l @'34*








                          TRANSCRIPT OF PI-TOCEEDINGS

                           DEPARTI@TENT OF @TALTH PZUChT.@t-0,N AND WELFARE



                              DIVISIOlq OF r-ZE.GIONAL ii@' ICAL PROu'RAYiS



                                     AD HOC MM-  COIJ41MITTEE



                                            PANAL A



















                                                                 R.-)ckville, Mciryland
                                                                 MaY 23, 307)-@





                    ",ages 229 thru



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                                                                                          228A


                                              C 0 N T E N T


                       REGION                      BEGIN             MOTION          APPROVED
                  2
                       IOTIA                         231               235             236
                  3
                       MEMPHIS                       237               251             266

                       MISSOURI                      267               278.'           280
                  5
                       NEBRASKA                      288               297             297,
                  6
                       ITEW MEXICO                   299               312             312
                  7
                       NORTH CAROLINA                313               321             322
                  8
                       NORTH DAKOTA                  323               339             341
                  9
                       NORTHLANDS                    343@              356             356
                  10

                  11   TEXAS                         357               401             402

                  12,  OHIO VALLEY                   404               421             422
                 .13   OKLAHO'-4A                    423               436             437

                  14   SOUTH CAROLINTA               440               455             455

                  15   SOUT14 DAKOTA                 4.57              466             475

                  I(;  TENNEESSEE MID/SO.            475               482             485



                  18


                  19


                  20


                  21


                  9-2


                  2.3


                  2,4


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                            2                                                 WELFARE






                            5


                            6


                            7



                            8

                                                       AD  HOC  CONSULTANTS  MEETING  FOR  REVIEW  OF
                            9

                                                                           RMP.APPLICATIONS
                            10





                            12,


                            13


                            14


                            15


                            16






                            18
                                                                                                 Cofiference  Room  H
                                                                                                 Parklawn  Building
                            19                                                                   5600'Fishers  Lane
                                                                                                 Rockville,  Maryland
                            20
                                                                                                 8:30  A.M.
                            21                                                                   Thursday
                                                                                                 May  23,  1974
                            22


                            2.3


                            24


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   5/2 3 am
  )/em                                  P R 0 C E E  D I N b S
                                        - - - - - - - - - - -
   8.- 40 am
              2
                              MR. CI-IAIIBLISS: I would like to say, first of allo,

              3    good morning to the members of this   panel.    Iindeed commend
              4    you again for the diligence and the   zeal   that you t@ick'led thi3

              5    most difficult task we had yesterday.

              6               I would like also to welcome to the panel Dr.

              7    Scherlis.   Good morning, Dr. Scherlis.

              8               DR. SCHERLIS:    The expression is "the la-:e Dr.


                   Scherlis".

              10              MR.   CHAMBLISS:  And  say we are glad to s  e  you,
              -11  and  we  are  still.waiting on Mrs. Wyckoff and Dr. Mi ler;
              12.  but, if  the  committee  so chooses,, I think we can pr ceed.

              .13             We're halfway through with our task and today  i-i-e

              14   have fourteen regions yet to be reviewed.  The order that I
              15   woul d suggest, and certainly this can  be  changed,  would  be
                   along  the  following  lines:  Iowa, Memphis, Missouri, Nebraska,
              17   New Mexico,  North  Carolina,  North Dakota,  Northlands,,  Ohio
              18   Valley,  Oklahoma,  South  Carolina, South Dakota, Tennessee

                   and mid South, and   finally  Texas,
              19

                              .DR. SLATER:  Sir, I have to catch a 5:10 train at
              20
                   the Capital Beltviay, so I have to leave   here ab-out 4:15  or
              21
                   maybe a little later,, if it's not raining; and I'm on Texas.
              22
                   I c aft tell you Texas won't take more than five minutes.
              23
                   Jesse  Salazar is the primary reviewer, it will take ten
              24

                   minutes.
              25

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                                                                           229

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                              MR. CHAMBLISS:  It will take ten minutes.

               2
                              DR. SLATER: We should  be  able  to finish.

               3
                              MR. CIIAIIBLIS:  I could  make  the suggestion  that

               4
                    we take Texas now.  It's too hot in Texas   to start wi-.,i Texas.

               5
                              DR. SLATER:    We're anxious to talk with each

               6
                    other,  because this requires some preliminary review  by  us

               7
                    to be able to make a   sensible presentation.- So if you could

               8
                    do it after lunch, we'd appreciate it.

               9              MR. CH2U4BLISS: After lunch?    All right, we  will

              @io   start out with Texas immediately.afte.r.the-lunch  hour.

              11              DR. WHITE:      Bob, where do we stand in terms of

              12    relationship with the other panel?

              .13
                              MR* CHAMBLIS:     The other panel, as of last night,

              14    had completed nine out  of  23, and we had completed 14 out of

              15    2 8.'

              16              DR. WHITE:    Some of us'have suggested  a  target

              17    of this afternoon's.joint meeting. Is  there  some  way  they

              18    can be reinforced in their efforts?

              19              MR. VAN WINKLE:     We talked with Dr. Pahl just a

              20    minutelago and he's over reinforcing that right now.

              21              MR. CHAr4BLISS: A suggestion has  been  made  that

              22    the first panel that completes its work would  go  over  and
              23,   join the other and help them speed-up.
              24              DR. CARPENTER:  I also have to   leave about  four,

                    and Northlands is therefore a bit of a problem, maybe  except
              25

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                    em3

                              I       if  we  finish  on  schedule  it won't  be.

                              2                           MR.  CIIAMBLISS:    I  think  we'll  get  to  N6rthlands

                              3       about       near  the  lunch  hour,  just  before  or  just  after.

                              4
                                                          DR.  CARPENTER:    Thank  you,  sir.

                              5                           MR.  CHA14BLIS:    Then,  shall  we  begin  with                                    Iowa,  and

                              6       welcorie  Mrs.  Wyckoff.

                              7
                                                          MRS.  V7YCXOFF:  Sorry  to  be  late;  I-couldii't  get  a

                              8       cab,

                              9


                           10






                           12.


                           .13


                           14









                           17


                           18


                           19


                           20


                           21


                           9
                           -2


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                                                                                                                                             231
              ern4

                            1                                      REGIONAL  MEDICAL  PROGRAM  REVIEW


                            2                                                           IOWA

                            3                            MR.  CHIU4BLISS:    In  the  case cf  Iowa,  Dr.  McP  e  ran
                            4         and Mrs.  Salazar  are  the  reviewers  and  Mr.  Z-ivlavsky  is-  the

                            5         staff  support,  will  provide  staff  support.
                            6                            DR.  McPHEDRAN:               . I  am  recommending  that we  give

                            7         Iowa  the  amount  that  they  are  asking  for.    I  think  this  is  a

                            8         good-Regional  Medical  Program.
                            9                            And  to  go  through  the  categories  that were  suggested
                            10        on  the  review  sheet,  first of  all,  a  little  background  from

                            11        me:    I  site  visited  Iowa  in  the  past,,  it                              was  several years
                            12        ago,  but  a  lot  of  the  direction  of  the  program  that was  there
                            13        at  the  time  is  still  there,  and-I've  had  occasion  to  meet
                            14        with  Charles  Caldwell  on  one  or  two  times  since  then,  and
                                      he  continues  to  impress,.me  as  an  imaginative  coordinator.
                            15
                            16                           From what  is  presented'in  the  application,  it  sounds
                                      as  though    the  Regional  Advisory  Group,  for  example,  had
                            17
                            18        great  stength  then  and  continues  to  be  a  strength,  anticipat-

                                      ing  the  form  of  the  review  sheet,
                            19
                                                         To  return  to  thatt  the  program  leadership  1
                            20
                            21,       classify  as  at  least  satisfactory,  and                                  the  staff-as  generally
                                      good  in  the  Regional  Advisory  Group;  a                                 good  group  there.
                            22
                            23        The  kinds  of  meetings  they  have                           held  in  t@ past  to  develop
                                      programs  and  to  monitor  it  as  it  goes                               along,  seemed  ima  inative
                            24,                                                                                                                   9
                            25        and  very  much  to  the  point.

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                                                                            23 2
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               1               Past performance and accomplishments as satisfactory

               2    also.  Satisfactory in all   of the other categories.i

               3.              I guess that the  program staff and the Re   ional

               4    Advisory Group principally   were the factors that make me feel

               5    that the over-all assessment of the region i   s above average,

               6    It is a well-administered staff of   gener alists. It's a

               7    stated policy,, that is,, that persons on the staff retain

               8    some-general competency in various activities that they

               9    conduct.

               10              There's a good de.al of emphasis on  joint  lecision

               11   making on  the staff members.  This  is gone  over in @e

               12.  current application.

                               I think  that  they have,, as I say, a  good  Regional
               13

                    Advisory Group support.
               14

                               The only sour,.note, I guess, for me, was  that  the
               15
               16   relationships with Comprehensive  Health  Planning,  which  I

                    thought previously were quite good,  seemed  to  be  somewhat
              .17

                    less than satisfactory,  as judged from some letters that I
               18
               19   think are included in our notebook here, which were not in

                    the original application.
               20

                               But, on the whole, I think that the general program
               21-
               22   purposes and their past  accomplishments  simply  weren't  what
               23   they have been asking for.  And,  according  to  this  master
                    financial sheet, which perhaps I found more helpful than I
               24
                    should, what  they are asking for constitutes only 80 percent
               25

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                                                                         233

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                   of what it was thought they could have in targeted available

              2    funds.

              3              And even if they  are expecting to request in July,

              4    it would only come to.about  95 percent.

              .5             I really think with the management and  direction  of

              6    this program it has been good enough in the  past  that  it

              7    certainly warrants that kind-of support, without going into

              8    further detail.

              9              MR. CH2U4BLISS: Thank you,, Dr. McPhedran,

              lo             Mrs. Salazar.

              11             MRS. SALAZAR:    I subscribe to Dr. McPhedran's

              12.  views, and this is the impression that I gleaned  from  the

                   application,
              13

              14'            Hoiieverp there are some concerns which I had  an

                   occ asion to discuss with rank briefly about the  CIIP  involve-
              15

                   ment and some other comments.  But the timing seemed to be
              16

                   bad, that they just couldn't get to them.  I would like to
              17
              18   hear from Frank.

                             MR. CHAMBLISS:     Mr. zi'vlavskyf would you
              19
              20             MR  .7IVLAVSKY:  Iowa,, from the beginning, had  a
              21@  very close working relationship  with CHP.  They.have maintained
              22   that relationship throughout their program history.'
                             That they have in the application is actually one
              23
              24   non-official B Agency comment, that there are 15 CIIP  agencies
                   in the State, fiv'e of the 15 are actually approved  B  agencie
              25

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                                                                           234
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                              The comment you have,here is a comment from one

               2    of the non-CHP B agencies.  They telephoned them in to

               3i   Division P14P and requested a three-day delay in their

                    application.  This was approved, and they submitted it on

               5    the 3rd of May instead of May lst.

