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                                                                   E001 745















                                     NATIONAL ADVISORY COUNCIL

                                             TRANSCRIPT

                                           June 13, 1974




   W Li D -
                                  NATIONKL ADVISORY COUNCIL ON

                                    REGIONAL MEDICAL PROGRAMS



























                                       BOARD MEETING

















                                                           9:00 A. M.
                                                           Conference Room G-11
                                                           Parklawn Building
                                                           Rockville, Maryland

                                                           Thur@day
                                                           June 13, 1974




     WHD-151


                                         C,O N T E N T S


                   SPEAKEP/MOTION              EEGIN      MOTION    PASSED    FAILED


                   Doctor PAHL                   3


                   Doctor MARGULIES              5


                   Doctor   GREENE             19
                      Discussion               26
                   Mr. RUBEL                   29
                      Discussion               41
                  'Dr. GOODMAN (Item 6)        51
                      Discussion               55
                   Mr.-REARDON                 63
                      Discussion               71
                   Doctor PAHL (Report)        75
                   Doctor GRAMLICH.            8,5

                   MOTION (Minutes)              98          98       98
                   MOTION (Mrs. MARS)          118         119      119


                   ARTHRITIS                   128         130      131
                      -do-                     136         136      144
                      -do-                     145         148                 153
                      -do-                                 154      155


                   CALIFORNIA                  169         173      174.


                   GEORGIA                     175         179      181


                   LOUISIANA                   182         189      190-


                  .PUERTO RICO                 191         196      196


                   MISSISSIPPI                 197         209      209

                   NORTH   CAROLINA            2-15        221      221

                   SOUTH DAKOTA                2,22        223      224

                   INTER-MOUNTAIN              225         243                 244
                                                           244      246

                   SOUTH   CAROLINA            147         250      258
                      Substitute               261         261      273


                                                                                     1

                                                                                 3

 @qD/en,                                 P R 0 C E E D I N G S

                              DR. PAHL:   Good morning.  I  would  like  to  call the

                   meeting of the  Ilational Advisory Council in Regional medical

                   Programs to order, and I would first  like  to  welcome  to  the

                   council table the new members of   the council.


                              Since we started a few  minutes late and there has@


                   some socializing, I have a suspicion  that  most  of  the  new
                   members at least recognize and have  perhaps  said  Hello  to  thei

                   current members of the council.  Since  we  will  be  here  for


                   two days, why, we will make every opportunity to.get you

                   acquainted with each other, but we  do  welcome  the  new  members;

                   and we are very happy to see the standbys here with us.

                              In that connection I  would like to say that we are

                   particularly happy to have three  members  on  the  council  who

                   represent reappointments.  We feel   very  fortunate  in  having

                   Dr. Kamerof, who cannot be with us    at this meeting  but  who

                   did attend the orientation meeting    last month,, llr.  Sewell

                   Milliken and Dr. Ben Watkins are ]lack with  us,  and  we  are

                   very pleased with that.

                              I would like  to.comment, for everyone in the room,

                   that this session of the council meeting is the open session.

                   We are delighted to see a  number  of  visitors  with  us.  We

                   wonot take the opportunity to  identify  you,  although  we  do

                   know who some of you are; and I  would  expect  thatt  at  the

                   appropriate time, before we go into our closed session,





                                                                                4

                  possibly very late morning or early afternoon, we will make

                  an opportunity for any member here of the public to make

                  whatever statement or comment he feels to be appropriate.

                  And if that does occur, I would ask the individual who wishes

                  to make a statement to please identify  himself  for  the  record.
                  And if he is representing an organization, if he would please
                  identify that organization or unit.

                             I wo uld like to introduce to you the  people  here  at-

                  the head table.


                             I must say this is a pleasure,    We have been known

                  to use smaller and smaller tables over the past years.  So
                  it's very nice to see a full complement down this end and

                  also up here.

                             I think that most of you, or a good many of you
                  of course, know Dr. Harold Margulies in the center here, who
                  is'the Deputy Director of  the  Health  Resources  Administration,
                  and will be making a presentation to you very shortly.
                  Again, most of you are familiar with the fact that Dr.
                  Margulies was a director o f a program for  several  years  before
                  moving into this position as Deputy Administrator.
                            On my immediate left is Dr. John Greene, who is the
                  Director of the Bureau of Health Resources Development in
                  which bureau we are located; and Dr. Greene has taken some tima
                  this morning out of a very busy health manpower legislation
                  activity that is going on currently to comment, and I think




                                                                               5

                   we will have'some comments along those lines that will be

                   interesting to you.

                             On Dr. Margulies' left is Mr. Gene  Rubel,  who  not

                   only is the Acting Director of a comprehensive health

                   planning program but also has the responsibility for

                   coordinating internally and in conjunction with what we believe

                   to be the new legislative directions,  the  Health  Resources

                   Planning activity of the Bureau, and is Associate Director fo

                   Health Resources Planning in Dr. Greene's  Bureau  of  Health

                   Resources Development.

                             Mr. Chambliss, on the far end of  the  table  here,

                     am sure you all have met.  I know that, as the Deputy

                   Director of the Division of Re' ional I-ledical Programs.  And
                                                  9

                   Mr. Ken Baum, on my right, through whose good  offices  ,  and

                   Mrs. Eva Handel at the entry table, this meeting has been made

                   possible, for all of the mechanics and  materials  that  have

                   been coming to you.

                             Now, with  those introductions out of the way, I

                   would  just indicate that we have a very heavy  schedule  for

                   this particular council meeting, and in order  not  to  unduly

                   delay the other activities that these  gentlemen  have  before

                   them today, I will hold off my report to you and first ask if

                   Dr. Margulies would give us some perspective  from  the  point

                   of view of the agency on matters that I know will be of

                   interest to you.






                            Harold.


                            DR. IIARGULIES:    There are two or three general
                  subjects I would like to raise with you, without taking up

                  too much of your time, but all I think relevant to the

                  deliberations of this council, and I think to the general

                  level of interest which you have in-the health affairs of the

                  nation.

                           When this council last met, a number of you were

                  not present, so let me briefly sketch once more the organize-'
                  tion of the Health Resources Administration, so you know what
                  is in it, and what it represents in terms of federal health

                  activities.

                           In fact, it's probably useful to those of you who
                  were here before, because there has been enough reorganization
                  to be confusing even to those who are very close to it.

                           The Health Resources Administration was created
                  with the belief,, which I think is basically valid, that there
                  is aneed to address the issues of resources and the use
                  of those resources in the delivery of health resources in a

                  rather special and.unified-way.
                           This council and the activities which it supports
                  are very pertinent to those concepts.  It is noticeable
                  in fact, as you look at the introduction of major legislation
                  and particularly as you follow the introduction of legisla-
                  tion national health insuri@-ice'and the debates on it, that






                                                                            7

                  they tend to divide into two major portions:  one of them

                  representing the processes of reimbursement; and the other

                  representing the processes by which reimbursement leads to

                  effective and acceptable services.

                           And, in fact, one of the legislative proposals,
                  the Kennedy-Ilills bill, goes far enough as to identify these

                  as separate responsibilities, placing the payment mechanisms
                  in one type or form of structure, and the health resources

                  in'another.

                           So that I think the philosophy and the dynamics
                  are fairly convincing, that if one is to set about paying for!
                  services as a general national responsibility, one must also
                  set about the business of finding out whether those payments
                  lead to effective services available to all of a reasonable

                  quality in a manner which is economical efficient and able

                  to contain costs.

                           That is -- the latter part is where IIRA is.
                           Ilow, it would be exaggerating things to suggest that
                  HRA represents all of the-capacity in the country to deal with:
                  health resources.  On the-contrary,, the capacity for meeting
                  health needs in this country remains essentially ovenqhelningl
                  a private function of the private delivery system,, and there
                  is even,- intent that it remain there for whatever period of
                  time is necessary to have the job done, hopefully forever.
                           There is, however, in IIRA, Ilealth Resources Administ!ra-




                 tion a collection of activities.which is sensitive, critic.@-,
                 and, in the course of events, could make most of the difference

                 between a different and an excellent result as we  continue
                 with our efforts to utilize federal resources for general

                 benefit.

                           If you look at the structure, you will find  that
                 the three bureaus contained in any particular order you wish
                 to take, the resources or the capacities necessary to develop
                 data statistics or, in a broad sense, the intelligence
                 required to understand what is going on and what needs to be
                 done in the health delivery system, and this is largely
                 in the national Center for Ilealth Statistics.  It contains
                 a significant part of the federal effort and in some ways
                 the leading edge of health services research which will
                 assist the country in understanding ho@i better to do what
                 it is attempting to do in the delivery of medical care.
                           This includes economic analyses questions,  the
                 quality of medical care, the development of new kinds  of
                 systems, better types of communication and recording,  et

                 cetera.

                          And in the third bureau, which is  represented by the;
                 other people at the table here, those activities which have
                 to do with the supportive institutions which produce  the
                 health manpower and with other.aspects of effective uses of

                 health manpower.




                                                                            9

                                          es which have to do with the federal
                            Those activiti
                  interest in developing health care facilities., hospitals.-
                  nursing homes, and so forth, and the planning elements which
                  are probably, along with the intelligence elements,, th-
                  key contributions which IIRA can make to a better understanding.
                  and a better delivery,of health services, now, and even more
                  so in the future, with national health insurance.
                           We have been trying to integrate these activities
                  so they represent a common kind of a function.  It is not
                  difficult for me as an individual having coming from the RMP
                  to move strongly in the direction of an effective planning
                  activity and to recognize the relationship between what this
                  council does and effective planning.
                           I was pleased not long ago, because this kind of
                  recognition comes rarely, when someone gave me a certificate
                  which is based upon the contributions I had made to compre-
                  hensive health planning.  I have been trying to do that
                  since I came to RMP.
                           The first statement I made when I came to Regional
                  Medical Programs was that this program, RMP, must be dependent
                  upon an effective planning process which, at that time and at
                  the present time, is comprehensive health planning.
                          That confused people initially, but I think in the
                  course of time most people became dedicated to the concept
                  that there is an interrelationship beti-ieen the tv7o; but that




                                                                             lo  I

                  a planless system is an undesirable system,, and that therefore
                  effective planning was critical to effective use of  always

                  limited resources.

                            So HRA is moving along, but still facing some real
                  problems.  Its problems  are those which are familiar and
                  which seem agonizing to visitors to Washington, they seem
                  agonizing to those of us who live here as well, when we get
                  to mid-June and we have no legislation which authorizes  us
                  to stay in business and no appropriations to pay for us  if

                  we did stay in business.

                           That's- not really too remarkable.  It merely has to
                  do with the pressures of other events in Congress and in the
                  Administration.  And there will be legislation which will
                  extend those in a variety of ways, and there will be
                  appropriations which'will probably come in varying periods of
                  time, some of them soon enough, some later than they  ought

                  to.

                           Of most interest to us h'ere is what may appear in
                  the form of new legislation which extends the activities of
                  RMP,, CHP,, flill-Burton, and-so forth and I,will comment on

                  that in just a moment.

                           Ile will almost certainly have, without much
                  difficulty, an extension of the legislation for what was the
                  National Center for Ilealth Services Research and Development,
                  now it's the Bureau of Ilealth Service Research. That will,,






                 I think, pass without much difficulty or delay.

                           The same thiAg is true for the National Center  for


                 Health Statistics.


                           My own personal concern, and I think the concern of

                 the agency in this particular context is to give very high

                 priority to the development of an enhanced and growing

                 capacity in the National Center for Health Statistics, @o

                 develop an intelligent base, a source of knowledge and

                 information, and analytical capacity which we do not have  in

                 this country anywhere at any level, and to do it in such a

                 way that it's useful at the national level, at the State

                 level, at the urban, the inter-urban level.

                           So that when people attempt to get something  done,

                 they know what their base is that they begin from, where

                 they are going and what needs to be done.   This is clearly

                 top-level priority in this agency, along with an effective

                 companion planning activity, to make sense.

                           The passage of the legislation, therefore, for thOSE

                 two activities is important, but the sense of Congress  which

                 goes into whatever they propose is even more important.

                 Ilealth manpower legislation is highly uncertain at the presen

                 time.  The bills which have been introduced are variable.

                 The Adriinistration's.bill moves in one direction, the lIouse

                 bill in another, and the Senate bill in a third.

                           There are points of agreement, and many points of




                                                                                 12

                  great disagreement.    What will happen  with  what  has  been

                  known as the Ifill-Burto,.'l legislation is also  uncertain,

                  because the Adrqinistration-does not  propose  to  extend  the

                  traditional Ifill-Burton program.    The Senate and the Ilouse

                  have other versions, and that will   make a considerable amount

                  of difference.


                            As I  am sure you know, a planning bill   which   is  to

                  extend, as I indicated a moment ago,, CIIP,, Ilill-Burton, IUIIP

                  and some specific  activities  like  area  health  education

                  centers                                                     far
                           has not yet been   reported out; but  it  has  gone

                  enough so that one has reason to feel  secure  in  what  it  will

                  produce, what kind of a bill we will have.  And I think there

                  is reasonable optimism now about the passage of new legislation

                  in the fairly near future.

                            In any case, Mr.   Rubel and  his  staff and the staffs

                  of HRA have been working  assiduously  and  I  think  rather

                  remarkably to anticipate  the  passage  of  new  legislation;,

                  have actually been looking at multi-ple possibilities and so

                  are prepared to move in  whatever  direction  Congress  and  the.

                  succeeding regulations require they move.

                            I think the transition will be    much less   difficult

                  because of that kind of effort, than it might    have been had we

                  merely waited for the events to catch up with    us.

                            I think vihat we shall probably  see  in  the  new

                  planning legislation is a combination of the Administration's





                                                                             13

                  bill and the Rogers bill    and rather than using those names.;

                  let me tell you essentially what would be contained in the

                  activities.

                            There will be legislation to support within States I

                  a planning activity which is essentially designed around a
                  combination of public and private interests which act together,
                  the planning agents will be private, non-profit in character,
                  and they will depend heavily upon an interrelationship
                  between what needs to be done and the capacity of the
                  market and the professional and public leadership to respond

                  to sensible planning activities

                            There willo in all likelihood, be an associated
                  agency established at the State level to coordinate, review,
                  approve those kinds of plans and to make sure that there  is

                  a balance in those kinds of authorities.

                            There will, in all likelihood  be a separation
                  between planning functions and regulatory functions,, but the
                                                                              y
                  will be -- certainly the regulatory functions will remain the
                  State's responsibility, like those that are associated  with
                  Section 1122 of the Social Security Act, which is  concerned
                  with the construction of new facilities, the addition of new
                  beds,, et cetera; the kind of certificate-of-need legislation.
                           That kind of planning authority would be an
                  improvement on an extension of comprehensive health nianning.
                  It would contain a modest amount, I suspect, of developmental





                                                                            14

                  funds in order to make things happen which might not  otherwise
                  happen, but primarily as a kind of stimulating or  coordinating
                  or catalyzing activity, rather than having a large outfloVT of
                  funds to dov7hat appears to be desirable at the local level.

                           If this is done so that the legislation makes good
                  sense and is manageable, and if it represents, as many of us
                  suspect it does, a modification in planning understanding
                                                                                t
                  at a time when people have begun to appreciate more fully
                  the importance of planning, in fact the essential character

                  of it, and with the high likelihood that we will have
                  nat ional health insurance in the fairly near future, we will
                  have a combination of better legislation, strong federal
                  support,, better State understanding and a new zeal, I
                  believe, to put some rationality into the system.

                           I can imagine no way in which any kind of legisla-
                  tion will prove effective if the decision makers of the
                  country have not reached the conclusion that it is better to
                  do it sensibly than by guess and by chance; and I think we
                  probably have reached that point, although not consistently
                  throughout the country.

                           T@ere it has been inconsistent, I am sure that Mr.
                  Rubel will help to make it more consistent.  That will be an

                  Interesting activity.

                           This council now, in reference to that kind of
                  legislation, has a heavy kind of concern, and I would like




                                                                            15

                  to make a particular pointin reminding you of what this

                  counc,.  is and does and should do.  It's a rather remarkable

                  arrangement.

                           The National Advisory Council was created by

                  Congress, saying to the nation and to you members of this
                  council that you are to be depended upon to carry out the
                  will of Congress in ways which combine your understanding
                  of the legislation, your concern of the Public welfaret and

                  your various kinds of professional skills.

                           This council is unusual in that it is given  more
                  authority for the approval of g@ant awards than are councils

                  generally in this government.

                           You are told that you will be given some applica-
                  tions which have been carefully reviewed and which have
                  been put in a form of presentation which you can understand,
                  and understand quite readily.

                           And that you will make recommendations to the
                  Administration, without which grant awards cannot be made,
                  but which do not necessarily represent the amount of the
                  award that will be made.  In other words, you have a veto
                  power and you have an approval power.  If,, howevere the
                  approvals which you provide exceed the funds that are
                  available, quite clearly there are adjustments which have to

                  be made.

                           The forms in which you make your actions, the comments




                                                                               16

                  which you make represent the distillation  of  public  interest

                  representing Congressional action and your final  move  in  the

                  direction of public welfare.

                            It is a heavy responsibility, and one which

                  requires your greatest possible attention.  It becomes

                  especially difficult how* because you are encumbered by a

                  rather chaotic history of IUI.Pls, certainly in the last eighteen

                  months.


                            You enter into-it  in  what are administratively and

                  ethically perilous times# so that you need to pay close

                  attention to what you consider to be right and wrong.

                  And you are also looking at a set of activities determined.by

                  a court order which at the same time move in the direction,

                  we are certain, of new legislation before-many of these

                  activities are well launched.

                            You will therefore have to express some judgment

                  about how these activities need best be carried out.

                            It seems highly likely that before  the  funds  which

                  you are going to be looking have been provided for Rr4P'S,
                  and certainly before they have been  formally  expended,  there
                  will have been new legislation, new considerations, and

                  new activities facing those organizations which receive these

                  grant awards.

                            As a consequence, you must keep open the likelihood
                  that there Still be a new set of pressures on institutions here




                                                                              17

                  and elsewhere throughout the country which may  determine  the

                  best possible use of these funds.

                            I think these ideas need to be set well  aside  zrom

                  your basic concern, fror-.i the fact that you are operating

                  under a congressional Act, which has not been  changed,  under
                  court orders which are quite clear, and under a  public purpo.sq
                  which you are the best individuals available to determine.

                            Now, finally, let me say in that regard,  and  asa

                  special note again, taking advantage of an  opportunity  to   be

                  personalized, that those of you who have served on  the

                  council before, and many who have not, are fully aware  of

                  the tremendous workload which is involved in bringing  to  you

                  grant applications which have been reviewed, given the best

                  possible consideration to be put in form for you to act upon.

                            In past years this was done by a large staff, and
                  it was hard work.  This time it was done by a much smaller

                  staff over a shorter period of time under extraordinary

                  difficulties.


                            It is customary to give thanks to a staff  which
                  has operated in these circumstances.  This is no customary
                  comment. This has been an unbelievable  undertaking  by  tho--
                  who are dedicated and who care and who have done what they

                  have done because they believe it needs to be done.

                            They have done it in circumstances where their

                  e.-,.istciice is threatened, where their jobs are unsure, wher
                                                                            e




                                                                            18

                  their future is unknown, and where they have been given.dam

                  little encouragement from any source at any level.

                           And this goes, certainly, probably several times

                  over for Dr. Pahl, and down on through the entire organization,

                  It has been remarkable.  There is no kind of award, there is

                  no kind of statement, there is no measure that I know of

                  that can fully recognize what difficult times these haVe been..

                           I remain astonished that people will'work that
                  hard, with that much vigor and that much honesty, in the
                  circumstances in which they have been placed.  And I am very,
                  very grateful to them, and I am sure you will be before you

                  are through with this council.

                           Nowt if there are any questions that I can

                  answer, after what has been about as long as I-expected to

                  talk, I will be glad to respond.

                           DR. PAIIL:  On behalf of the staff and myself,
                  Ilarold, thank you very much for those comments. I think we

                  do indeed appreciate that commendation.

                           Are there any points -- I believe you can stay a
                  few minutes longer, but perhaps you had better nab Dr.

                  Margulies while you have him.

                           If you need anything else from that agency point of
                  view on the tenth floor.

                           I should add here I am glad Dr. Margulies charged
                  1.1r. Rubel with bringing consistency into government, and we




                                                                                  19

                   will be working toward that end, too.

                              Well, perhaps we might move  on to the next  speaker,,
                   and I am particularly delighted to bring to you Dr. Greene,

                   to discuss again matters of importance to the council from

                   the Bureau of Health Resources Development.

                             RMP has been located now in three agencies since
                   its history. It started off  with  the  14ational  Institutes  of

                   Health as a home; it was then moved to the Health Services

                   and Ilental Health Administration, and when  that  was  organized
                   last July 1, we moved him to the  lIealth  Resources  Administra-
                   tion.  Since last July we have been in two bureaus of the
                   three bureaus of that aaency, and  I  am  particularly  delighted
                   to state that we are presently  under  formal  consideration  for
                   inclusion in only one bureau, and it is Dr. Greene's Bureau

                   of Health Resources Development.

                             DR. GREE@TE:   Thank you very much, Herb.

                             I do appreciate the opportunity to meet with the
                   council.  It's my first opportunity to do so.

                             In looking at the agenda, I have just noticed that
                   it's a morning filled with remarks, and I guess tl-Lat's kind
                   of a remarkable morning     if you turn it around the other

                   way.

                             I will keep mine very brief, so you  can  get  on  with
                   the rather full agenda that you have.
                             And I know, since it is scheduled  on  here,  that  you




                                                                              20

                 might be working on Saturday, I am sure that you  are  anxious

                 to keep things short at this end so you can riavbe get out  of

                 here, so you don't have to,worl-, through the weekend.  So

                 I will try to help you in that regard.

                           It is a pleasure to follow Dr. Margulies, and to
                 echo some of the comments that he made very  briefly about
                 the adverse situation under which the staff  has been  working
                 here in relation to the Regional Medical Programs and in

                 relation to all of Health Resources planning.  And the

                 outstanding dedication and work they have done, as I am

                 sure you will recognize as you work through this council

                 session.


                           But I will let it go at that and add an "amen" to
                 what Dr. Ilargulies has said; and I an, very grateful to them,

                 .as I an sure you will be, too.

                           I would also like to congratulate you as the
                 council and the Regional liedical Programs in general, for
                 the work that has been done and the-work that vou are doing,
                 and the perseverance of the people who have been dedicated tol
                 Regional Medical Programs through some rather adverse and

                 difficult tines.

                          The fact that you're continuing to carry out the
                 purposes that Dr. Margulies outlined on Regional Medical
                 Programs in the interest of the public and public concern,
                 and congratulate you for it, and I want to express my




                                                                               21

                   appreciation to you and  to the Regional liedical Prograrrsin

                   general for that effort.

                             Dr. Pahl mentioned that the Regional Medical Programs

                   now scheduled to formally move into the Bureau of Health

                   Resources Development, and there is a formal request to make

                   that formal, although we have been operating  this  way  since

                   last February; that there is a request now to  make  this  A

                   formal transfer.

                             We have not a formal, official reply to that, making
                   it official, but it is expected to come at  an  early  date.

                             14ow,,.Dr. Margulies indicated that the Bureau  of

                   Health Resources Development, into  which  Regional  Medical

                   Programs is moving, included the comprehensive health plannind,-

                   Ifill-Burton program, as well as the old Bureau of Health

                   Manpower Education, which has, as its legislative base, four

                   pieces of manpower legislation:     the  Comprehensive  Health

                   Manpower Training Act of 1971; the Nurse Training Act; the

                   Allied Health Act; and the Act that  covers  Public  Health.

                             Now, all of these pieces  of  legislation  affecting

                   manpower expire at the end of this month, and we have been

                   .quite busy on the Hill and within the Department,  trying  to

                   help fashion a new piece of manpower legislation.

                             I thought I might just comment on that for a few

                   minutes, because I know Regional Medical  Programs  have  been
                   quite busy and active in the manpower area, and I  thougl-4-
                                                                            ,I, you.




                                                                             22

                 would be interested a little bit,as to what the  current  scenel

                 is and what might come out of it; and I will try to make  this

                 brief.


                           But, as you probably know, the Congress is -- the

                 Congress and the Department and the general area of  manpower

                 and education are more concerned now about the type and

                 location and utilization of manpower than the total  numbers  of

                 manpower as had occupied the scene most since the Health

                 Professions Educational Assistance Act started in 1973.

                           The focus up until this time has been largely on

                 shortages and trying to increase output, of number of  health

                 professions of all types.

                           As we move into considering what is needed over  the

                 next three years or the next legislative cycle, the  emphasis

                 has shifted away from a focus on continuing massive  increases

                 in output and has shifted to greater focus on other  problems

                 problems more of location of people, geographic location of

                 people to deliver services;  the types of people; the

                 specialty distribution question; the problem within  medicine.

                           The greater emphasis on trying to increase

                 productivity of health workers of all types, with great concern
                                                                                I
                 about the continuing qualifications of people after they  are

                 out in the marketplace, and out delivering services.

                           Now,, as to how this all will come out is anyonets

                 guess at the moment, but let me just run down some of the




                                                                            23

                 provisions,, some of the kinds of things that are being given

                 attention a little more specificity than what I've just

                 mentioned.

                           I-Ihile there is less emphasis on continuing to

                 stimulate increased output, there'is general interest and

                 concern about the stability of the institutions that do

                 provide manpower.   This interest and concern is expressed
                 in different ways, in different pieces of legislation  those
                 of the Administration,those of ilembers of Congress.  As you
                 are probably aware,,    the Institute of Medicine study which

                 recommended a certain level of capitation..  The Congress
                 has been quite interested in that study, and the recomenda-

                 tions made by it, and are likely to latch onto those

                 recommendations in their committees.  That is, in my estima-

                 tion.


                           Ilo@.;ever,, the Depart,,nant is reconiending lower
                 levels of capitation  to maintain stability of the institutions
                 than was recommended by the Institute of Medicine study.
                 But in all likelihood there will be continued levels of

                 support for the health professions' institutions.

                           1401.1,, it also -- there also is a lot of interest in
                 exacting something in return for that front-end money or
                 basic support.  As a minimum it seems that there will come
                 out of this a requirement that the institutions at least
                 maintain the current output or current enrollment of matters





                                                                            2 4
                  of people within their school.  I think that's a riinimum..
                            Now, it goes on from there in some of the proposals
                  in Congress to require such things as having to  be
                  eligible for such capitation  support that all students
                  within the school would either agree to serve in the national
                  Ilealtli Center service corps or serve in some shortage area
                  or shortage profession within the country.  This is in the
                  Kennedy bill, and this is an extreme at one end as to the
                  kinds of requirements that mav be placed or could be

                  placed on capitation support.

                            It ist I think, unlikely that what will come out of
                  Congress will be to that extreme.  I do think the Congress
                  will ask for more assurance, that the  institutions will be

                  addressing the problems of geographic  distribution and the
                  problems of specialty distribution than they have in the past.
                           The question of specialty distribution, the major
                  concern is the growing shortage of persons to deliver
                  primary-care services,, and I think-we can expect out of the
                  legislation much more emphasis on getting involved and the
                  whole area of graduate medical education to assure that there
                  is a turnaround and a drift towards an increased output of
                  persons prepared, specially prepared to deliver primary care.
                           @d,  again, the proposals to Congress vary in the
                  strength of the leverage that they would apply to accomplish
                  this.  Some are quite direct, and others are more indirect.





                                                                             25

                            I think it's very likely that we would have some-
                  thing fairly strong in this area, because of the general

                  concern,


                            I mention again the question of geographic
                  distribution and what is likely to come out there.

                            We have been, I thinkf essentially unsuccessful
                  so far in materially affecting the geographic distribution or-
                  health resources -- of manpower resources, and because of
                  the very general and ser,)ous concern over this issue, I think
                  we may see fairly strong language and fairly.strong provisions
                  in here on this issue.  And this becomes an area of particular
                  concern to you, because you've been trying to do something
                  about this in the past.  It becomes an area of concern to the
                  whole Ifealth Resources Planning,, because this is an area
                  that must be addressed  to the development and distribution
                  of manpower to serve the country in the future.
                            There will be greater emphasis on productivity and
                  greater emphasis on the development of health professionals
                  who can work together and, in a team concept, utilizing para-
                  professionals to their maximum to deliver the most quality
                  services at the least cost.

                           The committee in the lIouse is novi in the process
                  of rqarking up a committee bill this week.  There will be
                  Senate hearings, or they are scheduled now to be held on
                  June 24th.  13ecause hearinas have not been held in the flouse




                                                                               26
                   to this date, it's highly-unlikelv that we  will  have  anything

                   to work with, a new bi'll to work with by the end of this

                   fiscal year.  It will probably be a few months yet, in my

                   estimation,, before we're ready to implement the  new  manpower,

                   the new piece of manpower legislation.

                             One other element in the new  legislation  is  likeIly

                   to be, instead of having the four pieces of  authority,  we  are
                   likely to end-up with two instead of four.  And  one  would  be-
                   for nursing, preparation of nurses; and the  other  would  cover

                   all of the other health professions, most likely it will

                   come out this way.

                             I will stop here now.

                             DR. PAHL:   Thank you, John.

                             Perhaps you'd be responsive to questions.

                             Dr. Haber?


                             DR. HABER:   Dr. Greene, in the  move  towards

                   greater provision of primary care it seems to  me  there are a

                   couple of ontions on a national basis, and I  wonder  if   you
                   could enlighten us as to what congressional thinking,  as to
                   which option seems to be most in their thinking, or are

                   they equally concerned with all of them?

                             I am tallting now about the move to increase the

                   scope and number of allied  health  professionals,  particularly
                   surrogates for primary care, in the nurse clinicians, pl-.ysici,---i

                                                 4
                   assistants, or are they more  Lkely to try to remal:e medical





                   education so that more physicians go into primary care?

                   or are all of these options equally significant?

                             DR. GREENE:    The primary attention in the

                   discussion so far in the Congress has been more towards

                   redirecting graduate medical education.

                             Hoiiever, there is interest on the other option that

                   you talked about as well, and likely the legislation will

                   provide authority to pursue both.

                             And in my opinion both need to be pursued, and I

                   thin]-,.there i-iill be legislative authority that will enable

                   us to do that.


                             But most of the discussion has centered around


                   attempts to shift graduate medical education or primary-care

                   specialists.

                             DR. PAIIL:  Are there other questions or comments

                   by the council?

                             Dr. Jane@.7ay?

                             DR. JAITEI-IAY: Do you think, Dr. Greene, that two

                   bills will come out of the House Subcommittee oii Health, or


                   just one?

                             DR. GREENE:    I-Ihen it first started, I thought

                   there would be only one.  The reason I say it now, and I

                   had not said it at first, I think there might be two is

                   because the Roy provisions have now been picked up in the

                   Kennedy bill and will have to be talzen seriously no-.,,,, I





                                                                            2 8

                  And Mr. Rogers nay hold out and not want that in his bill

                  that he participates in, and other members of the committee

                  may decide that they want to follow more down the line of

                  the Roy provision, and may come out with two bills.  It  s

                  hard to tell yet, since they are just starting.

                            They may come out wi th two instead of one.

                            DR. PAIIL:  Dr. Janeway, would you care to give your

                  assessment?


                            DR. JANEWAY:  No.

                            DR. GREENE:   I'm just reaching out for that one
                  at the moment.  They are going to make -- they are making an  i
                  attempt right nowt they are in session today to try to

                  compromise and try to come to one bill.

                            But I do think the Roy provisions have to be taken  I
                  seriously, more so than a lot of people thought earlier, at

                  the beginning.

                            DR. PAIIL:  Are there further comments or

                  discussions?

                            If not, I thank you, John, and hope you can stay

                  as long as possible,
                                      or drop in if your  schedule  permits.
                            I would like now -- we have not forgotten coffee,
                  for those of you who didn't find a cafeteria earlier  this
                  morning; but I think we might wait for that until we  have

                  had the remarks by Mr.
                                        Rubel, because I really do feel that
                  this package of presentations will give you a  perspective





                                                                             29

                  that's most important to have at this particular time.

                            And I am very pleased to have llr. Rubel be able to
                  come this morning, again it's a very busy schedule, so the
                  fact that he's here today is somewhat fortunate for us because
                  Mr. Rubel is intimately involved in the development.of the
                  Administration's point of view of the new legislation; andt
                  as Dr. Greene indicated, since about January or February of
                  this year the P14P program has been working closely with
                  flr. Rubel, who does have responsibilities for coordinating
                  internally our several activities under CIIP, RMP and the

                  Ilealth Facilities Program.

                            So, without further comment, Gene, will you take
                  whatever time you feel you need to bring all the information

                  to us.


                           MR. RUBEL:  I will try not to be too remarkable.
                           First of all, in the context of manpower debate,, I
                  would suggest to you an article appearing in this t,7eeklg
                  National Journal Reports on Manpooier Legislation.  I think
                  it is remarkably putp the-presentation of the problems as
                  well as the politics, and.there are a lot of politics.
                           I will try to be a little more down to dealing
                  with the nitty-gritty things.

                           I met with some of you back in February, and I am
                  not sure I knew then what I was getting into; but we did
                  discuss at that time what the Departrqent's plans were for





                                                                              30

                  spending RMP funds.  This was almost immediately after the

                  court had entered its order on February 7,  Dr. Pahl, in

                  his letter to you did summarize the situation as it existed

                  early last week.  It keeps changing.

                            You may remember that back  in February we discussed

                  the possibility or, as we saw it, the fact that Section 910

                  of the Public Health Service Act was in the law  and  still

                  is in the law, and I believe I indicated that  the  Department

                  was very much interested in utilizing some part of  the  money

                  that had been  appropriated under Section 910, which  is  an

                  authority we can use to  do some things outside  the  scope

                  of the individual  regional medical programs

                            The Department, through its  representatives  in the

                  Justice Department, did propose an amendment to  the  court

                  order, and we have gone throuah.several months  of  motions and

                  counter-motions, and all kinds of gyrations, including  a  lot

                .of time spent answering questions and the like.

                            We have reached a settlement with the  plaintiffs
                  in the case, the national Association of Regional  14edical
                  Programs, under which we would be able to use up  to  file

                  million dollars of Fiscal 173 funds under Section 910.   1,7e

                  have made it clear that those funds will not be used to

                  support any.kind of State activities in attempting to

                  plan for future regulatory rules.

                            Some of you have been very much involved in this, ar-,c.





                                                                                31
                   I won't take'a lot of time to go through this.

                             One thing is very clear, that the Department wants

                   to put this litigation -)eh-ind us. Vle are interested in

                   administering the laws that we have today as well as
                   anticipating what is coming in the future, and we don't see

                   any great benefit in continuing  to litigate here.

                             As I understand it, the judge signed an   order on
                   Friday, in which he requested each of several Regional
                   Medical Programs to comment on the settlement, and each of
                   the W4P's has, I believe, thirty days to do that, to the

                   extent that there is no comment, the final order will be

                   entered; to the extent that there are, he hfts indicated

                   that he will deal with them very expeditiousl
                                                                 y
                            So that I would hope sometime in  the  middle  of  Julyl
                   this litigation will finally be.concluded.

                            In terms of legislation, you have heard a summary
                   of i-ihat's happening. The Ilouse Subcommittee did spend Monday,'
                   Tuesday, and yesterda,, morning del5ating the questions of
                   health planning, as they call it.  They are kind of             I
                   following an unusual pattern.  The purpose of those  two and
                   a half days of discussion was to provide guidance to the staf
                   in order for them to produce a clean bill, a new bill.
                            The Subcommittee then intends to take that bill
                   and actually mark it up, go through it page by page and line
                   by line.  But I think, after the two and a half days,, the





                                                                            32

                  Subcommittee did give pretty much of an idea, understanding
                  0-1 what it wants; and I don't think the mark-up that is

                  going to have to come next will take a great deal of time.

                            It -is remarkable that we had so many members of
                  the Subcommittee spend so much time.  it is obvious that they;
                  are concerned and interested; both sides, from both political!

                  parties, young and old alike.

                            I would have to say in very general terms that the
                  kind of thing you're talking -- we are talking about, is
                  best embodied in H. R. 13995, which was introduced by most
                  of the members of the Subcommittee in general, to look at
                  all the pieces of legislation.  They are very similar, and
                  I don't believe we heard a great deal in those two and a half
                  days that is different from what was in those bills, with

                  perhaps one exception.

                            It appears to me, and I never said it explicitly,
                  that the Subcommittee is interested in including a large
                     relatively large -- pot of money at the State level for
                  the State government to somehow continue on, or with some
                  kind of variation      itys very difficult to know exactly
                  what -- of the facility construction program, the Hill-Burton
                  program.  That was not in any of the bills recently proposed
                  in any case.  Exactly what it's going to say and how it's
                  going to work, I don't know.

                           It beats me how that staff is,going to wr-'@te some-





                  thing; but they always manage.

                            In general terms, we have what we call a health

                  systems agency at the local level, non-profit, private

                  organizations, and the committee was very firm on that, with,,

                  by and large, a larger geographic area or population base

                  than we have in CIIP agencies today.  They cane down firmly.

                  on a minimum figure of 500,000 people, but which could be
                  waived by the Secretary down to 200,000 if he-found it to be-

                  necessary or desirable.

                           This agency would be responsible for doing the
                  planning for its area.  It would also have some relatively
                  small pot of money available for developmental activities.

                           There would be at the State level a State planning
                  council whose members would largely come from representatives

                  of the local health systems agencies, with additional members

                  appointed by the Governor, and it would be that council that

                  would approve the individual plans proposed by the local
                  agencies, as well as using State governmental support,,
                  filling in the chunks and making sure that a highway doesn't

                  stop on this county line and here and start on the next one

                  two miles away.

                           The State would be responsible for whatever kind of
                  regulatory features are going to be in the bill, and the're
                  was an awful lot of discussion of what anybody means by
                  regulation.  As you may or may not know, there are so@-e






                                                                            3 4
                 members of the subcornittee that are very adamantly against   i
                 regulation, although everybody agrees that something like
                 1122's view of capital expenditure, certification of need

                 is important and desirable.

                           The staff was instructed to draft provisions that
                 would allow, that would provide federal support on an optional
                 basis with -- for any State that wanted to get into rate
                 review activities,, and that was further than a lot of people
                 anticipated they would go.

                          You may know that Mr. Roy is very much in favor of
                 a mandatory review kind of role, but he was very happy with
                 an option, which of course is what the Administration propose

                 also.

                          I would be delighted to respond to any questions
                 either here or privately about features of the bill.
                          The liouse Committee has prepared a very,, very
                 exhaustive analysis of the various proposals that are pendil.lj..
                 Unfortunately, it's either in -- being printed right now or
                 on its way some place or other.  I am trying to get copies 'For,
                 you, either today or tomorrow.  I am not sure that I am going
                 to be successful.

                          In any case, if you want copies, you can write to
                 the Committee on Interstate and Foreign Commerce, and I am
                 sure that they will supply one for you.
                          Unfortunately, it does not have a number,, except a





                  little thing.on the side here, and I don't know  what  that

                  means, but, for what it's worth, 32-84.  This is Pn analysis

                  of all the bills that are currently pending before the


                  Congress.

                            The Senate has not taken any formal  action  yet,

                  although it's my understanding that this is a Commit tee Print

                  about to descend from some place.

                            In terms of a timetable, much like  the  manpower

                  legislation, som e optimists hope we will  have  legislation

                  enacted in August.

                            of course, there are a lot of other things going on',

                  on the IIill. There is an election to be run  in  November.


                  And we just don't know.

                            A week ago I was a lot more pessimistic than I am

                  today.  I think the action that the Subcommittee has taken

                  has moved a very, very long wav down the road, and the staff

                  is talking about working on Saturdays and Sundays; so that's

                  the kind of pressure they're under from the members.

                            Enough about the status  of legislation.

                            Let me turn to problems  of transition -- to what,

                  we know not yet.

                            Ile made a decision back in January, that we

                  talked about in February -- we have three separate divisions   i

                  operating here:  one for comprehensive health planning; one

                  for H4-11-nurton; and one for P@IP, and that is going to





                                                                            36

                  continue until Congress enacts new legislation.

                            That has caused some problems, but I think, by and
                  large, we have been able to continue operating as well as
                  trying to work together anticipating what is coming in the

                  future.

                           We have had  a series of grouses working together,,
                  trying to plan for the future.  We have had a group working
                  on possible organizations and another group trying to plan on-,
                  how we go about the area designation process; how do you take
                  into account sub State planning districts,, PSROareas, current:,

                  CIIP patterns,, standard metropolitan statistical  areas and

                  the like.

                           Vle are in the process of producing a series of maps
                  for every State in the country, and you see lots of lines

                  intersecting.

                           How you  make some kind of rational health planning

                -areas out of them is a major challenge.  I think we have come
                  a long way toward understanding hotel that process might work.
                  And many other groups, as we anticipate what is coming.

                           Just as soon as-legislation is enacted,, we intend to
                  involve in our planning process representatives from all

                  sorts of organizations, professional organizations at the
                  national level, representatives from each of the  components
                  that are going to be into this scene.

                           Ile don't feel, however, that now is really the time





                                                                                37


                   to do thatp with all the uncertainties as to what may come.

                             I would like to make one plea.  late have had a

                   fair amount of quibbling, fighting, figuring out whose turf

                   is iihose, over the years. I thin]-. that is one of the  key

                   problems that the Congress is attempting to deal with.

                             Ile have had a difficult process even during this

                   review cycle in how CHP agencies relate to P24P's.  Frankly,

                   from my point of viewt I am surprised how  well  things  are

                   going and how much cooperation and  coordination  there  really

                   is.

                             I don't believe it is to  anybody's  advantage  to

                   continue and perpetuate those kinds of arguments and

                   discussions at this point. 1-7e've tried to get along  as  best


                   we can.


                             It's obvious that if progress were to continue both

                   programs as they currently exist,, I think we would have to

                   do a lot of work, because I'm not satisfied with the

                   relationships we have today.

                             But I don't believe that Congress is going to

                   continue the current lawl.so let's devote  our  energies  to

                   how we can improve things in the future,  rather  than  arguing

                   about how poorly they've been done  in the past.

                             In terms of a transition, we have  worked  very  hard

                   to insure that the agencies, organizations that are funded

                   now will be funded through some transition  period.  Ile  don't




                                                                             38


                  believe it's'to anybody's benefit to stop everything  now  and

                  then try to start it all over again next year.

                            Most RMP's will be funded through Fiscal '75.    The

                  314(b) agencies, the local agencies, will be funded through

                  April of Fiscal 175.  We have a very real and big problem

                  with the State agencies.

                            Mr. Milliken works for one, where, as it was

                  described in a hearing, "we fall off a cliff on July 1.11

                  I think we can figure out a way to handle that with some       I

                  help in the Congress, as part of the continuing resolution,

                            In any case, we have tried very hard to find  --  to

                  insure that there be some kind of orderly transition.  I

                  think that's something that everybody agrees is  very  necessa
                                                                               ry.

                  The question has come up, and you are going to have to  face,,

                  during these next few days, to what extent there  are

                  organizations that perhaps should not be continued  during  that

                  transition. And that's something you are  going  to  have.to

                  deal with on a case-by-case basis.--

                            I would just like to give you my observation.

                  That I think you have to decide is something  marginal,  you

                  know, is it doubtful. We've been  carrying  something  along

                  for a long time in a certain kind of situation, and if that's

                  the conclusion you come to, my recommendation would be to

                  let' s keep going.

                            Why do we want to change things now when a vear  frori





                                                                                 39

                   now we are going t o have a very natural  kind  of  resolution.

                             On the other hand, to the   extent  of  organizations

                   that have no capacity, that are not doing things useful in

                   their communities, I think we have an  obligation  and  you  have

                   an obligation to conclude that federal  funds  will  be  wasted

                   on that kind of situation, and to act accordingly.

                             Finally, I have tried to make a plea for many months,

                   and that is that we don't want to see ma   .or  organizational   -
                                                             3

                   changes made at this point in time.  I  have  told  --  perhaps

                   some of you have heard this story, but last October

                   Congressman Roy spoke before the American Association of

                   Comprehensive Health Planners and talked about his concept

                   of a Regional Health Authority, and  that  evening  someone  came

                   over to me and said,, "TIhere do I submit my application?"

                             And I tried to say, 1-7ell, that's just one  Concrress-

                   mants idea.


                             Ile had people at that point that  were  prepared  to

                   make all kinds of changes in orde'r' to accommodate an idea

                   that someone had proposed.
                             Well, if that had happened, they would be in ve
                                                                                ry

                  -sad shape today because all of the concepts and ieleas that

                   Congressman Roy advanced have not been accepted, and I think

                   the same thing is true today. We  still  don't  know  how  this

                   is going to work out.

                             And I don't believe it's  in  anybody's  interest  to





                                                                              4 0

                  actually make changes.

                             On the  other hand, all of us are planning and
                  trying to come up with contingency plans; and  that  is  very

                  proper.

                            But  let's wait until the Congress acts before  vie
                  make any kind of permanent changes, because we  may  have  to

                  make them all over again.

                            Finally, I would like to echo Dr. Margulies'   point,-
                  you are going to have some very difficult decisions to   make

                  here.

