now is what we should do with it. -

      As you recall last year, they had an application in

for a kidney project. And that was funded. And perhaps it

will continue on.  And they have funding also for a

pediatric pulmonary regioxl program.  And that. essentially

they are tied into.

They have a couple of new projects that they are

submitting alcng with t.h-e grant,,application, .t.h,is yea.r. . but. .
       . . . .     . . :.

they are proj,ects essentially that are warmed over from btfore.

any ccw goals and objectives that have been developed by their

Region.31 Advisory Group.
                    , I
       Now,  as I mentioned, there has been a review by thr
                               -_                        ce*;ra

staff here and SLARP.  And there is a recommendation that I

would read from SnR?;

Naybe I better wait until the secondary reviewer

DR. SCii:aIIDT: 0,1X., Bill.

2lFt. HILTO;?:  I would add just a few things to John's


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good ovorvicw on this.   IIa and I  -- or I was with him actually.

lie was chairing thz sito visit that ho, referred to to

Washington. Ona of ths first obvious positives things I noted -

wall,  thsra ars ssveral positive things over last year, very

small stfps, howaver.  They do talk about addressing themselves

to undsrssrved populations.

      I recall stressing, I vividly recall stressing ona

of the ways that might be done would be to involve-d minority
                                  .
staff on the cora staff, on the projsct staff, to really

providE soma effective t.cntacles into the community.

One thing that. becama vary clear whan we had the

lady in who had bsan a RAG member and had not really been

involvsd in RAG from lJ.C, itself, on2 of tha. things that

bscama clear was that. no ona in thn outsids community, she
. . %      : . . . ..*      . . . . .           . . ,. . . . . . .       .:

told us, really had any awareness of what the Xatro D.C.

Ragional Hedical Program was all about..   There was no

effsctivs dialogus.  There weren't enough paoplz from those

~ ccmmunities who would talk to RNP.  And I st.ross%d at that

~ time that increase-d staff would certainly halp in thair
                                 -.

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i outrsach efforts in tha District itsslf.

Tha increase has been slight on tha professional

staff and of it.  And I dcn't. know that it is adzquats to this

day.  end I don't believe it is adecpzte to this day to handle
                                      

t-,hz proport.iop. of war:; that th-by s:lculd bs doing in tha Distric'

in -add;+ion ?ZG th5 other commitments.
        - -,-


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          1       I have not heard Dr. Kralzxski's funding recommsnda-
o ?    .2   tions.  I would suggest I favor a ccnservative level of funding,

311 far more conservative than they are asking for, not only   I

4 II  because of these continuing prcblemSy but because of the

   9 prospect of a new coordinator about whom we don't know what
  6 directions he might take*. Certainly, we hope that he would

   ? bring a stronger leadership to the program than Dr. 1Jent.z has
                                                                        -..

.C.   8 had.  I don't recall Xr. Choate very well in terms of what

    9 his abilities might be even now as an acting coordinator.

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I ng2d to touch base with ;Bohn on something I don't'

understand in the application.   There  was s0m.e talk about the

RAG disallowing respczsibility for cc+nsidering individual

prsj,-cts. Did I gst that right?
    '3                           i.JSS this their fzeling that

thz RAG should  not be involved in setting priority?

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        DR. KRALEI-,'%I:   140 .  'It. was; my impression they

were quite involvsd in it at the momexr;Lt..

       Spence, you might want to c2omment.

MR. COLBURZ: They review prcojscts an< set priorities

and so forth through a subcommittee system for all RAG members.

tion'  on the floor.

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DR. SCE!IDT:   All

DR. I<RAL%J'SI:I: I would lik= to read this recommenda-

right, Jc&n, let?? get-a rscommsnda-.

tion from SARP and then ask Spence if he would make some

, CC;;L?I~~C,S ~3 it since 12.2 staysd pretty' close to t.hlS.   And

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then wa might go  from there.


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SARP would rscomm%nd that program be placed on a

cnz-year probation and that they be funded at $850,000 level.

      Within that $850,000 level, the kidney project would

bs funded not to exceed $144,000 which is really what they

need, and that the pediatric pulmonary project be funded at
$147;000.

     And they recommend that no funds be budgeted for
                                                          -

projgct 51, the ctinccr detection clinics, until they clearly

It 903s along with policy.

The dzvelopmental component b2 denied.

And that the Director of RXPS be authorized tozward

an add ition~l $200,000 to the prcjsc,. + if hs br-li;l;vss that. t.h%ir

progress so merits during the year.
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      I thir,k that. this is -a good suggEstion.

Really, what we are saying is we will authorize

them about $1,050,000 and that that last ye,ar, as you recall,

I mEntioned th2y had $1.1 million which is awfully close to

this.

      ,

                  -_                          es?&+
It gives them soms running room and yet pou givs

them only thus $850,000 to start so thsy have some indication

they arEs going to hav.2 to make some progress bzfore they get

the othsr $200,000.  But the level is t.hn_re.

     How, t.h?? J?m1~~stion bit.,  I bzliev~ the staff might

clarify this for m3.  I bsli2ve VIIF? have had somc3 other


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programs on probation in the pzst and essantially what it means

is that you hav% a yoar to really show that you have bean a513

to rzorganizz ths prqram and make some substantial progrrss

or we are really going to stop it all at the end of that

year.

     C&n I get the staff to comment on that?

        DR. SCHIXIDT:  All right, Spcnc-?. _

      All right, wz h;;ve a motion on ths floor. Bill, do

you second that or'not?

        XR. HILTOX:   Yes,  S do.

        DR. SCHMIDT:  All right, Spent?.

        MR. COLI3Uru'J:  I really have no additional comments.

I thirk th2 cvsrview was very gcod.

     We did question the terminology used, the word
. .      _ -. . . .     . .     . .-                                            . . .
                               . .                    . . . ..-. . . .

"probation" in SARP, 2nd rsally.didn't corn2 up with any

dafinsd definition of what it mzans.  But essentially this was

the intent.

DR. SCXIIDT:  I think ~8 will szny that. probation

msans at the snclof a yoar obviously t&we will be a site

visit ar,d that if substantial prograss has not beEti medz

toward mzsting the gonls sst cut in t11.z advice given, tJ1.se

program will gc to zero fundir-g.