               6              They just admit it's a breakdown in their machinery

               7    for the CIIP to be processed, because they have always taken

               8    into account the CIIP comments, have been able  to  negotiate

               9    their differences with CIIP.@  They have submitted five

               10   additional letters here, but basically  two  CHP  agencies  ave

               11   delayed their review.  one has favorable comments.  one has

               12,  a recommendation for disapproval. And the  last  line,  I  just

               13   state that the Iowa CIIP has not yet responded to negative

               14'  comments or questions due to the short timeframe.

                              We received the                       , and  inserted
               15                            Pe on the 20th of May

              .16   these into the books of the  reviewers and  the  coordinator,

                    and we have not had-an official chance to sit down and

               18   negotiate on a one-to-one basis with each of  the  differences.
                                                 0
               19   of the CHP agencies. And I,usually  they  have  a  connent'in
               20   there that it's a breakdown in  their  machinery.  The  staff

                    is on top of it.
               21-
               22             I will be watching this closely,  and  that's  really

                    about where it is.
               231
                              MRS. SALAZAR: One of the things  that  I  noted  in
               24
               25   reading the  applicati.on is the resiliency of  this  staff  to

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                                                                             235
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               1    react and turn around and react to all kinds of crises, in

               2    a very flexible rqanner. And I think that's very good.

               3               MR. CIIAMBLISS:    Someone has said that's based on

               4    their youth,, because they all are very go-go types, young,

                    aggressive, they move quite fast.  I simply throw that in

               6    as an observation.


               7               DR. McPIIEDRAII:  So I. would move that they be funded

               8    in the.amount requested, which, to reiterate, is @l,,061,349.

               9               MR. CIIA14BLIS:  We have a motion on the floor that


               10   Iowa be funded, recommended for fund:ing at a leve  of

               11   $1,061,349.  Is that seconded?

               12,             DR. MILLER:    Well, the yellow sheet says 249;

               13   but maybe  there's a mistake here.

               14              DR. WHITE: IIhat is Mr. Cald@vell's background?

               15              MR. CIIAI,,MLISS."  I believe his background is either

                    in hospital administration   or public administration.

                               DR. WHITE:  He's  about the third coordinator they
               17

                    have had,  isn't he?
               18

               I!)             MR. CII2U.D3LISS:  To my knowledge he is the second.
               20              DR. McPIIEDRAII:  Second.

                               DR. WHITE:   Willard Prell was first.
               21,

                               MR. VA@l WINI"LE:  That is 249.
               22
               23              DR. I.ICPIIEDRAII:  Okay.  Amend that.
               24'             MR. CH MIABLISS:  Do you amend the motion?

                               Is there a second to the motion?
               25

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               1               MRS. SALAZAR:  I second it*

               2               MR. PULLEII:  It adds up to 349.

               3               MR. CIIAI-IBLISS:  It has been properly moved and

                    seconded that Iowa be recommended for the level of

               5    $1,061,349.

               6               It has been seconded, so we now may have discussion.

               7               DR. SCIIERLIS: I note that one of  the projects is

               8    for emergency medical systems.  I thought that was specifi-

               9    cally exenLpted unless there were continuing projects.  Is.

              10    this a continuing project?  It's for $74,50.0.

              11               MR. CHIV.IBLISS:  It is a continuing project.

              12,              DA. McPHEDRAN:  Yes, I think it is a continuing

              13    projqct.

              14               MR. CHM4BLISS:   Continuation of a previously

              15    funded project.

                               Is there further discussion?

              17               If not, the Chair calls the question.

              18               Those in favor?

                               [Chorus of "ayes".]

              20               MR. CIIIUIBLISS:  Those opposed?

                               [No response.
              21'
              22               MR. CIlAr4BLISS:  The "ayes" have it, and the motion

                    passes,
              23


              24


              25

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                                                                          237


       emlO

                                   REGIONAL MEDICAL PROGRAM REVIEW


              2
                                             MEMPHIS

              3               MR. CHAJ,,IBLISS: So we will now turn our  attention

              4    to the Memphis Regional Medical Program.

              5               The reviews there are Dr. Carnenter and Mrs.

              6    Wyckoff, with Mrs. Lorraine  Kyttle  providing  staff  support.

              7               DR. CARPENTER: This is a region that I I ve  had  an

              8    opportunity to visit.  As many of you may know, it is an

              9    interesting Regional Medical Program involving part of

              10   five States and growing out of an existing health planning

              11   body in the Memphis area.  That body later became a

              12.  Comprehensive Health Planning agency  for  the  area  and  that

              13   growth of the regional program made a  great  series  of  State

              14   and local PI.TP's, naturally, and probably it would  have  been

              15   an impossible situation,without that beginning.

                              But it really has worked well, and given the

              17   Memphis Regional Program, I   think, a particular characteristic

              18   of its own.

                              In some ways it seems to me to behave  like  a  very

                   broad planning agency.  The nature of the Comprehensive
              20
              21   Health Planning agency, as much as it behaves like a Regional
                   Health Program.  But I don't think it's all bad.
              9-2
              23              This is a data analysis that attempts  to  get  into
              24'  health care problems in the region.  It is the latest in a
              25   series of publications based on  .data that was,demographic

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                                                                         2 3 3
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                    data that was available and re-analyzed to meet the  region's

               2    needs.  Also surveys of health in various places in  the

               3
                    region.

               4              As usual, in the world, it's very  difficult  to

               5    determine that the program has been guided in direct ways by

               6    this  kind of data analysis, but I believe the ability of the'

               7    region  to generate that kind of data and  to-reinforce  and

               8    talk about the health care needs of Memphis  has  provided

               9    them  with a kind of credibility leverage that has been

              10    important in the development of the program.

              11              The region has a relatively stable staff.    The

              12,   coordinator has been there, Culbertson, for a  long  time.

              13    And they have d stable -- well, they have had some changes

              14    in their varying structure because we had  legal  questions

              15    about  the ori inal arrangements.  They are now settled down
                                 9

              16    into a standard RAG arrangement,  and that was not

              17    terribly adversely affected by the  regional  catastrophes.

              18              They are not terribly explicit in the  way  they
                                                 40
              19    write their application.  They list, I guess, four goals- and
              20    13 objectives; and, as I tried to analyze them, I  come  up
              21    with what I really think are seven ideas.  And  these  are
              22    related nicely to the usual medical goals of  the  Regional
              23    Program, and I don't see any problem there.
              24              They discuss priorities as though they were separate
                    from their goals and objectives, which is a little discon-
              25

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                                                                         23 9
         eml2
                    certing, but by the time one o'clock came around  I  had

               2
                    solved the fact that they were really  paraphrases,  and one

               3    can in fact group their goals and objectives  into  some range

               @4   of priorities.

               5
                              The request is for about $700,000 in core  support,,,

               6    a million six for 28 continuing applications and a million

               7    for nine new applications; $300,000 for  developmental  awards.

               8              The projects from the beginning of  this  region

               9    have not had very specific goals. They  have  been  very
              10    general:  Let's get together, sometimes plan;  let's  get
              11    together for general action kinds of  goals.  And  they've

              12.   not been evaluated particularly well.

              13              I have great difficulty in this  application  in

              14    understanding in some ways what the@), have accomplished.
                                                       1

              15              On the other hand, they have brought in  an  enormous

              16    number of dollars from other Sources to the region, or at
              17    least have contributed to it, and because of this very close
              18    working relationship between Comprehensive Health Planning,
              19    experimental health care delivery systems,  and  Regional
                    Medical Programs in the area, it is very difficult to  give
              20
              21    credit for what happens.  l@ich is certainly not-a complaint
                    at all, but it does make evaluation very difficult.
              22

                              I believe that the Regional Program in that area
              23
                    had a significant role in brin@ing something like  a  half
              24                                   9
              25    million dollars to the region in other support in each  of  the

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                     last three years.
                2               They estimate that the  have served 200,000     patients'
                                                         y

                3    in the last  year,  and  about  2,000 professionals have been
                     trained.  So  there  are  some  kinds of program evalu ltion that
                4                                                           a
                5    are available;  but,  again#  the  project  evaluation i@ a

                6    problem. And  one  almost  gets  the  feeling  that  the projects

                7    were ancillary  to  the  main  issue.

                8               Ilhich, again, I think is more an interesting

                9    different  approach, perhaps; but there are some dif icult

               10    I think.

               11               There is,  for instance, $60,000 invested in a
               12.   project to improve death certificates.  lqhich reall@ turns

               13    out to be an  experiment  by  one  of  the  pathologists who   does

               14    one and a half autopsies a  week,  and  tries  to  see whether
               15    X-rays and gastric  analysis  would  add  anything  to his

               16    ability to perform as a pathologist.

               17               That was hard for me to see as a Regional Program.

                                MR. TIIOMPSON:   It's  interesting,    though.

               19               DR. CARPENTER:  It's very interesting.
               20               Of the million  dollars,  roughly,  for  the  nine  new

                     projects,  half of it goes  for  area  education  centers  in  ten
               21
               22    hospitals, and  really,  this  project,  lial.f a million dollar
                     project buys an organizer, a librarian, and provides space
               23
               24    rental to the hospital, provid@s a secretary and some books,
               25    journals, and  audio-visual  material  for  the  area.

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                                                                        to   be
                              And the outputs of that project are said
               2    to list the educational and clinical resources in  the area

               3
                    of these ten hospitals, to relate the leadership oflthe

               4
                    clinical and educational resources to  determine  the   need

               5    for new educational programs, and to develop  an  ove -al

               6    manpower plan.
               7              No;,7, I just believe that that's the work Df the
               8    Advisory Conrqittees, not $500, 000 worth of  staff.  knd  I

               9    also -- I don't know, at a time when this program i3 going

              10    to be phasing out, I wonder what  the  meaning of a

              11    developmental award is.

              12.             flow, let me stop at that point and see  wh    my

              13    cohort would say.


                             'MRS. IIYCKOFF:
              14                               Ilell, I think Memphis has the
              15    most beautiful case of euphora about PJIP than any  of  the
              I(;   P14pls.  They have chronic optimism about how this thing
              17    is going to go on, and they are just going to conquer all
                    the problems in the world.  And it's partly  .due to Dr.
              18
              19    Culbertsonts personality.  He carries the thing on his back.