                            I think we have to hit the hard issues hard.
                  There is no point in trying to gloss over things.  I think the
                  staff has done a very good job, and the review committees
                  have done a very good job of raising the problems.  And
                  they are going to be difficult to deal with in some cases,

                            I suggest that we try to make difficult decisions.
                'This is a time that many people are questioning whether
                  the government can function at alf-, let alone function
                  effectively.  Let's see if we can demonstrate that as
                  servants of the people, really, that we can,do the job
                  e f fe cti ve ly.

                            DR. P2UIL:  Thank you very much,  Mr. Rubel.

                            Are there questions or comments by the  council  on
                  any of the matters touched upon, or just perhaps glossed over,,
                  in view of the vast amount of activity that's going on at





                                                                              41

                  this time that you would like a little  further  clarification

                  or amplifaction?


                            Dr. Merrill?


                            DR. MERRILL:  I have realized, from what you and
                  previous speakers have said, that no one has the  answer;  but
                  what I would like is perhaps an educated,guess,, so that I

                  can respond to people who ask me such questions.

                            One which I hear most frequently is the following:-
                  Let's assune the transition period works and all the

                  contingency plans are fine.
                            If funding for luIP is continued, in what form, unde@

                  what authority will that be?

                            f@IR. RUBEL: I can see about a 99.5 percent
                  probability that funding for JU4P, as such, will not be
                  continued.  I spent two and a half days before the Subcoruiittee
                  and I did not hear a single member even once raise that as  an
                  option.  It is conceivable that it will be done on the Floor
                  of either lIouse, or yet within the-Subcommittee or Comittees;@
                  but they clearly are looking to set up a new kind of

                  arrangement.

                           Now, on the other hand, it is also very clear that
                  they intend to build on the structures and the people that  we
                  have working in the CIIP agencies and in the RIIP agencies.
                  I can see many RIIP'S, as we know them today, with or without
                  changes, becoming very much a part, becoming health systems





                                                                                       42

                     agencies in many places, and that kind of thing.

                                I don't know if that answers it.

                                DR. 14ARGULIES:     John, can I pick up that five-

                     tenths percent, because you and I are physicians and understand

                     about that.

                                There is, up to the present time, no planning bill         'i
                     which has even reached the IIouse, and we have seen many
                     misfalls  in  legislation.   On   that   five-tenths   percent   basest

                     what could happen is a matter of technical process.

                                It is a continuing resolution and an extension of

                     legislation in  its  present  form.  Ile  will  certainly  enter  the:,

                     next fiscal year in some of our programs on that kind of a
                     basis, and you realize -- well',, I'm not so sure you realize,        !r
                     a lot of people  don't  seem  to  realize,  even  at  high  levels  in@

                     government -- that when there is a     continuing     resolution,
                     which says that the appropriations     will  continue  into   the

                     next  fiscal  vear,  that  also  extends  the  authorizations  to

                     which those appropriations are attached.

                               So that possibility could exist.  That would
                     immediately be negated with the passage of legislation        which
                     would replace the Rt.IP,, CIIP, flill-Burton,, et cetera,, with a ne@-,,
                     kind of planning legislation.
                               MR. RUBEL:     Or  b'  passage  of  an   appropriations
                                                  y
                     Act.                                                                  I

                               Ilo@\r, to be very candid, Dr. Ilargulies and I were a@





                                                                                  4 3

                   an Appropriations Subcommittee hearing not long ago,

                   we were told  by -- we were  asked,  the  Administration  was

                   asked:  You're proposing to eliminate the MIP program


                   and then we were told not to hold our breath.


                              So, you know, there are a lot of things that are        I

                   possible, but I can report to you that  in  two  and  a  half  days.i

                   before, you know, eight of the eleven members of the liouse

                   Subcom,nittee there was not one mention made of continuing

                   any of the current programs in their current form.

                              DR. 14ERRILL:  I think the thing that's been confusing

                   to many people, including nlrself,, is the kind of thing that

                   you state, and what I've heard repeatedly,, and that is:

                   Let's keeo things going the way they are.

                              And,, on the other hand, the statement that theress

                   99.5 percent chance that things will not be kept     going the

                   way they are.

                              I realize there's probably no other alternative,

                   and I certainly don't have one.  But  --  I  think  you  have

                   defined those difficulties.


                              DR. GREE'-TE:  With the councils
                                                                permission   and

                   because of the importance of   the topic, I would like to

                   recognize Dr. Donald Sparkman   in the audience, who is the

                   chairman of the national steering committee of RriP

                   Coordinators, who would like to  make  a  statement  on  this

                   point.                                                             7





                                                                             4 4

                            DR.-SPARI,',IW4: Clearly,, Doctor, Mr. Rubel is n ch
                                                                            u
                  closer to the legislative situation, and Dr. Margulies, than
                  I an; but from other sources from which I learn information

                  about this, it is not quite 99.5 percent sure that there will

                  be no IU-IP.

                            There is a consideration of this, and I would
                  remind you that as of a year ago the Administration said
                  there is going to be no RRIP as of June 1973, and the
                  Administration officials, Mr. Rubel and others, clearly said
                  that.  And beyond that time P14P probably will not survive,
                  and the Secretarv and others took steps to make it as

                  difficult as possible to survive.

                            We are still in business.  I think there is at
                  least a reasonable possibility that some modification of the
                  existing PIIP concept and function will continue, and I find
                  it difficult to accept his statement.

                            DR. 14ARCULIES:  John, may I pick up on that,
                  because I think  our point is an
                                 y                 important one.
                            Partly because it provides us the opportunity to
                  separate the rather restricted federal view of affairs fr%JILL
                  the much more mobile and flexible view at State and local

                  levels.

                            Let me go back to what I said earlier to this
                  council.  You are operating under existing legislation, and
                  there is not much reason for you to speculate about what new





                                                                             45

                  legislation 'Will do. You are also operating under a court

                  order, and it's quite clear what Congress intended, and

                  Congress has not changed its mind.

                            In fact, this IUIP will continue, as does any other

                  program, unless Congress specifically rescinds Title

                  which is the basis for the legislation.

                            But beyond that these comments are, in  a  sense,
                  specious or irrelevant, at least; because if there is to be,-
                  with or without legislation, an effective amalgamation of the

                  programs we have under discussion, it will be because of the

                  efforts of people at State and local levels.

                            The wisest thing that we could do with this

                  council activity is to encourage and support the Rt4P's  to

                  function in the most material manner possible, and the

                  wisest thing they could do is to combine with their CIIP

                  colleagues and other appropriate agencies in the State   to

                  talk with one another now about how better to function   at the

                  State level, regardless of what ha@pens.

                            I don't think there is the slightest doubt about the
                  need for that to occur, whether the legislation is passed or

                  whether it stays the same.

                            In fact, if the States could deal effectively with
                  the elements within their boundaries, which we are dealing
                  with at a distance, they could do whatever is  proposed  in
                  upcoming legislation without any new legislation being passer-.,





                                                                               46

                             The fact that they have found that difficult  to

                  do has encouraged Congress and the Administration to  alter

                  the forms  in which they function; but the best thincT we

                  could hope for is for people to act together in a common
                  interest within the State, knowing more about what's  goin
                                                                             9

                  on than anyone else does.

                            And I would add  to that, Don, and I know you would
                  agrees because we talked about this before, that the time has-;,
                  passed for us to concentrate too heavily  on two programs
                  which happen to have been  passed about the same time and
                  have somewhat similar interests. V?hen we are talking about
                  planning for a State in the field of health  that  involves  a
                  wide range of institutions and-activities in which the CHP

                  represents the major, and from the federal point of view,
                  the critical planning  force; but it has to deal with
                  maternal and child health services, mental  health  services,,
                  hospitals, nursing homes, payment Mechanisms, the whole
                  gamut, not just two programs.  And-if we can get a little
                  further toward that understanding, I think, regardless of
                  the legislation, we are going to be better off.

                            DR. GREENE:  Thank you.

                            Are there other comments?

                            DR. 1172UUIOCK: I would like to  echo  that  feeling,
                  because of being involved in that situation of  getting  the
                  States involved, to accept @.;hat's going on as a  cooperative





                   effort, and I think that some effort has been made in that
                   direction in some areas to  do  that  very  thing.  Because  ywu
                   have got six different roads or detours going off doing

                   different things.

                             And I heartily  echo  that  situation,  regardless  of
                   what happens to PJIP,, because there are things in here that

                   are salvagable and worthwhile to be used in the future.

                   And if we can combine these with  the  efforts  that  the  State
                   level is trying to do, I think we are going to be better off.

                             MR. MILLIKEN:    To this end, I think there is a
                   need right now.  A good demonstration of the need for pulling
                   this together, to have an effective activity.
                             I don't know about the rest of the country, but
                   Region 5 and Region 3, IIEI@7 regional offices,, are in a kind
                   of a problem of working with States who are tending to
                   pull back even,,-thing to within their State boundaries.

                             Now, between Indiana, Kentucky  and  Ohio,  there  has
                   been, for a long time, a very significant cooperative program
                   where both PI.IP and CIIP are in interstate health trade
                   regional activities.  And there is an urgent meeting called
                   next week in Louisville to bring regional offices, States
                   and local areas together to see what can  be  done  to  continue
                   this kind of cooperation.

                            Nov7,, the IIUD program and other kinds  of  government
                   planning are not unrelated to this, and it  does  begin  to  put





                                                                               4 8
                  us into,, you ]-,now,, if we can'thave a strong front here,
                  in view of the need fok keeping these @-ind of trade area
                  voluntary coordinated kinds of programs, then I think we

                  f ace a very serious problem.

                            DR. IIARGULIES:   I think one of the reasons that
                  there was and is a heavy commitment to the private,,' non-pifofit
                  approach to thing is because it does lessen the likelihood       I
                  that the artifacts of political boundaries will be too

                  constricting.

                            On the other hand, you've been on this council long
                  enough to know that at the State' level that artifact is a
                  very po,..7erful one.  After all, funds flow into States on a
                  geopolitical basis around those boundaries.  But I feel
                  reasonably heartened, as I would think you would, over the
                  very successes that you pointed to, like that tri-State
                  arrangement with both IZZIP and CIIP that you've had down there,
                  that peoiole have managed.  And I think it's much more likely
                  from our experience that that coulA be  worked  out  between  the
                  people there than for us to do  anything  certainly  dictatorial
                  at this end.  It just won't come out that way at all well.
                           MR. RU13EL:   I can report to you that the Subcommittee
                  very firmly stated it is in favor of interstate areas,, and
                  for that reason decided not to allow the Governors to make
                  the final decisions an area designations.
                           Certainly the Administration bill would advocate





                                                                               49


                  interstate areas.  It's a very-complicated kind of problem,

                  we tried to get into it, there are some 17 interstate CIIP
                  areas today, but there are 37 interstate Standard Metropolitai

                  Statistical areas.


                             Now, some of them we have irTterstate, some of them

                  we don't.    The political processes are quite apart from any

                  kind of knowledge about the medical trad@- area and  what

                  service patterns are, are very difficu-J!-t to deal with.

                  But it was something that the Subcommi.ttee  did  deal  with

                  very explicitly, and you may know that  Senator  Kennedy's

                  bill provides for areas wholly within @e boundaries of States.

                             So we will see how it comes aut.


                             DR. IIILLIKEN:  One more quiak question.

                             The net., legislation on the relation of  PSRO,.


                  was that left in?


                             MR. RUBEL:  It was brought up before the Subcommittee.

                  The question was asked: Well,  should  there  be  the  same

                  boundaries or not, and I think there        pretty  general

                  feeling that some of the P-SRO boundaries  don't  make  much

                  sense. And the  Subcomittee  finally  decided  to  tell  the

                  staff,to use some vague language about the need to coordinate

                  with various kinds of things,  like  PSRO  boundaries,  sub-

                  State planning districts, and the lilze-@, without any mandate

                  that you must follow.

                             DR. PAIIL:      Thank you, G@e.






                                                                                   50

                               Are there any otLier comments or points to be made

                    by the council?

                               If not, I would like to thank you for the remarks

                    and say that llr. Rubel has indicated he will be here for the

                    better part of the day, and there will be various points,.I--,

                    am sure, you may wish to interact  with  him  as  we  come  to

                    other topics.

                               Now, looking at the clock,  I  would  like  to  ask

                    your indulgence for one more thing, because I see that Dr.

                    Goodman has come into the room, and I know from earlier

                    conversation that his schedule is very tight today,, and

                    therefore I would like, before we break for coffee, to have

                    his few remarks to you, because he will have to leave for

                    another meeting.

                               I would like to go to Item  6  on  our  agenda  and

                    introduce to you Dr. Alvin I. Goodman, who is the Prog.LC"ti

                    Coordinator for the End Stage Renal Disease Program for the

                    Bureau of Quality Assurance of our sister aqencv, the Self

                    Health Services Administration.      They too are located in

                    the Parklawn Building with us.

                               We are, as you know,   as an Pd4P  program,heavil,,

                    involved in a kidney program, and those of you who have      been

                    on the council have witnessed the development and establish-

                    ment of dialysis  and  transplantation  centers  as  a  result

                    of the activities of luIP's.





                                                                                 5 1

                               Because of the Social Securi-@i7 ariendments of l-q72

                    anci tne-pavnents that are noi7 possible to Y--,atie4-its uno..2r

                     lios eamendments for tro-,:itrent i,it@ll dialysis and transiolanta-

                    tion, the End Stage Ronal Disease Proqram has )Dccn

                    Dr. Goodrtan is the director and  his asl-.cd, ovl-r rc-ccnt

                    for the assistance of Rec
                                             .Tior.al !Iedical ProcTrEms in hclpi-nc,

                    to inplcirent in the in-L -L-ial stages the activities which

                    required to establish and administer.

                              So I would like to  have him address you and stay

                    for whatever length of time is possible,- but I know it will

                    be brief, because he has, as I say, another meeting.

                              I think it's important that you hear the message

                    from Dr. Goodman.


                              DR. GOOD14AI4:   Thank you, Dr. Pahl.

                              14embers of the council, as most of @,ou, I ar, sure,
                    are well aware, in OctolDer 1972 as part of Public Law 92-GO3,!
                    Section 299(i) addressing chronic renal disease as considered

                    to constitute a disability,, was IS-assed by the Congress.
                              This legislation went into effect as of July lst,
                    1973; as part of the mandate of the legislation, there @:erc.

                    various requirorents, including a specific one for riedical

                    review boards.  As@yet these medical review boards have not

                    been constituted nor established in the field.

                              During the inter,---, period, an interim policy @.,as
                    enunciated in june of 197'j.  Since then, in April of tl@'.    -ir,





                                                                                      52

                     1974, final policies for the End Stage Renal Disp-,isc,

                     of Medicare were announced by the Secretarl7.

                                For those the do not have copies of those final

                     policies,  I am leaving serve on the   desl-, here.

                                These final -,3olic4-s reflect the inniit of ranv

                     professional  organizations associated with d-@livery of
                     End Stage Renal   Disease Care, including professional  iii-,:;tit

                     from the Pj4P office.

                                The major aspects and issues to address at this

                     moment is tlie fact that there will be finally what IU.IP's
                     have been working  on  for  years,  a  development  of  a  network

                     approach  for End  Stage  Renal  Disease  Programs,  in  that  the
                     broad  array  of  professional  skills  and  facilities   required
                     for the treatment of such patients requires such a coordination
                     of effort  and  that  facilities  will  be  organized  in  regions

                     on such a network approach.

                               And perhaps  at  the  apex  of  the  netqork  will  rest
                     a medical review board to screen'-appropriateness of care,'to
                     screen quality of care, and to assist with other organizations
                     in  facility planning.

                               lqe are in  and in-between phase.    This was quite
                     discerniblewhen I arrived.    On the one hand, those local
                     bodies, PJIP's %.!ho have had expertise in these are.Ds and plans
                     which, to a lessor or   areatcr  degree, were being implemented
                       often, unfortunately, to a     lesser deQree -- their





                                                                                   5 3

                    was threatened as was discuss(-,d +--@lis r,,iorni-ng.

                               On tl-i@ other hand, the      groul-)s were quite, and
                    still are, in their -i.iifanc@,, so i@l, )-)ccc@-@ a questio.'l c-@- how
                    does one, as rapidly as possible-, esta,')li@,",l these nct,,.,or'rzs,
                    establiF-,Ii these medical       !,,,-),7,-ds @,7itho-,it going
                    the loiig,laborious history t:-iat                     t"l,-It are

                    establishing PSRO'S.

                               In discussions  with members of PI-IP heret it
                    became clear tlaat it might be possible, i-7itl-i the willingness 11
                    and cooperative approach of various M.IP offices across the
                    country that we can initiate the program and implement the
                    program through these PI-T offices, and see what develops in
                    terms of what their future history is, and what the PSPO
                    history is in trying to phase in appropriately this program
                    and then phase in eventually perhaps, with PSRO.
                              This program will be.adriinistered through the
                    Regional Ilealtli Administrator's office.  It is readily   recognize
                    that the RIIA's andtl-ieir offices n'either have the e.%pericncc
                    nor the on-board c.-nertise from the Professional Point of
                    view and from the plannin.g point of  view tocasily implement
                    this program, yet virtually everv community across the countz)-
                    every region across the country still has an existing P"4'P
                    office in which there resi0e@, such e>:r)ertise ind much

                    plannin(T in terms ol' renal disease.

                              So %,That is hopeC. -@c)r, i,-i essence, is that var4- C)





                                                                                  5 4

                    Government agencies and authorities in the given regic,,-is

                    will be able to associate themselves together, some londiiia
                    forth the organizational c;truc+.-tire, the federal structurL-,
                    the regional health offices and o-Lj'-.Iers aivirig their e.,@pertise
                    in rei.---.1          p rc           in g to@@c-.rd the raniCi
                    implementation of the  net@.7or"@ concc-@l-;t, the affiliation of
                    institutions in @i given region, and a development of local
                    medical review boards appropriately to work out in the initia@
                    difficult phases this type of planning and this type of
                    logistical and administrative support.

                              Tliis,is sort of quite compatible with the statement
                    made within the program of trying to use that type of
                    programming and expertise still inherent in @IP in facilitating
                    new programs and new plans as they come about.  Ile hope that
                    we are able to develop this cooperative approach.
                              I still have plenty of time for questions here.

                              DR. PAIIL.-  Okay, thank you.
                              I think we are interested in bringing this message
                    to you at this time, because this is one of the instances in
                    which the existing organizations kno-,@n as  PiIIpls are finding
                    themselves to be of great importance to another administra-
                    tion's program,, in fact another agency's program, and we
                    are delighted to be cooperative and helpful with Dr. Goodman.
                    And tJiere will be official materials developed and sent out
                    to all PJIP's shortl,,,, about ti-iis-. liu4-- +--here has been a lot 04,





                                                                             5 7


                            We estimate that        percent o--F all renal

                  dial-,,si-@ currently nerforr.@,cd in this co=trv is perforr,.cd

                  by the Vc-i4-er-ans -\f2
                                                      have an e -cf ect4 ve


                  arrangement unde.- which a small. L-u@- growing nuipber of non-


                                            'in our
                  veterans cai-, ')e di,)!@ize-11.  eLcility t7nrc)u-Th sha-r-,i-ic@

                  arrangement.

                            Tli erationale for this being that we will dialyze

                  non-veterans in exchange for comparable services for

                  veterans by whatever hospital or medical school we have  such

                  a sharing agreement with.

                            This@is entirely consonant with our basic mission

                  of providing care'for veterans.

                            This effective arrangement of limiting  unnecessary

                  duplicat ion of scarce resources is threatened by a legalistic

                  argument as to whether or not the Social Security Administra-

                  tion can reimburse third-party payers, who in turn  reimburse

                  the medical schools with which we have these sharing

                  arrangements.

                            T@io issues are at stake. One is the legalistic

                  argument I mentioned, whi.ch I hope can be r-eso'Lved; I feel

                  fairly confident.it can be.

                            The othe@, which I an almost certain can b6 resolved,

                  is the question of ncdical standardization.  And we are in

                  entire symnathy and support with Dr. C-,oodman's contention

                  that one standard for renal dialysis should prevail throughout





                                                                                 5 13

                    the couti"-ry, since most of the people in the VA -- I'm        i

                    talking about physician providers no-@.; -- who are involved in
                    this are peonle who are emploved on a part-tine basis with
                    the %7A and they are also emnloyed at the schools of medicine

                    and so forth.


                              So we feel reasonably sure that this 'viill. be

                    consonant      our Fission.   Sil,ectness and lighk-- will prevail

                              DR.         'Thank you very much,, Dr. flaber.

                              Dr. Merrill, did you have any questions or   col@'Liii@,i L@ r!

                              7uiyone.,,on the council?


                              Mr. Milliken.

                              MR. MILLII.'.EN: Well, I think I have spent more
                   time in the last month on the renal thing, the renal problems
                   than I have time for, or intended to.

                              Because of the lack of coordinated concept at the
                   present time, of who is already in the act and who is getting!
                   into it, and what the process, indeed, is.
                              It's n,@i, understanding ih our region, for example,,
                   that the Social Secur-@ty office in Chicago receives
                   applications for renal proarams.  They then forward   these
                   applications to the A agencies, who then submits it   to the
                   B agencies for review and comment.
                             Ilo@-7. at the present tine, in Ohio there was a very
                   good active proara.,ii initiated through Ri-@IP, which sort of
                   extended itsel@' into a Stat-Ei,.,,,-i.d.,-- renal idvison,- corLmiL'tc-c..-





                                                                                           59

                      and the-"e was some unfort-Li i-i a4k--e le;clz of cc)rp,,uniccitions I)e-i-@,cen

                      that committee and @-pplicants, and the confusion on what the

                      proc.-E.,ss @,.s for submitting @-r)tD!ic.@,ti-cns ai cTL--tting  clearance.

                                  I-v'e had one case in Co',-i:.--@I)as   a New JerFev  fir-,7,

                      has coi-,c in @-id set  up a            ---,rocTrl-@n, ind z,.t the -rcz--.c,,njL-

                      tir,,,2 they iia-,,c-- been unable to   b@-.ick-ur) arrangerien-l- froin

                      the ri@cd4Cal center a- the uni-@,@erEi--V.

                                  So the whole thing is stym4-ed and bogged down

                      right now because of the fact that the Social Securitv

                      office in Chicago is not able to get the kinds of clearance

                      from the B agency and the A agency necessary to recommend

                      and  approve  that  program  operating  in   that   city.

                                  It's  being  straightened  out,  and  it   will   be.   It's

                      well on the way, and we're having good cooperation.  I3ut
                      the  man-hours  lost  and  running  down  these  le-ads   and   problems
                      and  getting  the  right  peoDle  together  and  finding  out   who   is
                      doing what is absolutely amazing.

                                 DR. PAIIL:   Dr. flerrill?'-

                                 DR. @IIEPRILL:    I night, perhaps, in view of fir.
                      ililliken's  comment,  ask  Dr.  Goodman   a   questions

                                 As  I  understand  it,  what  lir.  hiilliken said   is   that
                      there  are  problems  with  new   facilities.   Do   you see th:is'

                      as more  of  a  major  nroblem  that  coorai.nition  oil e.--i@- ti-ncT

                      facilities, or are both equally      i-r,-Dortant?

                                 DR. GOOD,-"@ltl,":             is a ve-  clear





                                                                                  GO

                    There is an allocation of res-r,,onsihilit-,7 I:)etwe(,r
                                                                        the


                                                                         ,7e    z,. t
                                          -,ocial @c-curity ag,@:,.cy, Ind are

                    the stz-,ge now, we have the P--rof@Assio-,,nal input into the

                    program E,,.ncl. ii@ipler,,,.c-,ntin4
                                            ,7j pro-@cs.----,o,,Iil aspe--ts of --he

                              The Socin-1 Securit,,, office for a@Irrini-stratLve

                    purposes anC, ease of administration receives the aT)nlicatic)n.
                    C@IIP, which coul--', no'L -ind shc)lald be ign,)red, is sunp-@scd t.@
                    ascertain need on a local basis and on a State basis, to th-3-
                    extent that t--@lev are capable of doing so and do a good job.

                    U'his
                         facilitates.the flow of the applications and it

                    facilitates the-
                                    movement and their final adjudication.

                              Dr. Rubel and I are aware of the problem that
                    certain areas have.  The CHP'S, in some areas they do a
                    beautiful job, they come out with beautiful plans, as   .have
                    Pl,'iP's in some areas. And in some areas, as have some Rt4P's,
                    they have not--, and many more CTIP's have not addressed these

                    issues.

                             To the extent that they--don't, that means the
                    regional office then receives the application, the health
                    officer attempts to -- to the extent tl-iit they do not have
                    the expertise within that of-@gice,, we do here.  We pretend we
                    do have the expertise, and we riake decisions,
                             Now, we have received about a hundred applications,
                    we have approved Iv)out fitlr to date, since the program was

                    on.  Ile have referred others.





                                                                              62


                            Anv other co,-,jnents?


                            T.Ll I!
                                     1 wou'Q jusz indicate @at I guess iast
                i month, early last month,, Dr. Gooclman did meet with a number

                  of coordinators with the stecrinc, committee, and we ;@-cili:ed
                  abou4,- the details of how the PJ@iP's could be of practical hold
                I in initia4--ina this thrust.  And, as I sa@.,, materials will-1.)'e II
                  coTi@-ng fort-l-i to 7Lhe council, ou- re@,4 or-i-iil-tee, and also
                                                        el-7 C


                  PIIP I s in the near future.

                            I would  like to call a break at this point, and
                  thank Dr. Goodman  for bringing the comments.  And rtiay I
                  suggest that we-reconvene at  as close to 11:15 as possible.
                            Perhaps you would care for some coffee, soft drinks,
                  and so forth; and the staff and others can guide the new
                  members to our cafeteria for some refreshment.

                            [Short recess.]
 1-I.-20am                 DR.  PAIIL:  Hill the council please come to order.
                           As we reconvene,. I find myself being bumped to
                  lower and lower on the agenda, and-about this time I have
                  decided you won't need a report from Pie.  But I am delighted
                  to yield to the gentleman      the Health Services Ad@-iinis 4--ra-I
                  tion, who is sitting on my left, v7ho is I!lr. John Reardon,
                  Acting Deputy Director of the Division of Emergency 14edical
                  Services in the Bureau of _,-Iedical Services, Iiealth Services
                  Administration -- and that long title will be found under
                      7 on your agenda.






                                                                                 6 3


                            The rt-,P@,on I I-a-%re asked John to core and speak for

                  a few minutes @,7itli ,ou and again. be responsive to quest4-ons
                                      -Z

                  and inquiries, is because lie is in cliarqc@@- of the  Emergency

                  medical Services over-all program and is responsible for

                  coordinating our activities in the T,,!,'-S area with thosc- of t:-i--

                  Dcpartmen4l-- --f '-T'rt@,,n@-riortation, IT,ezlth Services, and otl-iers.

                            I have asl@ed him to please give you a perspective

                  of the total E.'L'IS activity, with special empl-iasis on how

                  the Regional Medical  Program  activiti'es'fit  in,  and  the

                  kind of cooperation which we have been experiencing together

                  over these'rnany months,  and  particularly  this  last  week

                  when there was a  meeting, which he  will  surunarize  for  yout

                  and in which all  of the  projects  from  our  regions  which

                  will  be  appearing before vou today and tomorrow were

                  discussed  and  put into a total framework.
                                                              I

                            John, would you care to give whatever comments,

                  and then be responsive to questions, please.

                            MR. RT',j%RDOIV': Thank Fou.
                                                    .2


                            Members of the council:


                             I t)-iinl-. th-;-s council has been involved for a num'er


                  of years in Emergency I-ledical Service type problems, and

                  you have funded a number of activities which, in the past two

                  or three years, I 'Derscrially have followed with interest,

                  and nanv of @.ihich T have been out to see, have been

                  involved  in, and an ve@l happy to report that they have





                                                                                  6 4

                    developed into the magnitude of   systems effort which no@j

                                         W-.!L,Llll.Lil Uur li@lw law.

                              In terms of programs,   the            1.@ledical
                    Servicc-2 j@rograi@-@, \;Iiich I art involved in, this began about
                    two years ago ,ihen i-7e awarded demonstration contracts.   These
                    are now in their second year of three.  We have had succe
                                                                                 sses i
                    and failures, but I think that's pa-"t of der,,onstrat4@ons.
                              I think we have demonstrated that the systems
                    approach to the delivery of emergenm, medical services    is
                    not only feasible but is a practical   and economic approach
                    to solving the problem,

                              We have full Emergency Medical Service systems on
                    the street, taking care of people on a regional basis, and
                    these systems are approaching self-support levels.
                             With that much of introduction and passage, if
                    you will, of our demonstration activities, as you recall',
                    last November the Emergency Medical Service System AcL@. of
                    lc,'73, Public Law 93-154,, was passed b@,, the Congress, signed
                    by the President, and we had funds in the amount of $27
                    million provided under the  Pirst Supplemental to the FY74

                    budget.

                             The funds basically are three and a third million
                    dollars. This year it has @one, been appropriated for research
                    which is being handled by the Bureau of Ileal-,"-h Services
                    Research in Health Resources z-dni-nisti,-,:ition. The traini_i-iq





                                                                                 6 6
                              Ile did receive $54 million %icrth of applications,

                             e'l '7
                                       I V",C)r@l C).r Y"ol
                                            L-1 L    JE:y

                              S O,-Ie o fthose we have not been through.  Sone of
                   there      atrocious.  1,@Te received few cood ones, and those
                   that were  good have a high probi'bi-Lit-@y of success. We will

                   f ul-id.


                              As r)art of this  I t_h 4
                                                    Lnil@ itts important that i@e
                   come back to your interest in the Regional Medical Programs.
                   We are concerned with a total system which, in my definition,
                   contains three major components.  The professional services,
                   of surgical, medical and rqental health services.  It contains
                   all the functional components of transportation, copununica@
                   tion, training, consumer education, information type
                   programs.  These are the kinds of things that people
                   routinely associate with emergency services.

                             Ile also have to pay particular attention to how
                   these services and the components are amalgamated in the
                   rural and the urban setting.  Ilow-you put them together
                   in the total systems anproach is significantly different in
                   the two types of environmental settinas.
                            We are concerned, though, that   we develop total
                   systems.   That is the charter of our law.  And the number of
                   applications we did receive were for categorical requests.
                   They wanted to buv an a,,@l ulincc!.  ',7e turned them doxin,,
                   because that. is no@-         by c)ur      a--id other funes -ire






                                                                                   6 7

                    available.

                               In the rc-,-Por4@- hot-II f rc)m the ITou,-e and Ser,,ite, thc-@
                    language of the rerc)r'@ 'Very clc-@xrly sets forth the intent
                    o4 Congress, and this particular.Act was to support total
                    systems.   '!'lie                 see!,, categorical f-@,,nds sh@,-)uld
                    go to otlier proc                tvT)es of funds.
                                    ..Trai-i.s for those

                              Nov7t as far as our working witJi other nrcgrai7ist
                    think we have perhaps set the ground rules way  back  i@ilien
                    we were working with demonstrations,.  We  just  finished  this
                    week a national review of the regional recommendations.  1-7e
                    had representatives there from CIIP,, Pd,4P, the Departrient of

                    Transportation.

                              T understand ll,,
                                                as you recall, has been ve-rv
                    active in training, communications, transportation.
                             Ile brought in Health Service, we brought in other
                    people like this who t-7ere spending money on categorical
                    components of a'total system.  We worked very diligently with
                    these people over the months, to be   sure that we  were  not
                    only concerned about the f-unds but also that  we  use  their
                    technical expertise to make  it  available  to,the  community
                    in terr@is of technical assistance outreach programs,  so  the.
                    can be part of the 'total system.
                             I,.le have cro.-,s-exch,-il-i(jt--d financial information in
                    terms of potential errant aboard n--ogra,,is, %@7here moi-ic-@y 'is
                                                                               J@-4 nr-j
                    s-@-nt, %7here it's being reconnn-nCed to he spent, to be sur-@,





                                                                                     G 8
                    that there is no duplication of funds, to make sure that our

                    f unds are complementary.

                               I am also lianry to report that within the two or
                    th ree regional medical programs that are fairly large,
                    that you have been involved in. over the list couple of      @7 @i r s
                    those progr@-ims have mide application and they have progressed.!!
                                                                                        I
                    in their'dc--velor-)ment to a point %.,,here they are now readv.
                    There are others approaching the level of beginning full
                    system implementation, and @,,,e are  very  receptive  to  those.
                               I should mention, if you don't already recognize it
                    that i-iithin our law there is  one  part,  Section  1207,  which
                    says, in effect, that other funds    of the PIIS Act, other than
                    the ETIS funds, cannot  be  used  to  support  full  EMS  systems;
                    and that'is a restriction which the Congress has placed upon
                    your deliberations.

                              However, Dr. Pahl, our general counsel and mvself
                    in  the EMS program have N-iorked on this, and we have no
                    problem with  the  recommendations  that  will  be  presented  to
                    you in your current meeting.

                              Ile feel that these  are not in opposition to the
                    intent of Congress,  and that  they complement our program    and
                    they do not conflict with our program.
                              lqe have also revi'e%ied these againstihe applications
                    that we have been reviewing in the past few days, ancl we
                    haNre no problems with this,






                                                                                  70

                                  are i.,ori-ing
                                               with the vc--eran-- Ad,,ri@iistrat-'c)n,i
                                                                              L
                    the Depar'-ment of Lal.)or,, in terms Of inclusion. of the
                    returning -,,reterans in traini7-i7, pr-ogrz,.r-s, g--ttinc-, them
                   involved in some of the paramedic    type activities.

                                                                              i,;
                              I thinl-l k.,-e have a v@a.,@\, exci-ti..riy proarai-,, a-, I c-',s
                   c T)rograi-i that has in effect been in being for  a couple O.,
                   years, but  has now new legislation, and we are    on the

                   thresholds

                              Dlext year the Administration has requested a
                   budget for PY75 of $27 million.  Again we look forward     to
                   our 176.pla,-,, we have already prepared the papers requesting
                   somewhere on the order of the full authorization of 75 million.
                  So we are looking toward building the-proqran.
                             We will stress funding of quality projects.  I will
                  say that the one efficient thing we have found in many
                  applications, and I think it is not due to the applicant's
                  fault, it's more due to the federal gove@rnment's fault, this
                  year is that we liacl many local communities, coun,--v, citv.
                  metropolitan community applv.  This    is fine.  It fulfills
                  the letter of the law.
                            IloT,..7ever, what we're trying to do is to develop
                  regional comprehensive systems which pull together and make
                  best use of the J-n,,7estnie,-t: ,into -,--csourcc- that the community
                 has.

                            I thin!,, we will see, tl,,rough our technical ass-LS4@-ailce






                                                                               7


                                                                      e cc)r,.,t-r@g
                    program and through the funds %@@e have spent in tli
                    year that there is a growing interec@,t.in this regional

                    approz,-ch.


                              lqe know it can work.

                                will bo very       to ans,@.,,er any q,,ie!7@tions ti
                                                                               t
                    ,anyone r,,,av ha-,re about this program, or anything that ri(-4h-' be
                    related to your discussions A4--odEiv,

                              DR. PAIIL:  Thank you.

                              Dr. Janeway?

                             DR. JANET-,IAY:  @Ir. Reardon, I can understand your
                   rationale for this short tir.@eframe perhaps, because I happen
                   to know of one area that did not submit a request because it
                   thought it could not develop one of high  enough  aualitv.
                             On the other hand,, the EMS research, I find, have a
                   four times application cycle,, and the EMS training, I guess,
                   will have one.

                             Is it your guess that with an  appropriation  for
                   FY75 that you will have four cycles for  applications,  or iust

                   one as you had this time?

                             MR. REAIZDO',-4: That's an issue which we are currently
                   -- currently have our grips on. I doubt  very  much  there
                  will ever be four cycles. If we're  looking  at  cycles  at all-,,
                  we will be loo@-.ing,probabl@y, at one or two cycles.
                            I would like to have a continuous cycle.  I th,"@k
                  any time a community has developed a meaningful applica-k-i-on.






                                                                               72

                   and has it ready, it should cor.,,e ii,,to our Consideration so
                   that we can immediately review it and start to critique 4-t.

                                                 is      guc,@s as to the

                   probability of having continuous, DT,,@Dlica@-ions?

                                 I'N-rARD@@T
                                                                  the a@@pro-),. -a@
                   tions c,,7c2.2, I t                        ii,,echan,@sm in
                                   -hinlc teats
                                                                            erms


                      a Continuous cicle

                             For example, we could be aLle to receive  appliCa4-japiS
                   in July, August or Septenbere but we won't know what our
                   appropriation is until probably  October, Nove@er or
                   December.  And it I-;ill be very difficult to make the busr_
                                                                                  f
                   investment with those moneys in July or August, although I
                   think we can review those, and we would hope to work @,744- @le
                                                                            h
                   communities to -- to work with them to approve a good
                   application, to the point where it should be- funded 'when the
                   funds @bo-cone available.

                            I think there  is a backlash, of course, on the
                   continuous cycle# and I think communities tend to res,,-cid
                   to a stimulation.  If we say it's got to be due bv a certain
                   date, they tend to get things ready.  If they are provided
                   an adequate period of time, sixty to ninety daysf notice,
                   we say itfs continuous, continuous in our reinforcement that"
                   we are receiving applications, tllat cori-littees will cTo..baclil-,
                   to sleet) and they won't stbq4-,@- the-,,.  And they lose
                 I opporturii t% .1is a dilemria.





                                                                                                73


                                    DR.  PAIIL:    Dr. I'latkins.


                                                     Did I misuii@lc-,rstand you on

                       when you said  ould avoid                   and tic--dicare, and
                                         y

                       obviousi,7 1411I.   Are you then goina to       depend on PI-!P  and one

                       other source?


                                    I i7asn't sure about that,

                                    I.IR. l@rAi'DO"I': I-hcii-- I said i,7as that as  we   begin    i
                       to develop and implement the local communities develop                and
                       implement and put on the street total emergency medical

                       systems, service systems v7hich are defined in our law,             we

                       are going to have to look for improved coverage and reimburse-

                       nent  in  the  area  of  Medicaid   and   Medicare   to   reimburse   the

                       provider of that service at the local community level for

                       the services that are provided.

                                   Ricrht now, as an,example, it's not unusual           for

                       Social Security Administration to be paying ten dollars for

                       an  ambulance  call.   Well,   that's   all   right   if   you   have-the
                       vertical or the horizontal taxi          'delivery, that covers the

                       cost  of  the  transportation  and  oxygen;  but   in   terms   of   the-

                       quality service, which is_      supported with ceXitral communication
                       well-trained people on board who can do El%G. telemetry,
                       treat trauma, stabilize trauma, ten dollars is a ridiculous

                       fee to he paying for this type of service.  And we must

                       obtain an equitable reimbursement.

                                   Ile are i@Torking wit!,, SSA  Dnd ST,,S  to  ir-tprove  their





                                                                                  74

                    coverage and rei,-.@)ursement necl-i@,ni.sms in this irea,.

                              "L"his has 'to go along i..--Lth our national ,Iic--,iltli

                    insurance proposals and PSPO and 111110 and some of the other

                    mechanisms that are also being Oc-,voloped.

                             DR. i-7AMi'.IOCI,': Are thesis Peonle going to c"assi-pic-,-'
                    as phvsician's assistants and El,D's, or what, if you're
                    tall,.ii-Lg about o-Li-I)oard assistants and physician's assistants

                    and so fortli?


                              MR. REARDON:  I can't reallv answer that because

                    one of the things we were chartered to do and reported to
                    the Congress this year is a legal barrier study.  There is a
                    great controversy and in some cases absence of legal
                    coverage, if you will,  were whether it's permissive or

                    restrictive in the States.

                              DR. 1-12UId-IOCK:  I am just asking for information to

                    clarify it in my own mind.

                             MR. RFARDON:      I think what we're finding right
                    now is that a few States do have   ermissive legislation that
                                                      p
                    allows these people to perform these services, and I would

                    say more comunities --t--e_operating under tl@e remote direction

                    of the attending physician.

                             DR. PAIIL:    Is there further discussion on any
                    of these noints, or other,-; -that liz,,ve not I-)een sufficiently

                    covered?

                             If not, thank vou vci-.1 much, John.  lle appreciate   I





                                                                                   75
                     that,, and we will let you esccz@ne.

                               l@7e will now get to the important part of the

                    meeting,

                               The advantage of having   so many speakers precede
                    you gets it N7hittled do,..7n to %%,here I thin]-. it -@von't take
                    so very long, @,,,hich I think is good, because one of the   r@io@e
                    important aspects we have coming up this morning is Dr.
                    John Grarqlich, who will be reporting to you about matters
                    x,xhich are of importance on the review  of  arthritis  applica-
                    tions.

                               So,, as a preliminary to that, I would just like to
                    make a few comments on a point or two,  to  make  sure  that  we
                    try to keep all of you up to date with some of the
                    activities that have been going on.
                              As you know, the council met last on February 12.
                   Much has transpired, and that has been reviewed pretty
                   by the preceding speakers.

                              However, we did develop   a letter to you just last
                   week which tried to bring @ou uD to date on matters, and I
                   believe, Ken, that that has   been handed out,at the table,,
                   in case you did not receive   it in the mail.
                              If vou ilave been following the Washington Post
                   stories about the U. S. Post--a! Service, we felt it        to
                   Xerox another copy and give it to you at the table also.
                             In that report I believe that we have covered  i-,osL@-






                    of     matters.
                                     You  j'-.now that the E)ecrctLir, did au--i-iorizc-,


                    individuals so that, had  all accepted, we would be   fully

                    auc
                      ,fniented at -LL'i-s

                              There i.,rere a couple of noxi-acceptances, for venr
                    valid reasoi-is, and vie regret that,,- but we are.verv pleased.
                    1%14-tll tJ-1e. fact x,7e have so inann,., new members herc...
                              In,order to make this initial experience for the
                    new members of the council perhaps more meaningful and
                    rewarding, both to them and to the work that has to be done
                    he ret.we held an orientation meeting for the new members
                    of the council and any other past members who felt t]-iey
                    would like to attend on May 31, and this was a very busy day.
                    I will just briefly indicate that we tried to bring ti-iis
                    group of people into full knowledge of something concerning
                    the history of their program, the major' areas of  activity
                    over the early years, the various earmarked progran@,iatice
                    activities of 910, kidney, EMS, ILMO instructioiit arthritis
                    activities, and so forth.

                             TV6. tr
                                  ied to indicate something  about  the  review
                    mechanism that we II-ad established and followed earlier
                    concerning the review crit6rici ratings, the development of
                    our mission s
                                t,-itentent, how this had been developed and a-Dplic-c3.-
                            Ile spent some time on the phase-out and extension    i
                     the program and that        had -done what obligations @nd





                                                                               77
                    res,@onsil-,ilities I-,,ciC,, I)een pl,3.cx-td Unr reg i o@-s,
                                                        ).rl 1 C) Cl 1    h c

                          -Locai regions nad indeed responded and survived 0
                                                                            ver    i
                    this last vear.

                              And we got into the cl.a,-@s action lawsuit and gave
                    them the current status             and what seemed to be
                    the direction we were heading %.;jth      And you hivc  heard
                    frori,. tlr. Ilu'@)el t-n-is morning tic latest on that item.
                              @.7e. dealt with what we saw to be the transition
                   period that we are now in, and @,7en@ into tJie current advisory
                   structure apparatus that we now have with the ad hoc PIIP
                   review committee and the ad hoc arthritis review committee,
                   what they had done just the week before, and what this
                   council, at both this meeting and its ne,%t meeting in
                   August, will be called upon to do.
                             We went into what regions are exnected to accomplish
                   through their local review  processes,     our management
                   assessment visi-Es'ahd so forth.  We talked about available
                   funds.

                             We discussed our organizational and staffing
                  position and posture, what it had been,, ho,,; it had undergone
                  changes, and what the current status is.  And we went into
                  such matters of interest as the Federal Advisory Committee
                  Act on confidentiali@- , conflict of interest, open and closed
                                        y

                  sessions of the council,
                            At least fror@i staf@Ll-- point of v-Le,.7,, I would 1-i'r-@e






                                                                                   75
                     to thank those i.:Iio tooJ-. @-hi-s e@-,trEi tir-,e to' come to
                     @le found it very rewarding    I-le kno@@., we provided too much
                                               @T
                     material in too short C-1 time, but we hope that Maybe sc;r.-Ile of
                     it will make this meeting  a little bit more helpful;
                     irdeeO    felt @t t to Lc, ave-r-lxo i,,?ort"h@..@hile t,,iir,g we
                     have that opportunity prior to coming toaether in a large

                     group.

                               17ith respect to our review activities, of course
                     the major part of this meeting will deal witli the results
                     of those activities, and Mrs. Silsbee, at an appropriate
                     point  will discuss some details.
                              But I would like to   say that we did feel pleased
                     that the Secretary of HEV,7 did establish, permit to be
                     established two ad hoc review  committees for the work that
                     we had t carry out.   The first of these was the ad hoc P-@,IP
                     review committee, and I believe you have at your table a
                     membership listing for both that committee and the ad 1-10C
                     arthritis review committee, i-7hich'-was also established under'
                     the Secretary's authority.
                              These t@qo cor,..irqittees each net for, three days.
                     The one on    22,, 23 and 24 to review the J?J,!P applications
                     from all 53 regions'.  Mr. Petersen and air. chambliss chaired
                     the individual sessions       the review of the applications
                     occurred; I chaired the  opening session and the closin-a
                     session,      the full corii,,iittee met, in the lattLr instance





                                                                                                                         79

                             to review the recom-iendriti..ons (-,--F the ti-7o separate                   p @,n c, -'t S


                                                                            I Cli L ;J J-       '-nce.
                                                                                           L3 L-1 -L U


                                             I think     I  should    just     too     one     rioment     and     express,

                             as  t,ie l@@@-tinci Director of the                          r-,v -ai@.)reciatioii  t--O I-rs


                             F,ilsk)ee  for the vast amount of @-iors:               that    she    and    her    total.