MR. IIIL'I'O:~:   PIr . Chairman, have wz zver canned ox

of t.h2s-': things?

DR. SCiIiIIDT:  Wll, in previous timt3s, the Director


1  .of Regional :ilc,dical Programs has in effect said this to

2

4  combined, as you know, and in effect phased out and phased

-5

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7

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11           DR. SCHIXDT:   I~IXS.  Flood.

..: . . . . . .

l-5

.16

1'7

.
18

19

20

21

22

23  that type of thing.

-
       25

232

regions, yes.  I am not sure we have ever kind of officially

usnd thz word "probation."  There have been a number of regions

into a larger region.

I personally s,- ~2 nothing wrong with saying this.

PlRS .  SILSBCE:  In a sense, isn't this the third year
                                             --

of its triennial support?  By putting that probation in, you

are really making d stronger message than you would be by just

talking about this year.

MRS. FLOOD:  I4ay I ask a guestion?,

DR. SCIiilIDT:  Plzasr speak into th.2 mike=.

MRS. FLOOD:  They were budgeted for $787,000 and . . .

          _`.* . . . . 1 ..- . . . ~.         . .         :
.-,. ..

$800 for staff. Did thsy expend that in ysar two, this current

year, entirely?

        HR. COLDURJ:  I don't know what their exact rate of

expenditure is.  But they don't exp?-ct to have any funds left

over.  About $200,000 of that goes into contracts.  $195,000.

                               -.                          czEF=
So it is about a $500,000, $600,000 for the staff:

PlRs. FLOOD:  Is that actually staff?

:4R. COLBURX:  Staff, some consulting activity, rant,

1lRS. FLOOD:  ;Gy concern was that ths recommendation

of the SARP was a poJ,-.ential expsnditure in kidn.sy and a


233 I

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10   nurtizr one priorit.y which they wanted to renew for a year.

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16           DR. BRI"ldDLEY:  And th2y can g--
                             a+ another $100,000 if

17

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~~~ot.er,tial expenditure in ped,~
                  47tric pulmonary of $230,000.   And

if they wtr*z 2xp%nding $787,000, it. didn't add up to $850,000.

        MR. COLBUlWJ:  New , this  is a reduction of funds.

         MRS. FLOOD:   YClC
                -3, but I msan it will actually mean

also cutting staff.

        MR. COLBURX:  it is going to require some hard

decisions.  They will not. necessarily have to cut staff, but.
                                                          -
t.hey trill not. be able to fund all their activities within the

period of continued suppo?t..  There wzs a project which was a

And t.hey will not hava any funds for contracting activities in

n.zw areas if t.hsy ccntinue to kczp the same level of staff

support-..

DR. KPSILEiEKI:  They will have four vacanciss thsy

they do a good jcb.

DR. LUGINUUXL:  Is it really f,a,,
                       o-p;ble to zero fund

a program?  Is that actually a political possibility?

DR. SCHXIDT: sure.  The President%% talking about

doing this.

(Laughter.)

DR. LUGIIJBU!IL:   I ;?m not. sure  that answers the

CLUES tion .

DR. SCIII~lIDT :  The answer is yo,s.


234 I

1

2  going to be threatened and who is going to bz chall=,nged so

5

6  rerzly are able to seizs initiztiv2 and direct. a program.

7

,:
e

DR. LUGI:JUUIiL:  Thz other question I have is who is

that. they do address the sxious problems of this program?

You have no coxdinator at this point..  You have a very large

RAG, 65 or 70 people.  And in my experiexcs, large groups

Thsre  has bzn a ssricus problem, I gath-zr, with the
                                             -i

grant.e.  It is the 14%diczl Society of t.h;Eg arsa.  And thsy have

                                  .
cl.zarly not shown leadrrship.  Who is going to respond to

this challenge that w2 ar.2 placing cn this program?

Are 142 simply gcing to havs no on9 to respor,d? And

.should we think about. other msasures such as merging the

prcgrem into another prcgrem or trying to get. anot.hsr gractze

or other devices to strength2n manzgcmsnt?
,. ._. , . . ..-. ..'... .     1'          :   . . . . . -              . . .

I          DR. iW.A.LEiJSKI:  I didn't mzan to indicat.2 that th3

/ Plsdical Society at thz moment is not supportive.   In the

initial years, th=ly ware not very supportive.  And as a nattnr

of fact, ir. our site visit last. year, thay had a changzovcr in

19  a lsadzrship of't.hs 112dical Society.  And they at that. time  I

20

21

ii

23

-.

.ip-dicatEd a great dzal morn interest in th% zgram.  And I

think that. th?y will COTIS through on this.

       I also think that RAG,  if what I r=ad in this

application hzs any bzring on the truth, will initiate or


235 I

It. is iffy,  and I don't. know.  But I think that is

{"
e

. . 1 . .

25

where it will come from.

DR. SCXMIDT: Dr. Ellis.

DR. ELLIS:  I would just like to ask one question.

When we made the site visit. befcre, there was a' woman physician

there who Dr. b1ent.z told us really worked to coordinate all of

the programs and make the changes es.had been suggested several

times.  What. happened to her?

        DR. KRALBIJSi<I:  I believe yqu might be, referring to

Dr., I believe, Woodside is her name.  And shz is no longer

with t.h5 program.  But as I undarstand it, she is one of the

candidates for the coordinator's job and I think that. probably

would do a good job if they can g-r;-t her.

        DR. SCWIIDT:  Sponce.
   : . . . . . . .   ,       . . . . .     ,.' .    - . . .    ,   . . .       . . . ..; " , -
.

PIR. COLI3URN:  That is` correct. Dr. Woodside is a

candidate.  They have had a search committee.  They interviewei

about, or they cona- -;dsrzd about eight candidates. land this

is a search committee, of the RAG.  And they made the reccmmend~

tion to the grantee and gavr them three candidates that would
                               -.                         --

be acceptable to them.  And the grantee has interviewed them

, all:  And there is some indication, although it is not

official, that Dr. Woodside is the first. choice,.

However, due to the unc;lrt.aint.y of the future of
               --w.

I if in the futurs it becomes cvidcnt that RMP will remain in


I

23G

\
  1 business that s!l.e will accept. tha pcsition.   I think she is

  2  interested in the job.