              20    pretty well.
              21              They also operate as a,very peculiar -animal.  They
              92    are different from any other RP,IP, because they're like  a
              23    family.  They seem to telephone each other and keep in touch
              24    with each other across State lines and across all the
                    terrible amount of paperwork and r ules and regulations that
              25

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                                                                          2 4 2
        eml5

                    exist.  They rise above it all and do it in an informal
               2    fashion, and they seem to get together after  hours  and.keep

               3
                    the wheels very well oiled, and do the thinas that   ave  o

               4
                    be done.

               51
                              It's an incredible.thing, and they  cannot  believe
               6    that they are going to be phased out.  They just don't
               7    believe it.

               8
                              Instead, as you can see from this  report,  they

               9
                    make all kinds of alternative plans, so they're  goiag  to

              10
                    survive no matter what.
              11              And I really have a little faith in them.1 I
              12.                                                       1
                    honestly think they may be able to do it.  They-havd  put  it

              -13   together, they have got this experimental  health  systems

              14    management agency, and of course their  Comprehensive  Health

              15    Planning Groups, and the Y11p, and.they are planning to get

                    ready to jump in any direction when the legislation comes

              17    through. They are going to be ready  for  anything.  So  I

              18    think tjieir development funds will be used to launch


              l@)   whatever needs to be launched at that time.


              20              They show more faith in survival, i-i-hen the crunch

              21    went on, they went right ahead v7ith their plans, and they

              22    are all ready to get their maximum amount of money  with  new

              23    projects and everything wli(mthe funds came through.

              24              They have only seven    I think it was  out  of,

              25    was it 18?  They had only seven,approved and unfunded request

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                     at the end, and I think they had 11 that way, succeeded      in

                2
                     putting through at the worst possible moment.

                3
                               So I really think that they may be    able to  a

                4
                     go of this.

                5
                               I would like to hear a  little  from  staff  on  what

                6    they know aboutthe new plans.they have for this newitrustee-.
                7                                                          I
                     ship board.   If there is anything in there.

                8              DR. IIHITE:  I wonder if Mrs. Kyttle might also

                9  -comment on this phrase "escro-vi accounts".  Is that a

              10     substitute for keeping money after the thin  g is ove ?

              11               DR. CARPEIITER:  That's a catalysm.

              12.              MRS. KYTTLE:  Well, you asked about the 0 ganiza-

              -13    tion that is forming, and you are quite right.  It's almost

              14     incestuous, because N14CC's spawned MIP, and PI.IP's spawned

              15     HSM.'  P14P responded to the RFP that R&D issued for experimental

              I(;    health systems, wrote the application, pulled the people

              17     together, set it under a corporative kind of stance,

              18     because that's what the RFP requires, and Voila, there's

              1!)    Health Systems I-lanagement, Inc., which is right across the

              20     hall from RIIP.

              21@              DR. McPIIEDRAN:  I'm on the ropes, Mrs.- Kyttle.

              22     RFPI R&D sent out a request for contract.proposals across

              23     the country.  That's a request for.contract proposals, for
              24     proposals  onexperimental  health'dblivery  systems.   Regional
              25     14edical Programs in I-lemphis sat down and wrote one, but  did

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           eml7                                                          24 4

                   not send it in under their name, because they were not at

               2
                   that tine a proper applicant, They spawned IISM, R14P and  the

               3
                   local B, which is one of the most active B's in the  State  of

               4
                   Tennessee, not just west Tennessee but in the State of

               5
                   Tennessee, had formed an umbrella trusteeship --  and  that's

               6   not a catalysm; that'Is tlieirs. They call it an  umbrella

               7
                   trusteeship.

               8             It proposes the merger of the  executive  committee

               9   of each of these agencies, and it is  a  straight-forward,

              10   unabashed move to present the three of them. This  is  not  an

              11   area where one is more interested in surving over  the  other.

              12.            The three of them want to survive.

              13             They did an intemmting thing. They agreed that each

              14   of these.three entities, if their full boards ratified it#,

              15   and since this paper was prepared all of the  boards  have

              i(i  ratified it, the full boards. -The body bringing  the  largest

              17   turf to this umbrella trusteeship, and without  doubt  that's

              18   RMP with parts of five Statest would. bring the turf or

              I!)  cognizance of this new group, should the turf  want  that.

              20             And so there is, then, the possibility  that  there

              21   would be an 30-county five-State Ilealth Service-Agency or

              22   whatever might come out of the new legislation.
              23             They thought that that would be the experiment,
              24   and that's the purpose of that -'Organization you asked about.
              25             MRS4 VIYCKOFF:  They believe in survival.

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               1              MRS. KYTTLE:   The three of tJiem, not just PIIP.

               2              MR. THOMPSON:  It does-offer complication's?

               3   however.   We're used to, you know, the  one-on-one  business,

               .4  whols on,  whols off, between CIIP and @MP.

               5              Now, they have substituted a menage a trois kind of

               6   thing, to  complicate it even more.

               7              MRS. KY'@"TLE: I don't know if they look at it as

               8   a complication in that frame.  The  possible  complication  is

               9   that Memphis PIIP has assisted, and that is from beginning to

              10   where they are now,  all other B's in west  ennessee  all   of

              11   them.   But the one  that is operating  in  southeast  entucky

              12.  is a Memphis PJIP, funded not any longer, but it was

                              MRS. T-7YCKOFF:  And Mississippi.
              .13

              14              MRS. 1'.YTTLE: Northern I-lississippi and the boot-

                   heel'of Missouri and eastern Arkansas.  The  five  operating
              15

                   B's are all B's that have been funded and initiated by
              16

              17   Memphis RMP.

              18              Now, if Memphis RMP comes into this umbrella
              19   trusteeship with the greatest territory, it  will  encompass
              20   the territory of those B's,, and they kno.,v7 that,, and they
              21   realize that that will be the option.    If those- 'local B's

                   and indeed the legislation permits that type of arrangement,
              22
                   they thought that that would be the  interesting  experiment
              23
              24   to form a new Health Service Agency for that  terrain,  wit-
              25   subcontracts with existing B's, that they have already funded

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                                                             e to give Dr.
                             MRS. WYCKOFF:    I guess you hav

               2
                   Cannon a little credit for also holding this organization

              .3
                   together.

               4
                             MRS. KYTTLE:  Yes,, ma'am.

               5
                             DR. SCHERLIS:    IloN,7 much of the funding actually
               6   would be directed to,,.,7ard the setting up of such a group?

               7
                   How much of it is seed money?

               8             MRS. KYTTLE: They seek no  funds for that. T e

               9
                   arrangement they have made is that they are rotating for'the

              10
                   first period of operation, the executive director  of  HMS

              11
                   serves as the chairman of this new  board.  The staff is
              12.  provided by IU4P, and the leg work is done by CIIP.
              13             And for the next ninety'days, they first started

              14   thinking of a year and they realized that that would be too
                   long a time, the next ninety days the coordinator of  PJ4P

                   serves as chairman;  the staff of IISM has to fund the money
              17   to get the staff work done, and the CI-IP organization does the

              18   regional communicating.
              19             DR. SCIIERLIS:  You'told us about that $400,000 in


              20   escrow,

              21             DR. WHITE:  There's actually  800,000.--There are

              22   actually two different escrow accounts.
              23             MRS. KYTTLE:    This application seeks no money for

              24   that organization.
              25              DR. SCIIERLIS:  Yes. But'where does the money come

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                    f rom?


                2
                               Two things:  how is it-labeled, and how can a sum

                3   of money be available?

                .4             MRS. KYTTLE:  All right, that's the first question

                5
                    you asked  about. The $800,000, when you total the two, it's

                6   a combination of five and three. Let's  speak  to  the  500

                7   first,, and that is the creation of local consortia to
                8   develop health manpower needs and relate them to identified

                9   health service needs, and relate them  to  health  manpower

              10    resources.

              11               MR. CHAMBLISS:   Is that to which the funds are

              12,   going to be used?

              13               MRS. KYTTLE:   rive hu
                                                     ndred thousand.

              14               DR. CARPENTER:   That's  for ten hospital

              15    librarians, ten secretaries, and  ten  planners,  community


              16    organizers.
              17               MRS. KYTTLE:  You asked  if that should not be the

              18    work of the local advisory committee, because  so  many  of
              ii)   these groups were formed from such advisory committem; but
              20    they have no local advisory committees.  These are ptedomin-
              21    antly in ares where there are not B's,   and this-is  ovi

                    Memphis starts B's.
              22
              23               DR. CARPENTER:  No, they.have B agencies now
              24    except in  -- organized in every area, but not
              25               MRS. KYTTLE:  They are not funded.

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                I              DR. CARPENTER: Two of them are not funded.  But


                2   they are two out of ten at most..

                3              No, these are not B agencies, these are

                4              MRS. WV.CKOFF:   Health Centers.


                5              DR. CARPE14TER:   These are hospital libraries.

                6              MRS. WYCI',OFF:  There's the seed money to start

                7   things.

                8              MRS. KYTTLE:  I said they have no local   advisory

                9   committee  in these areas, save Jackson.  Ther6.is   one in'

              10    Jackson, and there's one ongoing there.

              11               DR. CARPENTER: But they showed us   a map of the B

              12.   agencies,  right, and they cover the whole area except

                    maybe a few outlying counties.
              .13

                               MRS. KYTTLE: These are areas that have no health
              14

                    manpower committees working in them.
              15

              1(;              DR. CARPENTER:  Oh, okay.  No manpower committees.

              17               MRS. KYTTLE:  And that's how they have spawned,
              18    they have  first developed some health manpower committees

                    for B's.   These are areas wh@e the B's have formed without
              19
              20    he.alth manpower committees.

                               DR. CARPENTER:   That's the point I'm-making.  If
              21

                    they had the manpower committees, they wotldn't have to spend
              22

                    a half a million dollars.
              23
                               I-IRS. KYTTLE:  Well,'for some reason, and I have
              24
              25    tried to research it  and I don't understand it, the philosophy,

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            em22

               I    the Memphis-Regional Program thinks local consortia to

               2    address health manpower needs should be  seated in a

               3    hospital. They feel the hospital  setting  is  the  setting

               .4   for an IISEA,, and they have felt that way from the very

               5    beginning.  And that's where these are, ten sites.

               6              MR. CIIATIBLISS:  Dr.  Scherlis.


               7              DR. SCIIERLIS:   l@ow welve gotten through the first

               8    gear, what happens to the second ten libraries, secretaries,

               9    et cetera, for the second year?  They  are  being  funded?

               10             MRS. KYTTLE:  The same thing that will happen for

               11   all the others.  Some of them will make-application under

               12.  the new legislation as health service  agencies.  I  mean,,

                    that's going to happen across the country.  Most   of  them
               13

               14   feel that they are ready to make application.
               15             MR. THO!IPSOII:,- Ten libraries are going to  be

                    certified as health agencies, as' I understand you?