                             staf-@   did   prior   to    this    we,@tin(7,    and    again.    there    is    no

                             point in !)elaLori-ng it, bu-@- it @,z@-is                tre,-,'endou,s    -imou@-it  o

                             work     under     the     most     stringent      conditions      of      personnel,    time

                             deadlines,  and so forth.

                                            I    thin]-,    that    again    you    will    get    an    impression    out

                             of    this    when    you    see    the    applications    on    the    front    table     and

                             note   we    are    down    in    our    staffing    to    one-third    of    what    we

                             used to be.


                                            In    this    connection    I    would    like    to    also    thanltz    Dr.

                             Endicott, who is not here, but who did support his  commitment

                             made    before    this    council    in    February,    when     he     said     he     would

                             try    to    make    available     to     our     programs     the     agency's     resources

                             to    help    carry    out    the.worl-,load    that.we    had.    And    in    fact     we

                             were    able    to    call    upon,    I    believe    it    i7as    finally    seven
                                                                    -     i.,7ere
                             former PIIPS staff rl,--r.@'oers' wlio/ver,,7 experienced with  the

                             review process  to return              from tf-ieik job@@in         other

                             parts of            this  age.-.cy,  during the month of Ilay,,  to-                'g v'e

                             us  assistance.   And some of them are here,  but all of                            tl--  m

                                          I  thanl@ hoth  them anO 'their supervisors,,                   because
                             are not;

                             three did    help us  -,.ateriall,,          n cjcL--L-4-ncT the m,.ito-rials        for  -i.e







                    review   committees


                              r'Lho- second review committee, the ad hoc arthritis

                    corirl,-Lttee, met on Mal, 23, 24, and -@15.  Dr. Gramlicl-i served

                    as our ex  offici-o liaison council Mercer to that committee

                    and sat in  an  the discussions, and shortly will be giving a

                    report to k,ou.


                              I.-Ir. SDf-zar, our staff person for this activit7

                    has worked long  hours and, as with Mrs. Silsbee, deserves    a

                    special note of  commendation for the tremendous amount Of

                    work well done-in, again, a short time period from the

                    inception of this program, when we first brought it to your

                    attention at the February council, to this noint where you

                    have recommendations on a number of applications.

                              That committee was chaired  by  Dr.  Roger  Mas on of

                    the Nebraska IU.!P, who didan outstanding job as chairman,
                    and we had hoped to have him also here'to present a report
                    to you, but a prior commitment made that impossible.  But I

                    do want to note that for the  reco-rd,  our  appreciation to him.

                              Turning to another point, our o@qn organization and

                    staffing, to just merely @tate that voii havp heard from Dr.

                    Greene that we still functionally are   within the Bureau of

                    Health Resources Development, and   that there  has  been

                    submitted to the aaencv a formal request that we be in that

                    Bureau organizationally, whereas as of the moment we still

                    officially are in the @-ureau of llp-,-.lth Services Pesearch





                                                                                  8.1

                               Our personnel ric)@,7 nui-,!)cr al)out one-third of

                    we riaa DeT-ore, i i-,(-.I:Leve you @,iiii see from the woi.-k tlial-
                                                                                 is
                    coming to -vou that there are still. many peo,,-)le who z,-rc.,
                    committed and dedicated to this activity, and have done
                    excellent work, but, nonc-th(@1css, we have lost r-,an@, cl;corl
                    people; and, nonetheless, I believe we are mz-,ii,-iging

                    reasonably well.

                              Attrition continues of our staff, and this hurts
                    particularly in the office of, or Division of Operations that
                    Mrs. Silsbee heads,  and as people depart from that office,
                    why, vip particularly feel the attrition.
                              1-7e did meet with the national steering committee
                    of RMP coordinators in May and had a very fruitful day.
                    Part of-th.at discussion was related to the cooperation
                    with Dr. Goodman and the End Stage Renal Disease Program.
                              I%le also had a presentation from Mrs. Bernice Harper,,
                    who,is the Acting Director of the Division of Long-Term
                    Care, because there are program interests between that
                    division and this agency and the R-7-IP program, where perhaps
                    cooperation bet@,7E-,en the ti-7o areas can -Lrurl--hpr enhance the
                    responsibilities of both.

                             I would like to  make two announcements to the
                    council  I am both pleased and --egret to announce        two
                    of our senio-- peonle will Ile ci@.7a  -For short -r)eriods of t4-rq
                                                    y
                    I regret that announcement because this is our busy sea





                                                                                      82



                                                                                  J.] 0-
                     but  I am pleased to   canrounce it 1)(-@cF,,use I taiiril,- that t'
                     (-)pl)ur-Lui@ities that each will have in the nc:,.t few  %.,c-E@lcs
                     be very  nice for them, and will certainly make  their  o@,-,Tn
                     growth  and Oevelo,)me;-it -- will advance their @,rowth  anC,
                     develo.3rient  and   also    bring I-)a@, to the <-icje-ncv a b.-cadenco
                     outlook on matters which are of    interest  not  only   to   @,!P but
                     to the a@-ency.

                                Mr.  Roland  Petersen  will  be  gone   for   the   next two
                     weeks to attend a health executive development program at
                     Cornell, at Ithaca;   and I guess will be leaving this weekend.
                               The other   item  is  that  Mr.  Chambliss   will   be   gone
                     for six weeks attending a program for health systems
                     management at Harvard University..Graduate School of Business
                     Administration, and will be returning the end of July.
                               I think we will certainly be looking forward to the
                     return of both he and Bob.

                               Iqe have been operating, back   to our general staff
                     picture,   under   a   postulated   decentralization   of   Regional
                     Medical  Prograr.1  functions  to  HETI  regional  offices.   I   am
                     happy to say that  after    a-reasonable    amount,of     discussion
                     internally that ti,-cit decentralization   plan   has   not    been
                     implemented  as  of  novel  and  in  fact  I  think,  through   the
                     offices of     Rubel  and  others,  it  has  beco,,ic  possible,, for thp
                     Under  Secretary of liE-1-i to  ,314--ato  that  no  determination has
                     been made about such decen4,-,--al.iz@ition, and no deterT,@.inz-,Lt-@'ull G. TI






                                                                                        8 3
                      this point @,,,ill ',-)e -iide at least     after legislzi4L-ion

                      is K)assed.

                                 No;ietlieless, ha@7i-n7,, c;r.4-O.. t:,i,-it, Ivou will appreciate
                      the corLr@,ent that Dr. Margulies made earlier, tJiat job
                      uncerti4-t,r cont,@rii,-s to fac,@ our        henc;e tlie F@t-@.rition;
                                 .2

                      yet we are hanpy        @,-e can pi-ace our cm-,)lo-,7ees in Derhans
                      more viable jobs, although i.@e are, sorry to see them     6epar4l-
                      the program, particularly when they have had several

                      of experience.

                                I tliirLIc,, for the most part,  they  still  enjoy  what
                      they are attempting to accomplish.

                                Our  current  funding  situation  I  think  will   become
                      clear as we  go  through  it  today,  but  in  general  it's  some-
                      thing on the order  of  110  to  115  million  dollars  to  provide
                      support for the Regional Medical Programs out of both this
                      council and the August council.

                                During our closed session, you will be reviewing
                      the-recommendations of individual applications, and I am
                      certain that by the time the council meets in August we
                      will have an exact figure-  for you, as a  result  of  @-he  time-
                      table, with the conclusion  of this much extended lil--igi@-ion.
                      But at this time, the best i can do is to give you a $5 millio       a

                                                                                       4-
                      range under which @.7e're operating, and I thi-iilz tl-iat's prct,.y
                      good, from th'e T)oint that we've been a-t sorie  time  in  recent

                      months.





                                                                              8 4


                                                                             ail
                             lir. Rul)el and others have gone over in so.-ie det

                       L'= @l ZD -LCL " "-)!-L s -La LLI@ (,)f that, and i -feel that L don; t

                   xiant to comment further and take your time on that,

                             Ilith respect to the over-all prograri for the

                   council today and tomorroi,.,, I @,,,ould like to i ay that we

                 I will have a report by Dr. Gramlich, @,71-iich Ibelieve is of

                   general interest to the open session, about  the arthritis
                   activity.  And we have the other items shown on  the agenda.
                             And one or two items of business, which will come ,I
                   both at the tir,.ie,i,7hen the public comments are in order andI

                   under Otl-ier Bus@iness.

                            Then we will go into a closed session of the

                   council, at which time we will treat in detail the review of

                   the applicFtions, and staff will be present to add comments,
                   and there are a number of people from the regional offices
                   and other federal agencies, and they are invited to attend .

                   Members of the public may not attend.

                            The closed portion of th-e meeting is under the
                   restrictions of confidentiality and conflict of interest, and
                   I believe we brought that to  your attention,rout-inely in
                   certainly the orientation  meeting and I believe the statements
                   in the package of materials  given to you.
                           During this  oren  session of the meeting, horv,,ever,
                   the information is open to everyone, and I tlierefore'caution
                   speal,.ers or others not to   into specifics of applicaL-IO-QS,1






                      technical review'., Cor',@,@
                                             @it4-e(-, :-ipproac---, 1-!I,,en i 4@- me t on 2'@Ird @L-(.)
                      th c- 25@-1 of Ilay.

                                 All t" 0 mf%'!,')Grs were c)r@,sc.-n@
                                 The -funding there @,7as, -is  a-Tn sure you knov7, in
                     the n@i(:Thli)c,-Iic-(7. o;: $4f@-'S,O'OC" -vz',il @,71 ic"i the
                     Cori-@mittc,,-- haci  'le- prc)l)l-@-n          aching on an..
                                                  of  r)roperly appro
                     over-all  viei-7 someth-Lnc@, over @15 million in c;rant re,-Ti-,
                                                                                  ests.
                      -iere there 43 applications involved.-in these gran- requests.      I
                     TI

                                Interestingly, ten regions had     not submitted
                     requests for a varietir of reasons.
                                It was immediately apparent that this was a unique
                     P14P function, on a pilot basis, one-time-onlyt and some of
                    the aspects of the uniqueness of t-hi-a particul-arprol"lem were
                    well exposed by Dr. Pahl and by others, in that these were
                    funds that would be supervised by individual IU@LP's, that
                    there were no specific legislative constraints.
                               This funding oDerationg in toto had been somewhat
                    interesting in its ince-o-Linn, -but at the s--M-- 4@-..@-Le L@H-LS !'!as
                    a truly pilot type program, the development of i%,hich,, -iiid the i
                    philosophy,  micTht @,7ell have profound influence on   programmatic'
                    thrusts and  such even more remote aspects as the effects on
                    future legislative'action.
                               One of      ccrlxiittee r.,.err-',)ers promptly pointed out
                   that the @-IIP had
                                       Lreque,ntl,,, led ;'_he wav in such cr-Lti-czl
                   matters, and used   the           of the kidney   dialysis and






                                                                               8 7
                    transplant Program @.i@tli pilot stu(,,-@.ies and establis'l-@irq
                    policy  @nd networks leading to tJie Ul-4
                                                            P)ate adequate
                    legislative funding, aiid he hoped tliaz-_ such a situation
                                                                             -igh-L.
                       1 develop with arthritis; an,d it might.
                              And to 1-uoll-e '@his particular comm4-t-l@-ce  Iie
                    said  that tells arthritis p@-ocTram riay he a unicTue oppc)rt,,ir,--tv
                    to make  amajo-- impact.
                              Now, the committee had the benefit of staff review,
                   and although Dr. P-largulies and Dr.@Palil have very properly
                   lauded Mr. Spear and members of his supporting team, I think
                   the highest compliment that I could pay them as an observer
                   at this-committee meeting was that the staff work was good.
                             The requests were noted to have sc,,mral corir,,cn
                   characteristics?in the patient care area, there were many
                   elements aimed at the development or enhancement of inpatient
                   or other central facility care, leading in turn to satellite
                   clinics for arthritis.care.


                                                                     e-lucat@
                             Many of the requests had str ng pc,-"-en4L.    L 0 171
                  components and public education components, and here an
                  interesting linkage with -the arthritis foundation developed,
                  which was that the Arthritis Foundation was involved in many
                  other grant request s.
                             There were some specialized programs to develop,. --For
                  instance, juvenile artlirit-"-'F, programs, arthritis care
                  programs, gout-. was in a lot of t-l-ie grant requests, and there






                     were program elements that were quite common to most of the

                     requests also, such as ma,@or eqtiil,)rent acqtiisition,
                     purchase of vans, de%,elopment of r;@oec-'--alized laboratories,
                     enhancorqent of existing equipment, audio-%7isual.  Some

                     grant rec.@,@c@,sts h,-.,@' consider@-31c facts hoped for in -Le -ms of

                     research, includinc,- epidemioloq
                                                        z-,.n-' tonoc-Trr-,phy as well

                     as patient care and basic research.

                               Some grant requests were   looking towards specializes'
                     units in hospitals, arthritis and rheumatism units some.@,71iat
                     similar to intensive care or coronary care units.

                               After the assessment of the over-all view of the

                     many requests, Dr. Pahl very kindly discussed some of the
                     committee's policy chargesi and this was an enormous asset
                     to the committee in its  functioning  and  future  thinking.
                               Ile first noted that it was  important  that  this
                     was to be a national program, not a series of small isolated

                     prO3ects,, but that its impact would be significant if the
                     committee sticceede-(l in putting it all to-etlaer, and that
                     this aspect should be seriously kept in mind during its

                     deliberations.

                               The essential  elements of  the  one-year  program
                     were outlined and in this regard there was some effort made
                     to devise the appropriate direction of appropriations ol. of
                     activities in @ic areas of +--.lie Triorc- sophisticated art@ri,--,@t
                     units already in existence-,, or in those with minimal or






                                                                                       09
                      widely sz)read caT3ebilities.

                                 Tlle pilot aspect was emphasized  as  was  tl-ie
                      necessity  for some measurement of the one-@rear  outcol7lil@s
                      for the benefit of the  ongoing  legislation  prograr.,t,
                                 The appropriate role of a local      arthritis cil-)- ap
                     was discussed at some length, as was the foas4-bilit,,7      of
                     proposals that carie  through  the  arthritis  chaDL--ers.
                                There was considerable direction toward       the
                     desirability of giving addit   ional weight to program elements
                     such as outreach in response to special population needs.
                                Pati'ent-focuing rather than general public-focusing
                     prograns,  and  the  basis  for  the  continuing  deliberations
                     of the committee was clearly established.
                                After the summary of the staff review, the public
                    comments were called for? and then the committee went into
                    full session.

                               Now, this  signaled  the  beginning  of  a  full day's
                    deliberat;Lon'in  closed  session  as  to  the  guidelines, the
                    appropriate guidelines for assessing equally and in-depth and'
                    impartially all of the grant applications. And the committee
                    did give a great deal of thought and effort to establishing
                    the appropriate guides by which the evaluation and recomenda-
                    tions for funding could be made for each individual aDDlica-
                    tion that was being processed.
                               The first plan t2iat was i-iorl-.ed out is a brief





                                                                               go
                    surinarv which discussed about nine or ten areas of policy
                    significance.  The corArrehensive health care for patient--
                    group@, that is the ele,-ients of coordinated care, @..,as
                    discussed at some length.' The matter of professional
                    education of people,n@viding-care, including the cutr ach
                    area, the concept of "train the team" and including           I
                    techniques O.L reaching or training the patient, was a MaD,or

                    consideration.

                             Quedstions as to what niiqht.be the best module
                    for delivering caret the kinds of provider roles, the
                    different kind!'of patients, coordination of communication
                    took the attention of the committee for a considerable

                    period of time.

                             The matter of the delivery team, how best it could
                  be managed, facilitated, what the range of its functions
                    might be' was considered -is an element important in the

                    assessment.  Rbsearch and evaluation was an obvious need
                    which was considered by the committee, as were the problems
                    of needs, assessment and quality control.
                             Then the matter of funding ongoing existing programs,
                    as opposed to new stcirt-ups,, was considered at lenath by the
                    committee, and finally the matter of needs for future funding
                    after the expiration of the one-year RDIP grant was a major

                    concern.


                            These were just broad guide lines that were then






                                                                                     91
                     distilled into the resolutions and guides i,.fhich you have in
                     front of you in the minutes, and which I won't need to

                     detc-3.il. particularly.

                                I would emphasize that   throughout all its
                     deliberations t)e con,@i'-tee l@@6p@ in mind the need  for  a
                     degree of cohesiveness on a   national basis, and a-L.  the scim,@-
                     time maintaining an objectivity in the assessment of each

                     of the individual  grants.

                               The Guidelines that you leave in front of you
                     emphasize the importance of outreach, and this was a major
                     consideration  as the main thrust of the programs to be
                     approved and funded in the opinion of the technical review

                     committee.

                               There were some negative aspects, and the committee
                     felt strongly that data banks and registries, per se, should
                     not be funded. At the same  tine  it  felt  that  these  were
                     not appropriate funds to spend on expensive hardware,
                     particularly complex audi-o-NTisual, televisi-1-1-  -F41m
                     ventures that would have..-very short-term, if any, payoff.
                               The coi-T@ittee did feel, however, 'that if  -there were
                     demonstrated needs and usefulness for audio-visual materials,
                     using video tapes as an example, there were certain areas in
                     the country of expertise @,ihcre , on a loan basis, widespread
                     distribution night be obtai'-@ied of rlateriils on a some-v;,!-iat
                     more centralized basis than if each unit went about establish'@@rici





                                                                                 92

                    its oxen,

                               In the matter of public education, the problem caTiel
                    up sev e-ral times of pul:)Iic pro7,ra@is -iimcd -it fund .-ais)'-n-,,,
                    and of course it was immediately apparent that this is

                    prohil),L.ted b,,,, federal recTti

                              Vt@l-iicles were mentioned several ties in parL--Lcula'r
                    grant rc,,Iuests, and it ;.7as felt again in general by the
                    reviei.@7 committee that it x-ias important that large amounts of
                    funds not be spent individually on.equiprqen+-- that might have
                    very little long-range use, and might be unsupportable by
                    future funding.

                              So that there was definite concern about large

                    amounts of funding for hardware.

                              The final negative guideline was in relationship
                    to professional training, since a number of applications had
                    requests for funding residency programs and degree granting
                    directions for 'personnel.

                              The IU.IP policy was such that the residency programs
                    in general could not be approved.
                             Ilo,vi, this sou,-icls a little negative.  It is not,,
                    actually, because you will find v,-hen vou start going through
                    the applications that the matter of positive effect in terms
                    of outreach, and the various principles involved in the
                    solution to the problems of the pilot program were carefully
                    dealt with and the discussion we.,-it on in depth and was not





                                                                                 3

                    pressured at all.


                                                        @il)p-llcaLlons,, each
                    application was rc-v-e-,.ied i,%-i depth the entire committee
                    and L-hc: o@?cr-all national         N,?as 1-@o-pt strongl@-, in
                   mind in the assessment of e@@

                              The individual aopi.ic@i-"ion was assessed  It, was
                   sometimes modified.   It wac3 ci v,--n a ranlzing score. And a-"rt--,r
                   this the committee discussed D,rogram coordination and outcoi@.1
                              And this, I think, merits a quote.  The notion
                   that communication and evaluation of this program pervaded
                   the entire technical review conruttee's deliberation.
                             The committee felt strongly that the development
                   of experiences and innovative  activities -- and I am quoting
                   now -- "conducted under the pilot arthritis program should

                                                                            'lar
                   be widely publicized, that a periodic newsletter or simi
                   communication about development of supportive programs
                  should be supported by BTIRD, to increase shared experiences
                  and to avoid duplication of effort."
                             The committee suggested, if possible programs should!
                  make quarterly renorts, and that there should be enough
                  action on the part of the individual recipients that sta@f
                  he well underway at @iL- end of three months and that per@onn'el
                  and organization be completed and in operation at the
                  six months.

                            In       oil evalu@,,%--ion, the committee requested, if





                    possible, that there should JI)c conference in Siy, jr-onti   c, r
                                                                              IS

                    some reasonaiDie period,, at -which tir.-te they would see-
                    tliev or the committee woul.@- see      was  going on in tlie
                    funding proc-ram, to maintain cc).,itl-'L.,-.uitv.


                                       reCol-@.
                                                                    was respccL'-f-u -y
                               1 twas

                    requested I)v the technical rc@, -nT,@ committee that the actions
                    of this council,  the advisory council, be made reasonably
                    available  then, so they could appreciate and evaluate the
                    benefits of their i,7ork,

                              This committee was a distinguished committee, as
                    Dr. Pahl has mentioned it was chaired by Dr. Mason from
                    Nebraska, and I will briefly tell you who was on the
                    committee -- not for subjective reasons, but because it
                    will perhaps help in future deliberations this afternoon
                    on the grants themselves, about the membership of the committee
                    which included a Mrs. Annette  from  California,  a  nurse;
                    Dr. Baily, an arthrologist from Georgia; Dr. Donaldson, an
                    orthopedist.from Pittsburgh; Dr. f@ngleman, a rheumatologist
                    from San Francisco,- Dr. Pfeiffer, an orthopedist from TIashing-
                    ton, D. C.; Dr. IIastirgs, a podiatrist fron,l.-7ashington;
                    Joi-in Poleski; Dr. Larsen, an orthopedist from loiia City;
                    Pranli: Schmidt, an arthrologist fro,-Li Chicago; Dr. Schulman,,
                    arthrologist @.-o,-n Johns Ilopi zins; llrs. Silverstein, occupational
                    therapist f,--cri Balti-iore; I-I,rs, 1--,Iilso,.i, a social workc@r r (N-"l
                    California; lirs. '.Jarl.)orougli, i-7ho is a physical theraois,4t-- from



          r






                    Georgia.

                              I served as a swaying L)a7idge from the technicc--,l

                           cor.-.niittee on one side to nat-L; i a 1 -7,dvisorv-

                    council- on the other, over the si%--@@Lam of action that t-I i o-

                    review c(-,:n,-@:iittee float---'-.-i7,

                             Tlc-comin,-ttee o:or@:cO. Ionic and hard.  In fact, a   -Lc c-- r
                    a day and a half of establ.irhincT guidelines for fair

                    assessments of the applications, the!i took another day and a
                    half to review individually and collectively each

                    application.

                             This' was not the easiest occupation, since, I
                    believe, there was a little trouble getting the PtLrl-,la@@in
                    Building to keep the air-conditioning working Saturdav; but
                    they persevered and adjourned in the afternoon on the third
                    day with a self-laudatorv comment which I-latt Spear hae-
                    included in the minutes presented to you,  They said that
                    the-efforts of this committee have been exemplary    fa
                                                                      as   r
                    as acting to the best interests adhering tc the guidelines

                    proposed.

                            We conside- this to be a very rqeager effort to,.,,,ard
                    a tremendous Problem, and it in no way begins to provide a
                    solution of any definitive kind.

                            No@..-, t-ley E-,lso made one very important point..
                    The additional funding to -Lnclude many of the projects
                    t-l-i.at N@iere rejected, as wo'L'L as L-ho- bulk of other projecL--i





                                                                                     9 6
                     which should have        submitted but @7ere nc-,t su.rr..it,L-.ec7i

                     -lecause-ti-ic guidelines provided by the legislation or  b-v
                     the constraints   of t4-.ri-a should be considered when stic-la n-@ncyL,
                     @@.,ould become available.

                                In other N,7ords, the. committee really loolze@ upon
                     itself as a x-.,a,,,station in a truly pilot program that  has
                     national'implicatioiis and should have  a  long-term  payoj-.L.
                                I think that there is  one  other  comment  that  is wc>r@i
                     making, and that is that it   is typical of  IVIP  flexibilia-
                                                                                  ,-y and
                     viability in that this program could  be  thrust  upon  on  a
                     crisi-,.oriented' basis and that the staff could come up with
                     a proper Administratioh to bffectively,get th'e-p!r@g@am  'to'
                     tlle'sthLte:,it!nQw, is -'in'a very short.period of time.
                               A great deal of credit is due Mr. Spear, Dr. Pahl,
                     and the entire staff.

                               DR. PAHL:  Thank you very much, Dr. Gramlich.
                               Are there questions for Dr. Gramlich on this      rather
                     brief survey of what was intensive  effort  of  the  arthritis

                     center programs?

                               The minutes pf -tli'lat meeting,, that; have been
                     distributed to you, as Dr. Grainlich stated, are quite important
                     because they contain the  resolutions  and  guides,  that  is,
                     the prenises upon which  the  committee  later  evaluates  the
                     application; and also there is in that document recommendation
                     for follow-ul) by the Division of Regional '%iedical Prc)gra...S,





                                                                                    9 7
                     so as to try to  make it an effective. national Drograi,-,,
                     even thouah it be a one-year effort, as John has stated.
                     And 1 @!ii-nk it ",ould either be @ip.@nror)riatc now or at a later
                     point in -the meeting, if you have not had time to read those
                     minutes, to have a formal council adop,"@ion  or endorsc,-en4@- of
                     those resolutions and guidelines, @is well as 'the recoz-,,,i,,enLla-'i
                     tions to our agency in program, for an appropriate kind    of
                     program involvement following.tbe awards for    the approved

                     programs

                               And if--it is the councils wish, this could be
                     done at a later stage.  But I think it would be well for us
                     to have that formal endorsement of the committee's proces    ses
                     and basic-underlying premises, because this is an initial
                     thrust, and we believe the committee not only did an out-
                     standing job,, but they set'for themselves certain rules and
                     procedures so as to try to carry out, to the best of
                     their understanding, the mandate that was given to us.-
                               I dont know to what extent you have had an odnor-
                     tunity to read these materials that Matt has.  These
                     materials are at the  desk  today?
                              MR. SPEAR:    The riinutes aren't here, unless they
                     have been distributed.  They were nailed out.
                              DR. PAIIL.-  O'@cl-.y, they were mailed out to you.
                     If you have had an opportunity,  perhaps you would care to
                     discuss that       'or, if not,  that could be lef t     we nc,-e(i





                                                                               9 8


                                                                          not
                   s ome e:c4t--ra co.pies, @,,hicii j..-ielic..i;'_es to me tha' tiis is

                   the appropriate time, then, to -@l:al@e an@,- action.

                             I x7oul.cl su@c-fest ti-,at -..,e c-,c, extra conics and
                                                      fet sor

                   give them to  ou, and -oerlici-L)s later todciv, or at such a time
                                y

                   as x.@,e ti.-.l':e ul? t'i'le z,,,@.'@hr-Ltis these couIC, be

                   gone over and that action ins-t4Ltutecl.

                             Are there anv points of discussion for either   Dr.
                   Gramlich or Mr. Spear at this time on the arthritis

                   activity?

                             Ilell @hank you, John,. very much for your  report,
                   and we will be getting into the detail matters early this

                   afternoon.

                             I would like now to take up one or two it.--ris of
                   usual business before the council, and that is to ask  for  a
                   consideration of the minutes of the last meeting of the
                   council, the February 12th minutes.

                             If there are any changes or amendments?

                             I=           'fair would entertain a mo4-i-- for
                              -L not, the C.

                   adoption of the minutes.

                            MRS. I-IARS: ' I S-0 move.

                            MRS. MORG-Al-7: I second.

                            DR. PAIIL:  It has been moved and seconded.

                            All in favor say "aye".

                             [Chorus of "ayes".]

                            Dr. P'kllL: Opposcd?





                                                                               9

                             [@To response.)

                             DR. PA','lL: So moved.


                                                                               the-.i
                                     also      to c,--l", to -,Our -ittention ti-i.-t

                   next meetLng dates for the council are August Sth and 9-t"-h, and

                                     t-h                                St4
                   I wo-Lil d h op c tli,-i4@ -7, schc-(Iiiled mc-etincT is

                          4
                   appropriate for you.  Ii-- has been very Oi'Lficult to arrana.&
                   meeting in ilugust, and we do urge all of-you, and those W'@k I 0

                   are not present this morning, of course, to make that

                                                               appl4
                   meeting, because at that time there will be     i-cations

                   from 43 regions or so, requesting something in the

                   neighborhood of $42 millions.

                            So there is a reasonable set of responsibilities
                   involved in that statement, so we would hope that all of
                   you would try to make that August 8th and 9th meeting.
                            At this time we are not attempting to establish
                   a meeting date beyond that, because, very frankly,, we would
                   not know what date to suggest or what the needs and

                   responsibilities are,-so if you w@ill bear with us until
                   August 8th and 9th we will bring in a large calendar and  see

                   what we need to do at tha'@- time.

                            Before we get into the last item of business, I
                   would ask for any public comments or comments by members Of
                   the Dublic on anv of the .-la@--ters that have been brought up
                   today by us or otlier matter,-; relevant to the council

                   consideration that you care to make.





                                                                              lo o


                             If there are individuals @-,,ho care to make

                   or conr@,,o@hts, I would asic ,,ou %to i-d-2nt4-fy yotirE:el.@ -for the

                   record, and if you are representing an organization that

                   a.s, someone other than yourself, please identify whom you

                   are representing.

                             So the floor is open at the rqoment -for anyone who

                   feels so inclined to make any general statement or cor.%-,,c-nt

                   upon what has transpired so.far.

                             MR. POPPER:  Ily name is Robert Popper, and I have

                   been on the Now York Regional ?.Iedical Program almost since

                   its beginning.  And for the past three years, or something

                   like that, I have been chairman.of the IUIP.

                             Noii,, I have watched PIT as a concerned interested

                   citizen, because I an, a volunteer.  Nobody pays me anything

                   any more.  And also as a taxpayer.

                             Now, I take tl-iat responsibility very seriously.

                   Considering the alternatives, I would rather pay taxes than

                   not, but I do want to a-et my money's worth.

                             I have watched R:',P over these years and have

                   watched some of the.things it does, particularly in our city,

                   that I have never seen done before.  It has managed to

                   convene some people who never before could have believed

                   that today was Thursday, and I have managed to get these

                   people, to sit them down in,a room, to establish prior;illics

                   and implement programs; and it has baen really quite a



                                                                               101

                    .remarkable thing,

                              A lot of these people have nothing to gain from
                    RMP,, they are not people who submit grants, they are just
                    people who think that RMP is worth something..
                              I think this is good, and I think it's important.

                              Now,, I come to you particularly with an unusual
                    problem with New York.  I hate to bore you with statistics,
                    but the fact is that I memorized them on the plane coming
                    down, and I'll be damned if they're going to go to waste.
                             We have ten million people, nine counties, twenty-
                    one congressional districts.,, two hundred hospitals,, and,, so
                    help me, seven medical schools.

                             Now, if you think that that's an easy group  to get
                    going on anything -- you are quite right; it is extremely

                    difficult.

                             In December of 1972, when we had our site visit,
                    our director had just resigned, our grantee was asking
                    permission to withdraw  the PJIE was acting under wraps
                    because we never knew from day to day what our powers were,
                    and I can assure you when I cross Fifth Avenue the cops
                    didn't stop traffic for-me.

                             Today this is all different.  We have a grantee
                    who is responsible, respectable, and who cooperates,, but
                    does not interfere.

                             Ile have relationships with our comprehensive health



                                                                             102
                   planning agencies and other planning agencies in town that
                   have never been better, with a good deal of cross-federaliza-
                   tion and a great deal of conversation, particularly with CHP,
                   we are in good shape.

                             We have a staff that'-s absolutely devoted and
                   competent, and works just as hard as the staff down here, and
                   we have a strong and vigorous PJIE which attends meetings"
                   and which deliberates and which does everything it has to.
                            Now, I'm not going to go into all the projects
                   You have them here.  I merely want to say that if you think
                   all urban areas have problems, we, with our ten million people
                   and seven medical schools, have ever so many more problems
                   than anybody.

                            But we have the solutions to solve those problems,
                   and all we ask from you is consideration of money.  We are
                   five percent of the population of the country, we are putting
                   in an application for roughly five percent of the impounded
                   funds.  Anything you give us will be deeply gratifying, and
                   if you give us more, that's even better.

                            Thank you very much.
                            DR. PAHL:  Thank you, Mr. Popper.  I am glad we
                   received those statistics also into the record.
                           Are there other members of the public, or are there
                   comments by the council at this time relative to this

                   statement?



                                                                               10 3

                              If,not* are there other general statements  to  be

                   made before we go into the last item of business I have

                   in the open session?

                              I would like to have you turn your attention, then,

                   if you would -- I am not sure in what form this was given to

                   them, Ken, is it in the agenda package?

                              In the material which contains your agenda,   the

                   last two sheets,, there are two staements there which the

                   ad hoc review committee for the RMP applications formulated

                   and addressed to the council for their  consideration,,  and

                   I would like to, at this point, have you  consider  them  in

                   this  open meeting because they are not related to any

                   individual'application or the review of any individual

                   application, but rather are matters of  general  interest  to

                   the review committee and to this council.

                              The first statement I have is the CHP  review  and

                   comment. Do you all have that statement  in  front  of  you?

                              MRS. MARS: Who drew -this up, Dr.  Pahl?  What  is

                   it?

                              DR. PAHL:    This statement was drafted by Dr.

                   Teshan, who was sitting on the review committee, but I

                   believe that there were several.  He's the one who presented

                   it to the full review committee.

                              The full review committee considered this statement

                   and passed favorably upon it for submission to an action by





                                                                              10 4
                    this council.  So this is a proposal to you to consider and
                    adopt it, amend its or not act upon it at all, but it is
                    brought to you from the review committee, and we are serving
                    in that capacity.

                             In introducing to you this statement,, you should
                    be aware of the fact, and this is particularly addressed to'
                    new members of the council, that there is a procedure within
                    the RMP guidelines and policies whereby applications from the
                    local P14P are submitted to the local CHP agency for review
                    and comment,, and that these comments by the CHP agency are
                    returned to the local RMP,, where the comments are to be
                    considered by the regional advisory group and the RTIP,, and
                    some kind of positive response made,

                             That does not mean that the advice by the CHP
                    agency has to be adopted in all cases, but the comments have
                    to be seriously considered and an appropriate kind of action
                    taken following the RAG consideration of the comments.'
                             In some areas I think it is fair to say that
                    there has been very good-close working relationships,, and I
                    think we just heard a statement from Metropolitan New York
                    RMP,, where such activities seem to be working out very well.
                            In other areas of the country I am afraid things
                    perhaps have not always been as smooth.

                            Consequently, there has been a spectrum of both
                    the kinds of advice given IU4P's from the CHP B agencies as




                                                                             105

                   well as the kinds of responses that RMP agencies have  made

                   to such review and comments from the CHP B agencies.

                             As Dr. Margulies and Mr. Rubel have already

                   stated this morning, much of this is past history,  because

                   we are moving into a new direction, and I believe that  the

                   sources of friction are much less-widespread than rumor -

                   would have it.

                             In many places.things are proceeding very well.

                   Many of you who have sat on the council know that the local

                   P14P's@have done much in the past to staff and help establish

                   the local CHP.B agencies,

                             They are sitting on the RAG's and on the CliP B.

                   agency councils and boards, people from the other agencies;

                   so there is good collaboration and cooperation in many

                   quarters,, but it is not uniform.

                             As a result of still this divergency of  interest

                   and activities,this statement was drafted by the review

                   committee for your consideration and I would like to read it

                   into the record, and then you may take whatever action,

                   following discussion,, that you care to.

                             Mr. Rubel is heret and I think this is appropriate,

                   because he has these two sets of responsibilities.. and that

                   is not only as Acting Director of the CIIP Program, he is
                   interested in such activities,, but in his more major role,,'ane

                   that is the Associate Director for the Health Resources




                                                                               10 6


                    Planning.  It is his reponsibility to try to make a more

                    effective program both internally and externally,,  between

                    the CHP and RMP functions.


                              So I would like to read this review'committee


                    recommendation for your consideration into the record.

                              OCIIP Review and Comment.

                              'Re.commenation for Council Policy and Request  to

                    Health Resources Administration:

                              'While recognizing legislative mandate and Division

                    of Regional Medical Program regulations  regarding  RMP-CHP

                    relationships,' Council requests that the national CHP

                    leadership transmit to Areawide CHP(B)  agencies  nationally

                    the mandate for fully reciprocal relationships with  RMPS,,

                    especially in calling upon RMP assistance  for  professional

                    and technical input into ongoing CHP plans development; and

                    in the interests of fairness and full  reciprocity  Council

                    furthermore agrees and instructs ad hoc RMP Review Committee

                    and Staff to set aside any influ6nce of negative CHP

                    comments upon an P14P application unless the commenting CHP(B)

                    agency has provided the RT-IP with (1) the criteria and a

                    description of the b-agency review-and-comment  process  and
                    (2) a list of the b-agency objectives and  priorities  upon
                    which at least a part of the P14P response should be focused."
                             Perhaps it might be appropriate,  since  Mr.  Rubel
                    is here and has already treated this, in a sense, in his




                                                                                107

                    earlier statement, to first make a co=nent or two which I

                    think may be helpful and then ask for council discussion.

                              Gene.


                              MR. RUBEL:   As I tried to say before,  it  seems  to

                    me this statement is an attempt  at raising issues  that  have

                    been very bothersome and troublesome in the past,, and,,  very
                    frankly, I don't see it as providing any  positive  effe@t  for

                    the future.

                              There is no question that there has  been  an  awful

                    lot of each agency trying to further its own means within

                    the RMP world.: There has been the question of  "who  sent  you

                    out to be our master' kind  of a feeling, and it  is  certainly

                    evident in the discussion  of the review council,  that  that

                    was a major one of the problems.

                             .@""We don't respect you, anyway; we know what  we're

                    doing, and who the hell are you to tell us what vie should do?"

                              That has been the attitude in many places.

                              on the other hand, there has been  an  attitude  on

                    the part of many CHP people, one of, in many cases, jealousy,

                    envy, 'you have all the bucks and we*re struggling; and

                    weire going to sabotage what you're doing.'  A  lot  of  that

                    has occurred as well.


                              I think the  Congress is in the process now of tryinc

                    to reconcile the problems that we've had in the past.  We

                    certainly, I would say, over the last three months, four




                                                                                10 8


                    months, have tried to do it here as well.

                              When the applications went out to  the  RMP's  back

                    in February, we sent copies of them to the  CHP  agencies  as

                    well. The first time that had ever been done.

                              We tried to explain what the rules  are,  where  we

                    also try to lay out some priorities,, as we saw  them,  where

                    they could be working together.

                              As I travel around the country,, I have found  an

                    amazing amount of interaction that people are trying to work

                    together. I think perhaps some people  feel  the  problem  we

                    have as bigger than what really is there.

                              There is no question in the context  --  the  first

                    part of the statment, I am not sure I know what it means; but

                    in terms of reciprocity I think that is  happening,  people

                    are talking to each.-other.. And I am not sure what making that

                    statement really means.

                              Well,, let me@stop-there, and I will  certainly  be

                    glad to respond to any comments-you have.

                              MRS. MARS:  Personally I don't think this is a

                    responsibility of the council, and I don't think  it  comes

                    under our prerogative to try to settle internal  politics,,

                    so to speak, in that this is more or less a political
                    issue. And I would be very much  against  recommending  it.

                              DR. PAIIL:  Dr. Merrill,

                              DR. MERRILL@:;  I agree with both  those  comments.





                                                                             109
                   Since I have read this thing, I wondered where the other
                   eight commandments were.

                             I think it's calculated to raise the hackles of
                   the people wlio receive this.  It's extremely High-handed,,
                   and I think the issues which are involved, which are.much
                  dealt with by a soft sell rather than an extremely hard and
                  irritating sell such as this one.

                            DR. JAN@IAY:    John, on those two commandments
                  hang all the Laws and Prophets.

                            DR. PAHL:  Mrs. Flood?
                            MRS.'FLOOD:  I would inquire as to the interpretation
                  of the OIP(B) agency by the wording of this comment.  Would
                  this encompass also,the areawide.planning agencies that are
                  unfunded, that are strictly voluntary and functioning in
                  areawide health planning without any federal or State
                  support, but who fill the role of review and comment for
                  these levels?

                           MR. RUBEL:   Under current Department policyp there
                 is only a requirement to get review and comment from those
                 agencies that are funded by the federal government.  I think
                 in practice it has turned out that there are many other
                 agencies involved as well.
                           Hopefully, in the relatively near future  we are
                 not going to have that difference, we are going to have
                 planning agencies covering the entire country; but there is





                                                                              110
                    no way, there is no requirement that an RMIP get comments
                    from anybody other than a federally recognized and funded
                    areawide planning agency.
                             MRS. FLOOD:  But in reality they do,,' they go to the
                    areawide planning agency, recognized though unfunded, that
                    does fulfill this role.  So my question would then lead to:
                    If this policy statement should be adopted, would it be
                    forwarded by your office, Mr.,Rubel, to these unfunded yet -
                    functioning areawide groups?  Through the (a) agency,, perhaps,
                    if you use that mechanism for dispersing information.
                             MR. RUBEL:  Well,, we. certainly would be telling it
                    to the (a) agency people.  We have no formal communication
                    channel to the unfunded areaviide agencies.
                            MRS. FLOOD:  Well, that is an interesting fact when
                    you consider that the regional offices would require a review
                    ad comment from even the unfunded agencies before they consider
                    applications that are.not directly related necessarily-to RMP
                    but to other funding sources.
                            In light of the fact that this particular policy
                    statement then perhaps dispersed through the (a) agencies
                    would reach even thse unfunded agencies, I would also feel
                    that it is a high-handed approach and would cause many
 cl@
                    problems for Regional Medical Programs.

                            Thank you.

                            DR. PAHL:  Thank you.







                                Dr. Gramlich.


                                DR. GR2U4LICH:  Dr. Pahl, a question    of information.

                     Is there anything in DRMP regulations which requires that
                     DRMP s-Eaff and council not fund an otherwise Appropriate

                     pro3ect which has received a negative comment?

                                DR. PAHL:    No,, the regulations, policies  merel-i.-

                     require  that  the  applications  before  being  considered  have

                     gone to the CHP(B)  agencies  for  review  and  comment,  and  that

                     such comments be received,, considered  and in some way disposed

                     of, affirmatively or  negatively;  but  beyond  that  there  is  no

                     requirement.

                                And I should say, and this will come up     as  we  go

                     through our RMP applications, we made a very-strong effort,

                     as we have in the past, to make sure that despite the short-

                     time periods for the present applications, that our applications

                     did go and be reviewed  by  CHP(B)  agencies,  and  this  placed  a

                     very heavy burden on the (b) agencies.

                                The time requirements Were very,, very strict.

                     We have received the comments from the P14P's about the (b)

                     agency comments and what their  actions  are.,  and  I  think  we
                     have tabulated these, and both Mr. Rubel and I are quite
                     satisfied that everything that could be done in the periods

                     that everyone had available has been done and it has been

                     really a remarkable  performance  by  both  the  CHP(b)ls  and  the

                     Pl@ip , S.





                                                                               112

                              That is not to say sweetness and. light exists  in

                   all quarters,, but it is far less than whatpeople believe.

                   And, as with most things, a few cases of dissention seem to

                   color what is not truly a generalized situation.

                              MRS. SILSBEE:  Well, in practice, some  of the (b)

                   agencies did have difficulty because they have such a

                   tremendous load on -- and have been sending  in  comments  that

                       to Mr. Rubel and copies to us and to the  Regional  Medical

                   Programs.

                              In some cases the review committee had  those  late-

                   comers,  In every instance we felt that the information would

                   be accepted, but the real forum for discussion  was  back  at

                   the regional advisory group, and we have been trying to get

                   information about what the process is that is going on

                   locally.

                              DR. PAJIL:  Thank you, Mrs. Silsbee.

                              Dr. Sparkman.

                              DR. SPARKMAN:    I'm @ohn Sparkman.  I  am  Director

                   of the Washington last-guard unit, chairman of the steering

                   committee coordinator; I can't speak for them, but  I  think  I

                   reflect their views, and I would like to take a different

                   approach.

                              It seems to me that the approach so farbas been  to

                   tell RMP'S, you just must abide by CIIP review  and  comment,

                   and we have had this mandate laid on us.





                                                                               113
                              On the other hand, I think what the authors of
                   this particular statement had in mind was that the CHP should
                   at the same time be told, Yes, you have a mandate to cooperate
                   with RMP'S.

                             I would agree with what Herb has said, or  what  Mr.
                   Rubel has said relative to the fact that in general relation-
                   ships between CHP's and RMP's are good,, and they are better
                   than the general rumor has it.
                             I agree further with what Mr. Rubel has  said,  that
                   there is no point in looking back and  having  recriminations,
                   when we should be looking forward.
                             But the fact remains that everything that  has  come
                  out of the central office'has not seemed to be to this effect,,
                  and I don't have specific comments,, but I know from sp  eaking
                  to my fellow RMP coordinators that they feel that Mr. Rubel
                  doesn't quite reflect to his colleagues in CHP what he says
                  here to us.