3         The quos"i ion was where is she now?   She  is at

4  Glzorge Washington.                                 

DR. SCHFIIDT:  Are there other issues?

6

7

MR. COLBURN:   I wonder if the  commi+.+os has a
                                               c u-u

reaction to the size of the RAG or has any definite recommsnda-

8  tion or suggestion to make to the program.   Because this is

9  kind of a --

10
/' II

DR. SCIII~IIDT:  1.1~ reaction is that across the country I

11 II thare are some large RAGS that are effective by virtue of their I

        12  @sing advisory in nature.  They give advice and consent.  Th&
e      13  is all a very largs group can do.   The successful ones have

       14  very sound subccmm~ttze structure that doe.sVJhe,Sv,ork.. . ,. . .
                                                          I. . .      . . .
_ . .    . . . .     . . . .  ,.     . _. . . . .      . . .:.    . . .

         15         And a large ona  like this can meet two or thrse

!
L1

16  times a year and vote yes or no.  But the mwasur2 of the

17  effoctivenzss, the strength to which the individual iRAG

18  members in groups of six and eight and ten get.at the work of
                           .
19  the program and the size of the &\G pr se isn't. as important.
                                      -.                    - .
20  as what they do on th'e subcommittees, what typs of subccmmittszz,
21 thsi ar? and what. effect thsy have on the program direction in

22   some way.

23

M-t. COLBURX:  But this RAG dols have t.he u1timat.e
               -- .

      24  system and has a vol:xe. cf abou?= 120 people that are eligible
eral Repofters, Inc.
      25  tc scrva one time or another Either in the primary capacity or


alternate capacity.

: .

,--.*
t.., .

23

25

There is a jeopardy, I feel, by accepting this

alternate system.  You dilute ccntinuity.

I just want a rextion.

DR. SCiWIDT:   The alt, arnate thing doesn't sound --

everyone on the group who has a serious concern about that

alternate system please raise your hap-d,

(A number of her:ds wzre raised.)

      We could conv2y to tham the weakness of not a GO-man

                                   .
RAG per se, but certainly 120.

         r4n .  Iax :  I think cne of the problems to the RAG

is that each member has to reprssent an organization.  This is

. .

    i4R. COLBURX: It is not &ach m%bor, but it is a
                           ,
. . -. .          . . .    . .        .                     . i. . . . . . . ._

high percentzgo.  It is probably 95 percent of the mzmbzrship

institutionally affiliated or an agency or somn,thing of this

nature.  That is the basis for the RAG.

DR. LUGI~!NJlIL:  Do %EY have a strong executive

                    I
cownittee?
  I

                                          em
DR. SCIIiIIDT:   Is there a strong =exxutFvE committee

of thE: lRAG?

MR. COLIJUX:?:   Yes.

DR.  LUGIiJi3UiIL:  iiCW largs is it?
               'L1.

? ?* o  coLcYU';iI-::; :  I think it is  seven rnz-ibsrs.

i4R.  HILTOil :  I think Bill's quastion is he asked


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    25

how strong.

IlR. coLlXJIIIJ:  Thzzy are meeting morz frequently, and

I think it is becoming stronger.  Some of the chairmen of the

subcommittees arcs now and havs shown a lot of interest and

promiss.

         DR.  SXiiIDT:  John.

DR. I;RALE:IiS;:I:  I think the whole qua,stion ova t.hs

Regional Advisory Group and how functional it. will b? is really

on2 that is only going to bo answzsd dfter they gat ths

core organized.  If they organize a core, I think they will be

abls to handle that large RAG group without any trouble and

organizl- thEm well and get. them t.o participate pretty ~11 and

an cxecativz cormit.ts.~ to do thn, samz thing.

      At thn moment, they don't have that organization.

. . . . .; . _       . . . . .     _. .       I. . . ,     . . . . .

rind as a result, you have got a disorganized 63 or 119 or whate

shows up at the m.oetings coming in.  And that is difficult.

Now, on tha other hand, during our sit.2 visit the las

time * wp, visited with a number of the individual RAG msmbC?rs.

And thzzrs are some raal strengths in that group.  And I think

                               -.                          eiez-

that those strengths will corn2 out once that second le,vzl

group get.s organized.  And I suppose that is really where wo ar

placing,our bets.

DR. ~CXIIIDT:  Spzncc.
               'LI-

:.IR. COIXUIL; :  Just. a correction.   'Iher  are 13

msmbzrs on t.h? exn,cutivo, commit.tf?z.  And the form Fndicatzs


e

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-ic a fat

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    25

t.hey only mst. two times last year,  although I know they

have met more recently than that since July.

DR. SCHM.DT;  That is not a very strong commit.t.Qls.

MR. COLBURZ:  It is really on the threshold.

DR. SCIIPIIDT:   O.K., we have a motion .on the floor

for probation for one ywar,  site visit at the end of the

year, $850,000 leval with t-h--\ director having the authority to
add to for good behavior and progress during the year if there

is a strong coordinator who does indn,ed need the money to

advance the good causs of ihe program with zero funding for

project. 51 unlass some substantive issues are answered by the

program.

With this, they would fund the kidney project at

no more than $144,000 and the p%diatric pulmonary at $147,000.
                   . .

. , ..:..r.. ., : . :              . .
     Are there questions to the motion?

. .       r *

(No response.)

  _
Is that the motion?

DR. RRALD~~S~<I:  Yes, sir.

      DR. SCHIIIDT:  All right,  thsn I will call the
  8                            -_
yuzstion.  All in favor plzase say, 'tAy9.' -     -

(Chorus of ayas.)

Those oppos o,d s~iy, "NO."

(IJo response.)

--..

And that motion is carric=d.

DR. KRALE!ISI<I:  Shall we rate this one?  Do we rate


240 '1

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'ters,

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25

all of them or just the ones that ars site visitsd?

        HRS .  SILSBIX:  Rats thnm all.

        DR. SCIIi3IDT:  IIorotofor2, ws have rated them all.

SARI? did rate it.  They rated it. down if you look on this one

shse t hzre.

DR. KRALEWSKI:  Right..

DR.  SCIIKIDT:   Fiatro D.C., SARI?, 176 from 207.

       MR. CIIX.IBLISS:  I might point out it. is your option

to accept or rarate.  Hs leave that. entirely to the Com&.tten-.