                              MRS. KYTTLE:  One of the first things the local
               17
               18   area is going to have to do is to create its own manpower

                    committee.  The librarian wiri not be -- even she's a part

                    of the system, but she is not  the  pivot.
               20

                              DR. WIIITE: I'm  suffering  from an  inability  to
               21

                    recall Webster's definition  of  "escrow". But it seems to me
               22
                    it has to do with putting money aside for  future use,
               23
                              MRS. KYTTLT:   They w"ant to impound  their  own
               24
                    money.  They want to put $500,000 Aside now so that   they feel
               25

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         em23                                                               250

                   by July they will have gotten these things ready to go to

               2
                   contracts, or in the writing stage now  of  when,  I  think one

               3
                   is in Kentucky and  the other is in  Crittenden  County  in

               4
                   Arkansas.     Rather than coming in in July with thl3   proposal
               5   of ten sites all worked up, they want to escrow the money

               6
                   out of the total package now, so that it can begin in July
               7   rather than make application to us in July.

               8
                              MR. THOMPSON: So, in other words, they wa t to use

               9
                   the escrow business  as a substitute for a specific proposal.

              10
                              MRS. XYTTLE:  Yes, and they want to tell you now

              11   what they  want to put it aside,for.

              12.             MR. THOMPSON:    Has this proposal been  matched  up

              13   through the whole internal review  process  as  a  proposal?

              14              MRS. KYTTLE:  As a concept.

              15              DR. CARPENTER. I think there  are  a  series  of

              16   small proposals. Isn't that the way  it  got  through  the  RAG

              17   as small proposals?  But  it did in part, in $25,000 hunks

              18   it went through RAG.

                              MR. THOMPSON:-    $25,000 hunks up  to  $500,000?

              20   That's a nice piece of business.


              21
                              DR. IIIIITE:  They have got $800,000 there.

              22              MRS. KYTTLE:     And it all went through at once.

              23              DR. CARPENTER:    They didn't hide any of it.
                                                    e
              24              MRS. KYTTLE:     It did not bleed through,, it  went

                   through as a concept, and   $25,000 apiece for  ten  sites.
              25

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                             DR. CARPENTER:    Can I. at this point, break into

               2   the conversation and make a funding recommendation?

               3
                             MR. CIIAIIBLISS:  You may, indeed, Dr. Carpenter.,

               -4
                             DR. CARPENTER:  I would, just to get the discussion

               5
                   going, move a certain funding level.    Their annualized  rate

               6
                   now is a million and a half.  Their targeted rate is about

               7
                   two million three,  and  they request three million four now

               8
                   and predict that they will ask for a million two later,

               9   and that will get them at two times target.

              10             I think that the  region is pretty good, but not

              11   in a position to go from a  million And a half to four million

              12   seven at the time of phase-down.  I would suggest a funding

              .13  level a little above the target level, of $2,,600,,000.

              14             MR. CHAIIBLISS: Will you place that in the  form  of

              15   a motion?

              1(;            DR. CARPENTER:  Yes,, I do.

              17             MRS. WYCKOFF:  I'll second that.

              18             MR. CIIAt4BLISS:  It has been moved and seconded
              19   that the  level be established for    be recommended for.-

                   Memphis at $2,600,000.
              20

                             Is there discussion?
              21,

                             DR. WIIITE:    I would like to pursue this  further,
              22
              23   and I an, going to. We've talked about  the  5OOtOOO.  There's

                   another 300,000 in escrow dollars, which I interpret as this,
              24
              25   Mrs. Kyttle, as underwriting the survival of these three in

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               I   whatever form they're going to take.

               2              It says that, I think.

               3              MRS. KYTTLE:   It says that high priority out of

               4   this developmental will be given to those agencies,  'You know,
               51, in the total region.  That's the RTIP region that I'm.

               6   pursuing, the logical kinds of things that the new legisla-

                   tion proposes.

               8              There again that falls within the umbrella purview,

               9   but the umbrella -- the organization that is the  umbrella  is

              10   not seeking funds, but it seeks to fortify its philosophy

              11   that it's a good umbrella, it hopes that the legislation

            .12.   will speak to a State, you know, whichever one comes out first,

              13   and it wants to have agencies funded within it, that it can

              14   contract with.

              15              That's what the high priority is for those agencies.

              16              DR. IIHITE:  Now, is that $300,000 the same as  the

                   developmental fund?
              17
              18              MRS. I'\,YTTLE: Some of those are B's.  Yes,  that's

                   out of that.
              19
              20              MR. TH014PSON:  I think what we see here is probably
              21   the bald statement of the problem that you are finding more

                   or less in the same degree in all of these, most of the
              22

                   proposals, and this is an attempt to second-guess what the
              23 i
              2,4  legislation is going .to be as f'ar as, you know, whether
                   this is regional health authority or State  health  authority,
              25

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                                                                         253
        em2 6

                    and it's floating around in all these crazy bills.
               2              Now, I think we have a'policy problem here,

               3
                    whether our RI-4P funds should be used to relate an agency,'a

               4
                    proposed agency for nonexistent legislation.  And  I  think

               5
                    that's true here, I think that's true in a subsequent thing

               6
                    that I'll review to you.

               7
                              In other words, when you,  from PI.IPS sent the

               8    message down: Fellows, get on the ball with  your  CHP  and

               9    no kidding this time.   We've seen a lot of getting into bed

              10    with CIIP, and it's -- in fact it now looks like a plot  by

              11    the two of them to survive, whatever happens.

              12.             Now,, I don't know what's going to happen if this

              '13
                    legislation setting up this envisioned Regional Health

              14    Authority is delayed by two years.  You know, all this

              15    money that we're pouri@nej @n here to build these various

                    elaborate umbrella agencies, the consortia -- they have about

              17    six names for it --.it's going right down the old,tube.

              18              MR. VAN WINKLE: I would like  to.point  out  that

              19    they have been encouraged to start various programs with'CHP.

              20              MR. THO@IPSON:  That's what I'd like to know:  who

              21    has the crystal-ball authority that they can tell me-  that

              22    the Regional Health Authority is going to be established

              23    by the end of P14P's life, and take'over RMP's staff or skills

              24    and start in business.   Who the hell has got that information.

                    I don't have it,
              25

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                                 MRS. KYTTLE:    Mr. Thompson,  you  know  it  would  be

                 2
                     beautiful if  that  were  the  case,-but  no  region  has,had  that

                 3
                     word, and they are all trying to take the most logical        and

                 4
                     flexible stance that  they  can,  trying  to  provide  for  the
                 5                                                            1
                     possibility  of  State  structure  as  well  as  providing'for  the

                 6   local structures, until they    see what the legislation is*

                 7               MR. TflOf4PSON: When you cover all the  bets'  on  a
                 8   racehorse   -it costs a lot of  money,  and  that's  what  @ese

                 9   people are doing.  They Ire putting two bucks on eve          horse

               lo    in the race, hoping   that somebody will come    in  and   ey will

               11    be on it! As  long  as  it's  not  their  money,  that's  okay.
               12.               MR. CHAIIBLISS:    This is one of the poli@ questiois

               13    that we alluded to earlier on when the committee was convened.,


               14    and this is one of the issues that will be dealt with as the


               15    review goes forward.

               16                I would like to acknowledge the presence of Dr.

               17    Margolis here,  our  former  Director.  And  since  this  is  a

               18    policy issue, I'm wondering if he would say a few words-on

               l@)   this   point.

               20                DR. SCHERLIS:     I was just going to make one

                     suggestion.  I  think  that  Memphis  really  shows  some  good
               21

                     judgment with the idea of an escrow account for $800,000 and
               22

               23    I would think that  some  of  the  wisest  judgment  that  this
               24    Review Committee could  make  is  to  have  an  escrow  account  of
               25    a hundred, a hundred and twenty to 'forty thousand dollars,

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            em2   8


                         that we would have available, and say, let's save that for

                   2
                         some decent health planning as of July lst, 1975.
                   3                  @ihile  'I wasn't here yesterday, which is a

                   .4    calendar error that I apologize for, I spent, really, as all
                   5     of you did, a very difficult time reviewing these, because
                   6     we're doing it on promise and hope and faith and, frankly,

                   7     charity.

                   8                 And all the old judgments that we have used have

                         had to go down the drain completely in reviewing these; and

                  10     I think that if Memphis gets approved for an escrow account,

                  11     that my next suggestion will be that we vote an escrow

                  12,    account of a hundred or eighty million dollars for July lst,

                  13     to be used if there will be health planning then.

                  14                 I don't think that putting this into some thirty,

                  15     forty, fifty little different projects, that we're begged

                  1(;    for and scrounged for by going out and saying, Come on in,

                  17     we have this last chance to get it.            A  lot of them read that

                  18     way.    That that is really the equitable way for us to use

                         government funds.
                  19

                  20                 I have the serious questions that all of you have

                         had, and we're operating within a very difficult framework,
                  21@

                         to reach equitable decisions.
                  22

                                     I am all for escrow accounts, particularly of most
                  23
                  24     of that one hundred and twenty or hundred.and forty million
                  25     dollars.

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                                                                        256
        em29
                             I didn't mean to pre-.empt you,, but I wanted that

              2
                    stated somewhere along the line.
              3              DR. tiARGOLIS:  Well, my most positive word is that
              4     I an delighted to see my good friends here again.

              5
                    I am delighted to see that you are tearing at things as

                    usual.


              7
                             I don't understand.your concern, John, in not

              8
                    knowing how to spend money on nonexistent legislation,
              9                ioney was appropriated, impounded in 173  to  be,
                    After all, r
              10    spent in.176; when the authorization would expire by June

              11    30th, anyway.,
              12.            So itis a perfectly clearcut situation!
              13             I would like to address this  question,  because  I
              14    think the points you raise are important, and rather than
              15    matters of policy, althpugh.they certainly  involve  policy,
              1(;   there are also senses of timing in judgment, which will have
              17    to replace, as they often have in this program, some kind
              18    of policy base.  In all of the discussions on planning,
              19    legislation, developed both some kind of unified health
              20    planning proposal, there has been more dissatisfaction  -- and
                    not very well hidden -- than satisfaction  with  everybody's
              21
              22    proposal, as you implied.
              23              The administration is not wildly enthusiastic
                    about what it has proposed.  The Rogers Committee feels about
              24
                    the same about its own proposals..'Theke  is fjreat uneasiness
              25

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         em3O                                                              257

                    about what would occur. Time  is  running  out.  And  some
                2   of the basic problems remain.
                3             The problem which everyone has  looked  at,  usually

                4
                    defined so poorly, that it is looked at  plainly,  is  the
                5   meaning of planning,, the relationship between  planning  and
                6   implementation; and  the relationships between planning  and'

                7
                    management.