                            Now, I don't question h'is honesty, but this is
                  the feeling that still exists, and it seems to me that the
                  first part of this,, down -to "furthermore agrees and instructs"
                  does in fact include a positive recommendation to say:
                  All right, P14P is going to cooperate CHP's are going to do
                  likewise.

                            But I think I would agree with the scratching of
                 an ad hoc PIIP review committee and stafft to set aside any




                                                                              114
                   influence of negative CHP comments.  But then I would
                   think it is reasonable to ask the cHP agencies to describe
                   the criterion and description of the review and comment

                   process,,.and to list the -(b) agency's objectives and the'
                   priorities,, and the basis on which their judgment was made.
                              I know from the facts that,our own'region,, but I
                   don't know on what basis a judgment was madep and I clearly
                   think they should be told this, and I see no objection to this.
                             It seems to me this is a positive thing to do, and
                   not a negative thing.  And I further think that it is the
                   responsibility-of this council to look at this and act-on it.
                            Let me say that the coordinators hold this
                   distinguished group in great respect.  We recognize that
                   from the beginning the national advisory council have played
                   an exceedingly important role in PI.IP and detrmining policy
                   and quality by actually setting policy, and I see this as a
                   policy, and also by the careful review of applications which
                   we are all going to do, which is an important part of
                   determining quality.

                            So I see this as a positive thing, and I see it as

                   your responsibility.

                            DR. PAHL:   Thank you, Dr. Sparkman.

                            Are there other comments?

                            Dr. Merrill.

                            DR. t@'M-RRILL:  I would just like to reply to that.





                                                                              115
                             In my comments I did not mean that I didn't think
                   this was at all a fine thing to do', but I think this is
                   entirely the wrong way to do it.
                             What this proposes is that this council formally
                   request that the national CHP leadership transmit; now I
                   have a very strong feeling, perhaps shared by other members
                   of the council, that it will never get any further than that
                   and might simply irritate people.
                            I think there are other ways of effecting the kind
                   of thing that is intended here, and I think this might be
                   done without a-formal statement.from the national advisory
                   council of P14P.

                            I would suggest perhaps that  it might be done on a
                   personal basis, or a man-to-man basis.  I think you're
                   quite right, it would be nice for a local RMP to know the
                   (b) agency objectives and priorities; but I think for the
                   (b) agency to transmit these to the local MIP by reason of
                   a request from the national advis-ory council, coming from
                   national CHP, has the effect of making more of an issue out
                   of it, I think,, than is warranted.

                            DR. WAMMOCK:    You're talking about that local
                   people make this comment rather than the national level,
                   is that right.>

                           DR. MERRILL:  Well, I would suggest in this stage
                   that the national T4P people and the national CHP people get




                                                                             116

                   together at the request, when and if it originates    and
                   I think it's reasonable -- should come from the national CHP

                   without the tag of the RMP, which would only serve to be a

                   sting.

                            MR. RUBEL: If I could just make  several  comments.

                             First of all,, in terms of our attempts at suggesting

                   that @IP's and CFIP's work together, I would point to the
                   covering letters that went to both organizations when this

                   funding cycle first began, and I will leave that for the

                   record to judge whether we have or have not attempted to
                   suggest that there are very meaningful relationships to be

                   carried out.

                             The second point, the very essence of the planning
                   process, within a comprehensive health planning organization,

                   is its openness and the ability of virtually anybody to

                   participate in that process.

                             If we have to have a mandate from Washington  that

                   tells people,, Well, we've alread7y told them what they have to

                   do, it's very much in the open, to open it up some more,,

                   then we have failed even more than some of us here think  we


                   have.

                             It is very true that there are many planning

                   agencies that have not articulated very clear objectives,

                   but that same thing is very true of RMP'S.

                             It is very clear that we have CHP agencies that have




                                                                               117
                    not responded very well with specific comments to a
                    proposed project, but it is also true that many RMP's
                    have not justified a project in a way that a CHP agency

                    could respond.

                             Wh at I am trying to say is we have a lot of
                    problems.  To the extent that you ask,us to communicate with
                    CHP agencies, I promise you we will so communicate.  My
                    own personal-conviction is that all it will do is exascerbate
                    problems that we have,, and it will not be a positive
                    influence.  Let's face it.
                             The July applications are just about on the way.
                    Who are we telling, you know, you've got to communicate
                    before you submit applications.  For what purpose are we

                    doing that?

                             I would wholeheartedly agree,, to the extent the
                    current legislation will continue, that we need to find
                    better ways of communicating with each other,, and if I have
                    anything to do with it, if concurrent legislation were to
                    continue, we would seek to do that.

                            But,  in  light of where we are, I think it's
                    a little meaningless to try to start doing that from this

                    point on.

                            MRS. MORGAN:  I don't believe we as a national
                    advisory council have any control over CHP agencies at the
                    present time to demand what they should do.  Ile can over




                                                                              118

                   RMP's groups, but we certainly cannot over CHP(B)  agencies.

                             DR. PAHL:  Mrs. Mars?


                             MRS. MARS: I would like to make a motion  that  we
                   do not adopt such a resolution as being inappropriate for'the
                   council,, and perhaps along with that,, however, adding a
                   directive, such as Dr. Merrill stated, perhaps you would
                   like to phrase that a letter be sent or something.in  so@ter

                   termst rather than adopting such a motion.

                             Would you like to add an amendment to that?

                             DR. MERRILL:  No.. I think th at the thrust of  what

                   we all are thinking is very clear to Mr. Rubel and Dr. Pahl,
                   ad I don't think it really needs to be put into writing.

                   I am sure they could follow our wishes,

                             MRS. MARS: Well, leave it then just as a motion
                   to not adopt such a resolution as being inappropriate on the

                   part of the council.


                             DRo MERRILL;  I second it.

                             DR. PAHL:  It has been moved and seconded to not

                   adopt the proposed resolution.

                             Is there further discussion by the council?

                             [The question was called for.]

                             DR. PAHL:  All in favor say "aye'.

                             [Chorus of 'ayes".]

                             DR. PAHL:  Opposed?

                             [No response.].



                                                                              119

                              DR. PAIIL:  So moved.

                              The second statement,, which I believe is one that
                    the review committee was very interested'in bringing to your
                    attention, I think is fairly obvious, particularly from this
                    morning's presentations by all of the speakers,, namely, we
                    know we are in a transition period.  Each speaker has
                    indicated that it is necessary, essential, highly desirable'
                    for the local RMP's to order their own affairs, and seek
                    closer, more effective relationships with those groups in
                    their own regions, be they governmental or non-governmental,
                    so as to look in a positive way to the future developments as
                    we perceive them at this time.
                             And this recommendation by the review committee,
                    I think addresses itself to that statement.

                             I would like to read it into the record, and then
                    have the council consider this.
                             "Action to preserve PkiP Experience and Relationships"
                             "Recommendation for Council Policy:
                             "In view of legislative developments now underway
                    for further evolution of-RMP, in association with the CIIP
                    and Hill-Burton programs, in the interests of national health
                    planning, Council encourages RMP's to develop organizational
                    readiness and any remaining regional relationships which are
                    appropriate to lead,'participate in and accommodate the
                    anticipated new operating structuns and requirements.




                                                                              120

                    The purpose of this orientation is to preserve for the  new

                    formats within the States and regions the capabilities  and

                    voluntary cooperative relationships which the RMP experience

                         e@ted."
                    has cr


                              I believe I should convey to you the  committee's

                    intent here when they say 'organizational readiness",  that

                    they are stating that the local P14P's should look to'their

                    own internal staffing patterns and structures so as to be in

                    a better position to be responsive to both the regio nal

                    needs and the developing legislation as we all see it.

                              So this is not encouraging, by any means, RMP's

                    to adopt different forms of grantee organization, but

                    rather to look internally to their own staffing structural

                    patterns.

                              Now,, with that as background, I would like to

                    invite councils attention to this recommendation.


                              DR. JANEWAY:  I believe that this is anticipatory

                    of'federal legislation, and one cannot read the intent of

                    people who propose this to council, and I think it's open to

                    a variety of interpretations, and in its present form I

                    could not support it, a resolution such as this.


                              DR. PAHL:   Mrs. Mars.


                              MRS. MARS:  I would just reiterate what Dr. Janeway

                    has said.  I feel the same way about it.


                              DR. PAIIL:  Dr. Watkins?



                                                                              121

                             DR. WATKINS:  I believe -- I was going to say that
                   I don't even believe that we should have the responsibility
                   of voting on either of these things that came up today; we
                   should have returned them to them with the comments that were
                   made,, without a vote at all.  Because we are negating something
                   that we're not responsible for.

                             DR. PAHL:  Dr. Schreiner?

                             DR. SCHREINER:    This reminds me of a story about
                   a Czechoslovakian sheriff in Colorado, and due to local
                   budgetary difficulties they had gotten down to one deputy,
                   and they had a gang of about thirty outlaws holed up in a
                   shack, and the sheriff said, "Well, men, since we're out-
                   numbered,, I suggest we split up in groups and.surround them."

                                (Laughter.]

                             I think the P14P's that have lost a lot of staff
                   know that they are in trouble and are trying hard.  I don't
                   think they are going to be helped by this kind of a

                   resolution.

                             I think the ones that have the staffs, the reason
                   they have good staffs is-because they know this is a problem,
                   and they are getting ready for possible future legislation.
                   I don't see that anything is going to be accomplished by
                   this type of resolution.

                            DR. PAHL:  Well, I think, unless there is further
                   discussion,, the Chair understands the sense of the council,



                                                                                 122


                    and we will transmit such discussion back to the.review

                    committee,, so that they will know the disposition of


                    these,


                               Before we break for lunch, I would ask once again

                    whether there are any further points to  be  made  by  council

                    members or the public on any of the matters we have discussed

                    this   morning.


                               Dr. Haber?


                               DR. ABER:   Yes,, I would like to comment  at  this

                    meeting   about the proposed outreach of the arthritis

                    proposal.  I construe this as being very important and

                    possibly a mechanism in which the treatment of arthritis

                    can escalate and elevate itself up to a much higher

                    plateau.

                               The reason for this is that most arthritis is not
                    treated in hospitals, it's treated on an outpatient basis by

                    a variety of practitioners, some of whom may not be

                    qualified.

                               And I think if I sense the meaning of outreach here,

                    there will be an opportunity for physicians who are a tertian

                    kind of physician, who are involved with research and

                    teaching and so on# to be able to  relate  much  more  closely

                    to the primary-care physicians.

                               That is to say, the resources of the hospital, the

                    school of medicine, and all the rest which have been devoted



                                                                                 123

                    largely to life-threatening diseases on an inpatient basis,,

                    will now be turned toward this very important area of

                    arthritis.


                              I would commend you for this, Dr. Gramlich, and I

                    think it's a very  important step which could raise the whole

                    complexion of arthritis treatment in this country.

                              DR. PAHL:  Thank you very much, Dr. Haber.

                              Are there further comments by the council?

                              Mr. Rubel, -1 believe, had a statement.'

                              MR. RUBEL:  One further thought.  I mentioned

                    before that we have reached a settlement or at least there

                    is a proposed settlement of litigation, and that we have

                    agreed at least that  unless any RMP objects, that $5 million

                    will be used under Section 910.

                              It is our current intention to spend all of that

                    money,, using the contract authority, and that would therefore

                    not require review by this council.

                              On the other hand, by the time we meet in August,
                    we have to have our plans,, very hopefully,, firmed up and
                    I anticipate that.we will be discussing with you how we

                    intend to use that money,

                              The thrust of that effort is to  help us do research

                    into the technology of planning, as I call it, the
                    methodologies to be used, I believe the coordinator says,,
                    with major emphasis on criteria and standards for expensive




                                                                              124
                    services like open-heart surgery and the  like.

                              But we will have a very complete plan worked out
                    by the August 8 session,'and we do want to share it with you,,
                    and get your -- whatever suggestions you have 'for us.
                    We are going to be a little bit in the middle of a -- we
                    can't go ahead until we get the court order signed.' I am 'not
                    sure exactly where we are going to be on August 8th..
                             Wherever we are, it's my intention to fully
                    report to you exactly where we are with regard to that $5

                    million.


                             DR. PAIIL:  Thank your Gene.

                             Mr. Rubel has just distributed to you, because it
                    will be important to take this up in a closed session, which
                    we will convene following luncht the minutes of the ad hoc
                    arthritis review committee, wherein you will,find the
                    premises, guides, resolutions and recommendations for
                    follow-up by this agency in the arthritis program.
                             And if you should have a few minutes that you
                    could look at those, I think our discussion and adoption of
                    these would be more meaningful following lunch.
                            I would like to also thank Mr. Robert  Tarr# the
                    the HEli Committee Management Officer, and Mrs. Robert
                    Skinner who was our agency Committee Management Officers who
                    is attending this morning, and just state again that we could
                    not be-here and have the paperwork done that is before you




                                                                               125
                    without really the great help and assistance that they have
                    given to us in establishing and moving forward through a
                    rather complicated complex process.

                              The papers for the establishment of these two
                    committees that we have been reviewing this morning,, and
                    thank you for attending; it's nice to have you here.
                              With that, I will adjourn the rqeeting for lunch,
                    and suggest-that we be back at five after two.
                              tilhereupbn, at 1:05-o'clock, p.m., the committee
                         recessed, to reconvene at-2:05 o'clock, P.M.,, the same

                        day.]











   end em


   WD fls



  WHD-PM-1


                                    AFTERNOON SESSION
                                                                       2:15 P.M.

                             DOCTOR PAHL:  The Council-will please reconvenes,
                   now that the Acting Director is here.  I apologize for being

                   a few minutes late.

                             We continue to get communications from Regions; we
                   -do like to have the 'latest information as we go into the

                   review cycle, but I think we have to call a halt to it @t

                   this point and get to the.-business at hand.

                             I think that -- Judy, just let me ask whether you

                   would,prefer to-give your general comments now, or after

                   Doctor Gramlich treats the arthritis program?

                                             .-think it would be simpler ifus just
                             MRS. SILSBEE:  I'--


                   concentrated on the arthritis.

                             DOCTOR PAHL:  Because of the schedule, which permits

                   Doctor Gramlich to be here today but not tomorrow, we have
                   decided to ask him at this time, again, to present now in

                   this closed session, the Arthritis Review Committee's consider--

                   ations, together with a specific recommendation on the appli-

                   cations, and to give you a full picture of those events, and

                   then to ask Council to take appropriate  action.

                            Now, in opening this meeting,  I  would again remind

                   you that the proceedings from this point on  are confidential,

                   both the materials that you receive as well as the discussions
                   that will ensue, so we ask that you keep that in mind, and

                   also, should any application, either within the arthritis

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                    program or within the Regional Medical Program, be discussed
                    from the area from which you come, or if you know of some

                    other conflict of interest as a result of your own  involve-
                    ments in consultantships and so forth, please'excuse your-

                    self from the room during the discussion' of that'specific

                    Region's application.

                             Are there any members of the public who  are  here,

                    because if so, I will have to ask you to leave the  proceed-

                    ings at this point.

                             Doctor Gramlich, will you please proceed with your
                    discussion, and in that connection, I have been requested to

                    announce that because of the low ceiling and  the  aircondi-

                    tioning, it is hard for the Reporter and the staff to hear

                    the comments, so please use the,-microphones when you have

                    occasion to make comments or address the Council.,

                             DOCTOR GRAMLICH:  I think there are several things
                    that merit emphasis that I didn't pressure quite enough this

                    morning, in terms of discussion.time limitations.

                             First off, just a small subjective observation,

                    which, in addition to the listing of the Technical Review

                    Committee members, which I described this morning, I would
                    simply comment that this wa s a very  hard-working,  extremely

                    conscientious group of people.

                             DOCTOR PAHL: Pardon me, Doctor  Gramlich;  can  you

                    put the microphone a little bit closer?  I am afraid the air-


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                           conditioning unitsat this end are makkng it-difficult to hear

                           you.


                                        DOCTOR GRAMLICH: Is that any better?

                                        DOCTOR PAHL:   Yes, thank you.

                                        DOCTOR GRAMLICH:   This Committee was an able group
                           which devoted a great deal of attention to the problem,                     as
                           witness they.went to work at 8:00 o'clock in the morning
                           none of this'9:00 o'clock business, and on a couple of
                           occasions worked until 8:30 or 9:00 o'clock at.night, or on
                           one occasion they worked that late. The Saturday morning --

                           or the Saturday session -- lasted until mid-afternoon, so
                           in effect they put in three days of hard work in reaching

                           the conclusions that they did.

                                        That's   a small personal aside. I was there as an
                           observer. I have        been credited with the good work they have
                           done, which I would like to assume the responsibility for,
                           but my position merelyuas that of, hopefully, a bridge.between

                           them and the National Advisory Council.

                                        I did not contribute because I have no acpertise in

                           arthritis or rheumatology.

                                       Now, down to the work. I think              it is extremely
                           important that the Council is quite cognizant of the guide-
                           lines that this Technical Review Committee developed, because
                           it was the basis on       which they made their ob ective decisions
                                                                                      i

                           as to which grant applications should be funded, which should

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                                                                            129
   WHD-4

                   be disapprovedi,,and the,numerical ratings and prioritization

                   of the ones that were approved.

                             The purpose of using this  format was to make it

                   considerably easier, hopefully, for  the Council to do its own

                   job.

                             Now, I have very summarily named off  and  listed,
                   briefly, the guidelines that they came up with.  But you have

                   only just recently received an opportunity to read  them  in

                   detail.

                             I would first off ask Council whether  they  would
                   like to discuss these in detail, or whether they feel satis-
                   fied and'comfortable with -be guidelines as they  have  been

                   given to you on the written sheets that  you  have?  If  you

                   want to discuss them, I will be very happy to do so; iE  you

                   think that there is no need to waste time on  that,'that  is

                   agreeable to me.

                             DOCTOR PAHL: Is there any comment  by  Council  as

                   to whether we can proceed?

                             Have you had an opportunity to review these, either

                   prior to or over the lunch hour?

                             I think, Doctor Gramlich, we might assume then that

                   they are in agreement with the understandings reached by the

                   Review Committee, and you might proceed with the report.

                             DOCTOR GRAMLICH:  If that is true, then I would

                   suggest, as a matter of-the least confusion, that it might be

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   :WHD-5


                   appropriate for mO-'tb move that Council accept  the  report

                   listing the guidelines.

                             DOCTOR PAHL:  Is there a second to this motion?

                             DOCTOR WAMMOCK:  Second.

                             DOCTOR PAHL:  It has been moved and  seconded  for

                   the Council to accept the-report of the Review Committee in

                   which these guidelines and recommendations are given-in

                   detail.


                             -Is there discussion about any of -- Doctor Merrill?

                             DOCTOR MERRILL:  Yes.  I have one rhetorical ques-

                   tion which I have asked Doctor Gramlich before; I  know  the

                   answer to it but I'd like to have it for the record.

                             I assume that there were no sticky points  in  any

                   of these recommendations you made which you felt needed the

                   advice and concern of the Council? There  were  no  problems

                   which you felt should be dealt with at this level?

                             DOCTOR GRAMLICH:  I recall none.  Matt, were there

                   any that came up?

                             DOCTOR PAHL:   Mr. Spear, would you please comment?

                             MR. SPEAR:   11 can't recall any.  There were

                   specific cases    having established these specific guidelines,

                   there were specific cases    I think the best answer,  if  I

                   interpret your question correctly, Doctor, is that the recom-

                   mendations and guidelines that the Committee adopted for its

                   own guidance were done so with a recognition on their own part


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   WED-6


                   that these were not carved in stone, and if there were a

                   reasonable basis.to violate them, they would do so, and at

                   the moment,,off the top of my head, I'm aware that they did

                   so in only one case.
                             DOCTOR PAHL:  I think it should also be perhaps

                   noted for the record that the guides and resolutions, in part,

                   form the basis for the recommendations for follow-up by this

                   Agency, and in that sense there would be continuing involve-T

                   ment by  St aff to help make effective the recommendations of

                   te Committee, insofar as these guidelines were utilized during

                   discussion of any specific application.

                             So the two together are the package, the recommenda-

                   tions of the -- to the Agency, as well as the premises on

                   which they discussed the individual applications.

                             Is there further discussion by the Council?

                             If not, I would ask the question; it has been moved

                   and seconded to accept this report.

                             All in favor?


                             (Chorus of "Aye")

                             Opposed?

                             (No response)


                             So moved.


                             Doctor Gramlich?


                             DOCTOR GRAMLICH:  I would then think that perhaps

                   the next step would be the assessment of the list of the"'

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                                                                            132


                   recommended disapproved and approved grants, and the allowance

                   therefor.


                             In the sheet -- or, in the folder which  has  been

                   titled 'Arthritis," which has been just recently  handed  to

                   you

                             Now, you will note    these are alphabetized     that
                   there were --.You'll note several things first off.

                             There were grant requests totalling $15,866,581, for
                   the payable funds $4,275,000, but the Committee, of  course,
                   was always cognizant of the need to keep the  approvals  and

                   the funds recommended within the $4,725,000 figure    I'm

                   sorry -- the $4,275,000 figure.

                            Therefore, they went through the grant  requests  one

                   by one, with a primary reviewer reporting on his or her

                   objective observations, and a secondary reviewer  either  con-

                   firming, denying or altering the review of the primary reviewer,

                            In each instance, when each grant request was con-

                   sidered, this process was followed by total discussion by  the

                   entire Committee. That is one of the reasons it  took  three

                   days.

                            There is    the recommended funding for those

                   approved programs came out surprisingly close to the  amount

                   that was available. They didn't realize at the time  this  was

                   being done whether it was going to come out close, below  or

                   above, so they took the obvious route of prioritizing  them,

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                                                                             133
  WHD-8


                   and ranking the score, giving them a numerical rating as

                   well as the eollar figure.

                             Out of the 43 applications that  were  considered,
                   12 were disapproved en toto; the remaining  31'were  ranked,

                   and the recommended funding not ed.

                             I have just discovered a minor  discrepancy,  I'm

                   afraid, in that on the first page of my listing of the

                   Committee's recommendations, the rank score has  been  left

                   out.


                             Does yours have the numbers on it?

                             MR. SPEAR: We didn't put it on  the  first  page,

                   Doctor.


                             DOCTOR GRAMLICH:  Oh,, okay; very good.

                             So what you see there, then, is on the  basis  of

                   zero to 100, the Committee's estimate of the qua3ity of  the

                   grant request -- on the second page, now -- the total amount

                   requested  and the total amount recommended by the Committee.

                             I would


                             MR. SPEAR:  If I could inject one comment, Doctor,

                   the rank score is a ranking after the application  had  been

                   modified by the Committee.

                             DOCTOR PAHL:  Thank you very much, Doctoi Gramlich.

                   I think this give you a picture of the recommendations

                   that is, the final dollar recommendations for  the  approved

                   programs, and before asking for any action on this, I would
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                    indicate to you that the earmarked funds for this program
                    are $4.275 million, and the approved programs exceed that
                    amount.  What we would intend to do, following Council action
                    on approved and- disapproved programs, is to notify those
                    Regions that have had programs approved that we are also

                    sending some dollars with that notification, to the extent
                    that we can, but for those programs  that were approved by
                    the Review Committee but which go beyond thelactual earmarked
                    funds available, we would indicate that the Region may,? at
                    its discretion, use its RMP funds from the June and August
                    Council awards if it is in their best interests to do so to

                    fund the programs.

                             In other words, we would assume that they could
                    incorporate that-into their total consideration  of  priority
                    listings as to how to use the ILMP funds that we are making
                    available to them through this next June 30th.

                             Those programs that have been recommended  for  dis-

                    approval by this Council would r4ceive a letter stating  that
                    their application has been recommended for disapproval, and
                    therefore they may not Use PIAP funds for the support of that

                    program, and that the application basically is ended from that

                    point of view.

                             So, with that, John would you care to introduce a

                    motion  for the Council to consider?

                             DOCTOR GRAMLICH:  It would seem  to me the-easiest

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                                                                            135
   WHD-10


                     way to solve this problem, if the Council is comfortable in

                     so doing, would be to accept the list as  prioritized,  and

                     suggest to the @iP's that those programs.that  fall  within

                     the-total f3inding, starting from the top  and working down

                     of $4,275,000    be approved en bloc.

                               Now, that leaves a question about the ones  that,

                     were approved but ranked low - and therefore do not fall

                     within the funding purview of the amount available.

                               If you look at the list on the second  page,  the

                     gross total after Albany    sixth from the top -- comes  close

                     to the funds available.  That figure is $4,239,750.  After

                     Albany, and before Puerto Rico.

                               You probably also have noted that Puerto Rico  has

                     the same score-'rank as Albany. This poses a minor  problem,

                     in that if Albany is accepted and funded, we stay within the

                     $4,275,000, but Puerto Rico has the same rank, according  to

                     the Committee's deliberations. So there is  an  element  of

                     unfairness to that.


                               If Puerto Rico is added to the  list,  the  figure

                     that then totals out for the funds to be allocated is

                     $4,332,950, which is about $60,000 over the allotted $4,275,OOC

                               I would suggest -- and this is an independent

                     suggestion, that if we deem it possible -- if Council approves

                     -- that an additional $60,000 might be found somewhere which

                   ,would allow Puerto Rico as well as Albany to be  funded,  and

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                                                                             136
   WRD-ll


                     therefore would make the following-motion..

                               That Council approve the funding of the arthritis

                     grant requests within ranking limits, and if all Regions --
                     all RMP s, including Albany and Puertm Rico    accept the
                     recommendations of the Technical Review Committee and Council,
                     that additional funding to include Puerto Rico be found, if

                     possible, from other sources, so that it also would be

                     included in the approved and.funded list.

                              That's long and complicated.

                              DOCTOR PAHL:  I think the Council has the sense

                     of your discussion, though, and I would ask if there is a

                     second to this motion?


                              MRS. FLOOD:  Second.

                              DOCTOR PAHL:  It has been moved and seconded.  Is

                     there further discussion.>


                              Mrs. Mars?


                              MRS. MARS:. How does the incidence of arthritis
                     in Puerto Rico compare withalbzfny, and what is the compari-

                     son between population figures?

                              That in fact might be a very decisive factor.

                              MR. SPEAR:  That -- we don't know.  To the first

                     part of your question, Mrs. Mars, no one knows, other than'

                     that there is a higher incidence in deprived areas and in

                     areas in which family income is below $5,000 a year.

                              MRS. MARS:  Yes, but the climate also has a great

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                                                                                137
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                      deal to do with  it.

                                MR. SPEAR:  The field discourages that.  They do

                      not believe that that is true, accordingto present thinking.

                                With regard to present thinking,      regret to say

                      we do not have those figures.

                                MRS. MARS:  Well then,, how can you base it as

                      being equal,, so to speak' that one should have as much money

                      as the other?

                                DOCTOR PAHL:  Well, there were a number of elements

                      that went into the consideration of the review, which ulti-
                      mately led to the ranking priority of 40.  it is just coinci-

                      dental that it comes out with Albany in the ranking.

                                MRS. MARS:  I meant to say in rank, rather than


                      money.


                                DOCTOR PAHL:  Surely.

                                MRS. MORGAN:  Can we really give them more money

                      than what has been appropriated?

                                DOCTOR PAHL:  I thin@ the sense of the recommenda-

                      tion -- or, the motion- that is before us,  is to fund througl-.
                      Albany, and  if  it is possible for the Administration to find

 f                    additional   funds, to fund Puerto Rico.

                                That   is the sense of the motion, and this merely

                      gives  us  guidance as to what the Council wishes to do, and

                      we will attempt to carry out this request if that motion is

                      carried.  If it is not possible for us to do this, obviously

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                    we will then fund as far down the list as possible.

                              It also could be that one Region or another  would

                    find it inappropriate to accept their award because  of  the

                    modifications that have come about as a resul-E of the Review

                    Committee deliberations, and thus we are not certain that

                    these will be the final ultimate ones in all  cases that

                    would be the approved, funded projects.

                              That is why we have a slightly longer list to  tako

                    care of, which must.be the result of negotiation following

                    Council -- Doctor Merrill?


                              DOCTOR MERRILL: Because perhaps Puerto Rico  is  a

                    favorite of mine, but would  it be feasible, let's say,

                    instead of dropping Puerto Rico entirely, in the event  that

                    you can not find $60,000, to take $2,530 from each of the  24

                    above it and allot it to Puerto Rico? It's not a lot  to  take


                    away, and yet it would assure that Puerto Rico  was  funded.

                              DOCTOR PAHL: I think Staff has the  flexibility  for

                    negotiating within this rather strange dollar figure as a

                    ceiling amount, and I believe we can receive the guidance  of

                    the Council  and fe el reasonably sure that there is  a  possi-

                    bility of funding Puerto Rico without actually being able  to

                    commit to you definitely, sitting here at the table today.

                              MRS. FLOOD:  Also, Puerto Rico is a favorite of

                    mine, but also with a concern for equal ranking, and an  arbi-

                    trary line drawn for equal ranking, may I ask -- I would doubt,

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                                                                              139
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                    that any Region would turn down any funds that might be

                    offered, even though I find it interesting that  Ohio  Valley,

                    for example, with a request of $711,000,.receives a recomnen-

                    dation for $46,500, and another marked one, although   perhaps

                    not quite as large, would be WisconAin, with $267,800  and  a

                    recommendation  at $62,000.

                              May I -- there is one other here

                              DOCTOR MERRILL:  Look at Iowa right below it.

                    Compare Iowa and Ohio Valley.

                              MRS. FLOOD:  Yes.  Then there is Mississippi.

                              Might I ask of Doctor Gramlich, how would  --  with

                    such extremely high ratings of.these regions above could

                    their funding recommendation be so starkedly lowered?

                              MR. SPEAR: There are many reasons, and  I  will  try

                    to recall some of these to you.

                              Many of the Regions went the usual RMP route, in

                    which they came in on their applications with a full-fledged,

                    Region-wide care-delivery kind 'of,.program, and we had tried

                    to make that clearin the guidelines  that  @  limited  funds,

                    and with the language in the Congressional authority, this

                    was not what we were after; that we looked  for pilot efforts.

                              And one of the reasons in some of these  where  you

                    see such a stark distinction is where there was  a  very  sharp

                    cutback to just a pilot activity.

                              For instance, in  a number of  states where they had

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                   divided their states up into a number of various areas, and

                   then down into  sub-organizations of other kinds, and they

                   had pooled people, activi@s, in all areas of  the  states,  the

                   Committee said: only go for one or two of those and try it

                   out, and see if it workst and provide yourself a  working  basis

                   which is demonstrated and proved.  That happened.

                             Some of them had very large requests for  things  that

                   by resolution the Committee had decided not to  --  film-making,

                   videotape-making, development of publications, and  the  print-

                   ing of them.  Large computer data operations, patient

                   registries    all these are much needed in the country, but

                   this is not the program to support those kinds of things.

                             I know there are two or three other  reasons;  they'll

                   come to me.  Maybe if we take a case

                             MRS. FLOOD:  Choose Mississippi.

                             MR. SPEAR: Choose MissiAAippi?  Let  me  think  about



                             Mississippi has a ver 'fine, very  gorgeous  hospital
                                                  y

                   being built in  the state, I believe in Jackson, and the

                   application surrounded that installation,,that facility, and

                   as the Committee looked at all the various components  in  that

                   application, they came to the conclusion that what  the  program

                   was really being asked to do was to underwrite the first year's

                   operation of that institution.

                             And they said: "Thanks, but no thanks.  What  we  will
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                         do, for those kinds Of very small but  meaningful  out-
                         reach,activities you propose'to do with  that  institu-

                         tion, we would like you to start them now and do them.'

                              And that is what they funded.

                              MRS. FLOOD:  But you rated it 80.

                              MR. SPEAR:  We rated it 80 with  that modification.
                    Without the modification, they would have turned-it down.

                              These rankings are with -- at the lower recommended

                    amoun t, the ranking relates to that, and not to the  request.

                              MR. BAUM: Matt, there was also in that  one,  as,

                    part of an example, a request for something like $385,000 for

                    making motion pictures related to arthritis, and that 'is one

                    of the reasons for the sharp drop in money, since that  was

                    completely chopped out of the approved project.

                              DOCTOR PAHL: Thank you, Mr..Spear and  Mr.  Baum.

                              Doctor Haber?


                              DOCTOR HABER: The same question was  bothering  me;
                    here comes Iowa, way down the list with 97 percent of  what

                    they requested. But I think the explanation is  clear,  that
                                   e      '@o the excellence of a particular part
                    the rank-score r lates

                    of the project, and the total sum may be unrelated to what --

                              DOCTOR PAHL:  Mr. Spear?

                              MR. SPEAR:  Just an idea, there.

                              You see, you have -- like yourselves -- many people
                    sitting together makiV these kinds of determinations, and  it

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   WHD-17                                                                       142

                    is hard to tell on what basis a  particular reviewer will   make

                    his ratings.

                              Sometimes it was the excellence of  people  who  were

                    underwri ting a program.  Sometimes it was the'excellence of

                    planning; sometimes it was the  specifics of what they were

                    trying to do, in which they knew, by similar activities, or

                    for some other reason, that this was going to be a go ing   cbn-

                    cern.


                              All of these things came into it,,and we are not

                    quite sure in some cases what was the balancing factor.

                              DOCTOR PAHL:  Is there further discussion on the


                    motion?


                              MR. HIROTO:  One.


                              DOCTOR PAHL:  Yes, Mr. Hiroto?

                              MR. HIROTO:  Does the,RMP plans which were dis-

                    approved    were they primarily disapproved  because  they  fit

                    into the resolutions of 'non-activity'?

                              DOCTOR GRAMLICH:   They-were disapproved on a multi-

                    plicity of bases.

                              Some were disapproved because the  program  that  was

                    recommended was ent@rely outside the guidelines; other were

                    that it was felt that the personnel involved  were  not  capable

                    of doing what they claimed to do.

                              I think in this guise it is  important  to  emphasize

                    once again a point that Doctor Pahl has made, and so has  I-latt

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      WHD-18                                                               143

                    Spear, that of the approved programs, if there are other RMP

                    funds available, too, the Council says in effect it is all
                    right; if you can find the money someplace else, go ahead with

                    the part of the arthritis program that is not funded.

                              For the disapproved programs, as Doctor Pahl has
                    pointed out before, no RMP funds of any sort can be used --

                    should be used for that particular program.

                              DOCTOR PAHL:  Is there further discussion, comments,

                    questions?


                              MRS. 14ORGAN:  I don't know whether I understand or

                    not, when you say that they may use other RMP funds.

                              You're not saying they can use other PI.IP funds for

                    making movies and that sort of thing, are you?

                              DOCTOR PAHL:  No.  It would be within the

                              MRS. MORGAN:  Within the guidelines?

                              DOCTOR PAHL:  Within the guidelines.

                              I would like to act on this motion and the come back

                    to that point, in view of Councills consideration last

                    Fe.bruary. I would like to act on the motion to accept the

                    Committee's rank-ordering and overall recommendations,

                    together with funding through-the rank score of 4O.to the

                    extent that Staff can negotiate this or obtain permission to

                    exceed the earmarked level that has been given to us.

                              If there is no further discussion, all in favor,

                    please say "Aye."

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    WHD-19                                                                  144

                              (Chorus of "Aye")

                              Opposed?

                              (No response)
   cj
                             So moved.

                             Now, in connection with what I indicated to  You
                   before, as to our interest in sending letters to those  Regions
                   that did have approved applications, but are not.within  that
                   funding range, to provide them the opportunity to use  their-
                   own RMP funds to support the approved programs as,modified by
                   the Committee, I have had my attention called by Mr. Baum  to
                   a resolution that the Council made in February, which I would
                   like to read into the record, so that there is no misunderstan([-
                   ing or conflict between the two Councils, particularly in view
                   of the fact that we have a large membership.
                            In February, the Council approved the following
                   resolution in relation to the arthritis centers, and that is
                   on page 6 of the minutes of the Council meeting.  Quote:
                                 "Whereas the Congress has earmarked in  connec-
                       tion with Public Law 93-192 certain RMP funds for planninc
                       and developmen t of"pilot arthritis programs,  be it
                       resolved that the National Advisory Council on Regional
                       Medical Programs recommends that activities in the  field
                       of arthritis be recognized for support under Title 9 of
                       the Public Health Service Act to the extent that funds
                       have been appropriated for this function.'
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   WHD-20                                                                    145
                               Nowsp I believe it is fair to say that the spirit
                    of that resolution would be contrary to what I have just
                    indicated to you, and very frankly, in the press of things
                    which I have been concerned with, I had   forgotten that we
                    had this, and so I am glad you reminded  me so that we can
                    bring it to the surface and ask this Council, now meeting in
                    June, whether you would like to reaffirm, if you will, this
                    resolution that was passed by the Council, which would limit
                    then the funding of the total arthritis programs to those
                    that can be fitted within the earmarked, or whether you wish
                    to reconsider that, since it is the Councills resolution,
                    and endorse the position which I indicated to you was my
                    intent, and in all honesty, having forgotten the earlier
                    resolution, for which I apologize to Council.

                              MRS. MORGAN:  Could we say, take two percent or one
                    percat of all the others above and be able to fit Puerto Rico

                    in?

                             DOCTOR PAHL:  I wasn't referring to Puerto Rico; I
                    was referring to the fact that there are below that, four
                    additional approved applications which obviously are beyond
                    the earmarked.

                             And so it is in the interests, I think, of this
                    Council to consider whether it wishes to permit RMP's to use
                    their RMP money, if-they see it to be their priority, in those
                    app--oved @,egions, to support the pro grams, or whether you wish
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                                                                            146
   WHD-21


                   not to make that opportunity available to those additional

                   Regions.

                             MRS. GORDON:  Could you give up the rationale for

                   this particular decision?

                             DOCTOR PAHL:  Well, I think the rationale -- I am

                   trying to reconstruct; I am afraid our minutes are perhaps

                   abbreviated here, but it would seem to me that that was the

                   interpretation of what the earmarked meant at the time, and_

                   Also at that time, when the Committee met in February, we

                   were very uncertain as to just what level of funding -- I   am-

                   sorry; when th e Council met in February,we were very uncertain

                   as to just what funds we would have to su port the RMP program.
                                                              p

                             Having-the Court order before us, we felt we knew,

                   but there was also some uncertainty because of various con-

                   siderations that had come into play, and at one point in time

                   a rather large sum was thought perhaps to be better used for

                   other purposes, and I am making a report to you now that some-

                   thing like $110-115 million wil@ be available to support pro-

                   grams -- the regular programs of the RMP'S.

                              So there is a ques@n here of whether the Council

                   feels it important to permit RMP's to support programs

                   approved arthritis programs beyond those which reach the

                   ceiling mark or whether it is not.

                              Doctor Merrill?

                              DOCTOR MERRILL:  I wonder whether the Council might

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   WHD-22                                                                  147

                   consider, in that light, modifying  the February resolution to
                   say that these other funds not now  earmarked for arthritis
                   might be utilized for this upon application to the Director,
                   and with his approval in special instances?

                             DOCTOR PAHL:  Mrs. Silsbee?

                             MRS. SILSBEE:  Doctor Pahl, I think Councills
                  resolution  in February related to the earmarked and the   way
                  in which we administer the earmarked.

                             Once those-funds are put out under the earmarked,
                  the Region does not have flexibility.  That money must be used

                  for arthritis.

                            DOCTOR PAHL:  That's targeted.
                            MRS. MARS.  Well, I also think it was also to not
                  dip into RMP funds at the time, to be used for the specific
                  arthritis programs, that we felt that some had been allocated
                  and was adequate and ample.

                            And I think that the resolution should stand, even
                  in view of the fact  that we now do have further funds.

                            DOCTOR PAHL:  Al 1 right.
                            Is there additional discussion on this,point?

                            Mrs. Mars?

                            MRS. MARS:  Certainly there can be somewhat of a
                 distribution of funds, as it stands now, and send it back to
                 the Review Committee to see if they can reallocate.



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  TIHD=23                                                                     148


                              DOCTOR PAHL:  I am  afraid we dc not.have the time
                    available for us to obligate  these -funds by June 30th.

                               (Discussion off  the record)

                              DOCTOR PAHL:  I think that obviously the Staff will
                    do its best to negoatiate with Regions to fund as far down
                    the'list as possible, but I think we need a clear statement
                    from this Council  as to the reaffirmation of the early resolll-
                    tion, which is your point, or whether that resolution should

                    not stand, because I have misinformed you, in a sense, quite
                    out of ignorance, if you will, or of not remembering that

                    earlier point.

                              So let me suggest that, Mrs. Mars, you make it as

                    a motion and let's test it.

                              MRS. MARS:  Very good.  Yes; let the resolution

                    stand as it was previously passed.

                              DOCTOR PAHL:  All right.  The motion has been made

                    that the February Council motion stand.

                              Any second on the motion?


                              Mr. Rubel?

                              MR. RUBEL:  i'would just like to ask if in 1971 or
                    172, if the Washington-Alaska RMP had put in its proposed
                    project for $175,000 for this kind of activity, would that
                    have been accepted -- acceptable at that point?

                              Is this something that an RMP could have done?

                              DOCTOR PAHL:  -Under the original guidelines, yes.
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   WHD-24                                                                     149

                              MR. RUBEL: Do we have-any other  kind  of  quotas
                    that we are using here for kinds of special projects?  Have
                    we said in here that we could only use     I understood that
                    the essence of the RMP philosophy was to allow a Region itself
                    to determine what its priorities were.

                             MRS. MARS;.  I don't think that has anything to do
                    with this at all.  This was simply that we did not want to
                    supplement this four million    whatever it is -- and take it

                    out of RMP funds.

                             I don't think it interferes in the least with the
                    idea of a legitimate project on the part of any RDIP, whether
                    it concerns arthritis or anything else.

                             DOCTOR MERRILL:  Still, with the uncertainty that
                    has prevailed, perhaps  between the time of the original
                    application, let's say, for other funds, and this arthritis
                    application' priorities might have been reassessed, and if the
                    total amount of money from out of our pocket was not changed,
                    but simply an intramural reevaluation from one pocket to
                    another, in light of changing priorities, if this had the

                    approval of the Director with proper application,  would  it
                    not be the prerogative of local PJIP rather than perhaps the
                    Council to have a flat "No" to this kind of thing,  without
                    knowledge of the fact that priorities situations might have
                    changed between the two applications.

                            DOCTOR PA.HL: Is there further  discussion  by  the
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  WHD-25                                                                         150


                  Council on the motion?


                             DOCIOR
                                                   am not sure   I understand the

                  motion.

                             Is that-- in effect saying that p7e  can not support

                  Puerto R4.z:o
                               --cro-u fur.,@@,s other than this grant?

                                     Plr'%.@l-'LL:  He 4-S saying that we would n
                                                                            ot supportl
                  with fun4s beyond @,e earmarked any approved -- beyond       e'armark,@
                  lvel, any  of the approved appl.cations.% That is, we would
                  not.be giving the right to Regions.to utilize their funds for
                  the support of these applications.

                             DOCTOR @G-@-ILICH:  I put a little different reading,
                  then, on  this resolution in February.  You know, it is easy
                  to put all@ sorts of readings on-it, since I wasn't there ana

                   on   re,7t=-.- e-@ v;.tiat the Council had to saNr about it
                             But it strikes me that the'Council, in its February
                  action-,, wic-re it says:

                                   ... be recognized  for support under Title    9
                       o @L -L"-h@ r-ubl@ic H@aitli @Dervice AL-t to the ex@Lent that funds@!

                       ha-@c- bee.-,L.          --F or this function."

                                                   "we don'- know T,7-.;Iat Furds we
                  is


                                                           Let I s      t'.-lese while
                  are-       to ha-,:--@ f-c)r.

                  vi-e car-, wi-L-"L,@ut  t     i g a t eanything else,. out oz- monc--.,-@s

                                                  going to get,  and tha- perhaps
                  ati                  w---@ -:Iu .7,       PL  93-132 and the-mon(--%,




WHD-2

                  that went with it under Title 9 iiithout considering   any

               I  SuDsequent possibilities.

                             DOCTOR PAHL: lo'ell, I would suggest  that  since  we

                  are a full Council no,@v, that this Council act as  to  what  it

                  sees to be tl-@.e best interests of -Ehe program, because  there

                  is  @L.ul-l-       b-e'-'ore you as to our current  situation  and

                                    and the funding recommendations, and I.

                  believe you have #the right, as the Council, to make  whatever

                  reaffirmation or change you wish from an earlier point.

                             i-IR. MILLIKEN:  This is going to be'an amendment;

                  is that r4-ght?


                             No?  ltis a restatements

                             14RS. IIARS: NO, it's merely reaffirming the  motion

                  i,iadc- ir, Fehruary by the Council.  Reaffirmation.

                             DOCTOR PAHL:  '4rs. Flood?

                             1-iRS. FLOOD:  Perhaps being a little repetitive, but,

                  let me --!.ear now in my mind    we-are.saying  that  should'we

                  overrule -ciie policy action of the February Council meeting, 0

                  s          a newer, broader policy statdnien@, nonetheless, i-.-e

                  would                     '.,'Ledical Pi--ocjral.n-.s to e.,-.pF-nd-Ltures o.

                         c   -c. s p @@us @.a4@r own -un"  o the  ca@-ego--ies o
                                                                               f


                  act4@.v-'@t4@cs au-,rove-"" tile L-.ev-Le-,z


                             in          ,,,c   'id riot
                                            woui-                          to go

                     a d a r, du@--@--                   -hnr e-.,,@@-Pditures in an
                   rL

                  a r   z  s                        up to  t,-,e level ',-,-ed hc:rc as



                                                                                                                                                              152

  I-IliD-27


                                                                      we  would  Q-ive  them  only  the  authoriz-@on  to

                                      augr.-@nt  t.,ii-mir                 wF--!!&,   trey  are  above  the  cutoff.     Let's


                                      tal@e  S07,@on2  else.