         DR.  SCIIllIDT:  Lst mo ask just speaking for myself,

I could hold out through Nort.!l Dakota.  Would the CommittsS

liks to go on?

DR.  BR.I;lDLEY: On? more.

       DR. SCIIXIDT:  All right, :4iss Kerr.              . .      . .
_...    . . . . . .     . * . .      . . . . . .     . . . . .

       MISS KERR:  I am p1easz.d that you did bscauss I

know Dr.  Scherlis has to leave.

Lot m2 just. say that thz ravi.9 materials and I

ended up in the same place finally late Saturday.

Ncrth'Dakota Ro,gional 1,Isdical Program and I have

'gottx~ acquainted bstwosn thz hours of 3 and G: 30 this mornzg

But. 'I fz.el fairly well acquaint--d with it, and I am glad that

Dr. Schcrlis who was chairman of the last site visit team in

DecembG of 1970 is a secondary reviewer and also Dr. Jam%.
                             --.I.. . .

And I have 'ask& harold O'l7lah2rt.y. from thcr Xid-Coz:tincSnt
Branch Oprations Officer to join us bxause he has spent so


241

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much time with this region in the- last year.

First, 1st me tell a little bit about North Dakota.

i?orth Dak eta is the most rural State- among the 50 with a total

population of 613,000 is all.   I was amazed.  Three percent

Indian population, 3 percent non-1Jhit.r population, average of

9 people per square mile.  And yet I look at the available

physicians and regi,;,
           'pc=rod nurses and combined registered

and licensed practical nurses, and I will bet you Mcrth Dakota

-is better off than any other State I ~T?GW of ES far as ratio
                                   "
is concerned.

But they do have geographic problems.  And the

capital,  of course, is at P&mar&which is in the south central

part of the Stats.  And Grand Z'crks is where the Regional

:ledical Program is based.  And that is in the very r.ortheast
                     . .    . . .       _.. . .      .       . . .            .* .
. . . .  .

part. of the State.

And I tell you this because the grantee agency is

located at Bismarck.   And the grantee is ;Jort.h Dakota :@dFcal

Research Foundation which is a subsidiary of the State Medical

Society.  And so th3re is som-3 distance between the grant.%

                                                  as`i3 .
and the Regional ?.lsdical Program based at Grand Forks in which

city' also is the Univ.zrsity of i?orth Dakota which is the

~ fiscal clg.znt for this Regional Iiedical Program, although this

sezms to ba working vsry well.
                            \:

       This is an Innivsrszry rwiew prior to triennium.

Thxe wxe some problems, and I would like to identify those


242 I

o

I

as they were shown following the last. review.

Early in ths process, the RAG was made up of physicia

period.  And, of course, this wzs questioned, and t.hoy WP,TE

advised to brozd$n their advisory committee. -

The staff havs charact.crized the Regional Medical

Program as bein g ruggadly individualistic.  And I think I

\Jould havs t.o agree.

       To date, the projact that. had been funded had
bzsn cent.ersd around providing continuing education for t.he

physicians.  Thsre ~2s s~rw3 continuing c-duca",ion for nursrs,

howEvEr t.h%rs was no nurse, educator or nursing service input

into thcss.

Ths offsrings werca d-,valoped by tha physicians for

thz nurses.  So.thors was concern about dominatioq pf the,     .
                                                         .* . .
            . .           i
    . .

prcgram by ths St.it.z Ilsdical Society.  Th'ere was concern about.

ths failurs of the regign t.o de1inzat.s an action panel which

includes timf frams objzct.ives and tzrminal points. of eveluat5.o

The failure of tha program to r,$cruit. a dspu*Y

1

dir.?ct.or acd an assistant dirsctor for managcmznt. plnnr,icg snd
                                                       e3P
evaluation.

AnothEr cczczrn was t.hz lack of involvement of

minorit,y group repressxtat.iv.?s on th9 program staff in the
li?gional A;ivisory Group in ths committss st.r,uct.ur%, and it was
                             *-r-

felt thsk th.2 R$.r,:x;7_ !Islical Program had not. dsvslc;Jsd its

activities in terms of changing RPIPS mission.


243 I

  Thzreforfl;,  at that time,

It was intzresting to nct.e

thr;, coordinator in August of

for tha proposal on October

it was not accordad trit,nnia..

that whm Dr. Arndson

1972, in his letter, cover

27, startad out by saying

6  growth, faced with problems that verge on dilmma.

7

8

'5 II the Rtgional :4zdical Program is at. a critical stage in its  I

And having revi.zwsd what has transpired botween

than and now, I don't think he would mako that. staternsnt

911 quits so strongly, at, lrast.

10

11

assist this region.  And it would SZWI to m% that they have

rcspond?d pretty well to thCa problems that were identified

at that particular tim?.

    14

      . .
    15

      They do havs a nzw rxzcutivn dir-?ctor in Dr. ArnS'son,
                                                                           .
. . -.               . .       .       . . .     :       . . .:      .

as  I said.  And ha was ap;>ointed in August of 1972.  Apparently

16  his public relations are superb.  IIe cvidzntly knows the

17  Stata real well and has good contact within the State.   And

18  he works wrll with tha corz staff.

19

Thsrs have bcsn minimum of six staff visits out to

11s by his own admission is not as comp&.e,nt in the
                  -.

field of budgeting and finance as hz would lx to-be.

20

ill/     Just tcday sines having arrived hsre, thsrs! is inform:. I

22

  tion bsfore mc; that says that a deputy director and assistant
2311 diractor for managa~Etnt planning and Evaluation has bc,Gn

     I                               N.          
      24  znployzd as of this month and also 'char.? was a t.hird pzrson

eral Reporters, Inc.
      25  employad as director fcr community and public roiaticns which


244

..a..

,gives them,  as I count.4
                              - I a total core program staff of

18 including 5 secre,. "arias which means 13 highly prepared

professional pzoplc.

     In speaking of the program staff, I would have to

say at the risk of bsing called a feminist which I profess

not to bE, I do think a look at. the differentiation of

salaries and 1~~1 of preparation on this staff b'etween the

men and women is quite remarkable.