                8             Traditional questions which have been up for

                9
                    consideration time and time  again.  The  difficulty  involved

              10    in all the pieces of legislation and in  the  debates  which

              11    really don't get around to this is that'no one  is  ready  to

              12.   say what that relationship ought to  be.  Nobody  is  willing

              ..13  to come down hard, although there are indications that a

              14    position has been developed..

              15              For example, it is  now felt that  whatever  these

              I(;   health service agencies will  bet or whatever name  they  come

              17    out under,, they will be private, nonprofit structures within

              18    the State. There will be an uncertain  kind  of  support  for

              I!)   State structures.  The planni"ng process will be kept   from

              20    State implementation, however, there will  be  some  small

              21    amount of money for implementation, a larger amount of

              22    money for implementation based on whose  bill  you're  looking

              23    at.

              24              What is missing in the process  is  something  which

              25    can produce, in the health delivery  system,  a  cooperative

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               1    structure which allows people to operate in the private and
               2    in the nonprivate systems in such a way that they  are  able
               3    to do together more effectively those things which  they  wish

               4
                    to do than they can do them separately.   Which is an early

               5
                    description of Regional Medical Programs.
               6              It creates a real problem.  And in many ways what

               7    our reviews are attempting to do is being  approached  under

               8
                    other names, with different kinds of understanding,  and  with

               9    a variety of methods.

              10              But the debate has not been joined.  I  don't  think

                    it will be joined.  And when you' re through with this
              12.   session and we're through with the review session  which  is

              13    coming up after that, there is still going  to be  great
              14    difficulty in making a judgment about what  is IUIP going to
              15    do in relationship to CIIP, what will the planning  function
                    actually be, what will the relationships be  between  pl anning

              17    and implementations and, furthermore, what is going to be

              18    the role of the State government in this?

                              Because, in general, the role of  State  goverment
              19

                    has been downgradedalmost lost sight of
              20                                               there have been
              21    serious objections to it from outside and from within.  And
                    we're going to be entering the fall season  whether  using  an
              22
                    escrow account or not, with no more certainty about what
              23
                    that relationship is than exis@s at the present time.
              24
              25              What we have been saying,is a'consequence, and it's

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        em32                                                               2 5 -0,
                     about the only way out,, maybe not too bad a one, is that the

               2
                     most proved factor beyond a Regional Medical Program, and
               3     it's now my job in addressing all these programs, it applies

               4
                     to others as well, certainly the CIIP; but beyond the CIIP,

               5
                     the other kinds of federal programs which are in the

               6
                     States v7hich have sort of opted out  of this activity,

               7
                     the most judicious  thing for.thera to do is to get together

               8
                     with one another as rapidly and as fully and as enthusiastic-

               9
                     ally as possible, and decide what they're going to do together,
              10     regardless of what the legislation is going to look like.

              11
                               And betv@7een the passage or nonpassage, which is a
              12.    good likelihood,,of the legislation, its approval, its
              13     appropriation, its regulations -and its administration,

              14
                     so many'things will occur that if the people who are out
              15     there quit trying to decide who is going to be in charge and
              16     decide how they are  going  to  run the thing together, they

              17     are going to  move  rapidly  ahead.

              18               Now,  sometimes  this  is interpretative on the part

              1!)    of PI,4P people, if I'm talking  to them, as some of the RMP's

              20     are, is that  they  should  quickly move to take over.

              21               Now, that v7ouldn't work.    CHP takes the same

              22     response when they are listening to their own partisans;

              23     it's for you to take over.

              24               And if they will  get just a little smarter,, they
              25     will move together; but they are going to have to move with

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        em33


                   other programs.  Maternal and Child Ifealth Service, Community

               2
                   I-lental Ilealth Service, which, for' some reason, along with

               3
                   others, have never been considered a part of the general

               4
                   concept of comprehensive planning.
               5             Migrant programs, all of then have each been looked

               6
                   at separately, and all the conversations have been PFP and
               7   CHP as if those were the only actors in the game; when, in

                   fact, they are some of the actors, and in many instances

                   rather minor actors.

              10             Nov7, I think the additional.thing which isi going
              11   to make a difference, about  the time we get started,@ith it,
              12.  is the  gro.iqing concern with the regulatory function @within

              .13  the State which will produce an entirely different enviroh-

              14   ment for the total relationship between  planning  and.

              15   implementation.  Because,.the regulatory function will throw

              16   in a new responsibility which must be a State responsibility,,

              17   almost by definition.

              18             That regulatory function already  applies  to

              1$)  institutional development.  It's going to, in all likelihood,

              20   involve cost control, becaiiselwe get national health insurance,

              21   and there is freer and freer conversation nov7 about  a

              22   complement to certificate-of-need legislation for construction,

              23   and that will be some kind of certificate-of-need for man-

              24   power.

                             Noi.i, wien these kinds of things occur, people who
              25

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             em34


                    have been vying for responsibility may find themselves vying

                2
                    for getting out of sight,- because it's going to be no
                3   child's game.
                .4            And yet by looking at the total structure, as it
                5   will be much faster than many of us have expected, the

                6   relationships between the planning, the implementation, the

                7   operational and the regulato ry functions can become clearer,

                8   and the responsibilities for the various parts will begin

                9   to fall into place.

                10            But to try to assume full management or  full

                11  authority for any one of them is injudicious,, it won't work,

                12. and I don't think anyone would really want it when they get

                .13 all through with it.

                14            The real struggle, in all sincerity, will be on

                15  the part of those who are determined that the regulatory

                16  function, particularly control of rates and fees, be placed

                17  anywhere but where I am.  Nobody is going to want that.

                18  And yet it is going to be the part of the system which is

                11) going to have the greatest power, and from which most of.

                20  the strength is going to flow within the States.

                             I think it will go in the States gradually.
                21

                    The other big debate is whether the National Ifealth Insurance
                22

                2tl is to be more federal or State directed; but that's a

                    very fundamental issue.
                24

                             Now, I know that's not a policy thing,, but at least
                25

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           em35


                   it's a statement ofsome kind of dynamics which will work

               2
                   well some places and not others. 'The concept of escrow,,   I

               3
                   would certainly agree with you, is   certainly -- if '(OU  re

               4
                   going to consider the setting aside   of funds for an,uncertain

               5
                   but realizable goal in the immediate future, that should be

               6
                   a programmatic kind  of action  across the board, rat@er
               7                                                         I
                   than,.limited to any one program, to come up with that kind

               8
                   of an idea


               9
                              And even then, it is a risky kind of thin  to do,

              10   because you don't know what the situation w  ill be w  en those

              11   funds are released.

              12.             I don't know if  that  helps or not.

              13              MR. CHPIIBLISS: T,,Iell, thank you, Dr. Margolis.

              14   There may  be some questions  that  the panel would like to

              15   raise, in  addition to --,. Dr. Vaun?

              16              DR. VATA4:   Getting back  to this, not with regard

              17   to Dr. Margolis' comments,, the only  thina that concerns me

              18   about the escrow is that, does this   place any of the

              I!)  other P14P's that have seen fit to core back in July,,  at  a

              20   disadvantage?

              21              In other words, are these people gambling  that all

              22   money is going to be doled out on the first round, and,, reall@,

              23   whatlpulve been saying is not so there  won't  be  any  money

              24   left for the second round, so they're putting their little

                   nest-egg in escrow.
              25

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                              Has that thought occurred to  anybody?  Is  this

               2
                   v7hat they are tr-,,,ing to do?

               3              MR. CIIAT-IBLISS: There will be a sum of  moneys

               .4  remaining  for the second round.

               5              DR. VAUN:   So as you envisage it, this  would  be

               6   not placing anybody at a disadvantage?  The  other  PIIP'S.

               7              MR. CHA14BLISS:   Well, the total-amount is limited,

               8   so therefore what is ultimately awarded to Memphis comes out

               9   of the entire amount available.


              10              DR. MILLER:   Isn't it true that previously,

              11   except for developmental fund awards, which   has not  been

              12.  mentioned in the current directions, no  region  was  allowed

                   to just apply for escrow funds, by lump  of  escrow  money.

              14   You got it another way. But,you  couldn't  apply  for  escrow


                   funds.


                              And now you do not have an authorization or

              17   direction for regions to  apply for a development award,

              18   either; do you?

              19              MR. CIIAIIBLIS3:  We cfo not.

              20              DR.MILLER:    well, isn't it appropriate that this

              21   review  committee specifically record in the record  that  we

                   do not  recommend funding for that activity or that  kind  of
              22

              23   an award,  that part?

                              MR. CII7UIBLISS: That would be a  problem  and  we
              24

                   are looking to this  committee for its judgment on  that.
              25

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       em37                                                                      265

                1             DR. IIILLER: Do you want that  in  the  form of a motioa?

                21            MR. CI-IAIIBLISS: A motion is not  in  order at the

                3   present time.    There is a motion on the floor, and   that

                4   motion is-that the level of funding for Memphis be recommends
                5i  at $2,684,000.

                6             MRS. WYCKOFF: Well, v7hy  don't  we  do  it?

                7             MR. CIIPIIBLISS:  You may so indicate that, and the

                8   staff  eople will take due notice of it.
                          p

                9             MRS. WYCKOFF:    Should we amend the motion that the


              10    escrow funds be taken out of this?


                              DR. T@NIITE:  All of the escrow 'funds are on the

              12    yellow slieet, they are not on the application.     The awards.

                    l@Inat you see on the application@is a developmental award and

              14    a project, and I believe we are not supposed to get so deeply

              15    into the region's management  as to reject a specific

              16    project.

              17              I guess I have the feeling that if we reduce the

              18    requested funds by an appropriate amount, the region will

              19    probably behave fairly @,iell..'And I would be satisfied just

              20    to reduce the funding amount and then proceed.

              21              Does that make sense to anybody.

              22              DR. llcPIIEDRAN:  Then hov7 about, as a separate pieCE

              23    of business that does not have anything to   do with this

                    particular consideration of this program, that we could have
              24
              25    this motion that Dr.  Miller suggests.  Could we do that?

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         em38                                                                266

                               Just as a general part of the proceedings of this

                2
                    committee.  If we could do it that way.

                3              MR. VA14 WINKLE:  But the staff can also express

                4
                    your concern about these two items.

                5              MR. CIlIU4BLISS: Then I call the question,

                6              Those in favor please indicate by the usual sign

                7   in   voting.

                               [Chorus of "ayes".)