                                                           Lai.ces         Area,          for          examples          that is         below         the         cutoff

                                      14  ne.     '-"hcv  wood  only  bein  a  position  to  use  $45,000'of

                                             -Lr     u.-, d s   I-@or    that  component  part  of                          their                        application.

                                                                             the  -.r,,-.erp@4--ation  I'm  hearing?


                                                           DOCTOR             PAHL:             Yes.


                                                           MRS.             FLOOD:             Thank   you.'

                                                           DOCTOR       PAHL:       In       other        words,        what        we        have        is        a

                                      preliminary         review         group          that          has          looked          at          the          technical

                                      me-i@         and         has          established          guidelines          for          a          national          pilot

                                      arthr      4 tiS     center  program.

                                                           In       order       not       to       abuse        the        whole!        process,        -we        would

                                      appl,,  t.@.e        sar,@e  restrictions  on  all                           a-pproved          Regions           so           that

                                      tt-@y      c o   I   d not  do  locally  -.irha4.--  wasn't  really  approved

                                                                otherwise,   there  would  not  have  been  much  purpose

                                      in    -,:o4.ng  th@--ough    a  nalt--4-onal  review  process.


                                                                                                                                                                as
                                                           TL'tc-  -uez;@-,7.           --re  is  4t--ha@-  i-.-a  will  -cry                through


                                                                                                   t--  n-@--t--i-ionz;                       4ch  have  to


                                                                                        4        W 4         -.',le  P-,c-  g   n z;     ve                ride         a
                                      L_,a!_: C,


                                      @@ar    dDwr,      c-r@          s   !-is       as  wc       care  @-.,i-th  the  full  szr@e  and  dis-


                                                                                                                              c)


                                                                                                        a     o    n        .@..'.c-,thcr  P,:ali'ions  V,,ho


                                                                                                         --r  t'@24r                                              but
                                                                 '   , tf _.; 4 -
                                                                                                -:7
                                                                                       ,_r,
                                                                                -            'a   _2    i-         LI J-                        -








                      I


              1                                                               15 3

     2 8
                 where there is insufficient money" whether they may use
                 their o,@. P@-!P funds to support what we can't out of  the ear-
                 marked, and that-represents, I believe, the consideration

                 that is before us.
                            '-nd the motion, as I undertand it, that has been
                 riade-and s-econ @-u, woul-"! be to limit the 53 IU-,IP's in the
                  ilot art!-ir4-t4-s center program to those Regions' approved
                 P
                 applications to  the point-- where the earmarked funds have run
                 out, wierever that point happened    to be.
                            All in favor of the motion, please say "Aye."

                             (Chorus of "Aie")

                            Opposed?

                             (Chorus of "D:,o'),
                            Well, perhaps we might have a show of hands, if you
                  will, please.  All those in favor of, the motion, please raise

                  your hands.

                             (Sho-.@ of hands)

                             Four hands.




                                    ol- an s'

                             Th,,! motion is not-- carraed.
                             N@.,,, we will entertain a di@rfarenl-- motion.

                                                              to
                             DCC@               i
                                                                 nake  a motion that

                   the @Lunds               @z-,r   arth--;@tis r,--oject -- that tL@Lcs@--,

                                                  ar3 ,..Ot aviii-,aL,.Le -@@-om t,.,Lc




 WIID-29


                    arthritis Project be allowed within         the limits of the recom-

                    mended  total,  to  apply   other   funds   now   in   their   possession

                    to   the   arthriti-s-project,   upon   application   to   the   Director

                    of r,!,!P and subsequent to    his approval.

                                 DOCTOR PX'll',L:  All right'.  Is there a second to'




                                 VOI%@-E:   Second.

                                 DOCTOR PAIIL:  All right, that motion has been          made


                    and seconded.

                                 For clarification, I believe,       Doctor    Merrill,    you

                    would want to    state not necessarily the       funds   "now   in   their

                    possession,"  but   funds   currently   available   to   them   or   those

                    Which are to be made available        to  them  as  a  result   of   June

                    and August Council decisions, whatever they may be.,

                                              IT
                                 DO,--TC)R 1,@- RP, @L: Yes.


                                                  Is          -scussion   on   that    motion?
                                 DOCTOR PAIIL:    L  there'di-

                                 ILTIS. !-,LEIN:  M -@er Chairman, I didn't get     that'

                    limitation   straight   in   m%r mind.   is it a limitation     on    the

                    aroun-L.       ---LDP!4-cd -@or, or  -Lhe a.-L o u.- itl-, a IL-- i, Tas granted,

                                                us,--  c 4-r ot'-----r funcls7
                    w-

                                 MR.                The ariount that was     granted,  ric;"-A

                  @i Is that w.@lat %,ou mean.@        funds that i,;ere   granted.

                                                                       4
                                                        s         alD@,     fC)r; granted


                    a.-id


                                 D '-'C           'T                     of the Review




                                                                           155
 TET!ID -




                            @IRS. KLEI'  7 Cll, l,liSte
                                                     r Chairman,  that,  then,

                  would lie an extremely limited motion, would it not, and

                  would apply really to  these last two applications, possibly,

                  because    --'Ls it,-,ny understanding that there arc sufficient

                        ava--t-allll-e to fulfi-',-l a'LIL the other commitments?


                            D@l-T,@--a P.--.-TiL:  There are sufficient funds to pay

                  all except perhaps -- $500,GOO  total arwunt of recommended

                  applications, so it only has impact-to that extent.  It's

                  irLiport@ to those regions.

                            MRS. KLEIN:  I see.  Thank you.

                            DOCTOR PAHL:  Is  there further discussion?

                               no%--, all in favor of the motion say "Aye."

                            (Chorus o   "i%ye')

                            opposed?

                            (No res@onse)


                                              ried.
                            The notion is car

                            ;,,"Ll right.  Doctor -@ramli-ch,. are there any comments

                  YDu  a v,-- or -@'.r.         have on -.-le arthritis activity?   I

                                                    u d      one        comment,


                                                      mLccli-,,iical r%cview Committee


                                        the            activities, at intervals

                                         an-' a' --c            o@  the  grant  year.


                            T                t"-at              urc-,c: the Rh!P.Is to


                                   Io              41 t-.. S W; tlli- t' li,.i-S of
                          -  .-i 14 --
          i       carry     -@' ---        -          2   - i @, ;..Le r, @
          I
          i
          i                                              -                          II .
          i
          i

          I

                                                                                   T-@




 WlID31


                 feasibility.

                           Does this require a vote?

                           DOCTOR.P!!LIIL:  @io, I think

                           May I just please pass along the comment that it

                 is -,ol@         for us tc cct a record of the meeting,wi-Eh

                 mult-Lr-le              g     L-n in the room.  It is just a

                 poor ro37, for l@e acoust4-,cs, cr perhaps it's overly sensitive

                 for acoustics, so please keep the individual   conversatioas-

                 down if you can so that we can  get a record of the Council

                 meeting.-

                           Doctor @.-aml.ich,  the Staff,  I think, understands

                 through the discussion of the Council and the acceptance of

                 the minutes and so @@orL@h that the Council would wish us to

                 engage 'n these activities that were recommended by the

                 Co= 4
                                  s  , b,,, the Co=ittee   the Council, which
                      ttee,  enaor c@-

                 hopefully would lead 41--O an effective program over the year,

                 i.,,hich would     mean     that we would be calling together the

                 D4--rectors of these projects,  as'@c3.ng_for periodic reports,  and

                                           an@ give ass4st-nce to them in tho c--
                        to W                                                   s
                                             kA



                            as  call
                 areas                 dal--            s-.7-z ten, sprovide assis@

                 ar,.ce i:i       an@,-onr4La'L--e I 4-mited sources  for  --he production


                 oi: auCiio-visu,-l a;---Is and th@ngs of th,-s nature.

                           So I  don't bal4-@vc wc ne@--J a fo.rmal Council action

                          @-kat  wa  w-,ult'A  it c,--rtu--Lnly zLs the Councills


                 dezirc.







          I



  WIID-32                                                                                                                           157


                                                 DOC.'TOR JilNE@",AY:    I  just wanted  --  I'm new,                           and     I
                               would      like  to  ask  a  question  for  information.

                                                 Would.@,ou        defi.-.e    for    me,     to     make     me     a     little     bit       I
                              rr. ore  coilfc.-rta,')le,  about  the meaning of  a                       priority        score         of    207.
                                                 D      0 R  P     L      I  wou'Ld               to     ask     either     t@iatt     or
                              Doc-cr                                          it's  important

                                                DC@@TOR                        Because  it's  a            little         bit         different!.
                              then  I'm  used  to            hearing.
                                                ZIR.  SPEA7.,":    I  am  tryina            to   recall,  Doctor  Janeway,
                  I            ust what         that meant,  and  it  doesn't                    come  to me  at  the moment.
                              I can  look         up  the  records,  if   you want  to  take  a  few moments

                             while  I  do         that.


                                               DOCTOR                         No,  no


                                                                                                                                           to
                                               I.,M.  S'.O-rA@n,:    But  --  those  Regions  listed  below  PuerL-
                             Rico  have        !-,ad              successes,         and          lesser          successes along  the

                             way.

                                               1,@-.,iat   the    Cor,.i,.qi-t@@ce    -L,;as    looking    at    were    in some            cases
                                  F-:,.Li L-;,.ese  -v,,,ere  sozzie  of  t.iem,       certainly               in       all cases      to
                             t:-i--   c    ns    -'-,h-aL        ai  c,--,+-             s.--,ort            to  Dut  these pro-


                                                                            na-i ly  well  set-fortii p-Laiis;  the

                                              -",2  0 9." iz, a                n,@            able,  t--roucj.-i
                                                                                                                           ir


                                                                                                                                    where
                                                                                                          d,

                                                                             w-@.r,-, no4.-                               4@,-i the


                                                                                                                -u-;-Ii   as  an



 VnID-33                                                                      158

                  example, altHough I'm not sure   it applies specifically   to

                  4-
                        cas@.


                                -e there w@s an underlying   feeling  that  there
                            Whe@


                  were better resources there and   a   better capability than

                  they @ere sec-irg, and it raised  a'   little question  in  their

                  minds as to ti-.Ie real- intent and the   real cor'r.-in4Ltment to what

                  they i-7ere reading was in terms of carrying  out -- insofar as

                  carrying out those things the   Committeewas   willing to recom-

                  mend.


                            In some cases -- for instance, Puerto Ric6 would.

                     which is a 40 --  in the area  of  known  extreme  needs  @or

                  this kind of t,%ing -- not that it doesn't have many, many

                  other extreme needs, an-' it vias sort ol a joke among the

                  Co=.Li@"t--e, because in @@he Ce-@-ral Ho-p4-"al of Puerto  Rico,

              ii  there are 14 rheu.-,,ato'logists, and there are JzL--ge areas  up

                  in.New England, for instance, that don't have that.

                            And as they went through   the rest of it, they

                  sav:Lrg: "I -@q4-sh v-i-e could pass out spme of those rlieumatologist"

                  n  Puer4l--o R4.co.


                            Bu@- @,,cu     t'-n-,c-Lr P'La-,i %@-@-td us @.,ho x-xas

                                                 4S
                  going to direct it, and tha.      something that, going    back   I

                  to there    @-@is Councills a-ooroval, that is the  f 4-rst thing

                  we  are going to ask                your           up tl-ierL-?



                            L@ u t            ',-,nci@,@n, thc-- 14 rheunatolog-ists and


                                                                                                                                 I
                                                                                                                                  L59


                              sc)r,@,e allied ,Iealth peoole                      the   caT)abilitv   was    recognized
                                      @ii,:2re was s@i,2 outreach in                   it that-- loolzed like a good
                              thing --o do.             But  they   would   have           had a'.much higher score
                             i-' '@h@--y had to'Ld us who              was going to run it.

                                                 c-c --For inz--ance,,,ou see, these kinds of                           things

                             a

                                                        being adequate for               your question?

                                                      C!12@1:3LISS:  Maybe I             can  Ikelp  just  a  bit   there

                             Doc4@-or   Janeway.

                                              Ranlz-sco@-e is simply a                 technique that the'ad hoc

                             Cor,-L-ni@@tee use,"' to sort out, and in its sorting out it assigned

                             certain n-ar,Lers to each of them.  some of the ones below had

                             ran!:.-ings                the 40, or below the 20, and it was just a way

                             c@     7av4ng     oul     'Is     work     so     we     could     establish     a      pay-line      and

                                                         '-@-etwac--i  all  the contracts.


                                              DO-@TOP, J-'-@"iE@-7,AY:  I understand thatf but the intent

                             o --F  h    q,-,ezticn      @.,-as      different      than       that.

                                              DC,%--TOR Pt@-IIL:       I       understand        the intent of         the        ques

                                                                                      -.-70 Lad  ber-cre places  the

                                                                                   4-F.  r,2ach-4.ng on-a  of  those

                                                                                   other  action,           -hey would          have

                                                                               of reco          ,,en
                                                                                                   -a'@at4o.-is            established
                                                        t,,e


                                                                         L-@e  rccol-u--4@ons.

                                              S,3                                       o r  a x     -,le,    de-@e."Lo-.n  the

                                                                                       @,@3t    t  woL,. I    ',iavr-,  to  be   wit",







                                                 developed by the           Committee,  which is an

                          answer in support or your question.

                                                               -Ii conjunction        with his quest'
                                          ,IRS.  GCPDC:@@:                                                    3.on,

                          would       tiis @@h2n   be       would    your     ranking     be     sort     of'a     combin-

                                   of                 an(--       Co.-,,@ittee's  feel for their            ability

                          4-0
                                        -,La i-i@@  ?     ould ti@.at be a combination


                                         DO'-r@7OR  P@T:       Yes,.I think those were essentially
                          certainly      elements that entered into   t@e ranking score;                          yes.

                                         i-IRS.  GORL'JO,@7,:   You.could     conceivably      have       a       tremend-

                          ous   progra,--i,   but   yet   you    really    didn't    it    as    much    in    this

                          area   as    positively    as    you    did    in    another,    and     this     then     would

                          give          one with the greaL-.er          need maybe a higher score or



                                                                Co.-aoet@-ence    o'    staff    to    carry    out

                          the progran@L,  thz       abilities of        the organization to supervise,

                          to r,.a'f-le sure  LI-liat.fur-ds were properly spent,  and all these




                                                               I  v%rou'Ld                .7h@
                                                                           no@ k@ow           ch element       went


                           i,@ t:,D ri  c      a    t          score   'u%-- @,,iosc were considcration,@-
                                                    i c




                                             iv 4@ 1   a       a.t-                     tcj       Cou..


                                                            ta                an"'  cv@n@,,ia'ly ;,;e will re-@.-


                          to                         at   t.-ic-
                                                                     t-                            t-,e disposit-





   IIHD-36
                            We also will make Uic  awards -'or the arthritis
                   applications            same official award statement, after
                                                                   applications,
                   i i s%--o,-lncil, that we have for the regular R-14P
                   so that on t'--.e one a-,qard statement there will be shown the

                                    4-        31 4
                   u.-ids f or' vour ar.-h.-it4@s a@T  i-cations and there will be

          I                                                  for that purpose
                   se-:)ara@,a'L@.- 4L   so it will be used

                   witlin 4t- i I
                            Again, we remind  you that certainly the rankings
                   and the dollar recommendations and actions are confidential
                   and we will be iiorking with the Regions as soon  as' we can

                   to effect Councills decisions in this matter.
                             Now, I would suggest that we just take a five-

                   minute break -- Doctor Gramlich?

                             DO,'-'TOR         May I  make a final comment? I,

                   won"%-- delay the stretch more than 30 seconds.
                             As an exercise in crisis  management, this has been
                   very interesting.   You must remember the Congress only au@ior-@
                   ;-zed ti.iese  funds  last  .'all.  R:-JIP  was   -not   even sure they were
                               a,@a-@la'-la -anti' -zt-'d-'-Iarch, and -n that interval
                      icj to ;De

                                                 4 C W -
                    as ru-- to;@@"iar                      riave   =u@able ir@i-pa:-'-

                   o -I           Caro o-@ tile @-.Le--ri-can

                             But itoi7t! -L i-,        aqa 4@ -',@,i:,,.ons.trates the

                                                                     p   s
                                               am' tl-- a@i"     of
                   b      a n d

                                            Wo'Ll-,  thank you very much, Doc 4--or

                                                        S-@)-:2ar, an@l let's take a


                                                                                   16 2
   WIID-37
                   minutes to sL@-retch, and in five'ninutes come back and we w4@ll

                   ge-- ,qi th         s
                               ('@,'iiere-upon a short recess was 't-a'-.en.


                                                                                 16 3
  I'lliD-38


                             DOCTOR PAIIL:  We arc going to reconvene now with

                  some introductory            from L.Irs. Silsbee, and then we

                                    mov@ into applications in general.

                             I,,Te wished to take these up alphabetically, but

                  because of the             OIL some individuals, not only on
                  the           bu-@     arc- i-.-i the audience, an--' have something

                  to con-@r4-'--u4--c, there @-:ill be some departures from that alp',ia-,

                  betical arrangement.

                            -1 am going @-o have to ask the head table particularly
                  if they might wish to refrain'from smoking, because I have

                  had-a request from one of the charring members here that this

                  isn't conducive  to '@-lir-king al@out all t-,iese complex resolu

                  tio4-is


                            Judi,,, fly dor.'-. you jus--- proceed now, if you will?

                                             -All -4-h-
                            @'RS. SILSDE7:


                            D4 ck, v;-ould you cc-.ie on up?

                            This is the operations part    of t-h,3'S@-aA':f that is

                  ZL
                              a        eac, t-,-  here, and peopi-   tend to tal'z

                  i-I zhDr--.".-@nd around .1@ro, anL4  ,cu hear --he name "Silsb-:-a@a'


                                                                    4-


                                               -an@        -z-n         and all o-'


                                       dzn'-L.        s 11-jc     mean collec4,-dN;@




                                                       -@eal-.zod @,,,e,were go 4-ng

                  riav,@ t-.-!o                     o        a list o-F people -h-@'




          3 9                                                                                                 164


                         we   could    use    in ad    ho-    review    capacity,    because    as    you     recall,'
                                                                                                                    I
                               Council            -lovelier ha@  to do this themselves, and                  in

                         F@,br,,iar,, when ,they were faced with this Drospect,  asked

                         Doctor Endicott specifically for a first-level review                           to  help

                         tl-@em,  so that    C-o--".-.cil   ccu'Ld   concentrate    on    the    policy.    issues

                                     e
                                       And Doctor Endicott promised to                 do   this,    and    we'

                         were        operating under     two      possibilities      for quite     awhile,       But!

                         in-contact        the people we explained this-.            it  was     importanr-     ror

                         this    review     to have    people    w@io    knew     something     about     Regiona
                                                                                                                1

                         Medical    Progr@-rs-and    had    had     experience     in     either     the     Review

                         Coi-L-tii@@tee   at   the   national    level,    the    Council,    or    in    Regional

                         i@.edical Programs.

                                       In the    material    behind    your    Agenda     is     alist      of

                         individuals.@-hat       were         contacted and   i;ho    are    going to    serve    on

                         the Review      Committee, which as          it    turned    out,     did become      a

                         Co.-.mittee.     Three    of    the    members    that    were     listed on      there


                         %,,,ere unaj'-,le to   make   it   at   the   last.-minuL@.e,    but    we did      have

                         23 reoplc-                                     19 c)-@        origi,-ial list,      PI-us

                         0 rA   e:    r         a                  r cn, a      a                    iri@-,wer,




                                                                  L@o &@-al pr -@ra,7c amp
                                                                                           lications,        it

                         b,@,came apparenl-- 4L--i t'lic three days        -Great we lia@@  set     aside     that

                         it coui-,! nof-               as  a   tot'--al                during     that      entire

                                 so t'Le fc-rr..ar-              '.Iav@-                    c,-oen  as   a   grou'@




                                                                                                                                     165
            4 0


                               to  discuss  th.@  general  policies  under  which  they  were                                        going  to'

                               be   o-erati@-,g,             and          we  broke  into  two  panels,  with                        the

                               Regio,.n.s       that       were       served.bv       the       5outh-CenL@-ral       staffs       and        the

                                 id-Continent  sL"afFs  in'the  one  panel,  and  the  Regions  served
                               m


                               by  the  Eas'"-erii  Opera@@-'Lons  Staff  and  the  @,7@-stern  OlDerations

                               Sta@L'I-  in                       parc-.!.

                                                  Ess@-lit-'-Ially,       this  was  *ort of  an                even         group.         The

                               first    pa.-lel     i..,as     chaired     by     ?Sir.. Chambli@,          and          the          second'by


                               Ilr.-Peterson.


                                                  Each       of       the       applications       had        a        thorough        discussion

                               by  its  respective  panel.    @Lhe                     applications        have        been        sent        to

                               two       reviewers,        and        they        served as   the  principal  spokesmen  for

                               the  Region,  but--  -the            issues       that       were       involved        quickly        beccx.,L,.=

                               '@-he  C@-IrLrLtil---Lee  4-s-@uas  and       were       discussed,       and        each        Region        was

                               discussed by                    panel.

                                                  Then  on  th@                    dav,  one        @anel  ',-,ad      chosen       to       go


                                        o7,.7er      s     r-  i   re            of        reco7-@-andations        and        make        sure


                                                                        a  i,, o   a                      U,.-L-cre.--t            J@ashion
                               that  t---.ey      @c-      t@,iiav                   c:te,',  @n    ci.                                     for


                                                                   as C, z; c; Z.          'rie    @@zer                         tiey


                                                                                                                         c:---lai-giad    e   r


                                                               bas@.-"    c-l-.
                               r f-- -


                                                           t'- c                                                      @'i     @,,)r-tor     Pali'


                               E-z                             anLi   ,icam,-     L@--te            pane7 5'


                                                                                                                             and          their



                                                                                                        166

      WHD-411.

                                       At   '.hat   point   the   two    panels    recognized    that    one

                         panel ha:l mad   some recoi%-non-dations and they began to wonder

                         if so@,.e of t'-.3se racions had been in their panel, whether

                         the sa.-,,e                        .,;--uld have come out.   But -in those

                                               an  -.n--14-,.ri--Iual thou-,Tht there was some'discrep-

                         P-n--Y,         -:-ssues  were discussed.

                                       m@he Cc=.,Littee as a whole        did   not    make    changes    in

                         the panel     recoi-,inar,.dations,   and   I   belie@e   you    have    all    'received

                         both the coiazosite reccrr.L-,endat;.on8 and the individual recon,-

                         n@endations on each Region..   That constitutes a review                        process.!

                                       Noe7,  this afternoon we originally were going                  to

                         go   '@hroug'.t         Regions alpha"-e--ically.   But          because Doctor

                                                 @--c with us to-lay,  and Doctor         Gramlich to-"lay,
                         and @@or a cou--'-,-@   of  other    Regions     that     have     people'here     today'

                     I   we  a@--e  no@@           o us@- t'-,ia@- rel,hcdology.

                                       We     will get through the       ones tha-"    Doctor     I,,Ierrill

                    i!   and Dc--@@---: -@-t--a,.ilich rev4-e@,.ied; we oii-ll tl-ien include     Inter-
                                                                                                                 t

                                           Sou@.- C=rc'4na.


                                                              @-h@a order   in    which     we     go.today:


                                                 a   C










                                                       C7,,.rol in:-.



                                                                                                                                                  167
      @-71ID-42


                                                                South  Dal-ota;


                                                          S.   .'"7'@IS:     T I uld     you  roind        reheating  those,  please,
                                                          R


                                  Judvl>


                                                      i-lr%S.   SILSBEE:    California,


                                                                Georgia,




                                                                I;ucrto  Rico


                                                      liow,     'this  is  not  alphabetical,  because  Doctor

                                  @lerril.1             isn't leaving  alphabetically.

                                                                %Iississippi,

                                                                North  Carolina,


                                                                South  Da.,-,ota,


                                                                                                   and


                                                                South  Carolina.


                                                                            just  one  general  statement,  now.


                                                      In        bo,@-h        --he        instructions that were..sen-t  to                the


                                                                                                                                                          t
                                                      ed.-cal  Prograi,is  and  the  instructions  that                                  were  s  n
                                    -giora'         .@l


                                  to    @l-e                  Cj=-:       tC
                                                                            -_C,  there  were  certain  material@  that

                                        e   ci 1-i  i i   a     a n cl  w@-, allied  -L-he  IZ---gions  to  nrovide                               information!


                                                                                                     a   c         c   r-


                                  some             4u@--r@ent alon-  thEi-@e          lines,  an@l  w@-  aslzc-,-'                   individuai

                                                                                                      -                    a  rating  sheec
                                                                                                     4-0  give       us


                                  bzisad  o.-i              cri't-eria.


                                                                        @z)intv-to  rea(a  oul@-            the                        on  each


                                  i.LC@-11,               Lio       4
                                                                                                                             t-e  important  to
                    'I, -                         .   .                                                                                                   I  !
                    i         I
                    i                                                                                                                                        .I
                    i
                  . I                     .. -





      4 3


                  you at this ?c)-Li-it:

                                   Progra.-,i leadership,

                                   Progr4@it staff,

                                   Regional li'@Avisory Group,

                                   c@ast @erio=,,aiice and accomplishments

                                   O.-jqc@-ives ar,,d'priorities as outlined  in  the

                        appl!Lcat-Lon.

                                   Proposals.

                                   Feasibility.

                                   L4L'@-elihood tdiat these activities and  projects

                        can be successfully implemented with some results in the

                        -4"- 4-me and    proD--Sea.


                                   CHP relationships.


                                   And t.'.cn the overall assessments.

                             No;;, our suggested -.@ay of moving today      and it  is

                  up -@o  Couricil  as  to       you will procF-ed this way       is

                              of the i,@ e dto have some general statement on   the

                  Pcgior,   aii,"7 C    t L@-ee act-Lon, zi.-id     because-the      material i@c

                  sen@-  -to you    s;---nt at 4-=u--h alate date,  I will ask   each

                                                                a        sta@--c-.qent on




                             T,-i  w        ask                 re-@-'Lewe-- of Council

                                                               L                    ght
                  to Car--,, on  t.@e I-SCUSS4zn, and i@ t,at  'orTiat  s all ri
                          -Z


                        vou,          73 r C.) e u,@


                                      -,14
                             Cali;.-c-,r. -a: '-r. R, us s;-@'i




                                                                                                    169
    .1',D-44


                                                         CO
                                                           U'.ICIL O',.z REGIO:",U   @IEDICINL PROG@!'@:-


                                                      CALT FC)R"IA
                                                                     J.ZEVIEW


                                     1,L@@ SS,--"T7r:   Lc-l- the      record short  that -74r. Hiroto


                       lias absented               'Lrc,.-,i the room.




                                                                            CorMM4  t
                                                                                     tee   on   Reg
                                                             California                           ional

                       medic@-'L Procfra-.ns,as   sho,.;n on  the   green   sheet,    was     rated as

                       above   average.

                                     Regional lledical Programs.   In all the             areas that

                       1-irs. S2L@tsbee   mentioned,   %-.he   program    was rated from good to

                       excellent--, Keith         exception of the proposal, vrhich was


                                     Feas @l     'Y sa 4-i-s @Lac L--o"ry.

                                     Re 'L a kl- i o z-. p s    CHr- average.

                                     The sk--aff  is  s@.ro.-.g, very active.

                                     The                   -Lsory Group is a stable group and


                       -does

                                                                       -ecord regar-2@ng co tinua-
                                     T'--         a  a q o     track,--                           n


                       t4





                                                                                            San
                                                            i@l:     Da@,     area.c-=

                       a  e,-,   i't  n     1-"                           with    th@-  Dapa@-y Direc,"-CZ7

                       j U -7                               a     these areas     a --r abei rg aldre@-.,7,,@

                                     r
                       anci                                       di-1--rcn-    s.




                                                                                                                   171

                          which. are' critically important.   All of these things  are

                          co.-i-.a4Lned   in   hei:e,   a.@-id    were    really    a    trari-@ndoug    helT),    and    I

                          thin'-, the     new        system is     going     to     facilitate      certainly      our


                          wor.K.



                                                             're;
                                                oz:   you        -,ier-,ber the   classic           example       of-Puerto


                                                   as                                                             ce
                                                          i.,,e principal reviei,7et of               that, and   r-

                          .-ainl-.- or.@ 7za-,c-r,  it 1-oo,-.ed just awful.   When               we went      down and
                          4

                          found out       what    't:-ie real storX was we found                that it was a very.

                          good proposal.

                                          I think the kind of thing I was  looking f6r previous..y

                          is  all in here.


                                                 as    far    as    California    goes,    I    have    read     it,     I-

                          havc    @-lar'm-ed    sor,,e    questions,    things    that     I     thought     were good   and

                                        at I thought were           bad.    I     did     this     before     the other

                          s h e L-- sar--4-ved,  and 1 found that most of                  the things that I ',aad;i

                          marked     were in  aureement                    :the other reviewers.

                                          Tileir overall        program,  re'  ort,  for those            of  you    who
                                                                                p

                          havoc-, t,,ie big               -@.-@'-,iich begirs on,page 123,         I       think, explain@

                              4-                                         e7
                                                                           'pla4
                          wha-                                                  Lns   their            structure, it


                                                                                                   for       such thii-,as


                          as                     ;D r o,-, r a i @7, siri Monitoring     of      op;-nret-Lons,      and      for

                          review    and Dro--@-ess        c.' a@pi-ca@ion proposa's                       a view     to

                                                                     -v    c  Qro   ec t  -p-cposals while           th@@"
                                o 'T.1 7@ c@;   (D        7L qua@---


                          a  L


                                                                                      Ca 7   @,@r- -a,  the     record



                                                                                                                                                172
            @.47.

                                 of           accomT-,lisl-'E-ien+--s, which       is  listed  on  134,  I  think  is  very

                                    car!                       out,     it--     see.-.ad     to     me,     with     some     of      the

                                 tons      noted      by      the      Reviewers,      which       I       gather       are       being

                                 corrected.                    They've done  a  good  job.

                                                    --he  P.-czosed  Prograirs,  which  you will  'Lind  on  page

                                 'L-@7,  for                 o@        U   W--io   hav-e     it,      seemed      to      me      quite  reason-

                                                       @-a%te,     Lo   -- instance        --'well,        before        we         get  to    that

                                      they      have,      for     instance,          emphasized         the         thing         that  we       thin4l.

                                 is,so  -@n@iDorL--ant,          the  continuation  of  project  activities

                                 beyond  the  period               of  @.,IP  support.

                                                    S6         major project  activities  have  terminated  since                                       I

                                 iu'Ly of  '7"@,  and  of  these  Sr'i,                   76       were        designed        as        on-going
                                                             I.-Aave '@-een       continued       by       other       sources        of        funding.1

                                 T,.,-,at    seems    to    nie    a               goo-4  tra-k  record.

                                                    T"4
                                                                    regard Lo  the4.r       proposed           programs,           tiny  seem

                                                       4-        -L --ted  to  the  a4-rs  of  ILNIP;              one       of       them
                                 to   m@e                                                                                                 has  to
                                 do   w4@4--h manzowe@-,                   T  not'-a,  as  again  did              the'--evie'wers

                                 ard                                 you  that  I                  -this  note- before  t  saw

                                                                               so          -,7c          cartaLini-y are  in           the sarc


                                                                       hair@-
                                  a 1     a


                                 0-  ,ncre          a n  a         Tore  @.han  a         hundred  colleges  an-.'  universa'.-

                                    e s  o,:-, d  I'-'             t-a   s      d  c 1 i n    c s    a s  -m           s  c  f  t  h  e  c  on  s


                                 to             Ol-,.                                                                              --ional




                                                                       --,3u@-I    a            b   c,       r e  s- -L:rc-,  cci-.trol,
                                                                                                                                                 L -





                                                                          1 7 4


                probabi-v R.-.ore ef=cctive than it was in the past, in terms-of

              ri           of k--h@, activities.

                           -iR". S7L@ IE:  Doc-or !T-rrill has been -- has made
                a  o i    and it has been seconded, to the-effect that the

                                       D--2 approved at the level of $7,-353,OOC)

                                           ussion?
                                 e-a    cast


                                           Just a simple question.

                          I would like to find out how it is that California
                is in a seven million dollar bracket, and others are three
                million?  I wonder if they had any inside information?

                          MRS. S-LLSBEE:  Historically, Doctor Watkins, the

                Cal-:uz----::nia nroc- s,
                                     -Ince it has about 18 or 19 percent of 'the'
               popul.a@@ion,  has been @lun@--ed at a fairly high level.

                            4 S
                               p.=Ir-";-cu'l@ar application  represents continuation,

                       Y.

                         MR.            That is correct.

                               S-         All of these Regions will be coming

                                  aD;)Iicat4-ons -o-- iL-,ore --Fu,-L-"-s at another


                                                              -e s-c, on.
                               e e         is aconl-i,-iuci@icil qu







                            3 r uo




                                                                                                                           175
     WLID-50


                                                                      COLT@TC
                                      NATIO;@.AL    ADVISORY                  IL    017  REGIONAL      MEDICAL         PROGRA@.!s


                                                                                  VIER
                                                                G E 0 P-,


                                               MRS. SILSBEE:  The next Region will be Georgia.

                             1-ir.  Van    '.ink I e?


                                                                               @-7ell, I     am     only     going to give  a

                             ze..               h @-c,,,,  gh   t--,.

                                                                e-rs  had nothing but good  to  sa-                     f or  the
                                                                                                                     y

                             state       of       Georgia.        The        reviewers rated       this'        Region as a
                             superior        R-@egion;        they  gave  it     excellent         remarks          in terms  of

                             its experienced  leadership,  its                       strong Regional Advisory

                             Group, its co@=LLittee structure.

                                              The    same  blessing was bestowed on  their  experienced

                             progra-ii                 t@'Ley  noted  they had good CIIP working relation-
                             s-,-,ips,       and        considered      to be a'well-@-,ianaged  and well-

                             aa7Linisr-erc'"                        T-lel-cal r-l-ograr,'

                                              Georgia          had  reques@@ed       $3,629,757,  and            did not pro-

                                                                                                        y
                             pose      o core  in Ju'y 1  for  any  further,mone  s.                             Tie  Coimai  -C-

                               -co=e:l  -a       a-p-roval       a    the requested  level.
                             re


                                                                        Doc-a::      'I-Tcrr4


                                                                                                          a      v    that rczcr'-,


                                                                                             1.) ronc,@,- a 1 s  I %;,as  not
                                                                     vie


                                                                                        ht,. prcci-zic,-.,  and  possi'--ln-
                                                     sa-,i-.,@  dcc-L--c  cf   their


                                    4


                                                                                            to   d@3-.               to   begin

                              -z@,     a                                                                   -,roposal,



                                                                                                                             177

    WIID-52


                                             DOCTOP, 'IERRILL:    But  this  Section D  says:

                                                     "It  is  anticipated that ten hospitals will be

                                    sel@e--'%--ed  -@cor  any requests  to develop..."

                                             i@-IRS.  SILSBEE:   Mr.  Jewell             is  the  ODerations           officer

                            v;.,L-,o  is                    for            Region.        I     wonder     if     you     could

                            cive  us  sci@@.a  -,rs-,ghk@-  here?

                                                   JE@-1-@LL:    Doctor -.Ietrill,  this morning in                         the

                            mail we got  some  further amplification   on this.   Would                                    you

                            believe      it?   I have  a  letter dated June  4.


                                             1 have  it here,  and             I    didn't    want    to    load     you     up

                            with anotner  piece of  paper,  but here  are  the ten hospitals.

                            They  sent out this  reques@-  for proposals,    and                           here  is   the

                            list       of
                                                                         going  to  fund these             activities

                            %--hro-@,-h       pro@osed to  furd  t'L-Le@- activities                    through.

                                             D O'@' r-7,OR  :,ZRTLL:   Bu- nevertheless,                what  I am readings

                            here       is      type@  u-p as   a   proposal  from Gc-.rgia,  not as  a guide-,[

                        11  'lir@e     sent      to Georgia.


                                             !,Tow     s@-e                         a
                                                              t-ne -reason               t'--.y   tal.',, about  these

                              e n  hosDit+-@is,  bu4@-           s   -Lil  lea,@v-es  four paragrai--',-is        ivli i c h  s

                                                                             @c        as                        may       wcll


                              a v.--. "c     e    c u r i-  n    L, c   o      a r@ d ser@l-  -the@L   bac--   to you.

                                                                            you are                     Doctor,  is  pro-

                            poz.;c!d 'by                a   V,7e d--n'.t ha-,7e any guid.olin--             on  that  pat4L4D.'.'C.


                            care.


                                             DC;7,TC,7L         -L J--. L Til-,.a'-  is  exactly %@iiat  1  am sayi,-,;j.



                                                                                 178

 1-71ID-5 3
                      7,rught Lee was saying these were     the guidelines
                                                      They  are guidelines   that
                                                  0
                                 o-,:, to @'ic providc.,zs within the State  of Georc,-ia.

                                    S!Lc.BE@-':  Doctor !.Ierrill, I think perhaps the    i

                                       on the  a?p
                                                   lication frora Georgia might be


                      cr6er.
                              This,progran@       in order to get  this application
                    in, they -wanted to have a year   in  whicft  to do things.  It

                                                                              fics under-1
                   did'propose this umbrella operation, with       the speci
                   going review after we received the application.
                               I-,,-.qat 24r. Jei.;ell  has there are the specific areas

                   in w.iich  this ack@-ivity is  to  take  place.

                               DO,'-,.-,L'OR I.I@ERRI@WL:  All right.
                               @ie!'L, I will -L-he'n say only thal-- the coTu-,ients I have
                                also  to 4--he application '@Lor stro',@.e, cancer and
                    ki(2@-@@-ay, ar.,"@ ga-@h@-r that this is the reason t'--.ey did, and
                    yo-a@ are all sat--s=L4@ed     they are  coming in with good speci-@

                                                          tt
                      c         1 d  c r        agree        -c,'.ie recc,,@.-arda-ion.

                                                   S.  .forga"i,           a that
                                                                is                 you




                                                  i-.Luri CTOo   i:             progr

                                  c-,7@r -"Iii-a    and         s7A-Laa@-z,   I- second

                          r     r i  s i-.o G           y o,.ia c' a r.  iD,@ -i ?

                                                             r@a":c, a         in

                                                                         io
                                                        -a t t:-. -n ac




                                                                                                               179
    l@71ID-54


                          in   the amount of  $3-,62-9,757, which                is  the same as that




                                          .RS.
                                                               .1   secon,4   this    notion,    and    it    is    on

                          the b,--s,-s    that-k-.hey do noL-. come back in for our August meet-

                           r, g       1-rore fu,-i@",s.   T'@,.,is would carry them through.

                                          "Lha y h a v e a Ccordina-@Or v7.%o has been there for s@r-le

                          time and      is    doing     an excellent job,            and I  second it.

                                          I-IRS.  SILSBEE:   The       motion        has been made and seconded-

                          that the Georgia application                 be ap'proved,at the level of

                          $3,629,757.

                                          Is there any discussion              from the Council?

                                          DP,.    Gr@-IL-CH:     Tei.%at is meant      by   "target figure"          on

                          the ycllo,@7 sheet?   $@@,522,000.

                                                                      -or         Gram"Lich, %,.-Zen we were    sendirq.
                                          71     ST@q-EE:        Do'c4L.


                                   eSe    inS4-rU-@
                          o u, t                              in    March,    it     was thougl%-.t   tD    be    import

                          that        g@ve    t)..t   some    ballpark      figi;re       in which      they      might
               Li

                          a-iply LO7--    .,u.nds.      We too'jr,   the 173        level, and I won't attempt


                                                             c,    r  7 e   at              Ga.-,@1611    could     do


                                                 t                          and                   t-i,,2    amount    o@
                                                                                       Dase6 on


                                                                                                        Y,   took   lfivn

                                    t      t'
                                                                                           be   sor4-   o-c   a    targe

                                              s  @u@@    a  La!                                Doesn't ireai-i any-


                                                                       was




                                                              T,l -%--nur ez--rlicr    m   i   n,:7,1, voti sent      us


                                                                                           ISO



                                                                                   hen the
                                      I,-,_Iical Progran  and the    panel and t"
                                   G@arzill asse-sr,.Cnt, and the Review committee
                     re

                                                                                      f the
                      r e c  c r. @l a to ,i sand t'-,.at reflected a percentage o
                      request that was     being sugges@,c---'.
                                      r e   a-e se-,7;--ral in here thal- were called     super i c. -
                        a t Fre n(i L,             loo pen.-cen-. of their requests.'        Is thi-@
                      baca,-,se yGur  revi-ew=rs may have been on the         different teams,

                      or is it for    more specific reasons?
                                   L'-IRS. SILSBEE:   I think- we'll have to talk in terms
                      of  the specific reasons.   I think there is no overall prin-
                      ciple you can derive       from that.
                                   !:-i t'L-;.e case of Georgia, -,he reviewers         one of thci,,l
                        a,! be-@n on a         visit to   Georgia,    so understood the whole

                                      o- @.ai-  pro  a:L-
                       dev@ lo@i3rL i-              gr      i@iiic'--. has had a long history i-n
                   ji
                           ,-IS Oi- L-ne area f aci                          thought --he -programs
                       te

                                                               047 t
                                 -nanagt--d,  and in   terms  -   ae criteria they were
                       @,;as w@-11                                         L


                       opc-rat
                               ing  acainst  both     o,-F      @-A.Iought -@t was  e:-.cellent,  a
                       1  t'--a    -L. 1n-s   w   tT4le 100 -Q--rcent figure came     up@

                                                              -ou.


                                                                         L,SCUSEIOI-,.
                                                                 tn Aar

                                    All  r    i t a 'L, I@@n --'avcjr o-'-: @ie       Lo approve    aL

                        Li7i-                        leve.'L, !;ay "!.re.

                                       _iorus or  @le",




                                       73




   WIID-5u-


                                     "L'ne mi otion is carried.




                                                                                                     182




                                                                                        'iL PROG@'U4S
                            NATIO7.@,,,.-,, P-DVISORY COU,'iiCIL ON REGIONI@L MEDICI


                                                                REVIEW

                                   IIRS. SILSBEL:   The next         one is   Louisiana, and this           1


                      is

                                                           Louisiana was an interesting one

                      to  r-.e,             again not having read         i k-- over without bene,fit

                                  V 4 e.U all@.
                      bf  '--he r--            the staff work,  I thought it was rather a
                      good program, and that it hit            specifically at the areas in
                      which Louisiana was weakest,            and attempted to correct these,

                      and it had some speci.-ic methods by which they proposed to

                      co--rec--           @,zL@.,@-ch I thought were singularly appropriate,

                      kno,@iina something about Louisiana.

                                    1    do              'Lrom  reviewing     the previous
                   II LUU--,Ls@ana  r e   a s          -L"-.ere wc2--e some   I--,ersoi-ta'L problems
                      there ..@ere         lcr.-.s    -k"-ic:u".ar'l-y with integration in      the
                      Pr  -,,-a O. sec@--or-4-nto      P@l@ programs, and                I donl.t see

                                                                      perh
                                     --@ca.L@y        oncd   here,         -aps someone could co7,-,Ml@-lit



                                                                g      @7ou    a         Overview o'L

                                                               group.--                   :@a:.

                                                                                                   to
                                           C-                             n cazc             ited
                                                                      y


                       C Li                         a,      a t o n   u r    i:




                        Ca
                                          -a! irc,                        av-@rac,.@-, an@l vye o@,-ai


                                                                                                  %-3.ro-
                                                                                             e en"




   WHD- 5 8                                                                                                 183

                         application and had graded it               individually, and we-came up

                         wit.@   a comoos4Lt-a-, score.
                                        Lou4-siana    has   never achieved'a triennial status,

                         and  ap-,oc-ars  to  1,L-Lave content in           past to apply for the
              lit
                                   t-,,@e oF  crant

                                           c CeLord-na@or      has L-eeii, up unt- 1       recently,      serv
                                        T                                                                       i@nq

                         on  an          ---5 De-!--cant '--asis;  as of July lst,         he    will    b
                                                                                                         e

              r@         Increasing his               to 50 percent.

                                        The     Regional     Advisory      Group has several outstanding!

                         rie.Tbers,     particularly     its     Chairman,     and     its     Evalua-Eion

                                        leadership.

                                        Its   t-@aclz record in t@@le area of management of fu.-i@"@

                         has been goo@-, and         ',ts unexpen-.1--d balances on previous grant

                         awards have been rela-%---'-Ive'Ly  nil.

                                        .Lhe grari--=-e  4---scl-f 4@s a not-ILor-p---cz-@ Jt-- organization

                                                 -a-i        hoo   s,   and its indirect         costing has
                         in con--rac4-     to m @--cal sc


                         bec-n


                                        The    e;n-- s c n     -@-hc. R@-vi@q  --cra-i4-ttn-e approved the

                                           s t 0                        C   n  e@,senc--.,_              pf


                                                                                                         0-
                                           7


                                                                        r i r,:,-   s-2r-,.@i c-@s @o -scope

                                                                                U 1-@ 4-0  4-    prescrt t4-,
                                                               d-n,


                                                               4-                                C. rill.