      At the tim2, it& thought that t&nsions existed

among the sgveral ClIP B zgencizs r;nd t.hF3 RH?.  Apparently

since Dr. Arnason has c3m.z aboard, thus% relationships have

jmprovsd considerably.  And thara is much support, there is
mutual rzprss%tation on the rGsp.zct.iva advisory groups, end

they szsm t.o be working much bet.t:?r t.oget.her.
          . ...* I. ,. .                  .                        . .  . -
     At. that. timz, ths objectives were felt. t.0 be VS:gUE?.

I note by the material that. they do have them dalineated.

The gcals are within keeping of t.hn, mission of t.he RLJP.
    They had not at, this morning's rr-ading shown t.00

much progrzss in thz area of scrt.ting priOrit.isS.  However, in

                               -.

t.he information that. czmz to me todsy, they ??% have set

th3i.r priorities.

The review process was not certified because of

sev.eral major identified d?ficisncies at. t.h"l last. time in thE

                            -. . .

staff cbszrvztions.   IIO'il"`JC-r
                                - - t the Fnformat.ion bEf0rs me t.oclay

says that their Lview process has b22n approved.

II


245 I

         1       The CHP agPnci.es wern involved in revi3wir.g th5
e       2  propcszl prior to the timd-, it. was admitted.  And of the four

3  who respcndcd, threz wzre very supportiva.  Ons felt. that they

4  could  not support th t3 funding for four projects requested,

5  and I think this nzsds some explanation in t.hak it was

6 dEt.-trminsd early that this Regional Medical Prcgram had much

7 to do to get. its house in order. Ar.d I think it was not felt

8 thzt it probably could do it as readily as it has,nor as
                                      *
9  rapidly as it hzs.  And so at that time, it. was rzccmmsnd$d

10 /I to thm from the staff that thsy may want to consider spending I

11

12

13

14
. *

15

16

17

th2 r.ext year pickir.g thnmsslvzs up by the bo'otstrzps rathar

than to g=t involved in a lot. of n-3w proj%?s.

licwcv2r,  as they movzd along and fait thamselvrs

that. t.h.zy wzre maturing, it was the RAG itself that id%r,t.ifi%d
                                                                      .
                 :. . . .     . . . .
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fsur projects w!lich t.!l~y would .lil;e to bs pursuEd acd for

which thsy would like t.G requast. funding.

So again it was a CI-IP i3 agsncy in Bismrrckwhich w?,s

18  theone bzfors that. was (?. lit.t.15 cantznkarous, Gut. of the four,

19  this was the only one that had r ss.5rvat.ion about. this particular

                                                           aa+
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21 '     All t11-2 proj.5ct.s which they had undzrtaksn b8fGrz w3rE

22 ccntinuing education 2s I mcntior.Ed ezrliar.   ,211  cf thos?

23 113~~ b5zn t&en Gvzr by other sources of funding.  So t.hfzy arz
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Their third year, thb_y received funding at the 12vel

of $323,401.  At this particular anniversary rzvisw, they ar2

asking for $707,025 with no id%nL.-
                      +;ficat.ion as far as d,2vftlop-

mental compnent.

In Dr. Arnsson,  it would sezrn that tha -y hava a parsol:

who is going to bs able to provide batter leadership in a

bzttsr atmosphers.  And hz has a cora staff evidently that are

highly motivated, I would say fairly sizable in number for the

size of the operation to datz.  However,  I do np,%d to dr.aw

attention to this group.  knd I havs strong frelings about

this in view of t.hs adequacy of t.hz rL-3viEw comk.ttE.z about thz

lack of minority reprossntatation.  And it was treated, I

thqught, quits adamantly last. -t-ime to my disapl~ointmsnt..   And

psrhaps I am a littl- 0 biassd on it because it was from my
                                                      . .._                      : *
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prssantation last time relative, tG it.

But I have heard this aftarnoon thr,&s or four times

we have t.alk2d about regions whare tha minority rsprasentation

is no,rcaably lacking or absent.
      +*                    And y&  I haven't heard that

ads,quacy today." But this particular region has bczn told
                               -_                          em+
about this a number of times, and wa still find only ona

minotity on thz RAG.  And this is an Amc-rican Indian.

P Thr,ro is no minority rcpressntation on ths program

staff or among the ccmmit..tez of which thnro are two and

                             -.

provision for othxs i;.s nstded.

The Regional Advisory Grou?, the grant-2 and t.h2


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coordinator evidently are working vzry well togather.  And

they have set out and accepted the politics of th4.r own and

describe their roles and relationships.  And it. sB$ms to be

working well.  So this is apparently a major improvement

over the last, and they did follow the recommendations.

      So their review, their technical review process

has been approved.  Their rslationships with CHPs arzz

considerably better.   The policies on the relationships of

the coordinator, Regional Advisory Group, grantee organizations

szzm to be moving vary smoothly.

     It is my overall opinion that it has mado, an

about face.  It has found other funding for its formerly

ongoing programs.  And in submitting its request for funding,

thz funding would cove,r program staff and;four projects.
                                 . .         . .*                                 *

Program staff of this $707,000, $411,000 of it is for program

staff which is 7.6 percent which s;2,ems pretty heavy. HowWar,

they havE also asked funding for four proj8sct.s.  And just

grossly, those are Emargency Mdical Servic,zs, .Rsgional

                    .

Extension Csnter for Rohab Szrvic?s, communicrrtions tG sf?rvE
                               -~                         -z%e

diabztics and educational cc-nt.;r for alliad hz=;elth psrsonnsl.

      They have in their pricritins put Em-zrg?ncy Hfidiczl

Service  assessment No. 1, asking $63,241.  They have put thz

sducation center for allied hp,alt.h personnel iJ3. 2, the
                             -.
                                      
regional ex.. +ension c?:ltcx for iZr!iaL Szrvic~Es ijo. 3, and

communications for diabetics No. 4.