                9
                               'MR. CHAIABLISS:  Those opposed?

              10
                               [.No response.]

                               MR..CHIU4BLIS:  The motion is carried.  At two

              12.   million six, with the concerns of this panel being conveyed

              13    to the region in the advice letter and by staff,

              14               I must say that the privilege that we've had of

              15    having Dr. Margolis, the Deputy Administrator of the

              i(i   Health Resources Administration, come in just at this   key

              17    moment, when we were discussing a very critical issue   having

              18    to do with Memphis, was most timely.

                               I would endeavor to ask the staff to set the


              20    whole question in some type of framework, and then we would

                    like to have Dr. Margolis comment on those issues    be
              21

              22    conveyed to the staff and to perhaps some of the regions.

                               I think this is very timely, what he has done.
              23


              24


              25

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        em39                      REGIOIIAL MEDICAL PROGPUL REVIEW

               2
                                             MISSOURI


               3
                             MR. CHA14BLISS:    We shall now then turn  our

               4   attention to a review of the application from  the  Missouri

               5
                   Regional Medical Program. The reviewers here  will  be  Dr.
               6   McPhedran and Dr. Ililler, and staff support will be provided,

               7
                   by mrs.,Resnik.

               8
                             Thank you, Dr. Margolis.

               9
                             DR. McPHEDIWI:  Yesterday Dr. Miller and I got

             10    some additional material on the Missouri  application,  and

             11    I cite this now not to beg off, because I have read  it,  in

             12.   fact, but it was interesting because it was. a staff  visit

             13    to Missouri and it was suggested to me that maybe  I  ought

             14    to chan'e my views to some extent, In  fact,  the  value
                          9

             15    of this program and the,.merit of the application, specifically.

             it;             But I must say I think  it hasn't changed my views

             17    a whole lot, and, while I've got  more to say about it than

             is    I did, it really remains about the same.

             19              To go through the review sheet:  program leadership,

             20    I was unable to classify one of the categories, and have

                   checked "satisfactory to poor" because I think that  it  is
             21

                   variable, without mentioning particular  persons.  I  think
             22

                   that it really is uneven, and I'm basing tJiis on the  fact
             23

                   that the leadership seems to me very much the same as I recall
             24

                   it from at least two     because I've been there twice
             25

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     em4O
                   two previous site visits, and a lot of discussion at various

               2
                   National Advisory Council.mectings.

               3
                             I really think that what has  happened  in Lis.
               4
                   application reflects this leadership to a considerable
               5   extent.

               6
                             I have no criticism to make of the  program  staff,

               7   and never did, except that I'tliink it used to be ve   large,

                   and the proposal suggests enlargement.  I can't   _- pnless
               9                 the marking of that enlargement, it ii

             10    currently 30 with a proposed addition of  45  staff.
             11              The program staff in the past we used to Friticize,
             12,   maybe this should have been more a criticism  of  th elleadershid,

             13    for its lack of initiative in helping people in  the region

             14    to develop parts of the program, develop projects and

             15    develop other component parts of the program.

             1(;             According to the.most'recent visit,  that is not  a

             17    problem now, but it certainly used to be.

             18              I am persuaded by the recent visit, I have said

             l@)   that at least it's satisfactory, but I really wonder whether,

             20    if it's satisfactory now, it is justified to consider all

                   the additional staff to such an enormously  large-staff  that
             21

             22    is proposed.

             23              The Regional Advisory Group which, until  a  couple
             24    of years ago, numered only twel've, has been increase4, I thin-,,
             25    by two stages to a total of 55 members, and it  appears  that

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         em4l                                                               2 69


                    it is satisfactorily supervising the activities of the

               2    program. In the fourteen montlas-before this application

               3    there were four Regional Advisory Group meetings, I think

               4    eight of the Executive Committee, and several of  the  various

               5    technical and standing committees,
               6              So the committee structure has continued to functio@

               7    and the Regional Advisory Group also said that there is a

               8    fifty percent attendance rate at these several  RAG  meetings.

               9              Past performance and accomplishments, 1 think ate

              10    mediocre for the most part.  I found it difficult to either

              11    say satisfactory or poor or inadequate

              12,             Considering the amount of money that this program

                    has gotten in the past, it is difficult for me to be more
              13

              14    generous in my assessment of this.

              15              In the past there was a very large  investment  made

                    in a lot of computer centered activities, and I guess that

              17    this still remains with me, although it's all gone from the

                    present application.
              18

                              We thought, those of us who visited it,, that  there
              19

              20    was bad judgment and even, perhaps, appropriate for the State

                    of Missouri
              21                 mulishness about following the direction and

                    guidance that we attempted to give.
              22

                              The objectives and priorities seemed to be satis-
              23

                    factorily stated.
              24
                              I think that the proposed activities, and I can
              25

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      em42
                    summarize briefly the categories  are  satisfactory  but  not

                2                    e feasibility, that is, the likelihood that
                    imaginative.  Th
                3   the activities proposed can be accomplished in the    ime  that
                4   they anticipate the program will continue is, by th i
                5   own statement, likely in some  and  unlikely  that  the

                6   manage in others.
                7              For example, they -state that all the EMS activiti s
                8   that they-have proposed, and I  will come  back  to  thIis, there
                9   is a question pertinent to the   one Dr. Scherlis raised
              10    earlier, whether or not these   are new EMS activiti  s;  but
              11    they say that they feel  these  activities can be up  q, raded
              12,   in the next year.   I really ,7onder whether that is  Is 0.
              13               The cooperation with CHP seems to be  quite

              14    satisfactory.
              15               l@ over-all assessment of the region  is  that  it

                    is only average.
              17               I am afraid I have more comments  and  remarks  to

              18    make.
              19               In this Regional Medical Program there appears to
              20    be no serious problem in the  relationship  of  the  grantee,
                    which is the University of Missouri, and there-never has beer,
              21
                    and that continues to be,-i gather, a satisfactory relation-
              92

                    ship.
              23
                               MR. TIIOI.IPSON:  You'don't shoot Santa Claus.,
              24
              25               DR. McPIIEDRAN:  No, not intentially.

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          em43                                                                 2 7 1


                               The major thrust that  they have stated for then-

                2
                    selves are five:  emergency medical systems; health;

                3
                    manpower; education, and under that category especially

                4
                    training people to deal with the problem of high blood
                5                                                          1         1
                    pressure, and training seminars to be conducted for many

                6
                    categories of hospital personnel.

                               Third is listed as  integrated  health  care  delivery

                    systems, with especially heavy emphasis, as I see i,:, on

                9
                   -supporting hospitals in developing JCAII type criteria, and

              10
                    also a problem of oriented records for local practi ioners.
              11               Ambulatory care systems, particularly con@erned
              12@   about availability and of care.

              13               The purposes, the major thrusts are as general

              14    I'm quoting from the application  there;  just  general,  as  I'm

              15    stating them to be -- systems for-end-State  -@-  kidney  manage-

              16    ment.


              17               Their fiscal year  175 suggests that their EMS

              18    role will be completed, and   the local communities will be

              I!)   able to take the  developed  programs  and  projects  and  handle

              20    them on their own, although I don't  think  that  my  reading  of

              21@   the application particularly supports that.

              22               Then I went through the request for funding,

              23    including  changes in core staff.  I. spent less time, I

              24    must say,  on the continuing pro  ects, but a good deal of

              25    time on the new projects, and tried to dig out for my own

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      em4A                                                                     272
                I   purposes what I thought was a necessary expansion    of core

                2   staff.  And what I questioned might be new EMS projects, and

                3   I realize the staff might have gone through this and may want

                .4  to, perhaps, dispute my judgment.

                               The excisions that I performed enabled me   to  cut

                6   their proposal from $3,010,113 down to $2,295,113.     I  felt

                7   that there was $713,000 that   could and in my view should be

                8   removed from the proposal; and it  happens  to  coincide  with

                9   what staff, in the person of t@irs. Resnik# has  recommended,-

              10    and I guess it also coincides to some extent with    the

              11    targeted amount.

              12,              But I think it is worthwhile to suggest  what


                    specific things there were.
              13

              14               There were, for example, requests for what amounted

              15    I think, to increases iki core staff. They have six district

              i(i   consultants, and the recent staff  site  visit  suggests  that

              17    they should be continued.  I have no quarrewl with that.

              18    But there is a suggested sum of $31,000 by sub region to

              19    increase staff support for tl7e distrist liaison to $186,000;

              20    and I will quote from the application xqh.at the ultimate

                    justification is.
              21

              22               It is said that the specific outputs would be a
              23    plan and method of implementing the plan to operate under
              24    the new legislative  athority.  If  no  legislative  authority
                    is forthcoming by fiscal year 176,'this  year-Is  effort  will
              25

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                                                                           273
       em45


                   have been one of which the Missouri Regional Medical Program
               2   can well be proud.  We will have'brought toge-ther at the

               3
                   working level members of principal federal and State health
               4   agencies, to work toward a common cause of improving the

                   Statewide health care system, and I think that I would really

               6
                   have felt that even in a rorm 15 something more specific than

               7
                   that could have been given me as a peroration to convince
               8   me that that money ought to have been spent.
               9             There are other things in there that I  feel are

              10   similarly if not worthier of support.  I won't bother you with

                   the details, but I do want to mention that I thought that

              12.  there were about around twelve, as I see it, new projects,

              13   no EMS, twelve, roughly, totaling around $245tOOO, that I

              14   just don't think are in the guidelines, are they?

              15             MRS. RESNIK: We're treating them as sub-components

              i(i  of already existing and ongoing EMS projects, which is

              17   essentially what they are. They are dealing with training,

              18   but in different locations.  And they tell us that they

              19   understand that that is within their authority under the.

              20   present guidelines.

              21@            They are applying  to the  EMS bureau, but they

              22   don't foresee any grants.

              23             DR. McPHEDRAN:   This looks to  me like new EMS,

              24   and so that's 245,000, and then  going thro'tgli some other

              25   projects, I noticed this, but I  did it an@iay,, I thought there

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       em46
               I    were several things,, like there's a quality criteria
               2    project in a hospital in Jefferson City, and it looks to me
               3    as if that really is PSR activity, and I wonder if that

               4
                    similarly should be excluded.

                              And several other things that also  seem to me un-


                    suitable.

               7
                              So that, in summary, what I did was I felt that

               8
                    at least $715,000 could come out of it, and I came.out with

               9
                    a recommendation, as I say, of $2,1295,113, which is obviously
              10    unreasonably precise, but it is approximately where the
              11    targeted sun is.  I would have no quarrel if we said the
                                                                     I
              12!   targeted sum would be satisfactory; and I would like to know

              13    what Dr. Miller thought about it.