                                                                           -cu--



                                                                                                    -d
                                                                               d







    T,T

                                            a@-c-ars  to       4.@C -Lo bc        the real     St
                                                                                                  rength of  that pro



                                                               @n@,  4-nL-,o  too              o- --'.,cse things, they

                                                                                    m-.d;     cal education and  physi-

                                                                                                  a L-i  of  'Linding  out
                                                                                  with        the

                             r_c.                                  t@niness        s@ayed  in       Louisiana,         whv    they

                                                                                    =r,:acialties they     do,  and how         t'
                                                    c.   go   in--O                                                                 cy
                             ni@ be        persuaded        to go  into   specialties which  are more

                             necl:i
                                  @C-d.    And  t:qat--     certainly  is  singularly appropriate  for

                             Louis4-ana.

                                              They  Iiave  a program on  the                 assessment of  quality
                             medical  care,  which certainly --  and                          consultation service,
                             W',,ch-certainly  is                                because       again,  as  pointed  out
                                                             h@-re,  one  of  the reviewers  suggests  that
                               L. e -,Ij, -Aav@- 4.-wo 'finds   of                  care  and  t-,-.a-L-  LI-he  two don' t

                                              1,  Cj 0  -Cc

                                                        @el--ha,@s  LI@@  :Ls  re@Lorring  to          the    problem which

                                 brou;7-'-i'-- uz) ea--!-Ler;       is              correct-.-'




                                                                                                          @ec@-i   done  to



                                        y
                                                                                    a lot rather  have            ",r.  Zivlavsl:-.i



                                                                             Coulci     y o,, i c   a    i4-@le    mo i: r-, speci.-


                               'Lic?




                                                                                                                                                               185
     I,IT.ID-   0

                                                          DOC@@ OR         @'.ILPRILL:         Yes.
                                                          It  was          brought  out  a',--             one  of  the  Council  meetings

                                                                                     -,,-,u.Ls.,Lana       w
                                                                                                             as  that  there  were  two
                                                            i,,iedic-.1        care;         one         for the  indigent  patient,  and
                                     systcns  0-
                                                    e-- r,@-iT,                                      clinics for  the  more  affluent
                                     t-l-ke  o-i
                                                           and      %'-.iat     t'i-Ae so-called.private  doctor                               did  not
                                     n; a c -z!     r          s e,@-   eye         to e-@e,   and         indeed  tended  to  resent                            the

                                     activities  of  ICIP'S.
                                                           i@-IR.   ZIVLAVSKI:     Several  of  these  project  activities
                                           here        the  new  ones,   specifically  55,   the  Earl  K.                                            Long
                                      Char-Lty                   Hospital    this  is  one             of  the  activities  on-a  new
                                      proposal;     project  54  is  a  Charity  Hospital  of  New  Orleans
                                                     y.     Project--'5-  agai.-i  is  Earl                                 Long  Charity  @iospital-
                                      act       v



                                                                     Pro4-c-  49  is  tne  La@a-,re--                       and  the  main  %@..-Arust@-

                                      for            tne            indigent in  %--iie  inner-cik--Y  is  La'Layette.
                                                             In  project--           53,.  @-hey  are            tu'Lizing  abou,t.the  inner-c-@.Z

                                            and t:ie                       d i g e   4--s
                                                             'D 0       a                                        rt,e;     -v.-hat- pa,.ics        are  these



                                                                                                     at-,  us%-nq        uiie  pope
                                                                                                                                                   n,@,,bers  G.-,_

                                        tl--@--                  page      c     t        YE@@L'!cw  sh=-c-@.     The  s-@aL@rL                   s-c-,ra,,iary  on

                                          h   c @-e'Llow
                                                              D 0 C'-,-    Z   1    F, T  L          1,4. a -4 's  all      r@@gh'L-;           4us-.     i@.,ailte-d



                                                                                                                                                                 186


                                                          !,IP.            ZIVLAVSI@I:            Looking            at            Louisianals            history,

                                   these  near            proposals         pro!Dably         reflect         a          change          in          the          leader-
                                   ship           of the  @-,6G  Chairman,   and  more  of  an                                outreach         in          the          rurali

                                   cor@jiuni44--ies  o-'  Louisiana,                        as  well  as  some                   of          the          indigent


                                                                  the  c-'_tj@-es.


                                                              '-@hinl",,                are         some         plus          marks,          w'.-iere          previously.,,

                                   in              zas@-                 liaver.'         had  a  good  track                    record         in         the

                                   cities,   because  of  what  your,--

                                                          DOC'"LOR         L@IERRILL:         'Yeah;         now,          that          is          certainly one

                                   of  the  nlusse5,  and  I'll                                      those  that  you  have.

                                                          I  -L-.hirak-the  Lafayette  plan  is  particularly  good.     I

                                   th 4- rik       tiie           --'-.S,            thc--'agii-risk            neonates,            the            transportation

                                   s y s       i   for   the  ;-ndigeiik--  --  are  all  things  v,-L-,Lich  are  eminently                                                 i

                                   approp--@--ai--e -Lor Lou4-,slana.

                                                          .Du'-  again,  -xy  concern                                are                   -L-v.:o  groups             0-    I

                                   p.-A y s i   --'La,6-,s      4-ri      Louis-@ana      who      do       not       see       that       these       kinds       of

                                   prograias        are         4@ntporL@-an@@         for         the  ind--'Lgen4L--          of Louisiana?                      And




                                                                                                     c.,-)u'd  I                         a                   bit


                                                                                                                                                  c@-i        this


                                                          t c                                                                                        '@rA      the  r.@, i

                                                                                                                 o--,   th-2  Statc             of  Louisi,@,r,@-,.


                                            T:hi t     @a     k.-, i o     a r-,  a   z   a-r             C   p    ZO, 1    Sys t               C"Losc       to     7@


                                                                                                                          @lcur      2..-i
                                                            an                                                                                cTerit  poor


                                                                                                                                 zor     carc,             and
                                   I VC@                               i c    IL      t,.D t.-i c s         @D s 7,





                                                                                                                                               187
                .62


                                 thrc,-,g"-Iout  %--ha  reviews  of  the  Louisiana                             ar3pl.4cations          by          both

                                 the            -w  Corc-@,,,4              and  C  ui-i  4 Is,  this  has  been  hard-hit
                                                                                      0     C-
                           T!

                                                            overall       pl,41ozonhy       ol        the        state        in having             this
                                 as    Fear  as


                                 dual  sys@-@,.

                                                                  a@    is  iio-@     to       say  anything          at  all  as  far  as

                                                                           to         c 'I-.a r i L-Y  s y s   @-,m  but  to  respond

                                                                          question:             ha               done       an        thing        about
                                 sr,                        o  ,ou-                              ve          they

                                 th 4-!j    a--re  'they      doing       anything               about  it?

                                                    The  ex-Surgeon  General,  who  is  living  in  Florida

                                 now,  has  been  elected  as  @-h-c  Chief  of  the  D-cpartnent  of  Socia

                                 Services, wherein the new reorganization, the charity syEteri

                                 'Li-t--s  in.  Specifically                  just v7here,           and  how  far  that  would  l@-aa

                                 into      the      -future      is       con ecture  on  our  part  at  this  time,  but

                                    hon-  th-4-  an=7,7ers                       question.

                                                                  !,,'-@R.RT'L:    We'           I   think             and     par@4cularly

                                 because of the thrust of the burdens of the                                           new     pro.-rams, and

                                                                                 @-i-ons about L-.'ne            pc--son,-iel,         I would

                                 a,@   e          al-'-Lho--l--'Xi    no-L.     as     en---;-;.Usizi@-t--r-ally     as           the       others

                                       ar.,d            a --ecc,:i,:-.enda@-i.c)n  t-.-iat           t          IC @u?.-,    e. d  at the -Full




                                                                                                 @o,-n     y    ,c:4   I     vcu   a-,7e  an
                                                              S :r,
                                                                                                                   7L  -L



                                 0     C) r u i-@
                                                          o     -ZD:-  at


                                                                                      zio. Tilc  sarLe           Ct'-,@s=ns  Come            to


                                                                      -)ctor                               --@u don't have a                 Ti-'
                                 ,air niin@l    as d-c.@ to D,


                                 6  vicia-tio@.-,i,       or  anvtlii-r,.-j       I        t i



                                                                                                                                                                          188

    V;IID-63


                                                               i'll.@S.   -DTISBEE:                t@To.


                                                               DocL@or  Schreiner?


                                                               DOI.'TO-TZ                                    I        just        wanted         to         make         a         comment

                                       that           although            those            charity            hospitals            are            separate,            and            they

                                       --usto.--tar.-L'@-y         reaara            a            orivajL-e  sector,                   they  are      very  closely


                                             d                 ,Lxj u -'@ s -L a  n  a S@-ate              Z..L@-dical              School.


                                                                   was,jus-              gone.  to,  saythat  I                           am      familiar  with

                                       sote  of  the               lateralization                           of the                  charity  hospital   systems,

                                       and         'this         was  originally-designed              under               state               aegis               to               follow

                                       -he           horizontal            east-west            main            transit            line            across            the            roads,

                                       tl.-Lat  tied  trade  areas                          together  in  Louisiana,   from  east  to  %rest

                                       and   this  h,3-=Pital  -zyster..,   ir@ile  it's  true  it  doesn't  tie   into

                                       thincs                      the  C,-.;.-rer  Clinic  in  -Lulane,   it  does  tie  in  very

                                       C'@os      ly          to                         State  schools,   and   there  are                                     rotating

                                       louse         SL@a"@@Ls.                 -Iere       are      @u,@a@@4@na              fu@LIL--Lir,-e               @-acul@Ly               members

                                                                                                                                                                          to
                                       Ln  eac,'].                                so            that   b-yl  coripar-@son,                                                             the


                                                                        t,-,         are       un--'@-r      'Louisiana  S;@-atc-                                                  School,


                                           dc,--@    -c   t    i rik                 wouio         s la,@- 7 er     mu c 'II    by  comparison.


                                                                                                                                    -hans,                      some  o'  t"--7-
                                                                                                                                                                                L
                                                                                                 class  arison,                je@-


                                                                                                                                     e       c      zi        C-1 C) @n e d         c--  -





                                                                                          T-                                                             a'          @,self
                                                                                                                                               to     r,     4@ia  M.Z


                                                                                                                                             IT,
                                       c                              r L,                                     poi-i,.t   T         7 a                         Gcorge.


                                                                                                        -at  ciie-  o-c  @'-c!          z e  @.i


                                                                                     "-,a             t2  s  in     -7"  c, r    o .7:" 4- c o                     is a  E;ir..:




     ;qliD-G4


                           kind o@' torri,--o-@y,  has been their enlistment                      of private


                                S4CianS
                           phy              and     private      hospitals      in      cooperation      with      these

                           other ];.inds      o@' activities,         and    that,    I    think,    has    not     been

                           trLie   of    Loi-,- S 4


                                                                                   i  L--  is   pretty tough     on the

                           p                           1   -@.ese peo,,)Iel.-are on the          s   -L--ate    payroll,

                           and   tL'ie@v  ar@--           on   a 'Lull--time salaried            basis    in thd

                           hospital.

                                        .-It would be pretty hard for a private doctor;  most

                           of   L'.%.@-se doctors arc on a full-time salarv.


                                                  SILSB"-E:         Doctor Merrill,          would you like for

                           us to as)-,     t'.ie Reg,-on to address itself more specifically to

                .L.
                                   Ln      their Li'ul-%? application?   In ho-4 they see this work--L ,i g


                           out?


                                                                      I
                                                               L:         h4          since the question has
                                           D C.           it


                           been               zL            of   times,     I  think     it      might be   well      to
                                         a.n4- T@ certF--@.-,ly ,,ould      li',@e  to    know    il,6 answer.         I

                                                        -v:hv the question          has     not     been raised       in

                                                                            g--.aat   -@ervor,    un until


                                                                                     c. u  i t    c   he       answered.


                                                                                                         i  don't
                                                                            '.'-C li-IaL,e a  '@'LC) tC)n


                                     L r.   e d       s  c o I


                                                                                                                              7
                                                    Z.1                                   tl,.           -tee recc:z,


                           n@ el:a    C,       r              '-at





                                                                                 190

  @FtID-65

                             !IRS. SILSBE7-7;  The motion has been made and


                   seconded.

                              Is there any discussion?


                              Al-, in -7z-.vor?


                              'Ch:)-----s "Aye")




                                  response)

                              ,he motion is   carried.






                                                                                                                                                                          191
     I-IliD-66


                                                                     -1 VISCAY COU:CIL  O,'                        r, T-'GIONIU          @EDICi'@L PROGP@,!S


                                                                                              -0 RICO           P%EVIEW
                                                                                     PUEPJ.


                                                              14RS. SILSB'@",E:  'he next one                                 is Puerto Rico.
                                                                                                 L


                                                                                                                     w7.lo  is the Chief of the

                                                                                                     ',as b.ee-,ci called a;@:ay because c-@
                                      his fa@.,--::'s                                    ar,@     so       1 am going to wear that hat                                    Zo-r      I

                                                    4-
                                      a -,Linut--.


                                                           -@But since Doctor i@,lerrill and tirs. Flood are much

                                      more        expert on Puerto                       Rico, I am going to defer                                   to    Doctor

                                          r r


                                                                             "ERP
                                                             DV-CTOR         ;.,I     I T   L:             1, as you know, i.,-e site-visi ,-@d 1
                                      Puerto   Rico,   following   a   very   un.'avorable'review,   simply

                                                                                          a!-one.


                                                            We                   T-                   ver,7                pi---asa-n+--ly surpr4--sed  by  the

                                                               of  the  s+-a-Ff,   bv                 t    e
                                                                                                                           -Y      C.L   the  Di.re--tor,   and.

                       ri
                       I              par'--4-cul-ar'L-,,,r         of         --he         Associ-al@-e          Director,          at  that          tire,           and

                                      4L-,qe  lov-altv  of              the                        and                        particularly by          the          number and

                                              c                                                    @@ere   in-c-rez+-,d                  in    the      progra-i.

                                                            1                            are               i@,k  the                       f   i        too --



                                            a          s c.   -L- h    i s    v zi z      ac,,@, n,        c-:-zac--ly  -Lo         th@      'i@-@rds  of  things

                                                   -.@.ere    needed   in            P u e r              4L       such          a       emergency  health

                                                                                                           aric7i  @tani-@o-,q@r                                 evalu=-

                                      t.:L o n  o-@                                                        and     thi:-iicis         I                        a


                                                                                                                        Service,, in




      WHD-67:                                                                                                                       192

                             hospital             health       services,  rather                  Ryder      !.'Lemorial  flospit@-a,!;,

                             v7as       asso@-ir,-,"-ed                 area  government health  center,  and
                             although  two  n@w hospitals were being built,  they made  every

                             e.L.Lor;@-     -n     the     instruction      and      olanning      of      the administration,

                             to    see            --he::               no ciu@lica"-ion       of       services,        and        these

                                                                                s-cl-;,,,-'Le.:.,,ented each  other.


                                                                       L-                              puts  on paper            soi-e
                                               Ess@-r@                     s  grant      reques'L.
                             of  the  things  we  saw at                that         time, and  I  am enthusiastic  abou@

                             it.


                                               It       apparently       was        called above-average          by           the

                             reviewers,             but it was recommended               that      it      be.funded      in       full

                             at     the     rate     of $6,1@5i862,  an-,A  I would agree with that.

                                               I v:o u'- d            to     ki-i..3w     if     anybody     could     answer      this

                             CIU_S-"40n  On  S@a@@:
                                                                            or rio@  sci@ie  of  the  staff              people

                             %,,7ho have  I:-al-@t  th@
                                                                                    cr-:,7@c    back     in     an-     cipation     of

                             @,s,  or will  come  bac'tc?


                                               You           rerie@.-c-7-      iat   one  of  the  things  that  strucl.

                             us   was  that alt'.-.ouc:h          so;-,.-te    o@L    the    sta-'f    had    wor;zed     very     hard

                             on                     had         -@;h e r,         believed  -"'-tat        --Fl-,nding   was        not

                                               ze  aae-4a-ze,                   @ai  c-D:,,e  into       c)taer      Doi)s      in trie


                                                                                                     w    r;,.


                             -or                      hourz-,   w 4- L   u                   arci   many     c.L' them         had


                                                                              tc;  coi-,c  ',--@ac:k  @-u'L --tiTrte    into     the


                             3rogr


                                                                          i,, o   micas  any  arsw@r  to  their-?




                                                                                                                                                                 19    4
        WIID-69


                                     s a,.,7  t'@-@ 1 s  a.3         ;ay  o-F      doing  business                  in  Puerto  Rico,   and                      did

                                     not,   as  perhaps                 i     -a     c i@., ot'-Ie@-  similar  situations  wl--iere                              the


                                                                                                     have           .'ad            concerns of         two         kinds:


                                                                            sL@-a-'f,  be--a-aso.             they         don't          -- except              for

                                        c) E.            t   a c c  c.@,@          s            c.-Jase      red,         write         and          blue          dollars


                                                                                                     ubstantive  concern.
                                                                        c          ",!,a


                                                          .@e           ccr@-a@ril_y            didn't have  a  concern  that                      there             was


                                         rIP-0                              S
                                     a              f'                      oriet4-;-tics  had  been  --                   also,         but          again,          this

                                     is    based  o--i         i.-I.lat  I  cfticil--ly  recall  from                      Bill               Furman's                review;

                                     he             been       there,       ar,,d       I       have        less        Irnowledge        than        you        and

                                     Gerry,         bu@-         h--ving         c.-4aired         the panel            and            listened             closely,

                                                                                   Bill           @ias suci          a           forceful           and           picturesque

                                     r e,.,  e      r            -s.    i-io--    @-Oo    d-'_,     '-'-@i-culi--     to     recall     so.L-,,e     of     ais     co.T.-

                                                                            ----&4s  -,oint  specifically  to  this                                point,



                                                                                                                                           t-aa4-4on  actually;
                                                                              R    R L   L      lqell,      I       saiq       that       si

                                     as  an  ass--,  iecause  it                         meant          L@.hat-thev          @-iz--re           available,           and

                                                                                              ID


                                                                                                       -cr                                     --t d    a        bit




                                                                                                                                                   t  same       prc@!,:,-
                                     i-I..c.:-.ber-@  c;2               s        j@, az,,!    x-7.-7is concerned  al:)cu-,@




                                                                    i- n           z,-.id     lo-rgo     1--h@ir  sta@'@@  lias                          re-ola-_ccil

                                                                                                                                                        I      did


                                                  t--,D           7 a i,,   ci                                                it c




                                                                                                                195
@'ilD-70


                                         I-IRS.  SILSDEI":     I,,Ir s. Flood?

                                         @,@@IPIS .  FLOOD': I might add some explanation.

                                         They   havo   a   'Lang-L"'-iy   li'.-,t   of   staff   people   in   the

                         application,    and    as    1:'.r.    Cl-iambliss    comriented,    there     are     few

                         faill4@.liar           t.-.erc,   but   there   are   sorie    new    names,    and.    we

                                                                     -Y Coordinator.up there now.   I,-,e
                         dc) not     av-z a Dar@--'-.4@rLe DeiDu4t-


                         have a                    Ass4.si@-ant     Coordinator,     at     least     by     virtue

                         of this particular core-persorinel breakacwn.

                                         They    certainly    seem    to     have    a    full     complement     of

                         staff,  although they have a few positions                       vacant,     and      some

                         are   at tire health educating level,  and one,  a secondary

                         associate coordinator s'LoL@. here,  and perhaps that was where



                                         But   L@-he--   ce---Lain'Ly   see.-.   to   have   more    staff    than

                                                                             li-.'r-.e    to    reiterate    Doctor


                                                                                  review.


                                         Thev   are                     involved in concept           develorjrti-@-@-i-c


                                                                        @-.-erer  ana           have


                                                   4
                                                                   -0
                                                                   L                           1.7a@        sector


                                                                                        E-               ley   hav.


                                                                        @;-,l c- a-- c-


                                                                                                      c al     Prcc   @L
                                                           e-



                                                        r
                                                                             as                s s


                         n  -,ir                                                  co   to       c 1-i   e v    can


                                                       t




'@IIID-71

                            I would second the  recommendation for the funding

                 as recom.,oeiided by the Review Commit@-ee.

                            ZIRS. SILS-@EE:  '@ie motion has iDr-@en made and seconded

          7
                 that the Puerto Rico application    be approved at the requsted

                 level o,-c 7'j    2


                                  r, -2       discussion


                            Al 1


                             k'Ci,,orus o'L' "Aye")

                            Opposed?

                             ('-@o res:Donse)


                            The motion is carried.

                            Doc;tor          we appreciate   your rapid-fire review@

                 t7,Aere;    sorry you have to leave.



  WIID-72


                   NATION.!L L@-DVISC@n@y COU'@IC-'LL O@@'T RT-'GION@-L 1,1@DICI-@L P.-tZOGM@ix-IS


                                    11-Tc-SISSrLPPI R-RVIEW


                         IRS. S-L-BEE: Now, Doctor Gra'lich, we are  goi
                               +                      rri              ng

               to put you on the grill.


                             Van-


                                          I a-,-i sorry. Doctor Terrill could-,


                                  7                t:l- 4 S
                                      'd s"             Region.
               stay @or      or,@.  a   d    -ViSi

                         On@ o@L-  the  revie-@iers was a    former    site-visitor, and

               he was highly complimentary  of MississlPP3-. -He   felt   they

               deserved.quite a few pats on the back.

                         They   were   consi-dered'to   be-an    above-average    to

               supe-r--.-Dr reg--on, program    leadership    was     considered to

               he s-'--t--ong and viable; they have a c@7@petent leadership staff,

                                     i-,s    progra-i  @L'f,  I   -=hould   sa
                                                                     y

                                     was             and  -ve  -@el-t  they were


                                                                          0
                                              goals an-' cb-:@ct4ves   to supp




                         a-ae prozosal as SUI@-rL4,t-'L di..@as to     congruent


                                                 a a       -Program,-,,,.
               W@


                                      A.                           r-roposa'L





                                                        a-!-



                                                  r          ri a n       OL


         ri
                                                               ba@---d  on  a


                                                                  h a 4-




                                                                                                                       19 8
 IIIID-7 3

                            --c reali-S'ically         accompl;shcd  in the tirefra,,ne remaining for


                                  pro@-air,.

                                             Mississippi  requested             $2,350,409;  the Con,,.,nittee

                            reco.-,-r,,iendation         $2,200,000.


                                                            Z 7-':  D3--tor Gr
                                                                                   a.-, 1 c h


                                                                                 -,ld  like   to corL-iant,  fir@-@-

                                     ha-     1 f4@,d  4r,        @,ello-%@-  -@ol(aer, which we received on
                            of--'   t

                            arrival   today,  a transcript                 of   the Review Committee's comments,
                            which wou-@d have been very helpful had they been early enough,

                            then I had had tire to read @Lhom.

                                             !IRS.  SILS3@-E:   Could I make a comment about those?

                                             '"Lhosze traz.sc,--4.,ots   are put in the folder and we

                                                      to get out of  %the
                                                                                         ou4---o@c this room.

                                                              he hc-lnf,,ii;  ,,,e     would have liked to have

                            sent there to yo,@l         in ad-,zance,  b@-,@L-    because of  tie           confidential,-'.7r

                                         -oceedincrs,        we chose  %'-'his method.
                            of the'p,

                                             But I    agree;  I wish we could have                   had them,  too,

                              bu-" l@-ecause the Co@.-Ii--L"tee di'n't @ow that                      they     were going

                            to be usc,-d. in                              we felt        @.ta@      it was    important

                            tc,  i,@st '@-ave                r         '-@.ere i.-n.  t-@i-18  roo!n..

                                                                              SUDP
                                             D       R  C-@-                        ose    tlen      as a   corrollary

                            tc.@           Wr,. I..7@ u                        0 0  s 1. i       you?

                                             I-ITE!ll,    -s s 1- s s       generically         speaking,        unfortun-

                            at@'-@y,    i iL t:,.at all     o!- the-   RecTions    to    wiicii    T   was    assigned       as

                                                                                                                           ri o-r
                            ci  -,z   a r    rE, .i    -r        c  'superio       or abo,.,,e             Cie to   SUE)C


                                                                                                                                 199


                                   w',.iich   Tables  --he  job        easier,       of    course,  and  I was  interested

                              :L-i---h,2      figure          was  reac'Liad,        because  I  reached mine  in  a

                              sor@-,.e-,,7iiat  different      way,     in     a     more  programmatic  fashion.

                                                I  looked       in        SO.1,,,C.detail  at  the  projects  request,

                              a.,i,-@   rote-Ct for                    that         there  were  several  programs,

                              as  i;as  cbsc--vcd                            b   St:aff.,  that r  ' lly raised                 a   1   0
                                                                                                         ea
                                                                                y

                              o@   qucs+--,:Lcns  as  t-o          e L-Iher  they we're  R@,IP-oriented  or  not.,

                                                For        example,         solid-i-7aste         management         training,         which

                              is     a program i-7-@reby  the  State  Board of Health                                  or,           through

                                   e State  Board of  Health,  aims  to  train  landfill                               operators,

                              which  seems  to  be  pretty much  a Public  Health  operation,

                              rather               a  f lat-out RTILP  plan.

                                                               Z."ng     a   the      yellow       sheet,       and the  numb
                                                         loo,'                                                                    er    o@i


                                       particular  one  -Ls  C-137.

                                                C-     5 Is   !.'ocd  Sei-v-Lce  Trainirig                  Program night     more


                                                                                 -h Service.
                              approprizl --a 1. y      be    r@i    14.c ileal4t-

                                                Also  in      &the         yellow sheet,      in      C-140      to 144,     I   had

                              a       spac-La'L observation  about              this,        b
                                                                                             ecause           these four     programs

                              were     canc@ar-re'L-at(r-,,,',         but were     all  to     be        @-oanagea by  the


                                                                                                _a
                                              Corcc,-,                 y          --aal      pro@        an!  a7-4--hough            they

                                       small  --mc.,,urts,            it 's  r u c.'@- me  tha tl- perliar3s      these were

                                              t,'---,4.-  woui-t-        -@a            ]ust supplerqent4-nq          things  that

                                   e     e r i c -a nCan--,er      So,-,                       -ldy   done
                                                                             -v lias        airc-


                                                                                                                    'bi'
                                                'Ar leave    had     sc-.-.a concern  about           R;"@   visi               Lity,,and  I

                              r. c--, a  dii"@ o            pro'--rai.-,Ls,  p--obabl@,      erroneously,           but      I can





   @'i"IID-75                                                                                                                            200

                               imagine       the       situation       whereby       the       @IP       would        provide        the funds
                               and     the  Cancer  Society would                    get  the  credit  for  it.
                                                 Now  that may be  paranoid,  or  it may  be  realistic.
                               V.iey were        small  amounts,  I  grant.
                                                 I       had        sor-,-a_question        about C-159,          which           called the
                              Quality      o@L      Sarvice      @or      th,--       l.Lc-n-ally Retarded;          it           struck me
                              @,is  was  an  unusua';  request..                          It didn't  really  lay  out-any

                              program at  all.

                                                 I  had an  equivalent  question  about  C-162,  which was
                              a  hypertension          survey,          Pearl          River          County          Hypertension          Siarvey,
                   ,L:        in which  they  proposed  that  the  emergency  room nurse would
                             take  blood pressures  on  all  patients  who  came  into   the  emer-
                             gency  room,  and  a  -@l@ag  went up  that per'@-@.aos  that  nurse  who
                             takes  the  b'-ood  pressures  should  take                             the    blood                DressurcS
                             v.,.ae-.her  she  is  being             sup.@orted  by  P,-NL@         program or  not.

                                                     @Ln.    a   s                                                                     d
                                               Ag@,'                  l'    program              $10,000             but           it'di
                             s t    1: a me     as      a      little      costl,,-      'o- the    doi-            -'a..routine  dut
                                                                                           r              ,ig.  of                            y
                                      '-!IC  -,iurse  should          or--' i zi a r 4-    do.

                                                                  a   c--bl-c    IZV   proc7ra-,i  @ror                        and       I
                            %Seoul(!  L-e            -,--::Z;4-  to   a.:i r--   ti-, a-   T  dcn         un-,CzstaTi.-d  it  care-
                            f7@-I          or,  t-,Dro,@hil              but     as    I   read     the  p--og--ani,  1  wonderc--"
                            4F           p@.yo'-@     -,qaz       rea'.7-y                          t -1,@ L-        L: 4- '-,,a r a

                                                                                                       .-----7ical  Costs  at  ficzlle.
                               1-1@  Is are          1                                                    -Fur         -i,
                            T@;                cir-c@-1-1-Y  a  :Ci-larc                                      @ctic)i       and     aaain
                                             IoLir                       p u      c I y -       Q @l I'ater  cysLe@ils;
                                                                                                                                      the
           .   . , ;, I'@;                                                                                                                         i   -  .
                .  , . .                                                                                                                           I

                   v
                   I;



                                                                                                    201
@,lliD-7 6


                      nrogram soug'@@ to -jav for half tlle costs o@             installation o'

                      flourida@-io-i ecuipiren'L-.

                                   T wonder if @,IP is interested in            that sort  of  pro-

                      ject?


                                                                                                   n
                                                             wi-iic.i are the last    several   o


                                             s-.::uck b-,,, the la@-t four       0-36, 37,      38


                                                                                    to say:"
                      and 3-@l,        fcr                        appear to    me

                                                   these   are   some   new   projects    that    we

                             think     are pretty good; give us some $600,000, we'll

                             spend    it as we can develop the projects."

                                   It  s.ounds   good;   the   titles   are   fine,   but    this

                      loo'--@led l@-':e abla,-i'.: checlj,-, sa@ring:

                                          "We are a goc4 outfit; give us the money and

                             we      s,-j@-rd i t-- wisel-,r.

                                   Noo.,,  lust as a   riatter   o.@ philosophy and      policy,

                      if  this i-@ an -,pn-cpria--e wav to go for P-IIP, fine, and              there

                      is  no      question but thaL. the titles of the projects are             good,

                      but @L-cre is -io substance        behind the projects, in         t@-ms     of


                      0   nll 4
                      -la  -ng an.d Drocess.




                                   MR. VA!i               -@-ie application itself       does addressli

                      those, DOOL--or.   Othcr C-ian      @.his  yelloi-   sheet,   t".iase   four    te
                                                                                                       ris


                      are, %--he sar.-,a thing that you    were   looking   at   on   t.-ie   Georgia     I.,

                      aiDt:14@catio,-i; tiiese are-w,-iore they had      sefit out .;ritten requests

                      @or proposals.   Thr-@y do have        the-' request       in-house; they     have




                                                                                            2()2
@YVIID- 7 7


                     many more requests     than they have money to support.

                                 Now,   at the tir@.ie that the decision is    handed     down

                     by Council as to how much money they received, their RAG-

                     will meet again in terms of their.priorities of what they

                     can fund ;@74-thin -"nose general areas.

                                 l@ilov,, the primary reviewer raised the    almost     identi-

                     .cal same questions on the same projects that you were men-

                     tioning, and they did         we  do  have  a  list  of  all  of   those.

                     They  will  be  communicated  to   :the   ',Iississippi   RMP.   However,
                     he did not c'---oose  %to  say'that  "You  can  not  fund  this',  fun'@-

                     that, or fund theother."

                                 lIe said that he   thinks they    have  a  very   low   prior-

                     ity, and felt that they should be allowed to determine within

                     that unless it was against Counc@-". policv to decide.

                                 -IRS. SILSBEE:'  1-irs. Flood?


                                 I,IRS. FLOOD:
                                                'Is this.an A-rated region      with   a  tri-


                     ennial status?


                                      'IAN           Yes,  it  is,  or  it  was  'at  the  time

                     that we        doing that -Lvpe    of --hing.

                                                                               Doctor,
                                                    I might mention     a!4o#              that

                     we in"Sta--F@L have raisc4- the same questions,      almost to the

                     letter,  that you   have.

                                 Ile need the he'L.z) of Council   heria on  the  solid waste

                     a,-id "Peter #'-Ile Pe'Lican" and '4-4 i so IL-.her b r o #--',i e r shere-, and
                                                                                            to

                     get your    gu4-dance as t(:) whether we  should sacc@ifically     deal.





                                                                                    20 3
 fill D- 7 8

                i  with so.-,ie of these projects on an individual  basis, and seein

                   that they are eliminated   on the grounds that   they do not fit

                   within Historical @,IP operational activities.

                              DO-,TOR Gi@-ILICII:  Incidqntally, and somewhat tan-#

                   gentially, for  t..e bene@Lit of the Council's advice, Pierre

                   the Peliczn a,-oears  to be a  how-to-raise-ciiildren program.


                                                That is correct.

                              Now, back to  the original point about the     $450,00 0

                   re4@es@@.  You said that information was available
                                                                          justifying

                   these, but is it anywhere in    these grants requests?  Because

                   I didn't  seers to find it as  I went through.

                                       -e point   is that it made  it hard for me
                              Any-way, 4-,

                   to sensibly review what  npeared to be a  blank check sort
                                             a..

                   of reques;-_ for funds.  I realize-that in some Recjions, some

                   Pi.IP's, that probably is a perfectly legitimate way to go,,

                   3ust to get the funds, but how.do we know that as we go

                   through this?


                                   SIT@SL'-E:  Well,  I       all revelers are


                                                -i.-,a on Ci
                   concerned  -"bouL-- just dc--pe-,ici    e written         and it     I

                   is '@-Iard to convey t;;-I.L s .

                                                      unity, Doctor Gr
                              Did you  have an   opport                 amlich,  to

                   talk i;  h Doctor i,lerrill before he

                              DO,'-'TOR G,:'@,ILICH:  About Mississippi No.
                                                                                        t
                              via S .            an sorry ha  had to leavc,   because

                   he had been  on a previous   site-vi-sit, which  *,a sa couple.Qf



                                                                                                 204

 lilID-79


                       years  ago.

                                   You mentioned that you went through this program-

                       matically.  Did yau come up with any kind of a level of

                       funding?

                                   DOCTO@'Z                A  f  igure?  It  was  interesting.

                       There were son.,2   that I had question marks on  a programmatic

                       basis entirely,     s-Dr.-e that I felt.-- like      this cancer society         I

                       business here --     -,iaybe if you fund one or  two  of  them  you

                       get'whatever little mileage there is to be gained from sayinal:

                                          "Yes, we are  indeed  in  support  of  you,  the

                            Ariierican,Cancer Society."

                                   I  scratched  the  ones  that  were  obviously  Public

                       Health Service and should,         in my  opinion, be in       that   area,

                       unless Council  decides        otherwise.  There were        some  that  I

                       had so.-,e question    about; I  didn't  di,-iinish  on  that  basis.

                                   I think  the     four items that were $150,000 apiece,,

                       the four projects, that Qn the basis  that  it  w,-.s  a  suoer3.or

                               diminished it  by  h@,  subtrECcting  the  ones-          that

                       obviously should be in  the         Health Department, the one            that

                       was       cable T@,'

                                   MRS. SILSBEE:       What   f icrure did  you     come up  with,,


                       Docto@-?

                                   DOCTOR GRA.".LICII-.    I  came  up very       close, within

                       $200,000   of t.,ic  s@-ne fLjure.

                                   IIRS.  SILSBI"'E:   Well,   they may    have     very wal
                                                                                                 gone



                                                                                                          205
",MD -  0
                         -L..'L L;:ough the same process in      their   review.   Do you feel that
                         the     $2,200,000     -- the concerns you        have will be conveyed to

                         the     Region;     there is no   question      about that.
                                       The figure I came to was $@,031,000, which was so

                         close they should@'t worry
                                       Do    you.want to   do   that       in   the form of   a motion?

                                       DOCTOR GRa2,!LICH:   Just to          get out of Mississippi,

                         I would move that we accept the figure of $2,200,000.

                                       MRS.  SILSBEE:   I would prefer the proviso.                    Do you
                         want to word something in general terms, not specific                         projecu5

                                       DOCTOR'GRA!,.ILICli:   Let-.Is     have a little discussion

                         about it,     and then make a separate motion.

                                       IIRS. SILSBEE:   The motion has been made.

                                       MRS. FLOOD:   My Fon,-nent would be that I                 think    you

                         are being a little generous.
                                       This is blatantly         transfer of funds to           Public liezLIt@:
                         Service   &@'s not just sort             of obviously, and they are in
                         small amounts, but this is trad-@tic>nal public health                       work,  and!
                         I don't see anything -A.nnovative about                 it.   It certainly does

                         not   si'@OW             wil    develoo     into      any repu'--able state      new

                                      'ie way you     are                        ss these     programs,
                         loc,"@  Ln                         goi27,g  to      addre                           that

                         yo,,  could use across the state.

                                                                                                         it  f
                                       -,his   has   no    i,-,nactua:l    Erogram as  such;     I  can        ind
                         any   objec--4uves or     goals    listed in          the application      that    this     i
                         addresses     -;@r-se'L  to.    Food-hard-j'e'rs'     classes?       '-;Iy goodness.


   Li i






      -3 1
 .WIID                                                                                                             2n6

                          Really,     tha,--'s      exactly      what it  is.

                                          MRS.  SILS'"OEE:   What action           do you want to take

                            'th t;-is     concern?
                          wi

                                          @L,@,S.    FLOOD:     Well, I wasn't     the primary reviewer or

                          the    secondary,    so    I    didn't    have    an     opportunity     to     look     at

                          't.-le Forn-, 'L@j  's  to see how many oil-       these   are.now.

                                          I     hope all of them are         new    and     that     they     haven't

                          been continuing          for some time.


                                          DOCTOP, GRA@ILICH:   All of these are new.


                                          !.IRS.   FL@CD:    I    would    take    a    closer    look,    and    it

                          would -Lal@-e --,le a  r,-LI-.-Liute  to  f  igure  out  how  much  I   would        give

                          them,   L-ut'.rL certainly         would   de'Late    the    public    health       issues

                          more                  than jusi@- to recommend to them that they do it.

                                                                                                                   re
                                          DOCTO.@,                  '..@y  don't  vou   list   wiat   they   a


                          so we w    -       "Invq?


                                           'RS.   E'LOOI'J:   137,   I.-idustry employee, education;

                          there's another one.


                                                                    Solid     waste     management,     C-144.

                                                 FLO-@D:   C-14',  145.


                                                                                                                   e
                                          DO','!()R GRI@ILICII-.     C-@Go'   is   the   Public   Health    on


                                                                    @.hen there's'anot-.,ier one-in there.


                                                                  the record.)
                                          (Discussion off


                                          DO%'-TOI-', C,!-'A-",'LLICII:  165, '-Iedical 'rosi@-er   I-Iomes,  is


                          really
                                           PuL-'Lic -Health;      that-is       a  welfare        program.


                                          .DCCTO:L  '"Ii@'L3        163?





                                                                                                                       207
    :WliD-32


                                          DOCTOR GRZ--'-'LLICII:      168 is flour4Ldation,  another

                          Public iiealti-i.


                                          That is     roughly $80,000, iirs. Flood,  which  doesn't

                          really

                                          MRS. FLOOD:  I know; it              doesn't really slap their



                                          DOCTOR G.L@MICII:  I wonder if it would not be

                          simpler ijl.,.-we accept the figure, vote on -that, and then dis-

                        ,cussed the problem of reassignment of inappropriate areas,

                          and too, the open-ended request, which I am not totally satis-I

                          fied


                                          But  there are ti-;o separate areas, and I think                       they

                          might be senaraL@-e@-,         and this might apply to other Regions*,

                                          MRS.  SILc"'@-@-Z:   Doctor


                                                                   For infoz-.,-,atio.-i, at       the risk of

                          exposing my ignorance,  what is 'a  "c-.rLloking Withdr&Lv.,al Clinic?"

                                               C-,_,@'j-37TSS:    ".ayl)e    I    can    answer    '-hat    there.

                                          So:-,e years ago,       the smoki-,-ig an,,'     her-@itli        activity

                          w---- an i.-,-L-egra"L part of our P,:IP's,  because              we    Lelt          we fell-

                          h-:a-,@-  @o   it 'rori the @-tn--c-       ----scase                                have

                          funde--' --Ln yea--rs   p n- s  sroj'zi,,-ig and health activities                 under the

                          aeg-!s o-F

                                                                                                                           r
                                          This  is   s-'@-"nly    athrowback,        1 would      assume,       to a

                                                 ty,                  P-%!P  in   --h c  a s      and   it is

                      l@  sii,-,t@ly a            o--F controlling        the'               as    a-preventive




                                                                                                209


 WliD-34


                      do  Rev4ew Cora-,ittee work or do Regional  Advisory Group work



                                    Doctor Gramlich has suggested that you'take a look

                      at the funding level vraich he made a motion would be at the

                      CoL-,n. i@L.@Lee recorx..iendatioii.


                                    DOC'-70R               $2,200,000.

                                    MRS. SILSBEE:      'V'-Ihich is $2,200,000.

                                  -.-Now, there has been a motion made.


                                    DOCTOR 'YIAI@12-IOCK:   I'll second it.


                                    MRS. SILSBEE:   Do you,want to discuss that further?

                                    All in favor?


                                    (Chorus of "Aye")

                                    Opposed?  Two Council       members opposed.


                                    The T,-@'t-'Lon is carried.


                                    Now we have the sj4.r.1ple    issue of the advisability

                      O.r
                            @'Regions pursuing this particular course, and I think you

                      are      really trying to get    back to t.ie Region in terms of their'!



                                    i%M S   RS:   @id I assuiae those taree         million dolla-@s

                      they a,-re going to re-ue's-"@    in     July and August'will be      reviewed?,

                                    YIRS. SILSBEE:   O"-Xr     yes.

                                    IIRS. @@,@S:    Because     this is something, I think,

                      znuz   we should    look at very     carefully, this further rectuest.

                                    DOC@@@-R               ZIay   Iask,   is it  appropriate       here,.

                      to  discuss the Principle            involved in the las- four      projects,,




                                                                                              210

                     whic'l were ,for $150,000 each, without         particular justifica

                     tion or,programmatic support?.

                                  Noa, this applies, perhaps, in this area, bu-t it

                     may fell           in other  areas,  and  iL  is  a  matter  that  came

                                          7
                     up a couple o4r    --"-.ies  durincT  the  arthritis  Technical  Review

                                  meeting, i-7,liere a good  strong PR-IP  said:

                                        "Give us  the money and we'll do the           job,"
                     but they didn't      exactly say what the job was.
                                  Maybe   t-4s doesn't occur very often, but if it does,i
                     we  should   have  some guiding principle.

                                  YLRS., S'LLSBEE:  'LI-,ere is -an application that you
                     will be considering later           Texas       @-at-brought ut) this

                     very same issue and the Review Cortnittee told us to take a
                     dif@Leren%@- kind o'L action,:waiting until they got'- the.particu-

                     lars.


                                  So  this is


                                                ICTI
                                  DOCTOR GP,@-M         Does  that solve the problem?

                                  I-!PS. SILSB-@@-:  ,to, no+--  ag  far as   -Iississippi  is
                     concerned'. - I t.:-iink  you have solved it, pro'---ably, in your            IL

                     LU:-,d -LI!  reCOia@re,-2d C.'l .


                                                                                              '@te
                                  P,      IiL@           a--. is precisely   what the Comni

                     a  @.p  -c d --o ,'o to resolve   i   by t@'leir L@unding   level.

                                  MRS. SILSBEE:   Doctor    Janeway?

                                  DO-'-'LOR JPj.'El--iAY:   Just. an observation, that  if  one-.
                     na?,es the   assu,,-,pi--io-,i that the funding level,  as  recommended,



                                                                                                                211


 ID-@J6                   dc!lei'-es    theze    programs     speifically.     That     is     his     one     set.

                                         If   c.-i th,2 ot;-,er   hand the funding level               is     set

                          on    the     basis of     certain     other     things     having     been      deleted,

                          and    then     one specifically proscribes the utilization of

                          these   --Fun,"-s,  t.-.ese   'Lunds    for    Pu'@,"L4-'c    Health    purposes,    then

                          he  --4L-h@n  i-4.-  i-vz-s ever, more 'La',--4--L-ude, i,,,ider lat-4-@-ul"e         for

                                                           -he use of non-prograr,---,iatic-orient
                          .-h-3   use   of            in 4-                                                      ed


                          funds.


                                                 SI.,-USD-@E:   Well,  it seems to          me   you    have    a

                          lever    here    that    you    would     not     ordinarily     have,     and.that     is

                          that   they   are    coming    in    with    a    oroposal    in    July,    and    you

                          could very well insist that you have,  at the tire,  specific


                                                              -ie
                          information aboul.- hc,@,q ti           Regional Advisory Group has chosen,,

                          @O   Oa,--J-ay    these    fumds,    v7ith    advi-@e,    in    terms of the concern

                          that you have,  and you could look at the Region again.

                                         That    is    not    an    opportunity    you     have     very     often, in

                          terms    o    this  short      tirief rame.