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The EfIS would b,s an 3 assessment in feasibility and

ths educational program for allied hn,alth, I would like to

speak to in a positivz manner because this would bz don2 with

i4ort.h Dakota State school of Science at Wahpdton.   It is not

fcr preparatory prcgrams.  They have many ongoing preparatory

progrcqs at. less than tha bacczlaurzztr levsl.  ThE purpcxe

for this is for in-sxvice education  of allied health

workers.  And they have dzvzlopsd a good natwork to get this

Gut Chroughout thz St.at.2, take it whers th3_ work,zrs are,

rath% than rzquir;3 that. they com2 ht.0 a central place for

conti:>uicg education, which is tco oftan impossible for many of

our people as I kr,ow front whsrz I sit in our Stats.

       so t.!l"y Il~V-? ask-xl $737,003 for prcgram staff and

for t.hzdE: four proj2ct.s.   Wxauso they have recently m&c?,
                                                        .          C..
    a:. .      . .  .,... . .     z                . ._..

t11ss e cii3ng,zs, &though both wi=,rz gocd, b.2for-a I make a

-recoxxn%cdation for funding level, however, I would nsk Dr.

Schsrlis  and thzn Dr . Jamas end IXarGld 0'Flahzt.y if they

would hsvz any commsnts.

      fiR. SCIIERLIS:  i,:ill you rsvsrse that and ask Dr. Jame

first?                                 - .

         1IISS KERR:  nil right.

         DR. JXISS:  V!ell, my comae..,
                        "+s Ere going to be vsry

fsw for the first time.   However, I was very much impressed

to 12am of 512 ccnplztr- about-facz th;lt thr- new director of

l?crth Dtkota RN? 'has taken.


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I think perhaps that. if we had had one of the

relief maps that wire passed around, we could really see the

vastness of the terrain in North Dakota because I think it

like Alaska and so forth probably offers the greatest. problem

toward. the  dispersion of services in the area and because

of the paucity of the population.  Their clusters of population

are into several areas.

I think that, too, the efforts that have come about

in the development -in the proposal of the four new programs
                                   6

involv ing all the CIIP B agencies which was not before, I think.
a part of their program probably lends support. to the fact that

there is going to be more community iEVOlVem%t.   Because I

had unckrstood that prior to this tine there was a tremendous

hold on the organization through the State Medical Association.
. : _. .    . I . . . . . _.. . . . . . . . . ..:           i ;. . .

        I would hav.e to say something in regard to minority
                                                       \

representation when cne looks at the figures.  That is if

the Csnsus peopl2 counted everybody because we are well aware

of the fact that a lot of pscple just don't get. counted. So

I den' t know whether or not. there are lG,OOO Indians or 2,500
                               -_

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blacks in North Dakota or not. But. anyway, we have to take

what: the figure says.  It. says that..  But I would have to

strongly wonder how many people on the reservation Still

haven't. been counted or vice versa,

But the fact. of it is that you can only have in

this coi~~~unity a 3 p"vrcent population.  And I am not. willing


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Council or anything by a quota.           .
                         That I.S out as far as  I am

concerned.  But I certainly believe that because there is

an Indian, large Indian population that certainly the

organizations should be represented.
     I understand that the Indian is a very intelligent,

highly articulate person who is a representative of the

India n Council.

        MISS KERR:  Chief.

DR. JN-ES:  He is a chief? He is a big man.

\iell, he is President, then, of the Indian Council.

MISS Ai\TDERSQ;?:   That changes frequently, though.

I think I hear you stating in that appar,ently aftsr many
. . . .* .         . .    . . .              .,, . . . : .: ,.     '_   :.. . .
years of really being sort of stymisd that this program

looks like it may begin to take off.  I am espec ially impress&

with the cooperation brtwcsn the medical school and I believe

the Idorth Dakota State school at. Wahpston.

XISS KERR: Yes.

        DR. JN.'ICS: To establish th& residzy training

prcgram, the intsrnship program, to bring the medical studxts

                                                                           .

again out into the community, into a community n&t.work, which

as far as I am.concernsd is combined also with gxeral
                            2, . .

educat-ion.  hnd I thi$: that. this ?-?ill have; a tremsndous

                  .

effect cn the distribution of health manpcwer.  And I bslieve


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        DR. SCIIERLIS:   Go ahead.

        IxtSS KERR:  I neglected to say that the advisory

committs,s has bzn expsnd~d from 1G physicians historically

to 33 ml3mbers, broad rsprEszntation from all health prof?ssiona

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this is ono of the ars,as WD, ars really confronted with --

distribution.

I have no ot>her comnznts to make.

MISS KERR:  L2n, would you excuse ma if I make just

from community p,zoplc , frbm consumers, and so forth.   There

ars 16 physicians on it, oni3 from coach of the Wn, I guess it

is, county madical societies.  And that doesn't seem unraascznzb

I felt.

     And I was very much iq2rzssod with thE change that
          - . - . . _. ., . . . . ,. . . .   _ fi   .: . . .    . .   .       . . . \ .'      . . . . .

has been mads in the Advisory Group.

     The other thing I wanted to say is of any bylaws

I havs never rsad anywhsrz for any organization, I think thzse

are tha most outstanding, ths onBs th%y hav? rezntly.  Thzy

r-scindEd.thsir'origiRal bylaws, and thzy havs a whole
                               -.
nkw set of bylaws.  And they arr- -just. worth zding.   I think

they zr-3 well done.

        DR. SCHMIDT:  I hop? you will forgive me if I just

intsrj5ct a comment hcr9.  I was sort of amused.

                            --

      I think a 2-zlicf map cE thz Stat-l? of 21crt-h Dakctz

wDuld be a wczste.of inonq.   The highest point in the State of


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North Dakcta is in the Turtle Xountains up near BOttineaU,

North Dakota, up near the Carmdian border.  Th2 lowest point

iS  in the Badlands ir, the  southwestern corner.  The difference

in those .-two heights is less than the height of the John

Hancock Building.  And it is a lot of land area, though, I

will agree.

Leonard.

        DR. SCIIERLIS:   When we made our site visit to Grand

Forks1 the point, you just made was brought home to us because
                                   .

when we went out that evening to Dr. Nright's apartment, as

we approached it, we wfre struck by the fact tiat it was or~n

of several units in a large brick building in which there wasn'

a single';Cndow outsids.  ,$nd this was built. on the basis that.

evzxything faced inside where they had built for all of t,?e
__ _. _ . . : . .    . . .    . .   . . . *. . .   .             . .
mits an ecvironment of plants and ~0x3 groznzry and some

water.  And it wasthe only place I have ever been where you

effectively insu1at.ed yourself from tie outside, both by view

and everything else.  Everythir,g faced in instead of out.

     And if ycu have been out. there, you would know why

                                                     a?@+ .

you faced in and not out as you pointed out.