              14              MR. ClIP14BLISS: Dr. Miller.

              15              MR. MILLER:  .This is an interesting experience we

              16    all go through.  I pursued a rather different and more

              17    devious route of arriving at the same  conclusion.

              18              I have known the Missouri Regional Medical Program

              I!)   for a long time and many of the staff people on it, an
              20    perhaps it is worthwhile to mention a little@ of the background

              21    on this.
              22              @lhen R14P got started, Missouri was really ready,
              23    because Missouri was more regionalized      in the medical
              24    establishment than most any State in the'union, having their
              25    medical school in Columbia, which 'is a small, a relatively

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        em47                                                                   275

                1   small city, and therefore, having had to farm  out  clinical

                2   medicine for a long time into other communities, which is

                3   almost never done in most of the other medical centers in

                4   the United States, and which was extremely repugnant to them,

                5   as you may all remember.

                6             So Missouri was, its time had  come,  and  the  mule

                7   characteristics recognized this, and they proceeded with

                8   vigor.

                9
                              They also had some people in the leadership posi'tio-i

              10    who have,considerabl.e skill in recognizing political

              11    expediency,, and when it is popular at the national level

              12,   to spend money onlelectronic  computer  equipment  and  remote

              13    control things, they were in there for millions and got @em.

              14    When it is politically expedient to turn th4m. off, they

              15    turn them off like it w4s a water  faucet.  Tqhich  they  have

                    now done, because something  else  is  politically  exp
                                                                          edient.


              17              I have four applications that are mine that are

              18    coming up today, all of them are somewhat similar.  And

              19    Dr. Schleris' comments previously have botlired me, yesterday

              20    and today and last night, and even lose.a little sleep over

              21    it.

              22              Because the principles formally ascribed    to

              2.3   Regional Medical Programs  of  quality  programs,  well evaluated
              24    demonstrations that are woth the,money, seem to be all gone,

                    and I suppose it seems a matter of political expedience, but
              25

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            em48                                                                2 76

                1   it looks like weire stuck anyway.  But it is bothersome.

                2   And in these four programs that are corung up, they all have

                3   applications, they are going gung ho for election, it's

                -4  politically expedient to get the money and they're out to

                5   get it.    And by whatever most clever mechanisms they felt

                6   could be used to get it, regardless of whether it is cost

                7   effective or will be continued really, or what the ultimate

                8   goal is.

                9              Noxi,, Missouri has done it to a.ratlier  great  degree.

               10   It has     it doesn't have an escrow   item in here,'a develop-

               11   mental fund item, but its method will  give  it  a  nice  big  one.

               12.             There are separately described staff component

               13   projects,, 26 of them in this application, either with a

                    dollar amount, none of which is excessive by itself; but
               14
               15   together is nice.

                               There are six district  liaison  systems  with  a  total
               16
               17   budget of $186,oob.  They went all out on EMS without
                    having a general State EMS  plan,  which  is  forbidden,  so  there
               is

                    are five continuations and el@-ven new EMS projects, for a
               19

                    total of $518,000.
               20
               21              It would be some little job to keep them coordinated.
                    Maybe they will need those district guys to keep all those
               9-2
                    different outfits working in any kind of    a rational coordinatin  g
               23

                    way .
               24
                               I could ao  on in more details, but I think I will
               25

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      em49                                                                     277

                1   say,, first, hoviever, that a little bit in contrast to Dr.

                2   McPhedran's view, I feel that the basic questions that we're

                3   supposed to answer on this review sheet, most of them

                4   relative to other RTIP'S, you'd have to grade Missouri as

                5   good to excellent.

                6              The program leadership, you may not like them, but,

                7   they've done a good job in  Missouri.  The  program  staff  is

                8   equally so.

                9              The Regional Advisory Group, they  get  along  with

              10    very well.  It's a little funny, but it works.

                               Their past performance  and accomplishments,,  they

              12.   have been  a leader in Missouri without any question. They

              13    have lead  regionalization in Missouri to a phenomenal

              14    degree, and they have more general acceptance than many

              15    other regions.

                               Their objectives and priorities I  would interpret

              17    As political expediency, and they have done   it extremely

              18    well.

              19               The feasibility, of course,  is.very  low,  because

                    we are theoretically supposed to grade these things on whether
              20

                    they can do this in one year, and they obv'lousl@-can't
              21

                    possibly do what they've got in this application.
              22

                               They get along fine withCIIP,, they,support them in
              23
       f            many ways.  So they will get -go'od'acceptan6e .by them.
              24
                               The total picture, 26 staff  component projects and
              25

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        em5G                                                                   278

                    27 continuation projects and 19  new projects.

                2              Much of this is overambitious for   one-year concept,,

                3
                    and it looks like it cannot be accomplished.

                -4             MI, conclusion: I recommend  funding,  however,  at

                5
                    the targeted level, which I think it is a way out of the

                6
                    dilemma of coming up  with  adollar figure.

                7              MRS. RE.SIIII,',: They are coming in with a $500 request

                8   July 1, they indicate.

                9
                               DR. MILLER:  We will address that t-i,7o mo ths from

              10    now.

              11               MR.  CIW93LISS:   All right, each of the
                                                                         reviewers


              12.   has cone up with a different amount here.

              -13              DR. McPHEDRAIT: Well, T really didn't make that'in

              14    the form of a motion.  I have no quarrel with

              15                   f4ILLER:----,Ohl I wbil-ldn't@mind if he 'd
                               DR                                      wante -t6-

                    figure out how you can justify c-'oming out  with  $2,295,113.

              17    I'll go along with it.

              18               DR. McPHEDRAII:  I will move the target amount,

              I!)   which is $2,364,333.

              20               MR. Cl,'Al4BLISS:. Is there a second?

              21               DR.  MILLER:  Iwill second.
              22               MR. CIIMIBLISS:. It is moved and  seconded  that  a
              23    recommendation for Missouri be the-targeted amount of

                    $2,341,490.
              24

                               DR. IIcPIIED@@:  I ]-,now you were probably semi-
              25

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        em5l                                                                2 79

                   facetious, Dr. Miller, in saying that tlle changing  in  the

               2
                   computer or the electronic program direction which had

               3
                   developed so many electronic aids to care  that  was  turned-

               4
                   off like a water faucet. In fact,  that  really  wasn't  so.
               5   It was damn hard to turn them off.  I mean it really was

               6
                   hard. It took a great deal of  effort  and  persuasion,  and

               7
                   determination, and repeated  visits, and Bob-Toomey
               8              DR. SCHERLIS:  It has not been turned off, the

               9
                   output has been changed.
              10              DR. MILLER:   Excuse me, I should make a comment.

                   I have been through this with several other JU@IP's, some  of

              12.
                   which I made site visits  on also as a coordinator.

              ..13            I agree with you. The  electronic  fanaticism  in

              14   our society is extremely difficult to turn off.  lqe  had  it

              15   in T@iany others.  Georgia was a good example, when I was down

              16   there.


              17              But it has been turned off now in almost all


              is   PL,IP S.


              19              I-IR. ClIM4BLISS: May I restate the recommended-

              20   amount for Missouri as.being @2,364,333..

              21              Is there further discussion?


              22              I call the question.

              23              Those in favor of the motion, please  indicate  by

              24   the usual  sign of voting.

              25              [Chorus of "ayes".]

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                              MR. CIIA@IBLISS:  Those opposed?

               2              [No response.)

               3              MR. CIIMIBLISS:  The motion is carried.

               4              DR. SClil@RLIS: I ask one question now that you've

               5   voted on it.


               6              This relates to the fact you said they had a great

               7   many different types of EMS activities, and  you  questioned

               8   coordination.  Is that correct?

               9              DR. MILLER:  Very difficult to do' this with  this


              10   many separate components.

                              DR. SCIIERLIS:  You mean they are making no

              .12  effort to  coordinate it?  Is there any umbrella EMS for the

              13   region?

              14              DR. MILLER:  No, no.  They would hope to get one.

              15   But  in  the meantime they are going to have all of these
              16   various sub-components v7eldh are 'allowable.

              17              MR. THO@IPSON:  Mr. Chairman, would you transmit our

              18   unease about the EMS situation in Missouri to the  EMS people?

              19              MR. CII@"4BLISS:  We 4,iill, indeed.  We are much

              20   aware of the discussion here, and we will be.in  touch  with

                   the EMS people,
              21

                              DR. SCHERLIS:  I would almost suggest that we give
              22

                   no EIIS funds if they are to be used in disparate  programs,
              23
              24              In the State of Maryland we have had examples  of

                   what is. now a large State support of some $2.4 million  throu(rh.
              25

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         em5 3                                                              2 81

                   the Covernor.  In the face of what are already small EMS

               2   activities and some not so small', and you will spend  endless

               3   dollars trying to coordinate what are programs  that  begin-

               4
                   with noncompatible equipment, noncornpatible standards,

               5   noncompatible operations.

               6
                              And I would think that if we perpetuate such

               7   support, that we will be causing an excessive amount of funds

               8   to have to be spent later on.

               9              Some training programs will differ, criteria  for

              10   State certification will differ because you will  be  training


              11   at a different level.

              12,             I think part of the insistence tha'L. we should  have

              13   would indeed be that these be coordinated,, regardless of

              14   what the ground rules are. Otherwise, we  should  not  support

              15   any EMS activity whatsoever.

              30              I feel very strongly about that, having spent a

              17   good part of my energies in Maryland, because of the very

              18   reasons that we have had different types of funding,

              I!)  different community structures and  different  involvements.

              20   We would be undoing a great deal of what has been done in the

              21   past.

                              MR. CIIAMBLISS:  The EMS people are moving towards
              22

                   State plans and State systems, Statewide systems,
              23

                              DR. SCHERLIS: But if you give money to that  group,
              24

                   they will do their thing.  The hist ory of our society is
              25

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                                                                            2 82
        em5 4
                    that everyone does his thing if he has the wherewithal   to

               2
                    do it,, and I would assume that by making separate structures
               3    administratively, with our own means of support,, they will

               4
                    do their own thing.

                              I hope this won't be true of Missouri.

               6              MR. VAN WIIIKLE:  Vie did that in I-,idney, you know,

               7    Len.  If that did meet with within the State  plan  itself,

               8    nothing was approved here.

               9              DR. SCIIERLIS: But we have this  leverage  over-

              10    these programs,, I gather from some of the feeling that  we

                    don't.

              12              MR. THODIPSON:  You see, the problem is that many

              13    of the States do not have State management.

              14              MR. CIIAIA-BLISS: A good amount of  our  previous

              15    funding for El-IS has resulted in the,development of State

                    plans.  I can assure you of that..