                                         DOCTOR GRA-I@,LICii:   That solves one               oz my    concerns,

                          iv).-,icb is  si-ri-)Iy that it      is  entirely            possible that   the      pro-

                          gra:p. wi'-@  Ibe v@-ry good,        exactly   w."Ia-L-    it    should    be,    but    since

                                            is   t'-@@   c;Dcn-c-n-@'_L@-c-chnique,   it    rl=       4
                                                                                            -res      -- very


                          cult   f  r    u


                                         I  @.,oul-"! ha,--e to sa-.:,:          you   can't     do   it"        because

                                   s .iot   w'--a+-      are sa-@.-ing a- all.          I would like        to not
                          I- ia4-


                          on.L y        s   e        -@o,-@u st is                       I  woul  d   like   4%-O

                          -,,,-olvo a @j@--,y                  coL:'-,  "Lc!ave t.,,.e  respor.,se      croen-,endecL.





                                                                                                                                                          213


                                    f   c t    ti-,at      we      don'l@-       have       sufficient       't-Ino%.71ea-ge       as       to why

                                          y                      I  t@ink  you  can  d.Lrcct  "-his  bacli-@  to                             the

                                    Regionai       Advisory       Grouo,       as       to       why        they        chose        to,--        yo@        &re

                                    looking       aL@-       t'@-la       qu@-lity@        o'L        -E-ic        decision-making        there,        and

                                    we  could  ask  -'or               additional          information          on          that          for          you, too.

                                                         DOCJIOR       Pi-@IIL:      I      think      we      would      like       to       go       back  o

                                    Mrs.        -rlood's        Pont,        that        a        lot        of        their        activities        don't

                                    fit       in       with        IL-heir        own        objectives        and        goals        and        programs, so

                                    that       I       don't       like       to       have       a        policy        that        rules        out.anything

                                    that       smacks       of       public       health.       It       may        make        sense        for        that

                                    Region      if      -Lt      is      part      o@'       their       program,       but       in       general,       we

                                    are        not        designedtd         take         over'tho.se         kinds         of         activity,         and

                                    there  are  so  many  good  uses  for  the  funds  that  I  would  think

                                    the  IUG  could  receive                      thit  advise  and  perhaps  act  more

                                    appropriately.

                                                         Certainly         they.could         look          at          @-heiA-          objectives          and

                                                    progr@-r,.-,ia,--'Ic      goals      and       how       these       @-ioule,       fit       into       it.

                                    Tha--  4-s  -the                       thing  that  i@e  are  4-n-Lerested  in,  but                                  I

                                    pcrzonal              d--n't  believe  we  shoul-d                       have         an         abso'Lute         rule

                                    ti-iat    -public. health              is       -Ehere;@-c;re       inapioro:)riate       to,       our       f       und-

                                    4@n@-@.     !:u-t    it  does  have  to                                    a-,,-- carefully.

                                                                                          I   was  -4us-  wondering  i@                      we         cxe
                                                         @@ISS


                                    going.      to  as'.,@     the  local                           t,, i c- r   --ns,.Ner  on        k@. @-i ;-3?       An-

                                    are     r@e   going        4L-    q e t    t  b,@
                                                                 0


                                                                                        If    t.;e    rr,' L-- @T       it    b,r-      la-uly ls-@,      V.'C




                                                                                 214
 "iiD-89


                  w,-ll be t 4@
                                        thereafter, because t.icy  do have to

               i  allocate t-a@-se dollars, and we will get.that   information.
               I

                             D@"-'LO.'Z GrA:-ILICIII:  And 'there is one other element

                  iii @llis s-a!-,ie                          tsmanship.'
                               ,@oblem thak-- relates.to gram

                             It is entire!,., r-ozsible that these were in thei-I


                  a.-,d --u--          7D-ar-@ectly le itimate,,but the reporting
                                                    9

                     @--eceived was iisu--c@Licient-to &nable us to make a judgment.

                             Now, I think this m6ssage might be conveyed, because

                  if we misinterpret vlhat iqe read, it is either because we

                  read it @,-rong or because it was written wrong.

                             ',,'RS. SILSBEE:  Is there any further discussion on

                  Mississippi




                                                                                                             215



                                                                    r
                                                                            (7 1 rD: 7 L"EDICAL P OG        M
                                       C 1-



                                                                  @'O."  T.?, r@VIET-17


                                       L'@IRS.    SILSBEE:    Okay;     how do you feel about North

                         Carolina,     Doctor Gramlicli?

                                                                 Have     I got some ideas about


                         !4 or th    o I


                                       In the 'L-'L--st place,  that 'airplane.   I am taking

                         the p--ogra-7L-..iatic apart.

                                       It has a superb RAG,           it is well staffed,  it's a

                         ood   organizatbn and has done a               good     job.     Its     track     record
                         9


                         is fine.

                                       $50,000     for    air     transportation.     That     is     hard     for

                         us   to   see - 001,  s@---cond ite7,-L.

                                       North Caro2L,:Lna ,.ias a lot   of outreach clinicS

                         throughou4L-.   @,e   st--ate,   and   it's   a   big   state   --   not   as    big    w

                         some    otL'ters.    They    like     to     transport     their     residents,     their

                            nursing s-@aff and consultants to these various outreach

                         programs b-,7 air,        a,-id t'@iis ma'l-.es so.@ sense, but as I read

                         the     grant request--,  it raised a question in iiy mind                  about

                         Wi-&et'@-ier it was an                                        or WI-ieth,:!r it could

                         perf,.,a,:P@; L,,a s-co-,:>cr4k--ed     year iiith   the understanding that

                             it  is tl-ia-   i  T.,ortant, then the state leg-sia-ture of North

                         Caroliiia oug,-.,'L-- @-o soo,,@.sor

                                       Tii@re is     som@,     n    a!--ouk-- this   in  the   grant    reque

                                                     answer as           %,rc   e r  it  was   an   opportunity'
                         but r-iol-  e. s@-,2c-




                                                                                                                                    216


                               tL,            u-l?          i,@,Lis   .Beat r-.@qht        otierwiso  not  bc-  tiicre.
                                                                                              iL


                                                 The  oiily                          struck         me          significantly          about

                                         k--arolinals     prQqr--r..      was      that      they      have      their      --      they

                               are      big      on      hvv-ertension,      and      beginning       at       66-A       through       66-L

                               t,,,ey  @ave  a      total  of  about  a  dozen  programs  all  related  to
                                                               i'n        tc-arr@,s         ol"doll'ars         they'represent         $459,739.1
                                                 I  realize  -"hat North Carolina  is  a very  good  RI.IP                                      I

                               and 'they might  be able  to T3ull  off  all  these  various  and

                               sundry projects  successfully,  but  it did                               strike me  that  that

                               was    a      lot      of      expenditure       for       one       particular       disease,       when

                               most      of      it      was      related      to      screenina      and      education       and       develop-


                               ment oil-  service          personnel.

                                                 They     have  some very good programs.

                                                 on  the  second page,  again,  there was  a                            very           large

                               bloc.-,. of  programs,  s.%-.arti-n-7. at  67-A                   and ending at  67-G,  on

                               the  providing of  rural health  care,                            and      I      like      this      general

                                          -h,  and  I  think most of  those                      were  pretty good  programs                    .
                               a.@proa.                                                                        L.

                          II   It see,-ie--l  to  be  well  integrated  and-                     t4-e  i,-ito'each  other

                               iriti,@ouil-    a    lo-L.     of     dupl4Lca-@i-on,     w.-.ici-i    ccLld.-i'        a I., for         sure

                               a@out  t,;l---    hypertension

                                                 Tiere  seeme,@7  to          be    some     overlap  in         -@haL-.  area.

                                                 rL@ia  rezq--  of            -@.@-ion           t-hc!  @,.'IP       se@amed  to       be


                               t o D          i t ,  and using  a                          obscure, tecl,.ni;7,ue,            came     up

                               with  exactly           the  same  -Fi-'ures.

                                                                                The                       was    also     quite



                                                                                                              217
 I-'*IID-') 2


                                                    the med;ca! air operations.              They singled
                     t    tha,- out ift:,,iediately;  they        also were      concerned about 63,
                          which       th@ considered, as near as th@y could determine from
                          t'@,.e information provided,  to be a pure PSRO,  and thus con-
                          S'Ide--ed i,nar,-Dro-,,-iate  for funding         by RIIIP.

                                                                    ,lan, I interrupt just one second?'

                                        1:   d-.dn"L- P-@ci'-. that up when I was reading it.   6               3

                          appears      to      overlap directly with 41-E, which is called "Area'

                          Health Systems," but when you read the request,  it is a

                          PSRO training program.

                                        I-IR. V"l ii WI:ll',LE:   They also expressed considerable

                          concern about 69,         Doctor, which was the university-linked
                          hospital 14-braries.   They thought this was completely over-
                          a,-,ibit-Lous;  @-iey didn'4.- feel there was any guarantee it would

                          ever be continued,  an.@@- more          ar,-zropriately,  they felt this

                          l@as sorte;@-h4@ng -Eiat Liese hospitals should Iz doing anyway.
                          hey sai-' libraries were nice,  but they didn't
                                                                                                really see      that
                          ti-.,is, -was  going to have any great ef'@Oect on the                system there.

                                        mha@   on@ toy had real concern wi-h;                   they also

                               C,-i a-1   a  t--n                   -@.-i 'that rur--l              clinic,

               i          an.-' they only    Tade   mention o-@r,  i--,.     Their concern wasn't.tha%@-

                          grf,-at.   T  tliin,c the=-,,,       much    as you -',o a!Dcut 'that.

                                        They  also    exD--ezscl" some concern           aL-out   the     fact

                                        RCS4
                          +-,hatt  i s     -on,               in          45 nc-e   projccts,  ti-&ey      were    a
                          b;_                         @-h-4-r  ability to       c@rr@      t!7tem out,  but th





                                                                                                                   218



                         wen-   alonj     @;4  Ih 4t base-!    on   their    past performance.

                                        Pi-@S.  SILSE-E'@:     '.Ir. @!41!i.kc,-i t..-as the secondary

                         reviewer.        Did   you have anything?

                                                               I   would    agree    with    w.',iat's been       said.

                         I th4-,-i'-@ -,,ve coul,-'   s4-:,-i@ly   not   go   along   with   allowing  these

                                                    -Eo    be    not    challenged.    We    should    certainly

                         ch-all@e.-ige @,,en in '-L.,e=,.,.s o-' allowing them to stay in.


                                        MRS. SIESBV.E:   Doctor Wammock?


                                        DOCTOR   It@l:,,IOCK:   I   would   ask    a    question    here    which

                         was    raised in 63.   This matter pops up                   at   every   turn,    and    I

                         know   that some way or an.toher we   are going to have to address

                         ourselves to this.


                                        MRS. SILSBEE:   I,,Ie are trying            to   work    with    the    PSRO

                         staff to     trv i@-0 get that resolved.

                                        DOCTOR @7@,%I:@-IOCK:  I realize there are iriDlications,


                         here,      and I   am   asking   for   information    as    to    --    well,-what    is-

                         the    relationship,    or    i-That    are    -they    endeavoring    to    accomplish?

                                        T mean,  1 sa".7 this i,,7-iti-i lots of reservation.   I

                         di,iil-'  wai-.   to 1),--irc, i-   u-n   bu-   in   my   c@v-n   particular   mind,    I       i

                         am       well,  I'rt for a       r.-e"er -review svs-ce@-a, period.   I'll say

                                w-'@4L-.icul-- any rascrvaL-.ions whatever.

                                                S  L
                                                               t:e'Ll, as you inay recall, back in

                             --te--ibor oF  173,  the Rn                   c tc,!"' to CDT,-,c illi with


                         re,-,ues'-s ti-ia't were     con-@inou to      f:-Ive  d4--F-'crent areas, one         of


                                                                                    ior o     tv,
                                                                       area'. a.-.otl-           il-cia was    hype--


                                                                                                                                                                             219
     HD-',! 4


                                                                                                      11 4
                                      tension.     So'som'e  of  these                             rings  which  you  see  in                            here  we-r-@

                                                                                 direc-,ive,   which  has  not  been  turned
                                      the        result        o'@        @hal-


                                      around.


                                                            DC)C"LOR                              Putting  it  in                 PSRO?

                                                                              L:     T7  I  could,                I  have         had            some            discussion

                                      IV, 4
                                            h  t h c        e,:,          ir-        -a  D: 2 -o a r       n t    responsible           for           PSRO,            an-,
                                      therl--        is        at         least the  possibility                  that           some            of            the-specific
                                      applications                         here as  well  as  some                that       might       come       in        in        the
                                      July  cycld',  at  least  to  the  near  view,   are  an  attempt                                                               a
                                      possible         attenip-L-.         --          an          alleged          Dossible          attempt,          at          circum-
                                      ve-i,.ting         the         PSRO.         rog@-am,         and we  are  very  much  concernd  with
                                                                          -P

                                      that.        I        doubt        very        much         -that the  Denartment  would  fund                               any.

                                      activity  that  would  do  that.

                                                           We  are  in  the  process  of  working  with  the                                              PSRO

                                      staff,   look4na  a-@'the  specific                                 applications            here,            to             make

                                      sure  that  that                doesn't  happen.

                                                           DO%"TOR                                          I  am  in          favor        of  this  business

                                      of   quality  assurance,  or                          whatever  ygu  are  tallzing                             about  here,
                                      because  1  r-,ean,                         gro-      W4-th  this  problem  everv                            day,            the

                                                         C@@L  qucsti-@-i                             -r      ou  are  going-  to                  call  it          PSE.

                                      or           wha4@-ever    t -L  S           quali-@@ assurance  or  survival

                                                           il-Li s . SI 7     -Dr,
                                                                                 -E:        -ir.   Rubel  tajks  about--                      trying          to     C.Lr-

                                      Cur.'.vent      t    L-           th4Lng.             is  looking  at  it  froze                        one      point         of

                                                                              y4 ng
                                      view,      an--'      I  was           tr         to  loolz  a-.  it             fron,       the       -ooint--        of        view

                                                           t.L                                 'L           -@e    -'-,hal-   @,e  ga-@e                          last
                                      o--F      the      con      @nu--t@,,   o     t.  e-  d-r@cl-




                                                                                                                         220




                                            I  do  think  that we both              agree  that we can't have

                           this    funded in  two  dif@'erent places with  two                         different          -sets

                           of priorities.

                                            DOC-L       v     OCK:    That was          what  I was  thinking about.


                                            LI, l@T' SSjT
                                                       @SB-@E:       i%Lrs.        Flood?


                                                    Z-LOOD:      ,Vell,      I      would just      like      to       reinforce

                           the     Review     CorL-aittee's     statement      about      NtL-nber      69,      which      was

                           the'network       of       hospital       libraries       throughout       the       state        linked

                           through  the University Health Science Center  tied                                 with

                           library resources.

                                            This  is       appropriately                there        was a tine when

                           funding      for      this      Las      available      through      the      National       Library

                           of      Medicine      in      small      14b-a-v      development       resource       grants,       and

                            ossibly  so.-,ie oil       that     funding could be available,                    but    it     is
                           p

                           a  massive  un-@larta'jzing,-         even     at this  funding,  for             a         one-year

                           developitient,  and should not                 appropriately be  addressed,  becaus@ll

                           indeed,  this  never            finds  continua@6 support                   if      @.he       hospitals

                           have n@3-  alrea:,ly S,-iown  -t.=           in-@rc-s@       to do     i     on    t:--eir      own.

                                                                     @US@ frCr,-,                         cc,-or Gramli-'@l,
                                                          @S

                       11  you haxl arrived at    the              s a,-, r erelative figure           that  the

                                            had,  and      t  c n  I began       to hear      a  lot of other concerns.

                           1,7.here. do   we  stand?

                                                                          I-i'C 1 1 ,tille- fu'L    --rundincj   w-as   not

                                       -idzad  bv       tlic Co@@-.    tc-,e;     c         -e  redu-cd       by          something
                                                                               t'.1 -2y wcx



                                                                                      22 1

 WIID-96


                    o,:,-,zz a       L'.ol-lars, .,.,,iich s--2emcd reaso,-iable.  @.Iiiat


                    seemed reasonable.


                                So I move '--hat we accept the    Review Cor@,ittee's

                    reconma@-i'@a4--ion of $2,375,522.


                                DO'@TOR            Second.


                                                 All in favor?


                                (@-horus of "Aye")

                                Opposed?

                                (No reply)

                                Carried.


                                icw-f we will get this back to the Region,       your

                    c@, cerns,  to t.-.e Regional. Med4-'cal Prograri.





                                                                                                                                            22
                                                                                                                                           2


                                    @N',ATIO, 14-:kL i@'-)V-@SORY COU.%CIL Ol,.'           @-Z--GIONAL MEDICAL  1'ROGIW.IS

                                                                SOU'Tll DAKOTA REVIEW

                                                   M.11S. SILSBEE:'  South  ba'r@ota.                       Mike?


                                                   IIR.  POSTA:  The   South   Dakota                     Regional      Medical

                                Progra.-,i  request  is  $729,417,   which,was                            aoproved in the total

                                &-.iount requested.

                                                   As some        of  you  might  r6call,   South   Dakota   used                            to
                   L
                                be, several years                 back, associated with the Nebraska program.

                                They got a divorce, and I think the separation has caused

                                both progra-as to imp4Love  tremendously.

                                                   Because  of  the   divorce,   both                     South     Dakota         and

                                Nabraslza  have   been              among  the  most   funded   regions   of                       the 53

                                that       we       have       funded novi.


                                                   For  instance,   the   12-Ttonth   annualized   current

                                funding  level-  for  Sout@-.!Li  Da';:bza  right                     now  is  $428,152.

                                                   Although  the  Region has  never  attained  triennial

                                status,        it  lias  been  considered  up                   until,        if  you  remember  the

                                last      Counciil-,      as      a olanning  Region                     rather than  one        that  has


                                acn@ea        o-.@ra-@ional-  sta@-'-!Si,


                                                   Tilie  reviewers          scored  -lie                Region as,an  above-average

                                              a    un4-ausliess        o     title   South  Dal-lo@-a         programs          is in  the

                                         @t'.-la@- i'-- is      t.-ie only  one        --'.,-.at  I           of      %%TI-ic!reby the     ciir,.

                                -ounc4 1 an,:                    .-@G        zL-c  o-.i,-,          @h@2  sar,,e.    The           do    provide',
                                                                                                                                 y


                                qrc-at     st--engt-,i to @@hc stLate.





   V,'iiD-9                                                                                     22 3


                                  Program   proposals were considered well defined and

                     had Priorities well.-,mesiied in with        the  identified health

                     needs of L@-he Reg4-on.

                                  All  there  is  is  a  small   staff   that   is being paid,

                     by '-Iio- R:,!-:;      are- many other consultants who ',lave given

                     ad   L@-.-'Lonal extra strength to t',ie     program.

                                  I think -Liat   would suffice as an opening.

                                  MRS.    SILSBEE:    Doctor     Gramlich?


                                  DOCTO-@ GP@ILICH:   This is  going to  be a very short

                     report.    I would make only one comment on the staff assessment

                     and 'I--hat is the  Region was assessed by reviewers as'not above-

                     average but as     superior.

                                  MR. POSTA:   I stand corrected, sir.

                                  DOCTOR'C@-',-@I-@H:.  I   could   find   nothing   Wrong,   I

                     have no cc.,@-nent;  I move'that they be funded at the rate of

                     $7@G9,417.

                                  This -Ls supplemented by  a 17-page              confidential

                     report,  @.:hich  says   e.@cactly   the   same-@Iiing.   Tie transcript -o-7

                     i@- c-, revlic-..-c-L-s' coa@,e.-its, a l'i-page renort,  ;that they couldn't

                      -L   aL S   i               c  :z o ii g W -L i i t .


                                  I.ZZS. SILS!3'-7 7-@ l@irs. Flood?


                                  M:I.S. FLOOD:      1 1 ,I only   ha-@  concern    about one

             L       prcgra--,i, and that was the project %'umber        12,  %,;hich  I   felt


                            ref7 CC,-                                                        I
                                    -e-L'L  a. sort o-@ a r, i  a  ma@-.zigeriLn'-- in nurses

                     C,,-- 13 a.-) c sr i   e r  @.ian anu r s     s':: i 1 J- d,3velopn@enL'. in the




                                                                                              224,
   L'@'ZD9 9


                  I         @r  i3ro-rai-,i, but      the newness of their independence,

                    and   w  h  their w@-11-@loclx.-te,-ited analysis of @-ieir objectives

                    f or  '@-'I-ie Region, xd the.--Fact that this might in truth be the

                    cause of a tremendous nursing personnel turnover, I-would

                    concede t:qa@- i-L- might --ossibly be an adequate manpower develor,-

                          l@-ype o@L project,  a,,i-'l I would accept the others       recom-:

                    r,,,c--nda@n.


                                MRS. SILSBEE:  Is      that  in th@ form of a second#,

                    14rs'. Flood?


                                I.!PS. FLOOD:  Yes.


                                MRS. SILSBEE:  Any discussion?

                                All in favor?


                                 (%@-'horus of Aye VI)


                                1--@)posed?


                                The     notion @@s carried.


                                All   rig.-,t. The Reporter has asked       for a  short

                    b- -!z,   and we    still have two  Regions, and because i@. Sidel

                               Recion      or p-z---h=-Ps i'-Is -Doctor S'del; I don't kno,.,r

                          'll           h-@e 4- o-,      an-d ',"r. Pu':jel  11 not -be -here,

                                                                                  ta4-n an@l


                    @-ut-                  -C


                                              a         recess was tall-Ic.,@.,-i.)




                                                                                                          225
  T@-71ID-10 0

                             't,,@@TIONAL ADVISORY COZ;'@@.CIL O'l-  REGION.A@ ,'IEDIC-@L P,70GRIU-IS


                                                                      r-,"-VIEW


                                                                  riq.@.t,  let's get started.

                                                been caught beti-,-epn a dilemma Mrs.' Mars and

                     I                  a--id      Rubel has given way,  so we are going to

                         L-ake                       up first.

                                            7-50-@T.,N:   Inter-.4ounfain.   Th-a reviewers rated

                         the Inter-!,Iountain program above-average.   The program has
                         good leadership, a talented staff,. and a most active Regional

                         Advisory G--oup.

                                      The Co.@.-ittee recorLTnended funding in the                amount of

                         two -Liillion dollars, which was            a substantial reduction below

                         the $'-',O-d-9,425 requested.
                                       Suppcrt for tha reduction was based on,  one:  the
                         relatively               unexpended balancesin this              Pegion over the
                         past couple of years;  -,uyo:  the large amount of requested funds
                         was ccns---re- -nverli, ai7@bitious,            and an example of this was
                         that 33    new pro-.osals are inclu@,ed in             the particular applica-

                         tion.

                                       I am sure       ha t  :,Irs. !Sears    and        I'lood.wi'Ll    wish'
                         to go on w-@th soue mo--e               specifics of  '-.he program,  and perhaps
                         -he-,7 T@it  iit @;art 'to          up   -he    @u--.diricj o@ the'l,-.calth

                                                      Cor@ora!-
                                          3       c             -io-     which    had  been brought up

                         at the    ii- -Hoc                            r.,---2eti7.tcT as a potential   proble.-a.,

                                                            r c a 1 y    a  rather    ince-,ised over      the





                                                                                                       226
 'v7llD - 1 0 I-


                                Cor-L,,iittec-,Is cutting this    proara.-n  down to 52 percent

                       of tl,ieir requesL-.ec'

                                    This progra-rq      have si'te-visited  twice.  The  last

                       time was        ':.iot-7 -Lia:ay months ago, llike?

                                         POST--'@:   it was January 15tli.

                                    @"IR-@. @:ARS:  it was January of this year.

                                    The  program,. is under new leadership, very  capable

                        ew leadership, and before           I go further with it,  I  think         that
                       n

                       to cut this program down to          52 percent is  lainly  a  slap           in
                                                                               p

                       the face.  I think it will absolutely kill  all of                    their

                       incentives.


                                    The program had a man running it previously who did

                        un a  very -4ght sh-p.          Howeve-, he also did not get'much
                       r


                       done  a-- far as outreach,       and this was one of  the recommenda-

                       tions that tl--,-e sil@-e-vis;--i"- tea-ri made at that time.       This      was

                       being corrected,   -anu' of-course, par-tly $this HDSC does carry

                       on that pi.-.i-losophy to  a certain dearee.

                                    The outreach program is benefitt--ij-ig minority             groUEt-,

                          i:; add4-,-,-g                    itself   is cacLd4-.-.cf Minorities   to

                   ;I  the sta@@f.   The ca'L-'L!,,,er that is required is @omeL-hiiig that

                       is very                to          a.,@i     area;    ho@,iever,    except    for
                         a                                  are very- muc.q in --'w@-'Ll,      the

             i         percentage    4-s very   s i.'. Z,'i 'L IL


                                                                        Site-V4_
                                                                                         -am    recom-
                                   Ort@- of the             tha                    it  tc

                       @.end-2d at                   a      @c r   r,4 @;7r@la            between    t'-i@.





                                                                                                                                                                227
    T,IHD-'-')2


                                    !.'Iountain                States  Regional           "1.1edical       Program,            the                 Colorado-

                      L             Ily@. ing,         and      the      In't-er-.'Iountain.     This                   is     being        carried                for-

                                    wal:-"4 , ai-"-  t',,ic-y       'i-lave       "icc-pt        r,-te        apprised        o'L        their        activities.

                                                              Th4-s was      another          thing          that          the          site-visit           team

                                                       "d
                                                                       was     very  concerned  about,   this   turf  prQblen

                                1                            'k--ha@-  was     as@-.ed  bv        the    site-vis-L    -.    t    e     a.-,i has      been  met,

                                    and     t.'-Le      @,vhol-e      '-Boeing here  is,          I         agree         the         program has      been-over-

                                    funded      in      the       past       --       I       can't argue        about        that,        but         I         think,
                      ri
                                    under  the  new  leadership,   that  this  money  will  be  expended

                                    and  used  very,  very  wisely.

                                                         The         HD.SC         --         Heal@Lh         'Develop,,ment         and         Service         Corpora-

                                                                                                           -profit                  independent                  corpora-
                                    tion,  which  should  parallel  a  non

                                    tion,       this       1.@'.'LP       was       developing        as        a        project.,        and        it.is        going

                                    to       be       to-@ai'Lv       sepa@-ak@-ed       .@ron        '--he        !R:,IP,        Which        cerl--a4-nly        should

                                    relieve        some        of        the        concerns        that        were        expressed         by         the

                                    Research           Adr.-,-Lnistra4;_-ion            of            the            University.

                                f
                                                              see  no'    reason              why  this           can           not           materialize.            The

                                      ela@
                                    r        -icnship  ti-iat  @@-ie  organization                             has  now.,  T,.-il-h         t.,ie'   grantee

                                    c-@ga.n- 1- za@-i@n         is     a            ve--y             ruchlimdroved one,   and              ti-,     IC  they

                                    will  worl%-  very  closely  t@-oge-"@her  to                                                        'any problems                and
                                    v.   L

                                    to    i--,L                 t@,e    T-. @;S     r,,-om    rc-=   'I   ly   be-c;o.-.L4   rcj a             support pro      cc-'


                                    0          a  T



                                                                  ZT   iz -
                                                                             -,aE:    a                         -u-din,-,,  --rorc@.               c   r sources,,

                                    anL',    IL-.h     hl-,-,7c   r    c e   v ej     a     n c,, w    d g e      n            a         e-1, would        receive,


                                    t':        F       i -                                                        !7.- so--,                               Th'





                                                                                                                                                     228




                                                                                  -ha+-     continued           fundin
                                 .ias                       succ@E-sf-:ul, so     4@                                        g     of      the projec,-

                                 IS      assu-'e-u       and       shoul---' not         require         IE.-4P funds        to        support        it.

                                                     I       to!,--'4       you        the        Tri-Regional        Coordinators        have        met

                                                 th@-@,,           a  new  P,!iG    Chairman  i-;,io  is                  one      of      the       most


                                                                               me,-,'--ers  of  the           public        that        I  haVt

                                 co@-=                                is gi-vin,-      more              of.his time        than        any         indivi-

                                 aual      that@-      I kno,,,i      of that      acts     as      a      P.AG Chairman


                                                     There           has been      a  tremendous  amount  of  rapport

                                 dcvelo@2d;       the       system        now        is        very        good,.        this'is        the        assess'-

                                 ment      of      their      pro4acts,      and      I       simply       feel       that       if       we       accept

                                 this      degree        of        detrimental         fun--4ing.here,         it         is         just,--         the

                                         iev is  simDly                the  whole  program  is  going  to  fall  apart,.

                                 be.@ause  I                             @iscouraaer..ient              is     going     4--O     'De      SO      great.

                                                     The  doc@-or  is  a  pediatrician,  I  believe,  by  profes-

                                 Sion,  @as          he   no,@-,'    v,-Ii-o   is  now  the  Coordinator?

                                                     I,IT.1,S.        SILSBEE:        He is         an          orthopedic          surgeon'.

                                                                             I' couldr.' t  rerie.Tber                what  he        was..


                                                     lie  is  giving  so  much  of  his  time  to  the                                         program now

                                       ne  was       not     originally            zL  -f u'Ll-1--iTn.@     Coordinator,                I  believe-;


                    L            4s    t,'-,a    correc@-.@           l@     tT
                                                                               -z-,e        s           A-JuL-  he    is    g  i  vi  rig  more      o

                                                                                       --er  da             and il-   is      just       a       shame to
                                                           to      i--,  da@,       a'4
                                                                                                 y

                                 do  tkl4-, s       to c--     ,Droc,-rali suc','l   zi, s  ti-iis.

                                                     I w-ou'La       cer        L--ainly                      that                ri      unt 0

                                                       a,-,crecised        a-L-   lccic-: t to      $--,,349,000,             zL!r  i,-ig  a  m


                                                                                                                                                 -iere arc





                                                                                                                                                             229
 W'.-ID-104


                                                                                               to        this        program        that        you        can't
                                    so  many  things                      cii  corci(-,  in,-




                                                         Tiiere.is          a          religious          philosophy          there.',          The           Church

                                    has  dor-.-,i@.atEL:  '-iie  program  until                            the  last  few  years,  and

                                    certaiz'Ly         now,         uL'-@r         Doctor         S4--ud'L--'s  'Leadership         this         is          not


                                    true.


                                                            have                        aga.L.-Lis,@-  the  Mormon  faith;                      I   th   irk   i   t

                                    is   a  great  faith.  but  it  has                          dominated  this  entire                        area,            and

                                    I  think        these         are          --hings         the          philosophy          has          also dominated

                                    the    University.    The  grantee                          was  milking  the  program  at  one

                                                            -iis  is  no  longer                 true,  and  the  whole  thing                               has
                                    point,             but

                                    completely  reversed                     itself,  and              I        think         they         should be           given

                                    a      fair      chai-ice      to      carry      oil              pro@am.

                      L                                  So  I  woulk--71  --ecorL%aend  '@-@,849,425  against  the

                                                                                                                                                               but
                                    $3,P,49,,.'r25      that       t@@-.=-y       ha@"  reauaste-d,  taking  a  million  off

                                    raising  the            level  of  funding  tl,.ak@.                   the  Committee  has    recom-

                                    mend@ad.              Trd      would  sug4est  that                    when  they  do  abnly  for  t',i,',s

                                    extra                                    we  can  look  clrsE!lv  aL.  that,   and  if                                    at

                                                                                                                                       i4-
                                    aiiv   t4-r,,e  we      are  qoing  to  de4y                   'Lunc@il iig,          thank               should        be

                      I.,    1,     p- t t'--,- a t         0                t'.--an    nc@:.


                                                         so        h s I  s    r, v  MO -L- 'I Oll


                                                            S                               s         LOD"


                                                                                                                        c-  i on             airfer in  quite
                                                           IS.     RLCOD:                 v,:-,---ws  of     the      T


                                    a  f c@.@  r -a--. T@3 c c L@-s -.crc":7.

                                                            wou'.---l  agr@G         With         c r    that       the                 influence of         the





                                                                                                                         230
           1 0 5

                            Univ--Ir,3"-Ly O."c              and by  its       very nature,  that             of  the Mormo4.
                            C@,,urc4li,        parri@at      t7.iis progr@ri,  b it I 'can not speak                  as

                            strongly      to the      facts      as      Mrs.      Mars       presents,       that.that is no

                            long true.

                                            I  -feel  that t'-,--re       is  still a       strong       controlling

                                                              a@'-, @ude  tha,--     only the  things which
                            'emanate  @Lropi Salt        Lake City       can be      done     in a quality manner.

                                           Doctor  Studt,  the           Coordinator,          is     making      an      extreme
                i           effort to      bring this program              away    from     that     concept,.      and      move
                            projects      from the  strict University base.
                                           There     -Ls,      though,      a      lack      of      professional      capability
                            in the Region to           the degree  that          has     been     expressed      in      the

                            past,    !.)Otl@i @-Y  4L--he -@'.IP and  ;_,-_s RAG,  but not to the extent                     that

                            e .-.ave been  led           to believe.
                            W

                                                  minority       issues     in 7Lie     state         have    not been

                            a-_4dressed.    I    do     not     feel  that the        are    ad
                                                                                                       equately addressed
                                                                                   y

                            -et,,        the          addition ol one minority aartinis-rative                         staff
                            Y

                            p@-rson,     an     T--Ter;@can              --Ioes not     in   any       Jay solve  the

                                                        a'4-s4L--  c     7@c
                            p                                                      c@   a@@-'@-adco      @,o,,ard   the

                                                   r l@ r t                              ea s  t,,       are   s e r -vre db I'll



                                           T- z, I   t:l        z  C,     z s  v -li,.
                                                                                         cri,-,aos          rccor@wcnda-


                                                                                                              1   --ght    o'
                                                                                        arsh,
                                                   m-.-   "C E2    r   a


                                                                       4
                                                                             p-@c,--c-s  a3@l      ti-  c.r   s4-
                                                                                                               @,af   fcosts


                                                                               t              '00,     0"--lus,       %-,shield,





                                                                                                    231
 "IID-106

                       ".Ould leave t'lem   10-ss  than   $3110,000 for new      project    start-ups!


                                              U-
                       W;@k--h        ar   s

                                   But  their request is       excessive,     even   with the

                       Skilled sta-@f   that   they   have,   in light    of  the   fact that the

                                                                                          ion    still
                       mztjor',-4--y of    projects presented in  the applicat
                       are  based         the Salt Lake      City area reaching outward,
                       and  not  reflecting  strong  interest        in developing their limited.
                       capabilities of the Region to stand alone and develop its
                       @;n expertise  in  attempting  innovative  projects  on  their  own.

                                   This Region had       d belief, whether erroneous or
                       not,  that  Lee,, could only      use  the  contract  mecahnism  to   pro-
                                       -Z
                       ide funding      for projects     in their Region and they never
                       v

                  I    indeed o-F@Lered a full      grant   project   fund to a     proposer.
                                   The si-te-visitors       reco'n.Lviended that   their animist
                       tion an-"! c c c s                        broadening @ie       scope   of thi
                       and if         have  indeed   done    so,   there is more      potential

                                                               at  the local     level   tha
                                                                                             t


                                  in    e  pas4-
                                       would   a-         a     c  r c 0    r, d a.0 n sof      Comriittee


                                  4-4-
                       are      -L.@io h-Frsh,   bu'@'I  @qould   not  grant the,--.i t.,ie $2,800,00@,-@

                       plus that           '.',ars su..--4ges L--cd.
                                    T  i,,,ould al-c-nz,,tel@.  ol-rcr $2,300,000     plus       the'odd
                       cents and    d@-Ilars,   i @L              --s a              figure   to   gi-,-e
                              the -at,-.abilit-,,, to,@dress   soire  of  the    Rec-,ioi-ilpriorl"-@ies.





                                                                                                           232
 WIID-1 07


                                         a'Lso i.@,ust  inquire,  in Doctor         Stud,@-  s letter

                        of ,--rars,-,tittal to Council,  to @IPS here,              hc- stated that

                    I   the R g'Lon.n-l C-@orc!4-nators -- the Tri@.Dlegional Coordintors

                        would iiie-c44-- ti-ie L@irst ;3art of -'-Jay, and j'.@irs. - I.Iars tells us

                        @@,i@y -save          and     ,.ou'Ld line to     inquire for my information

                        l.'L    Doctor    Curtis    did    -ndeed    attend and participate in         the

                        Tri-Regi-onal        Coordina-Lars'         meeting?


                                      MRS.   @IIARS:   I   do    not    believe    he    was    there.    Just


                        a minute;      I have the letter here:

                                              "On Friday,  June 7, representatives of the

                               Regional Advisory Groups' of the three luIP's serving the

                               Inter-l.t-:.oun-,"-ain area met in Salt Lake City.

                                              In   at@Landance    were    Mr.    Thomas    K.    Young,    RAG

                               Chairman oil Colorado-;-Iyoming Regional Medical Program."

                                      -Liais is not what you are referring to.   But however,

                        they did meet--,   tlie RAG's met.   I have the othe- letter;  I'll

                        find it in a minute,  so we might as well get on with                           this.'

                                              Sl@@SBEE:    L.Irs.     @lars, answer    her question sp

                        Lical--lv;   DocL--.3r CurL@.4Lss was Dresei-it.


                                            PC;S---'A:        the   RAG   Cliairi-z,-,eii ar+,! all the


                        Coort--'iia-tors ..;ere   th,@--re.

                                                        'Lhis       meeting tias purely    the   three RA@'s

                        f
                         rom the vzLr4-ous '-Re,,j-Lon3, an-i       there    were represcnL@-atives         o@

                                                                                                             d
                        ail        xose.      iae   I-eczing      wasa
                                                                                               if--    include,


                        an                    ouroviae     a-     tae !'BIG 'Le%rel anv   -"'e--ailed     typo




                                                                                                                                    2 33
  klHD- 1 0 8


                                                           o-'  any  project  plans  that                  will         involve          over-

                                                                                  -o          handle          notification,           coordina-
                               la-,3  areas,  how          each     IU',P     is  4t.

                               tion  oi--  a.@--                      tha@                move'boyond         the         overlap          area,,
                                                                                      A. t-


                                  icl  ir-.I,,act  co:7c,-@iunities  served                 situated         in         locations          served

                               r-@cl,,;S@VC7-y    3jy    anol@-h@j:    L-@,!.-71

                                                                    to  urge  each  Coordinator  to                     implement            a

                               regularly                      exchange  of  information among reporting

                               activities          any  activities  that  other  Coordinators  should                                       be'

                               aware         are  contemplated or  under way.

                                                  Agreement  that  each  RAG  sees                     that      internal                communi-

                               cation         is  strengthened        within        its        staff        organization         so         every

                               niem@ber         can be      expected      go      support      and      foster       each       RAG's       com-



                                                  k-i-atual  cooperation among  the  three                        M--IP's.

                                                  At  least       twice  dur-Lng  the  year,  each Coordinator

                                                                                                                 -"irkgs     at     each     oz
                               fall     be  urged  to         at+--end  at  'lueast  two  RAG meet-

                                                          -:T's.    Coordinators,  with at  least one  o
                                                                                                                                          ther


                  I            s -L-ai@-J'-              are          ex@ecteL@A  to     attend      all      @.ur.L@      meeL@ings,      and


                                                                                   --,i-rman w'-'l         telo-@ho-,a  his  coun'--er-
                                            ach     r,:,C     rlecting     @@:le  C.@ L

                               part  Lri      @ac-,-i  o'  @ia  o@ier                  P-".Pls

                                          at  4-@-le   n@@-!el-iiic,  shou-,,-'  ba  thared.


                                                                                  W411 Mee@
                                                     ic             0-hairrie,-i                    together  at          least

                               zLnriun-l@  '--Y,  aii-I    ri, -        Ciair:,-,a@-i           call  an  4nterim             meeting

                                     '.le  @Lee-is-        ad-,,-4-sabi-e      to    do  so.


                                                  A    j      4-- r.        g  0-                                           PAG I.,-ill      be





                                                                                                234


                             at jac':so.-i, ilyo,-ning on  June 23rd, so that takes care

                      0-

                                    ;IZS. STLS          'ell, it doesn't really, Plrs. Mars.
                                               BEE:     IV

                      TIl-c @@urf probe.-, is one     -,"-hat they-are finally addressing,
                      but it does 1.@ave          it  does need considerable work.

                                          'LiA:-"S Oh, I didn't mean it takes          care of    the

                                        ,io, not entirely.

                                   ZIRS. SILSBEE:   We have to keep on top of that all
                      the  time.     The minutes of 'he last meeting indicated that
                     a   nuraber   of   the    activities had to 4o back to their respective
                               Regional   l.@ledical.Programs, to make sure there wasn't
                     some problem,      so  they have not  really gotten at the intent,
                     of the   w. i o    L, 'Lin   the Regional thing.

                                   .?,S.             This is always going to  be        a problem
                     there.   The   way    the    Reg4-on is set  up -.t -nust  be @a    problem,

                     and  it  al-@qat-s  will   be.

                                  The -Lr4--R@-gional  Coordinators hav-@ -et, this ti:,e.
                                o o@@ the P.AG C.',-i=-ir--ien pres-=-n@-. It was a   :nost worth-

                                       and we are 'L o l@.'Lowing,it u-3 w4-4@-ii  a trip to visi4--

                     %' ou--ita i n@qtates @t,!P   in


                                                           CCen4--d each oj-her's      applications     i
                                         ";,le  Ynutually  a

                                  ---e        --ion  t!i a t@-i certain specified      projects

                           ,7e Fluid   coordincito    closely witi the other.involved            RI-,I,?

                           before     nroce@---7inc with 4--'-a eii7,ulcniontation.





                                                                                                                   2 35
      'ID-1101


                                                  "The            -.ro4ect    which has been of           any con-

                                   cern has been'a                        bv the University of Utah for                    i

                                   fu' ds  11--o idcnti-Fy               pr@
                                      n                                  Ler role   of the University

                                   as a re,--o-rral training center in what-has been charac-

                                          @ica-Liy considered to b3 its trade area."


                           t-.--id sc, c:i a.-I@--  so   -4octh.

                                                  @--'-LSBE7-:   And    that    is signed by Doctor Stud4,--,


                           is    it    not?


                                          -"IRS. -',IAPS:   Yes,     it is.

                                          MRS.     SI'USBEE:     Well,     the      one that we got   from all

                           of          has a   slightly different tone.

                                          I-IRS.    F@UOOD:    T-,@,o    is     serving as Chairman of the

                           Tr4@-Regional Coordinators?

                                          L@LRS.  SILSBE@@:       I'le   is.

                                          @@IRS.    I!kPS,.    The     other thing    that I would-like to

                           say   I.-M that    the    projects     were     also     all submitted to the eight

                           CH'-PB  agencies and thev were an roved,  the recorimendatbns.

                                                                                              arproved b
                               @,z    tha-- -Caere not aDDro-,7i--d were also no                              y the

                                      so                                                             acrencir--s,  of


                                                                                              c@e onc-- and a ver,,,
                              c;  li  ere are eigh@- is                         a very c-L


                                   oiic


                                          Hills far as goi-.-.c;            to  t.,-,e minority problei-,i, 'they

                           .,.,-vc a project .,7jz)inc,  @-or     ti-i-c             wor.-.erl:--,-  t@is  -Ls being

                                            a.-id              a                cro,-,iD,  whic.i of course


                              c o.-,  sa
                                                                                        ;TL4-n-,rit-Y I,,opulLtion

 - . @ . --- 7@' @-- , ,                                                                    -
              .  .                                                                                                          I - -
             I I..                                                                                                          I
                                                                                                                            i. :,




                                                                           236
WHD-111

                during the time of the harvesting, and  certainly,  the  needs
                of it are being addressed, and I would'say that this program
                will develop into one that will eventually fill the needs.
                          But I do feel that we must give them an opportunity.
                          MRS. SILSBEE:   Miss Martinez, you have a question?
                          MISS MARTINEZ:  I  would ask, of the migrant project,'
                how community oriented and  controlled it is?

                          It is one thing to serve  the population without
               itheir input or direction, and it is  another matter altogether
                to have the community itself set the goals.

                          What kind of a policy is it?

                          MRS. FLOOD:  I might respond there.
                          That is one project I have always watched closely
                in that Region, and they can point with pride to that one,
                and we don't need to view with alarm, too greatly.
                          It is a community based operation with a fund  in
                Salt Lake City for the services to the  migrant.  It is not
                based in the rural outreach area; it- is based in Salt Lake
                City, but'it is a primary flow area, solit does serve  its
                purposes,, and it does have some continuation funding in  this

                proposal.

                          But from the total amunt  of their  funding request,
                it is really a relatively small portion, when  you consider
                the needs of the rural communities of that area and  the  @eed



                                                                              2 37
  WHD-112

                ;,to break away from traditional programs based based only    in

                 the urban centers of that Region.

                            MRS. SILSBEE:  Doctor Sidel, did you have anyting

                 you wanted to say?   He is from the Denver Regional Office.

                            DOCTOR SIDEL:  Thank you.'

                            In view of-the discussion   and'the relationship

                 between IU.IP and some of  the  Regional programs in my region

                i@and my Region, incidentally, consists of the two Dakotas,
                                                                                     L
                @lMontana, Wyoming and Colorado-Utah,   so it#s somewhat different
                Ilin the context  that  we  usually  think of a Region in.

                            But a major concern of mine and the Region I repre-

                !;sent, which is that of resource development in   the Denver

                "Regional Office, has been to improve the level    of expertise

                 in the planning area, and I am talking about specifically

                'health manpower, and also, planning for    all health resources

                 development within the Region.
                            We find that the general level of many'of the

                                                                           -sort of
                 decisions  are based not on practical information, but

                 decisions  which involve millions of   dollars, both in  Federal

                 and   state money, as a matter of fact, so sometime ago, we

                ,.initiated a contract action through a source  of soft st&ements

                 to establish a Regional Health Planning Resource Center.