       I?hen we were there,  91 e program was totally

dominated by the Llzdical Society. Dr. Nright provided a very

strong 1eadersh.i.p by virtue of the fact that he in the Stat"
                             -.

was on2 - of t:1e stronq::st p5op3.0, ::i.xlically.  I think his plan

as far as either subrsgionalization or CiIP I3 agnncies was t0


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? hsvz thz county medical society serve for this U ag%cies and

-2   t.hp_ St.at.~ soci(3ty for t.hE: A agencies.

:3        But anyway, it is very, vn_ry mEdically dcminatrjd.

4           After a f,-,
               -adback session which I rsmcmbbr vary wall,

.jj hz thrust his indax fingc3r in my chest and told rnz that you

6 people from 1'7ashington jUS, + don't. know what is going on out

:7 hare.

*8        AS WB drove to tha, airport, hc obviously didn't. gst.

.9 any happier bacnusz w.a had a minor accident.

10         I think ths feeling out there thsn was that they

11  knaw what thsy were going to do with thair program and didn't.

12  want to have any direction.  k'ind I am impr,assed rgith what YOU

13 havs d.escrib?d in terms of nr~w ciiraction.

         14        I was interested did wz know anything about the

                                                           .                        . . . - .*.
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          15  iI3d3x program.  Is that. being funded through NIP at the pras-lnt

16 tins,? 13zcausz they wzre vEry rxcitzd about it th2.r. bccausc the: I

17  mak 3 r.%fzrznce to it.   '3Ut. I don't know who is funding it.

           MR. 0' FLAiiBXT'1':  D~partnsnt. of Labor.

19             DR.  scIXI1LIs:  It is bzing funded through them.

20          Also, at that. %.ims that was th2 onv Regional

2.1  i,l%dical Program that wasn't rscziving Government funds for

22  cvErhzad.

23 .        MISS KE:j?iZ:  It is asking for them.

                                 'c1- . . .
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I think ths changs in direction is apparent. The

programs do show outr.zach.  They have always had good physic&n

educational prcgrxx3, ar.tl they have had a base for developing,

I think, further onss.  And I would be interested in what the

finzncial rxomqandations are going to be.       -

      I third the documsnt at least indicatss a

significant chang.3.  I don't know Dr. Arznson, but the

document would r-zlfzct 3 change which is a significant one

from essentially a pure county medical society or State
medics1 society based program to a broad,sr base.

        HISS KERR:   It c2r tainly rrads a grzat chang?.

        DR. SCWiIDT:  Eizrold, do you have anything to add

to this discussion?

      HR. FLAIIERTY:  I think th2 group has very aptly
                                  . . . . . . . . . . .    : .           . .
      _.       : '.     .      .d .

&pi&d the issuss, the growth ar.d again scme of the we&n.sssz

that are apparent within fhs North Dakota Regional Hzdical

Program.

    They al-'8 inordinately mort3 outreach crisnted, and
there is a sinckrz drsirz or. the part of th2 staff to change
                               -.

the image h5re 2s well zs to do something tazblFj* in the Statz

cf Nor+.h Dakota.
        .        And I must add when Dr. Arne?son first cams

hzre,  ha met most of ths key IUPS staff.  He had been a

practicing surgeon for a while-, for a long time, and left ths
                             --

staff with a mixzcl i:.;?rzssion.  I gc2ss that would bz kind.

     But hr, .has stuck to it.  Ilc, has engrain5d hims,elf in


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the process and has learned a grea t deal and is again very

255

much committed and  b21 ieves vary much in the concept of

Par ticipative management.  He t.akes his staff, and they sit

around the room and they manage by group style.  He has gone

from on3 end of the continuum almost to the other.

And I was telling him ths last tims I was there I

would sure like to see iJorth Dakota hit a balance between the

complete participative management and management by fiat which

had been the case for four years previous.  But I think we

have some reason to be encouraged.

I met this sumiier with the Board of Directors of the

Nsdical Research Foundation, the group that tenaciously had

clung onto this program and wen, +- cvsr with them the RAG grantee

policy statement. f
    .         Ard it was. their porceptiqn that,they . .
could liva with it, and they have adopted it, which is before

you in the application, the set of rules that are most pragmatic

for a State such as North Dakota.

Their house is in order with respect to th,e R9G

grantee policy.  Representatives from Grants Ifanagement Branch
                                -_                        @S-3-

hava reviewed this and have echoed Iliss Xerr's santimants

wit3 respect to the efficacy and feasibility of thZ bylaws,

' They need to lay out for t.hsnsn1ve.s a three-year

plan which we s.hould S%Z.OR% yc-ar hence and tims frame their

objsctives and to bui3.d in m3rz of a viable- system for

avaluation.  But-. they arc wsll on their way to doing this.


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DR. SCIIillIDT: O.K., lc,t's g$t us a rscomendation

then.

HISS KERR :  All rigllt., bzczuse of these zrzas that.

still r,red son-3 strengthming 2nd becauss of the areas that.

zlmady havs be= -n strength%?d end because there is a feeling

t.hat parhaps they will ha Expmding a great. deal of time ir,hous

still t.0 cmtinue str~.ngtixxC?g ?zh~~~~lvss, I am r,scommsnding

fur,di.r,g ak.tha love1 of $525,000.

DR. SCIIMII>'I':  This is a one year?

                     0

ClISS XERR: YES.

All right, t.hcn, t.hz sscmdary raviwer was Dr. Jamc,s

iicv7 dszs t.!lz.,", hit. you?

          DR.  Jj+g.iE s :  I was 1ookir.g at the funding of the
                          ..:         .    . . . , _ -       .         . . .   .   . .
. . . . . .
prsvious y"zrS, 2nd I cculd very ~511, I think, undsrstzr.d why

tilt2  fundkg 1sv~l.s wzrz all of such a small nature: whc,n it is

cbvious th-?t or.3 cm SEQ ;?orhzps a chsr,gs in diractioz with

obvious icvolv3Xmt of th3 co;;L-nunit,y 1:~sourcss and t.hc, progrsss

                    
is to bs zedz=i.

not 'to put E progra in jz9pardy because of insufficisnt

funding to giv- them 2 lit.+lz bit. morrs.  Bs,c;luse I think it.

wonder would w.2 not. skynic their 2ffort.s and prcbably break


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their spirit..

DR. SCIH4IDT :  They wire at $323,401. .

PlISS KERR:  For 1G months.

        DR. SCK-IIDT:  The 431 was 16 months.   So the

ennualized lzvel was $323.  So this would be $200,000

addition in 8ssxx8.

        DR. JAiES:  I would like to r3commlend around $600,000
                                                           --

        DR. SCIIMIDT :  Wall,  that. is out of order.   There is

a motion on the fldor.  I will ask for a s&ond.   And thsn

if thz motion dies, wp_ wili have to --

        DR. LUGINBUHL:   Second.

         DR. SCIPIIDT :  All right.,  thsra is then a seconded

m~ticn cn thz flocr at $525,030.

         Mr .  To0ms.y.
                 . .
      . .              . . . . . .    . . . . a      . ,,.:     . . . . . .     . . . .:..

        PIR. TOO;-IEY :  No , that answered my question when you

annualiz? those dollars for salary.

      DR. SCIIXIDT: It is'$323,401 annualized.

        Dr. Hass.

       DR. EItiSS:   I notics that. substantial part. of tip_ir
                                -_
incrzass is for cm2 staff.  And I didn't hr;ayt.oo 'much about

what. that WCS going to do.

     We do have a lettar h3r2 which says all their

currzztly budgsted staff positions arz now filled.   And do

you hav- a god f2.21 -Zor w:?s;t t-.ho additional corz staff non2y

will do for that program?


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10   come  in with core staff and feasibility studies only.   So what

11  they did was to come in with a full-blcv7n operation one-year

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MR. POSTA:  Excuse me, if you take a look at page 6

on the yellow sheet, tilers is last y.zar's requn,st and also

an att.?mpt to brsek dob7n to ,t.he annualizcld level for the

last year.  So that that would give you-some basis for

.

MR. FLAHERTY:  In a nutshell, to compromise the two

positions that existed at the time of their R&G mteting

blob7n package with 'no feasibility studies.  The other was to

.packagl with feasibility studies.  So there is $120,000 of thz

program staff requ&st that is for fsasiblity studirs cs was

ra,cornrclend%d by tho,ir planning and evaluation committra to furth
                                                                           . .
            . .                 . . . .

design 2nd assess their ne?ds that ,%xist. in 2Jort.h Dakota.

MISS KERR:  The orientation of tho,se three new

as we talked about it.

                    .
         DR. SCiIl,!IDT:  Leonard,  comments on th5 $525,000 lov~~l

                                                         csz9
         DR. SCiICRLIS:  I think that is rsalist.icI  It is a

very' significant incr?asR ovEr wheat th3y have nov7.  And it is

cDm?arad to what.  As compared to $323,000 that w9 are talking

zbaut. $525,000.

                                      I
        I don't knc/- if t.11q could s;Icnd 2s much as they ark
asking for with I:Z;J lEadc?rship.  I am sure they will spnd


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ths $525,000 very wall.  They would probably spsnd $550,000

or $575,000, too, but I think $700,000 is high.  Where you

placx? it in betW3Pn, I think is a matter of judgmznt..

4            MLSS KERR:   If ther8 is a strong enough fodling

5  among the group, I will rescind tha motion for.a compromiss.

6           DR. JIV4ES:   Let rnE? say that now that I have had a

clearer understanding cf what t.hG annualizEd funding was, I

can morE rzaclily accept. ths figurr.

DR. SClI>IIDT;   John.

10           DR. KI-ALETJSKI:  This commit&s is getting too

11  friendly.

       l?

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I lik? thE --               ._i

DR. SC,III:IDT:  I EIn ir.t.crzst?d in what is coming cow.

        DR. KRALCiJSKI:  I like your suggssted amcunt,.but I

              .               ,-- . . . . . . .....       .         . .

wonder if ycu would have some edvic.s to them as to how much

16  cf that should be sprnt for core staff and how much should be

17  sp";nt on projc,cts cr can w=, do that?  :4aybe we3 can' t..   I think

        18
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thrir cars staff is gstting pretty largs. for that small area.

        DR. SGIKUDT:  We can giva them advice.  Generally,

*our funding level 142 arrive at. by saying so Eh for ocro,

so milch for projects, but t.h?n ths money is theirs.

DR. KRALl3JSiiI:  If they  lcez p using it up with core,

23

t.hzy ara going to do some rn,ally fantastic studiss that really

                             -. -..

lcok grzzt, but --

15
          25

KtSS KERR:  It is a littla ovcsr 70 pe-rccnt of ths


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11        And that motion czrries.

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total amount budgeted for cxx?.

       DR. SCiIi~IIDT:  Again, it is 70 pzcent of what?

        l.lISS KERR:  V&11, thsir total.

      . DR. SCWIDT:  All righty.  Going once, going twice.

All right, I will put the question than.  And the

motion is one year at $525,000.

All in favor plEasz say, "Ayz."

(Chorus of ayes.)

oppased, "NO."
                     .
(x0 response.)

All right, ths group has dona well.  FQe havs five

major r-,visws out of the way.  Tomorrow wz have fiva mere
and then a r,umber of SnnivErsarizs within cho, trien$um. of .
             .                             . -
                        . .      . .

anothsr 9 regions.

     So that in answer to soms qu%tions about how long

VJe would 9'3, I would wish that peopl- D not chenge their plan%

to too early in the day,  I would think we wculd probably go

until after lunch unlrss we don't discuss re,gions zn hour at
                                -_                 w!ze .

a crack which is kind of what vre hzv.2 besn doing.

So I will predict ~7'1 frill finish at 2, 2:30 type of

thing tcmorrow.

DR. TIIUlI;.lAN:  ~~l&ro i~ew York trill carry us to there,
               ---..

I.Ir .  chairman.

DR. SCII:X!ZDT:  All right., let's makr? it 3:30. In


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thar words, I don't think VJE? arEs going to finish at noon.

     Your rating sheets, you can lzav@ right her2 with  the

latarial, and we will reconvens at 8:30 and bc-gin sharply

,&hen.

     -Thank you.

      (Uhereupon, at 5:30 o'clock p.m., thg, msuting
:eczsszd, to reconvene at 8:30 a.m. on Thursday, January 18,

.973.)

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