                            The concept behind the Center is to provide        to

                 improve the level of planning through four different channels:

                                 1.  Technical assistance in  the skill area,

                 planning methodology and these types of things;



 WHD-113                                                                        238

                                 2.  Education, and   education based  on-sit--,,

                      that is, in  a sense, in the work setting, so when people

                      ask for  technical assistance it is provided in those areas

                      where it  is needed, but then at the same time it also has

                      educational content so  that  those  people  are  trained  to

                      do their own training more effectively.

                                 3. The  other  is  to  improve  the  communication

                      between those groups involved in planning.

                                 4. Through  special  studies"  let's  say  in  the

                      area of health policy determination which may impinge

                      on area designa@ns or a variety of other questions.

                           In response  to'the  source  of  soft  statements, actually
                what  it came in  with at one time  was  a  proposal  perhaps to
                form  a consortium of  all the  We's  in  our  Region,  to  get

               .development together   and develop a resource center.

                           Now, this of  course -- we sent him an RFP;     he
               ,responded  to the RFP -- that's a request for proposal,     and the

               :response  to the  RFP came from HDFC, since we were more'inter-,

                ested in  putting  money -- in dealing with   the    non-profit

                corporation  than  actually,putting money   into the -- one of the

                RMP's itself.


                           Now the q uestion then   arose,  of course, in terms   of
                the legal  status  of HDFC; it is a  recognized  non-profit corpora
                ation, they have   had a ruling  from  the  Attorney  General  on
                that.  We had had no previous experience dealing with        this
                particular corporation, so we have had to ask for an audit,



 WHD-114
                                                                          239
                both in terms of fiscal accountability and in terms of t
                                                                             he
                institution and organizational arrangements, and in particu-
                lar the conflict of interest question.
                          We do not have a receipt of that   audit  yet,  which
                should be in next week sometime, because we   need that   prior
                to any contract action  that we can take.
                          The response to the RFP in other respects   is   very
               good.  The  Committee that we have  reviewing these in  the
             'I Regional Office thought that it  was  innovative,  dynamic  and
               a superior proposal in all  respects.
                          The other question that has  come  up  most  recently I
               is one that I will  have to get  some  clarification  on,  which
               is basically a'staff decision as to whether funds, for example,
               that are awarded to IRMP can be  transferred  to  HDFC,  because
               actually, in the fiscal proposal  we received  from  them,  they
               list four proposals -- 132, 133,  134 and 135, as direct
               allocation to their Health Planning Resource Center.
                         So unless you know they  can in fact achieve this'.
               they are not in a position to follow through on whatever con-
              tracts they make.

                         I have been rather  amazed at the ability of IRMP
              and Mountain States to get together.
                        MRS. SILSBEE:  Thank.you, Doctor Sidel.
                        Mr. Russell, do you have anything to add to this.
              in terms of your recent tour through the four states -- the
              four mountain states, as far as'the  CIIP-RMP or anything?




                                                                          2 4

                            MR.- RUSSELL: I am really not quite sure what I

                  can say.  If I decided what I could say, I am not quite

                  sure how I should say it.

                            In our recent visit to the Mountain States  Regional

                  Medical Program, to verify their,review process, we found

                  some evidence that there was conflict, perhaps hanky-panky

                  involved, between some CHP activities and the  Inter-Mountain

                  Region. Mike may want to address this, because I  didn't  have

                  a chance to follow it through.

                            We also found that the Inter-Regional Executive

                  Council, which was set up to eliminate the  problems  associ-

                  ated with the overlap Turf, really had not been very  effect-

                  ive; a lot of this was due to phaseout, but as Mrs. Silsbee

                  referred to earlier, we have to stay on top of this rather

                  closely.

                            So we did, before this last Review Committee,  send

                  out a letter saying that we had to have these assurances.

                  The Inter-Regional Executive Committee, or Council, as it  is

                  called, did meet and give us these assurances, and we  haven't

                  had time to analyze the multitude of projects involved.

                            I don't know if this helps, but

                            MRS. SILSBEE:  Mike, do you have anything, any

                  input?

                            MR. POSTA: No. Essentially I agree  with  what  Dick

                  has just mentioned with reference to the CHP involvement,  and



    WND-L!G                                                                 4 -L

                   why perhaps Inter-Mountairr has a little bit  more  rapport

                   with the CHP(B) and (4)'s in that  area.  It  is  primarily

                   because they funded a lot more things to them, and a    lot of

                   things they funded have been good.

                             But again,  this is only human nature', and maybe  I

                   shouldn't even be on  the record, but with reference, I do,

                   think, to the representative of  Region 8 concerning the

                   Health Development Service Corporation, $415,000   in  this

                   particular application that came in  from  Inter-Mountain  was

                   earmarked to go to this corporation.

                             There are considerable -- or, there are some doubts i

                   as far as the IRMP staff is concerned  about  this  organiza

                   tion, about his free-standing position, but  you  take  that

                   primarily because we get the same views  from  the  grantee

                   institution, and I think the  grantee's  institutional  policy

                   will prevail; if the grantee recognizes the Health Developmentl

                   Services Corporation as a free-standing  organization,  and  is

                   convinced that their assets and their talent and  staff  --  to


                   be recruited -- will be able to carry on the activities of

                   HEW, particularly the RMP-philosophy, they  will  probably  be

                   funded, but I think Staff"s position here  a@d  in  previous

                   conversations under this subject,'wou  ld be to recommend at

                   this time that the -- to hold funds in abeyance  to  that  par-

                   ticular corporation until all the concerns  of  both  DRMP  and

                   the grantee have been fulfilled.



    WHD-117

                             DOCTOR PAHL: May I inject  myself  into  this  for

                   just a  moment?

                             This question of.the non-profit  corporation  is  one

                   that we  really do not wish to have  a  Council  recommendation

                   upon, because we are not able to'provide you  with  all  the

                   information.on which you can make  an  intelligent  recommenda-

                   tion.


                             The reason we can not provide you  vith  the  informa-

                   tion is that we currently are in  active  negotiation,  both

                   with IRMP -- that is, Doctor Studt and staff, as well as   the

                   grantee organization, as well as discussions with the Regional;

                      the HEW Regional Office, and I believe at  the  beginning  of

                   last week, the grantee organization had one of its representa-

                   tives come and meet with our Staff.


                             There were a number of issues  and  concerns  raised,

                   and the negotiation status is that we are  now  awaiting  some

                   official word from the grantee'as to how they  respond  to  (nr-

                   tain questions that we have.

                             So, we are not in  a position, really,  and'I  don't

                   tlink Council is in a position, to act upon a matter  on  which

                   we don't have the full picture, the full  information,  and  I

                   don't really think that is important  to  this  application,

                   very  --honestly.

                             What we are looking at is the review  and  the  merit

                   on the funding level of the  Region. The funds  which  are  tied



   WHD-118

                  up possibly in this new organization are hard to identify  if

                  the funding level is below -- that is, if the recommendation

                  by Council is below in the request.  We are not sure; it is

                  up to the RAG then as to what it wishes to do.

                            So I would like to divorce, for your consideration,

                  the status, legality, appropriateness and so forth,  of  the

                  HDFC aspect and return, if you,will, to the merits of the

                  overall program, and we will be reporting to you at the August

                  Council meeting the conclusion of whatever these negotiations

                  happen to show.

                            We are just not able-to make a determination our-

                  selves at this point.

                            MRS. SILSBEE: At this point in time I  need  some.

                  help from a parliamentarian, because Mrs. Mars,made a motion

                  to the effect that the recommendation-be $2,849,425, whereupon

                  Mrs. Flood made a -- seconded the motion, but she suggested

                  that it be $2,300,000.

                            Now, what do I do to get this resolved?

                            DOCTOR SCHRIENER:  Mrs. Mars has the option of

                  accepting or not accepting the amendment.

                            MRS. FLOOD:  If-I may, I believe t said $2,349,425,

                  and I will just run it to $2,350,000, which -- you  know  --

                  solves all these small figures, if Mrs. Mars accepts.

                            MRS. MARS:  No, I do not accept.

                            MRS. SILSBEE:  All right; Mrs'. Mars had made a



                                                                           A
   WHD-119
                  motion to the effect that the Region be approved at $2,349,425

                  and it has no  second.


                            Is there a second?

                            MRS. MARS:  Then we have another ma-tion.

                            MRS. SILSBEE:  All right, the motion dies for want

                  of a seoond.  I am ready to entertain a new motion.

                            MRS. FLOOD:  Mrs. Silsbee, I would recommend that

                  we approve a funding level for Inter-Mountain Regional MediEal

                  Program of $2,350,000.

                            MRS. SILSBEE:  Is there a second?


                            MISS MARTINEZ:  Second.


                            MRS. SILSBEE:  The motion has been made and seconded

                  that the Inter-Mountain Regional Medical Prmoam be funded

                  at a level of $2,350,000.


                            Discussion?

                            MR. MILLIKEN:  What would the instructions be with

                  this to accommodate the difference between what they have

                  asked for and what they are being provided?

                            I have some anxieties that some things may be cut

                  out that we think should not be, if they are allowed to do


                  this.  I see no assurances.


                            MR. CHAMBLISS:  The activities of the corporation

                  will certainly undergo some discussion here in Staff, and that

                  might very well be

                            MRS. SILSBEE:  Now, Mr. Milliken, if you take your


                                                                                ;e  4.@1
  WHD-120


                   viewpoint to its fullest extent,   the only thing  you  could  do

                   is to approve the  level  they  have requested.

                             So in terms of advice,   if you would like to specify

                   something, we would be glad to follow up on that.

                             DOCTOR  WAMMOCK:  I   only want to say one   thing.

                             I looked at this and there are six states involved,

                   and that is a lot of territory to cover, and I can see some

                   inherent problems --  transportation  difficulty  and  all  these

                   other things, and I don't know what the  answer  to  it  is,,

                   whether $2,350.000 because  you have  a  large  territory  to cover:

                   there, and I do not know what  the  total  population  is  of these

                   six states, whether it would be 6,000,000 people or whether

                   it would be 3,000,000 people.

                             MRS. SILSBEE:  Well,   Doctor Wanunock, that same large

                   territory is also covered by two other Regional Medical

                   Programs.


                             We have a motion  on the floor.


                             MR. MILLIKEN:  Do  Staff  have  some  insights  into

                   this, or recommendations  for  instructions  to  this  applicant?

                             MRS. SILSBEE:     think  the  instruction  that  we

                   would try to interpret from your discussion is that you     have

                   felt that on the one hand the IRMP  needed  to  get  into  the
                   outreach,' looking at the needs and the -- try to assist in

                   the  health care of population groups that have been under-

                   served, and on the other hand you  feel  that  the  Region  is



  WHD-121
                                                                        2 4 r-

                  onrerfunded and that they should concentrate on these areas,

                  at a reduced funding level.

                           MR. CRAMBLISS:  We will express  to the Region the,-

                  concern coming from Council about the minority issues in terms

                  of project activities; you have cited the fact that the

                  Region has hired one minority individual, and I seemed to

                  hear'you saying that this is a  continuing concern.
                           I further hear you saying that the project activity
                  touching on the minorities, and there are several minorities

                  in Utah -- the Indians, the blacks, the Chicanos, that there
                  is concern from Council that their health needs be addressed

                  in a more pos@ve way.

                           MRS. SILSBEE:  The motion has -been made and secon-
                  ded that the Inter-Mountain Regional Medical Program be
                  funded at a level of $2,350,000.

                           All in favor?

                           (Chorus of "Aye")

                           Opposed?


                           MRS. MARS:  No.


                           VOICE:  No.


                           MRS. SILSBEE:   Let the record show there were two

                  opposed, but the motion is carried, and let the record also
                  show that Mrs. Klein has  been absent during this discussion,

                  and Doctor Gramlich.

                           All right; do you want to call it quits for te day?




     WHD-122
                                                                               24 7
                         NATIONAL  ADVISORY COUNCIL ON REGlov,,.,AL MEDICAL  PROGRAMB

                                      SOUTH CAROLINA REVR.F-W

                              MRS. SILSBEE: Now we  will  ta-ke  up  South  Carolina.

                   Lee, do you want to put it in perspective?

                              MR. VAN WINKLE:  It was considered to be an average
                   or above-average  Region;  they  had  requested  $3,600,000,  and'

                   the Committee recommended $2,200,000.

                              The basic reason for this reduction was that here

                   again, this Region had requested  escrowed  fundsil  if  you  will

                   blank checks, as I heard referred to earlier.  With another

                   Region, they were asking for  authority  to  spend  funds  in  the

                   area of regionalization of services -- health manpower develop,r-
                   ment and improvement, strengthening quality assurance, and

                   other activities.

                              The Committee did not buy this, or     did not accept
                   it; they did not think  that these activities had gone far
                   enough through the review process in South Carolina for it
                   to be acceptable, and that is how they arrivi3d'at their reduc-

                   tion.


                              There are many  other  things  that  could be said, but

                   Isuppose   they will be  covered  by  the  reviewers.

                              MRS. SILSBEE:  The primary reviewer for South

                   Carolina is Doctor Haber.

                              DOCTOR  HABER:  In  reading  the  May-June review

                   on the yellow sheet, and the confidential comments in the




                                                                        2 4 8
    WRD 12 3

    6:OOPM        proposal, I sometimes wonder if I am looking at the same  pro-

                  ject.

                           With four  different perspectives, it became diffi-

                  -cult to reconcile these all.

                           Very briefly, because the hour is late, their pro-

                  posal goes through a narrative history which is a very good

                  focus.  It shows the development of a typical Regional Advisory


                  Group.

                            There are a couple of comments'in this that I think

                  are worthy of reiteration.  one of them is that the Regional

                  Advisory Group has maintained its integrity, quantitatively

                  and one must assume qualitatively -- in the face of what they

                  call a limited future outlook,'but they proudly aver that not

                  one member has resigned.

                            The organizational structure has been  modified since,

                  the inception of this program; they have gone through a number

                  of changes since their inception  in 1966, and they now have

                  a triple-headed Regional Advisory Group -- I'm sorry; a

                  triple-focused Regional Advisory Group  structure which seems

                  very adequate to the task at hand.

                            The review process and their relationships with the

                  CHP(A) agencies look good in spite of the somewhat tortuous

                  relationships in South Carolina, and the comment is made that

                  there are at least five different types of planning groups,

                  CHP agencies     (a) and (b), the Appalachia Group, the



    WHD-124
                                                                          249
                  Regional Advisory Group, hnd a new group composed  by  the

                  Governor, and the comment is made that this group is  the

                  line to his office, through a dotted line which seems  to

                  imply a tenuous future.

                            The caliber of the people involved, although I  have

                  not had the.benefit of a site review, seems to be  exemplary.

                  I don't think we can fault them on that.

                            The individual projects themselves, I think  are

                  worthy of comment on reviewing. I would disagree  with  Doctor

                  Gramlich's previous expression of dissatisf@ion  with  concen-

                  tration in one area. They haviv a number of projects  related

                  to hypertension, and I think this is good.

                            They have a number of projects which are related  to

                  the detection of hypertension through kidney disease  and

                  neuropathy, in black female children, in the adult male popula,-

                  tion, in general screening, and I think they are moving  into

                  an area very solidly, conceivably-with some overlaps, but  a

                  massive approach on this important debilitating and  life-

                  threatening disease is evident.

                            Some of their projects look a little naive to  me.

                  There is onein improving ambulatory care, which would  apply

                  certain statistical models to ambulatory care.  There  are

                  such models in existence, and it seems to me they  xe  trying

                  to invent the wheel.


                            I am concerned, although I don't have enough  infor-




  wHD-125                                                                250

                  mation about this World Mobile Health project; it seems to

                I me it is inadequately funded for all the wonderful things

                  they intend to do.

                            I was concerned about the nurse-midwife project,

                  which has been approved but not funded, and then withdrawn,

                  apparently because of the difficulty of getting people.  It

                  was very modest funding; it seems.J-ike an eminently worth-

                  while project, and I would hope tELe Council could somehow

                  help them in going ahead with this.

                            I think that this shows a good balance of projects

                  between rural versus urban populations,,minorities, between

                  various kinds of diseases, and I would say that in total it

                  seems to me the r organization is sound.

                            The Regional Advisory Group has fared better than

                  the RMP, which has lost, I think half its personnel.  The

                  ,quality of people is good; the proposals seem in the main

                  well-balanced.


                            I think it has been judaed average to above-average

                  and I would concur in that, and I would also agree with the

                  target that has been set for them; they asked :for $3,000,000

                  -and $2,200,000 seems eminently reasonably.


                            MRS. SILSBEE:  Mrs. Mars?
                            MRS. MARS:  I agree w:Lth.Doctor Haber and wit@

                  the Review Committee's recommendiation..

                            Ifelt that it is a particularly well-structured RAG,I



                                                                         25
    WHED-126

                  has a good review process, but there are SO many of these
                  projected activities that have not had time -- I have not

                  had time to go through this entire process by any means, so
                  that they are really requesting funds for some projects which
                  are still very problematic, so I'agree entirely, and I second

                  the motion.

                           MRS. SILSBEE:  Mr. Rubel?

                           MR. RUBEL:  I would like to address one specific

                  project that the RMP has proposed; I don't know how the

                  numbering system works here, but it is something like 32-F;

                  is that it?

                            Which is that -- an attempt at setting up an organ-

                  ization that would plan for the implementation of legislation

                  that I spoke about this morning.

                            I would like to present you with two facts and see

                  where it goes from there.
                            The Governor has expressed his very deep opposition

                  to our funding this project without approval by the  Health

                  Council that he set up. Governor West has devoted  a  major
                  portion of his last-two years to working on health problems in

                  .this state, and very frankly, he feels that setting up of

                  this organization is an attempt at by-passing the state
                  entirely and trying to position the RMP in such a way  that

                  it would become -- or play a dominant role in whatever kind

                  of organization comes about as axesult of discussions on



    WHD-127                                                                 252

                  Capitol Hill,

                            Governor West has on  several  occasions  discussed


                  what he is doing in health-with the Secretary, and Doctor

                  Endicott, and many other people.   The Department, for one

                  reason or another, is doing all kinds of things in South

                  Carolina -- I don't even know about them.


                            There is a lot of interest; that's point Number 1.

                            Number 2, the HEW Regional Office  in  Atlanta  has

                  expressed a lot of concern about this project  for  a  number

                  of the same reasons.


                            It is feared that the RMP is dominated  by the

                  medical profession and that, as I said before, there is per-  i
                                                                              erneld
                  haps an attempt at posturing here, that they  are  very  conc

                  ,:about. While it is alleged in  the application that the CHP

                  agencies are in favor generally, the Regional office has been

                  told by many of the (b) agencies  that they are very much

                  opposed to it.

                            I don't understand all t                this state
                                                    .he politics of

                  of South Carolina, and certainly not  the  medical  politics,

                   but we have a very difficult situation on  our  hands  here,

                            I certainly think we would very much appreciate

                  getting your recommendation  on how to proceed here.  I would

                  like to just set out four possibilities, and while it is true

                  that the Council usually does not deal with specific-proposals!,

                  it has on many occasions said Y-ea or Nay to specific ones



    WHD-128
                                                                          253
                  when the occasion warrant&.


                            Be fore I get to the possibilities, in  going  through

                  all the applications in front of us, there are other states

                  there are other Regions that are proposing  something  like

                  this, but I think it is fair to say that  South  Carolina's

                  is the most blatant, or perhaps the most forward, depending

                  on how you might view it.

                            We certainly know, and as I discussed  this  morning,

                  that RMP's as organizations, and the people that work in them,

                  are thinking about the future, and are trying to do  all  kinds

                  of contingency planning, and in fact different places work

                  in different ways.

                            You just heard something about what goes on in

                  Inter-Mountain, and that is going on around the country, and

                  we can't ignore that.

                            On the other hand, to what extent do we  want  to

                  allow money being -- coming through this channel  to  serve as

                  abase for one organization or another here?

                            Essentially, the four possibilities are:

                            1.  Tell them, you know, you decide what you want

                  to do,.based on whatever level of funding the Council recom-

                  mends, which essentially says that if that gets to  be  import-

                  ant they can go ahead and do it.

                            Second alternative is to say: "You can't do it."

                  Period.


                            The third alternative would be    say: "Go  back  and




    WHD-129
                                                                       254
                  you had better start negotiating with the Governor, and as
                  part of the application due on July 1, if you can get their
                  approval, or it you can't, at least if you want to propose
                  it again, please do, but we won't fund it during this cycle."
                           The fourth possibility is a conditional approval,
                  saying that there is a requirement for coordination here and
                  for working together which has not been demonstrated,  that
                  you may proceed and do this but only after you have consulted-
                  and gotten approval of the other factions-that are involved,
                  that are going to be involved, in whatever the legislation
                  covers.  If you-can get their approval, then you can proceed.
                           Those are the four possibilities, as I see them.

                  Perhaps there are others.


                           MR. VAN WINKLE:  The Review Committee -- this was

                  one of the thrusts, Mi.'Rubel, that the Comm ittee addressed,

                  and this was what they based their reduction of funding on.

                  This was one of those that they said they could not consider

                  at this time.


                           MR. RUBEL:  It is one thing to provide the reduced

                  funding; it is another to preclude money being used for this

                  purpose.

                           MRS. SILSBEE:  Does the Council have any suggestions

                  as to how we proceed?  This refers specifically to that one

                  project.

                           DOCTOR WAMMOCK:  Is that 32-P, did you say?


     WHD-130                                                                       I
                                                                           255
                             MR. RUBEL:  That7is 32-F.  They are proposing,

                  essentially, to spend 4165,000 to set  up  a  new  organization.

                                             - With the RMP funds?
                             DOCTOR WAMKOCK:


                             MR. RUBEL:  Yes, sir.

                             MRS. FLOOD:  But all of the 32's     A,B,C,D,E

                  except for F., aren't'. they rather nebulous? Or  at  least,  is

                  it D that is sort of a blanket fund that will be spent on

                  non-RFP's?


                             MR. VAN WINKLE: All of those  are  in  that  nebulous

                  category;  yes.

                             MRS. FLOOD:  They add up to a million-four.

                             MR. VAN WINKLE:  Yes.


                             MRS. SILSBEE:  That, as I understand it, was why

                  the funding recommendation was cut back.

                             Now @Mr. Rubel is suggest-bg that not only  the  fund-

                  ing recommendation be cut back but that there  be  some  kind  of

                  outline or alternatives which -- and theyuere all valid altern-

                  atives, and we need to have some motion in  terms  of  the  fund-

                  ing level and what you do about.that   particular thing.

                             DOCTOR JANEWAY:- Can I ask  a question, Mrs. Silsbee,

                  before we get a motion?
                             That is, can the Review Committee  make  any  specific

                  comments relative to the  areas  that  were  discussed?  Because

                  it could be circumvented and not be a  Council  policy  if  there

                  were specific recommendation from  the  Review  Committee  as  to



    WHD-1@>'L


                  deletion.


                            MR. VAN WINKLE: Not in terms of addressing  this

                  particular issue, no.

                            MR. CHAMBLISS: As a matter of fact, there was  a

                  correspondence that came in since the Review Committee.

                            DOCTOR JANEWAY:  They were not privy to this infor-

                  mation; is that correct?


                            MR. VAN WINKLE:  That is right.


                            DOCTOR JANEWIIY:  Because it seemed to me the sense


                  of the Council, considering the second resolution of the Ad

                 Hoc Review Committee was such that we were not in  principle

                  going to consider that proposal, that RMP organizations pre-

                  pare temselves for some possible future role.

                            MR. VAN WINKLE: They did not  address  that.  All

                  they said was they don't think these activities are  suffi-

                  ciently developed at this time for them to consider.

                            But if they come back in in July, then.they  will

                  consider them, is essentially what they say.

                            MRS. SILSBEE: Doctor Janeway is saying  that  the

                  Councills previous action7with regard to that proposal -- the

                  resolution, that the Committee in a sense answers this.


                            DOCTOR JANEWAY:  It doesn't have to be dealt with

                  inany substantive sense on the basis of this particular

                  Council.


                            MR. RUBEL:  I should point out tat this is referred



      WliD-132                                                              257


                  to as a Phase 2, that the RMP has been  involved in these

                  activities. They did  sponsor  a  conference  back  in  January

                  which Doctor Endicott did  attend.  Then  here  they  have  a

                  very specific proposal  here;  this  is  not  nebulous.  This is

                      it  says:

                                  "We're going to do  something.  We're going to

                        set  up an organization,, and until we set it  up  we  are

                         going to use RMP's staff to do it and what  it  is  sup-

                         posed to do."

                             So we can't fall back on: "We %ion't know what   t----

                  is all about."


                             DOCTOR HABER:  Well, can we approve all save that

                  particular project?  And then adopt one of the four alterna

                  tives that he outlined for us?  Can we do that?

                             MRS. SILSBEE:  You can do -- yes.

                             DOCTOR HABER:  Well, I so move.

                             I move that we adopt all     that we  fund  this  at

                  the level recommended, with the exception of  -that particular

                  portion to which Mr. Rubel has reference.


                             MRS. FLOOD:  32@F.


                             MRS. SILSBEE:  Now, in terms of   that particular

                  portion, are you.saying Option 2, no-go?    They  could   not fund

                  it?

                             DOCTOR@HABER:  I am trying  to separate that out from
                  the rest of the program.  If we can get a motion approved tha,




                                                                            258
    NUD-133


                  all but that would be approved,.then we can handle this  for

                  those four options.  That is holding up the whole thing.

                            MRS. SILSBEE:  IS there a second?


                            VOICE:  Second.


                            MRS. SILSBEE:  All right.   The motion has been made

                  and seconded that the South Carolina application be  approved

                  at the level of $2,200,000, with the exception of 32-F.

                            Any further  discussion?

                            DOCTOR WAMMOCK:  If  you look up there at 32-D  and

                  32-C, and 32-B -- I mean, I see no description here at  all;

                  it is only just-by title here. It seems to me it  all  falls

                  pretty much in the same  category.

                            MRS. SILSBEE:  In  terms of the issue that the  32-F


                  is directed at, which is that  the Governor's Council --  that

                  is a slightly different issue.

                            DOCTOR WAMMOCK: It's got a different twist  to  it.

                            MRS. SILSBEE:  That is right.

                            Further discussion?  All-in favor of the motion?


                            (Chorus of "Aye")

                            Opposed?

                            (No response

                            The motion is carried.


                            Now,. do you want to deal with 32-F?

                            DOCTOR HABER:  Can we have those four options again,

                  Mr.  Rubel?



   W'.P.D - s 1 3 4


                            MR. RUBEL:  First, you can leave it where it is,
                  let the RAG, based on the decision you just made, determine

                  its priorities.

                            Second is a flat: "You may not perform; this projecti
                 is unacceptable."  Just as we said earlier that any of those
                 unapproved arthritis applications can not be done by the RMP'.

                           Third is:

                                 "Come back in your July 1 application, but
                      satisfy us that you have worked together with all these

                      other bodies and that they agree to it."

                           DOCTOR HABER:  That is the option I want, and I am

                 making a motion on that.

                           MR. RUBEL:  The fourth says:

                                "You may use the two million whatever it is,
                      or part of it, for this project only after you have
                      worked with the other groups and only after approval by
                      the Director of the Division of Regional Medical Programs."
                           And that would only occur after he is assured that

                 those groups have been consulted.

                           Three kind of puts it into the next cycle; Four
                 says it is okay under this cycle, provided certain conditions

                 are met.


                           MRS. O.ILSBEE:  Doctor Haber, in terms of your.con-
                 sideratim of this, of Number Three, it is now June 13th, and
                 they have to come in on July 1.  Now, whether they can satisfy[





  QHD-135                                                                260

                 all the things you are talking about by July 1, I

                           DOCTOR HABER:  We know they are not going to satisfy!

                 all


                           MR. RUBEL:  Perhapsit would be useful for me to

                 read to you a paragraph of a letter from Chairman of the

                 South Carolina Health Policy and Planning @uncil:

                                "I told you in Washington r would not consider

                      writing this letter without the full     ledge and con-

                                           -and without  my  @ng  personally
                      sent of the Governor,

                      assured that he completely understood the issues involved'6
                                                                               I
                                This I have done, and I am now writing  with

                      his full knowledge and consent, and in fact under  his
                      direction, at the request that any application or communil

                      cation seeking recognition or funding for any purpose in

                      this field in South Carolina, which might be filed with

                      the Department of Health, Educat:bn and Welfare, not be

                      considered without having been referred to the South

                      Carolina Health Policy and Planning Council, which  is

                      the official State body created by the Governor's

                      Executive Order in January 1973 with the specific respons-

                      ibility for planning, reviewing and coordinating all

                      health efforts here in South Carolina."


                           DOCTOR SCHRIENER: There are two ways  of  saying:

                 don't do it.



     WHD-136


                            MRS. SILSBEE:  I wouldn't want   to enter into  this,

                   but in terms of the Council, you are in   a position  to  do

                  what you think is best.

                            DOCTOR SHCRIEIIER:  Oh, I think that is best.

                            DOCTOR HABER: I would'still make  a  motion  for  the

                  third alternative, and I do so.    And I put that motion.Derore

                  the  Board.


                            DOCTOR WAMMOCK: Would you so  state  what  we  are

                  going to vote on now?


                            MRS. SILSBEE: The alternative  Three  is  that  the

                     that Region may not do that with  these  funds.  If  they

                  choose to go back and negotiate with the  agencies  and  the

                  Governor's Council, the Council would entertain  a  request  in

                  the July 1 application.

                            MRS. KLEIN: I hesitate to  talk  about  this  because
                I.I know so little about it, but it seems to me  that  the  Ad

                  Hoc Committee did approve this,, did it not?  The funding that
                  we are discussing, this aspect of it, and they  had  not  had

                  this opposition expressed to them at time?

                            Well, it seems to me then that if they  did,  as  far

                  as the merits of it are concerned, that we  are  agreed  that
                  it is proper, then also, if they negotiate  with the Governor,
                  knowing how they sometimes operate, there  is  a  possibility

                  that they could clear this portion up, and  for  that  reason

                  I would certainly feel that we ought to go  along  with  the



     WHD-137                                                               262

                  fourth proposal, and that is to"-a'pprove it and then permit

                  them to make their peace, if they can.

                            So I suppose the-way to handle this would be to

                  vote on the preceding motion, or I might  offer  a  substitute

                  motion, if that is in order with the procedure  that  you  use

                  here.


                            MRS. SILSBEE:  I am the poorest parliamentarian

                  going, but -- Doctor Haber?

                            DOCTOR WAMMOCK:  She  is making an amendment now.

                            MRS. SILSBEE:  She is  offering a substitute  motion.

                            MRS. KLEIN:  This would preclude the other one,

                  I suppose it would be a substitute.

                            DOCTOR HABER:  I would accept that.

                            MRS. KLEIN: Well, I would suppose  that  was  proper.

                  I would second the motion, then, as amended.

                            DOCTOR WAMOCK:  Well

                            MRS. KLEIN:  He accepted  it and made a new  motion,
                  which in effect I am seconding, just so we can get  a  vote  on

                  this.


                            MRS. SILSBEE:  Mrs. Flood?

                            MRS. FLOOD: I have a question, or perhaps  it  is  a

                  concern, that by making the statement that we would  fund  this

                  type of a project, should North Carolina -- should South
                  Carolina RMP make amends and get friendly with  the  Governor,
                  we have set the precedent then for a request for  funding  for




     WliD-138                                                              263

                  just such organizational structure out of RMP  dollars  across

                  the country.

                            Now, we just said earT+er that we did not want to

                  encourage, or at least we wouldn't-accept as a  policy  state-

                  ment, a statement that said we       raged the staff to  start

                  investigating the administrative.structure that  they  might

                  endeavor to approach in light of potential new legislation.

                            But here we are talking @ ut setting the precedent

                  for buying the complete service or development.

                            MR. RUBEL:  As I tried to indicate before, this

                  kind of activity is going on in every Region in  the  country.

                            MRS. FLOOD: Yes, but  not  at  $165,000.

                            MR. RUBEL: Well, you know;  you  can  do it in various

                  and  sundry ways. You know that  it  is  happening; as I  have

                  been  going through the book here Ihave maraged to detect

                  very similar kinds of projects, and some people  have a better

                  way of hiding them than others, in I would guess,  at  least

                  a half-dozen other Regions.

                            So it is not  a question of: this is the  only  one.

                  They are the only ones that are doing it quite  as  blatantly,

                   but remember this went through a review process and nobody

                  really picked it up.  Nobody said; there is nothing I read,

                  and I mean, the first I heard about it was when I  got  this

                  nice cozy little letter here.

                            MR. VAN WINKLE: They refused to consider  it  for  a



    WHD-"L39                                                                264


                  different reason, too.

                            MRS. SILSBEE: Mr. Rubel, I  think  there  is,  in terms

                  of interpreting the messages that have gone out-to the

                  Regional Medical Programs,  and in terms of the whole thing,

                  it would seem to me that the Region is trying  to  respond  in

                  a way to a national initiative, and I guess I  am  a  little

                  concerned about the idea that it is trying to get there

                  "firstest with the mostest."


                            Now they are there, you have asked  them  to  get

                  ready, and they have used  various ways of  doing  that.  I

                  just don't think -- and they have the, money@, so the  fact

                  that they have the money doesn't mean  necessarily  that  they

                  are not being involved with the others.

                            Miss Martinez?


                            MISS MARTINEZ:  In some of these other states that


                  you mentioned, that are doing this thing, is  there  the  same

                  opposition from the  Governor?

                            MR. RUBEL: There might be if  he  knew  about  it.

                            You know, I know of many,  many  situations  where

                  there is a fair amount of-conflict there.  It is very diffi-

                  cult to say, because these applications haven't been reviewed

                  by Governors, so we don't know whether they are opposed or

                  not.


                            MISS MARTINEZ:  I think whether or not ittis


                  happening on a smaller scale, I think with  several  of  the



   WHD-140                                                                   265

                  srialler projects, and,whether or not it is a response to a

                  possible national direction, I don't quite agree with the

                  policy of spending program moneys on the possibility of a

                  change when they are -- there must be better ways to spend


                  program moneys.

                            I don't quite agree with  that  kind  of-philosophy.

                            DOCTOR WMIMOCK:  Mr. Rubel, what does South

                  Carolina have? What is her plan  called  under  the  Governor,

                  if you would please state that again?

                            MR. RUBEL:  South Carolina Health Policy and

                  Planning Council.

                            DOCTOR WAMMOCK:  Well, there you .'.are, see?  He is

                  in direct control of that.


                            MR. RUBEL: And that is  right  over  the  Department


                  of  Health.


                            DOCTOR WAMMOCK:  I venture to say they are the very

                  first state that have a program that is controlled by the


                  Governor.


                            DOCTOR SCHRIENER:  I just wanted.to say that   I  am

                  not terribly swayed by the argument,that some of these   may

                  be buried in other proposals.  The point is that we are dis-

                  cussing this proposal; I think this      I personally don't

                  think it is a good way to spend RMP moneys, and  I  will  vote

                  against any other proposal that has it, just like I am going

                  to vote against this one.


     VIHD   14   I                                                              ') C7
        -14'     1

                   it until they have shown us -that they have already done

                   it.

                              MISS MARTINEZ:  I still think it   sets a  bad  prece-

                   dent.


                              DOCTOR WAMMOCK:  Me, too.

                              MRS. SILSBEE:  Do you  want to vote  on  that  motion?

                              MRS.-GORDON:  I would  like an exact  wording  of  the

                   motion.  You are saying the same thing different ways, but

                   it isn't the same thing.

                              DOCTOR JANEWAY:' I was wondering, if we    are talk-    I

                   ing about "safesmanship," if one really wants a motion?       And
                   a vote, on something whereby you are going to establish      policy!

                   by exception.

                              And it seems to me that Staff  could  sense  the  feel-

                   ing of the Council with reference   to  this  particular  portion  1
                   of the grant request and indicate   to RMP the strong feeling

                   of the Council in this regard.

                              Because Wu are getting into two  situations,  it  seems

                   to me.  One is, you are overruling a Technical Committee of

                   the Ad Hoc Review Committee, which we have the right to do,
                    but it is not the general order of things.     It is  a  specific

                   project.

                              And if it is a motion, it is not  only  intent,  it  is

                   policy.

                              Now, I think Doctor Watkins  made  an  extremely  valid





     WHD143                                                                26d


                 point very early in the meeting about whether we were indeed

                 required to vote on proposals that we elected not  to  have

                 come before us. And the sense of the  Council  would  carry

                 the weight of a vote without having any.

                           MR. RUBEL: We in HEW are going to  have  to  deal

                 with this one way or another;  you know, if you decide to let

                 it go to the ext ent that you disapprove it, that is  the  end

                 of it.  There is nothing we can do.

                           But if you  decide to let  it go, we still have  to

                 deal with it,.,one way or the other. You can choose  to  tell

                 us which way you would like us to deal with or, or you can


                 let us deal with it ourselves.


                           The problem is not going to go away;  the  Governor

                 is going to be there tomorrow, and he is going to  pick  up

                 the phone and call the Secretary and we are going  to be right

                 in -.the middle of it.


                           MRS. SILSBEE:  Mrs. Klein?


                           MRS. KLEIN:  We would be setting another precedent

                 if we refused to approve-this, or approved it in such  a

                 manner that it implied that the Governor's approval approval

                 would have to be had for every funding that we undertook

                 from now on.


                           That would be my concern; I would be more concerned

                 in that direction than I would be in the  directicnof  asking




   NUD144                                                                   269


                  them to cooperate in getting approval by the Governor and

                  these other agencies before they actually went ahead with

                  the program.

                            MRS. SILSBEE:  Miss Martinez?


                            MISS MARTINEZ:  Isn't the issue one of .the RMP


                  duplicating part of the function of the Governor's  Council,

                  and isn't that why, rather than all that RMP    I don't think

                  this would set a.precedent for approval of all RMP  projects.

                  It is simply a matter of RMP duplicating its committees.

                            DOCTOR SCHRIENER:  Mrs. Klein has a point as far

                  as I am concerned. I don't think it is a very  good  expendi-

                  ture of RMP program money.

                            MRS. SILSBEE:  Well, Mrs. Klein?

                            MRS. KLEIN: I am sorry to be so  persistent  about

                  this, but this, to me, would be sort of a flimsy reason  for

                  disapproving the program.

                            If the Ad Hoc Committee approved it without knowing

                  of this problem, as far as I amconcerned, it must  have  had

                  some serious merit, and I am not in a position to say  there

                  wasn't -- you know, that it should be disapproved,  possibly

                  -because I don't have the information, but my problem here is

                  coupled with the Governor's need for approval and that  sort
                  of'thing, and I don't thtk we ought to -- I think it would

                  be a bad policy to require that approval before, you know, we

                  do any funding. Otherwise it certainly would get us  back  to



                                                                          270
    :WHD-1 45

                  the point where we would -- what are we here for?

                            MR. MILLIKEN:  Point of information.

                            Does the Ad Hoc Committee indeed approve or dis-

                  approve, or do they recommend to this Council?

                            MRS. SILSBEE: They recommend to this  Council  a

                  funding level.  Yes.

                            DOCTOR WAMMOCK:  I am sorry, but when you look at

                  the titles again across here -- whatever in the name of God   i

                  that means, I don't know; the specific categorical entries

                  Prime Health care, and Advanced Health Resource  Planning?

                            MRS. SILSBEE: 'Are you looking at the print-out,

                  Doctor Wammock, or the individual 15's?

                            DOCTOR W@IMOCK:  It is the print-out here, you see,

                  for this whole thing.  it is all described here, and it se-...-

                  to me -- Health Sources Development Initiated Phase 2, Advance!

                  Planning, Corporate Mechanisms in South Carolina, and anotner

                  one, "Program Needs on March lst announce Health  Manpower

                  Development Improvements;- one of the six really broad program

                  areas whichiere eligible for consideration in the future con-

                  tracts for project funds."-

                            I believe it is-semantics; it is ill  semantics.

                  They are all going in the same direction.

                            MRS. GORDON:  Did I not understand you to say that

                  one of the reasons for the cut in funding, or for the cut, wa

                  because the Review Committee did not see the value in these





                                                                            271
        146
                  particular programs?

                            MR. VAN WINKLE:  Not  that they did not  see  the

                  value.  These are thrusts that  this program is making; it

                  has been approved by the RAG.   This is the way they intend to

                  get into it.

                            But in this application the program had not

                  developed far enough for them to consider it.  They said: "If

                  it comes back in July we'll look at it," but they don't have

                  who they are going to contract with, they  don't  know  wno

                  the project directors are; we don't know the  amounts  of  the

                  budgets.  until@they provide us with that, they are just not

                  going to look at it, is what they said.

                            So therefore, we are going to cut  the  proposal  by

                  ,$800,000.


                            DOCTOR JANEWAY: Then the  Ad  Hoc  Committee  has


                  already said this.


                            MR. VAN WINKLE:  That  is  in  their'recommendation.

                            DOCTOR JANEWAY:  That is@all we have to say anyway.

                            MR. VAN WINKLE:   They did not consider the proposals,

                  at all. They just said: "At this time  we  don't  know  enough

                  about  it.'


                            MR. MILLIKEN:  Ques@n, on the motion.

                            MRS. SILSBEE:  There has been a motion   made, and I

                  don't know that I have the exact  wording, but maybe, Mrs. Klei

                  you could reword your motion, since it has turned  out  to  be




    WHD-147                                                               272


                  yours?

                            MRS. KLEIN: I don't know that I have  the  exact

                  wording either.

                            I would prefer that someone else word it.  My motion

                     all right; I'll make an effort.

                            As to these programs that we are discussing    And

                  I don't even have the information about them

                            DOCTOR HABER:  IT is the Health Services Development

                  Initiative, Phase 2, Project 32-F.

                            MRS. KLEIN:  Flunding was approved by the Ad  Hoc

                  Committee, was it not?

                            (Discussion off the record)

                            MRS. KLEIN:   They did not approve it?

                            MRS. SILSBEE:  They did not specifically disapprove

                  anything. They reduced the funding level, with  advice  to

                  the Region that they should come back with specific informa-

                  tbn in July if they wanted anything.

                            MRS. KLEIN:  Well now, I have made all of my

                  motions.  I am really gumming this up.  I have made all of my

                  motions with the premise that the Ad Hoc Committee had

                  appIroved the funding.,

                            MRS. SILSBEE:  They reduced funding for the Region.

                            MRS. KLEIN:  They actually reduced the funding
                  without knowing of the Governorts opposition, and the motion

                  now would be to go contrary to the'recommendation of'the Ad



     WHD-148                                                               273

                  Hoc Committee by approving the funding?

                            MR. RUBEL:  The issue, very succinctly -- given

                  the funding level that they have gotten, $2.2 million, may

                  the RMP embark on this project?

                            And as I understood the motion that you made, it was

                  that they may embark on this project within the limit of the

                  $2.2 million, only with the specific approval of the Director

                  of the Division of Regional Medical Programs, and that

                  approval is contingent     conditional on-acceptance by this

                  Council and the  (b) agencies in the state of South Carolina.

                            MRS. KLEIN:  In effect, then, this motion would go

                  contrary to the recommendation of the Ad Hoc Committee.

                            VOICES:  No,.  No.

                            MRS. SILSBEE:  No, because it just further specifies


                  the recommendation.

                            MRS. KLEIN:  I see.  In  other words, their approval

                  was just on the reduced funding,  and this motion would

                  increase the funding?

                            MRS. FLOOD:  No, it would leave the funding the


                  same.


                            MRS.  KLEIN:   All right; that is the motion then, as

                  to these specific projects, that the funding be approved

                  subject to  their  obtaining the approval and cooperation of

                  the Governor and  the  other agencies.

                            MR. VAN WINKLE:   One project.



     WHD-149                                                                 274

                             MRS. SILSBEE:  One project.

                             The motion has been made and seconded that the

                   South Carolina RMP be funded at the level -- at the previousl
                                                                                 yi
                   recommended level Council has already acted on of $2,200,000,
                   but that any funding by the RMP'of project Number 32-F is
                   conditoned upon the Region indicating to DRMP that they have
                   the backing of the (b) agencies, the (a) agencies and the

                   Governor's Council.


                             Is there any-further discussion?

                             All in favor?


                             (Chorus of "Aye")

                             Opposed?

                             '(Chorus of "No")

                             MRS. SILSBEE:  Could we have hands on the "aye's?"

                             (Show of hands)

                             Six 'Aye's."

                             Four "Nay's.'

                             The "Aye's" have it.

                             All right; now do you want to call it quits?

                             MR. CHAMBLISS: -May I just say this?  I think the
                  Committee should know that  there is one-sixth of its workload

                  completed.

                             I don't say that to deter the discussion;-simply
                  to let you know where you stand in terms of the overall work-

                  load that you have accomplished.



      WHD-15ri
                                                                           275

                            MRS. SILSBEE:  What time do you want to meet
                  tomorrow?  The Staff will be present, because a lot of them
                  have already gone.

                            At 8:30?  Would you rather start earlier?

                            All right; 8:00 ollock it will be.
                            (Whereupon, at 6;25 P.M. the Council recessed until

                            8:00 o'clock A.M. June 14, 1974.)