              17              DR. IIILLER:  Can I make some  comments?  I  have

              18    been connected with this at the local  level.  Although  I

              1!)   don't pretend to know it all-, I know quite a bit.

              20              EMS systems started out with an office of

                    Transportation funding, which is very large and  many  have
              21

                    them -- there are many of them in the  United  States.  We
              22
                    happen to have a very large onein  Minnesota.  And  they're
              23
              24    buying ambulances. They are h6aded by  ambulance  drivers,,
              25    by and large; they're buying ambulances and training ambulan(e.

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         em55                                                                         283

                      attendants,  and  setting  up  standards  for   their   performance,

                 2
                      and  that  funding  is  precluded  from  doing  anything   with.the
                 3    patient except delivering him to the door of       the nearest

                 4
                      hospital.  It cannot go any further.

                                 lihen EIIS incentives started  with  M,!P  here  a  couple

                 6    of years  ago, why,  the  focus  was  to  try  to  get  comprehensive

                 7
                      planning  for  comprehensive  care  of  emergency   caseslland   to

                      face the  issue about what happened     to  the  patient  after  they

                     'got inside the hospital.door.  And      so many IVIP's un(  r oo

                10    to do this, And many of us supported planning       for c riprehensire

                11    emergency system development in the States.
                12.              Then E.',,IS bill came through,  and  it  seeme.d@like

                la    that this  was  going  to  take  over,  the  over-all   coordination;

                14    but this,, as usual, has not happened.

                15               And  the  leadership  there  doesn't  seem   to have   the

                16    capacity yet for attacking the whole problem.

                17               So  at  the  local  level  the  possibilities  of  local

                18    B agencies or regions or districts within the State of

                1!)   getting funding through the new EMS bill was really quite

                20    remote and they came back to RMP in most of the local          levels

                      to do this.
                21

                22               So there are three separate fragmented kind of

                23    programs for  EMS  in  this  country  right  now,  and  they're  not
                      coordinated at the  national  lev'el,  and  the  attempt  of  RIIP's
                24

                      is to try to get coordination     at  the  local  level,  which  we
                25

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        em56                                                               284

                   have always been challenged to do in the IUT management

               2
                   system.

               3
                             MRS. I-IYCI',OFF: But if you offer them money and
               .4  say, If you will make a State plan and you have thi,[ money,

               5   would this create a climate?

               6             DR. MILLER:  That's exactly what we did two years

               7   ago.  Many of us did it two years ago.
               .8            -1-le paid for the deve lopment of some kind of a  State

               9   plan.

              10             DR. SCIIERLIS:  Not necessarily.  Iwas c  irman

              11   of the EMS Committee nationally that reviewed all    e

              12.  pro3ects that came in, and these weren't, except in rare

              13   instances, State plans. And I'd say if you look at  the  whole

              14   United States now, there are very few States  that have any

              1.5  semblance of a State plan.  Maybe two or three.

              1(;            DR. MILLER:  Now, there's a good difference  between
              17'  a good State plan and a State plan, so I'm not saying  they're

              18   good; I'm just saying
              1!)            DR. SCI-IERLIS:  My only concern here is that I hope
              20   in whatever letter goes out indicating funding that one
              21   proviso of that letter states that each of tliese-areas have
              22   set up compatible systems, that there has to be a plan

                   utilizing all their forces.  I don't think that this state
              23
              24   is large enough to have individual areas designated as they
              25   have, unless there is some over-all State compatible plan of

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                                                                             285
        em5 7

                     communications and eve rybing else that goes into it.
               2
                              I would think that unless we put  that  into  whatever
               3
                     support letter we send out, this will be something that will
               4
                     have to be dismantled later on and will have to be
               5
                     fragmented.  That's the only point of my observation.
               6
                              MR. CIIAIIBLISS:  We do appreciate these  observations
               7
                     that the panel has made.
                              We have at the  table Mr. Mike Posta, who coordinated

               9
                     the EMS activities for the P14.Pls, and he indicates to me that
               10
                     of the 23 site visits that were made by staff over the last
                     year, that the majority of them had, as  an effect of the
               12!    11                                               i
                     support, the development of State plans.
                               And we will keep in mind your admonitions for

               14
                     lessening fragmentation and more coordination between the
               i5
                     three federal agencies that are supporting EMS activities.
                               I want to assure you that P24P has already been in

               17
                     contact with the Emergency  Medi.cal Service Program here,  and
                     agreements have been reached as to what we probably might
               19                                 0
                     fund and what their area of responsibility  is.  And  I  assure
               20    you those discussions will continue before these funds are

               21
                     awarded.


               22
                               I would call to your attention

               231
                               MRS. RESNIK:    May I add one word about the Missouii

               24
                     El@ program and the thrust in  this application?
               251             It was stimulated, by and large, by  the  passage  of
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       em5 8

                     State Law 57, which set forth standards and requirements for
                2    equipment on ambulances at various training levels,:   to  the
                3    extent that these programs involve   program with 1    ttle

                4
                     training, and that is the majority   of the new acti   ities,
                5    it is not new in the sense that they are treating       new

                6    as ect of EL@IS.  They are training at various level  to
                       p
                7    conform, or their existing training to conform to      e

                8
                     state requirements as described in the law.

                9
                                And that is why,it looks fragmented, but it is part

               10    of eventually a total training system.

               11               I raised the question with  them  about  equipment

               12,   a4d various items of that sort, and there was still! a

               13    considerable number of dollars that has  to  be  looked  into.

               14    But there was a major point in establishing these as separate

               15    activities to conform to the State law.


               I(;              MR. CYIPIIDLISS: I think we have already had a vote

               17    on Missouri, and the discussions we have  been  having  is  an

               18    add-on.

                                I would simply suggest to the  committee  that  it

               20    mall wish to take a coffee break at this time;  and,  if  so,

               21    maybe we could return at 10:30, 10:33 with  our  -coffee  and


               22    resume.

               23               [Short recess.]

               24               MR. CliAt.4J3LISS: May I call the panel to order

                     again please, and indicate to  you'that  I  gather  that  the
               25

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                 em59                                                                                                                             287

                                      other panel  is  moving  quite  well  --  and  so  are  we  --  and

                              2
                                      suggest  that we  might  take  a  look  at  the  application  from
                              3
                                      Nebraska  Regional  lledical                       Program.

                              4
                                                         Yes,  Dr.  Thompson?
                              5


                              6



                              7






                              9


                           10






                           12.





                           14








                           17


                           18


                           19


                           20


                           21,


                           22


                           23


                           24


                           25

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         em6O                                                               288


                                   REGIOIIAL 14Er)ICAL PROGRAT4 REVIE@L

               2                           NEBRA SI'@A

               3
                              MR. TIIOMPSOIT:  I guess Iam the only one.

               4
                              MR. CHAMBLISS:  Yes, you are the reviewer, and

               5
                    the staff support will be provided by Zivlavsky.

               6
                              Will you proceed?

               7
                              MR. THOIIPSON:  I will.

               8
                              Nebraska has not been the most flaming W4P among

               9
                    the 53.  It's relatively small in amounts of money granted.
              10    It never.achieved triennial review.  Its status. has always
              11    been on an annual basis, although there were indications,

              12,   I understand from,staff, that they were going to apply for

              13    triennial review one month before the famous letter zipped

              14    down to tell them to phase out.

              15              They have a new man there who has only been there,

              iti   I think, a couple of months, about half time.  I expected with

              17    his history a far less professional job on that proposal

              18    than the one, I find before me.

                              Actually it indicates to me far more strength in

              20    the region than has ever existed before.- I don't know exactly

                    what happened to cause it.
              21

              22              I wish that every report we ever had did what

              23    Nebraska did very early in their proposal.  There is Exhibit 1,
                                                   11
              24    qoals/objectives, and they are fairly well spelled out.

                    Both the goals and objectives.
              25

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                                                                            2 39
         em6 1
                             lihat hay.5pened was that when they got  the  letter,

               2
                    the original RAG began to fall off and they then reappointed
               3    a committee for the phraseout, which consisted  of  selected

               4
                    people within RAG, and they began the  phaseout  operations,
                    and then when the breath of life came back into the program

               6
                    they selected from this committee, the  phaseout  committee,

               7
                    thirteen people from RAG, so they only have thirteen people

               8
                    in their RAG at the present time.

               9
                              Ilowever, when you look at the makeup of this
              10    committee it is very widely represented.  They  have  a  lot
              11    of public representatives, and th ey do have one Indian
              12.   representative amon the twelve, so there  @;zas  an  attempt
                                       9
              13                                                       in   this
                    to retain at least A Statewide representative RAG

              14    small group.
              15              I think what we have to think, to regard this, we
              i(i   have to remember the goals, and the goals are not all that
              17    innovative, but they are good solid goals, and I think they
              18    are within.their reasonable capacity of  Nebraska  to  carry

              I!)   Out.
              20              One of them is kind of unusual, in that their
              21    Goal No. 3 has the specific objective to stimulate the
                    development of comprehensive home health care systems.
              22
              23    In other words, they have really gone all out for home healtlk

                    care systems.
              24
                              Their goals, toughly, in broad terms, there is a
              25

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            em62                                                                                                                                  290


                                      planninc
                                                    .j  goal,  there  is  manpower  training  goal,  there  is

                              2
                                      this  goal  of  home  health  care  systems.-  There's  the  data

                              3
                                      reporting  analyzie  kind  of  goal.    And  then  the  last  goal  is
                              .4      the  facilitator,  coordinator,  gathering  people  together  kind
                              5
                                      of  goals.

                              6
                                                         But  in  each  one  of  these  broad  goals  there  are

                              7
                                      specific  program  type  objectives.
                              8                          And  one  must  say  that  there  is  a  very  close

                              9
                                      relationship             between  these  goals  and  the  kinds  of  programs
                           10         that we  see  coming  up  in  the  proposal.
                           11                            Now,      at  the  present  time,                  they  have  been operating
                           12.        at  a  level  of  502,000.    I  said  they                           are  one  of  the  smaller

                           13
                                      programs,  I  think  they  are  one  of  the  four  smallest programs,.

                           14         as  far  as  money  is  concerned.

                           15                           Their  target would be  some  868,1000.    This  package

                           l(i        here  is  962,000  with  an  indication                             that  they  will  be  coming
                                                                            request
                           17         in with  an  additional/of  $150,000.

                           18                           So  we  then  have  a  program  that  is  kind  of  climbina

                           19         up  beyond  their  original  base  level  support.    The  program

                           20         that  probably  would have  gotten  triennial  approval,  if  the

                           21         funding  thing  hadn't  changed.

                           22                           Now,  in  general,  they  --  the  most  recent  change  in

                           23         this  program,  as  it has  been with  most  of  the  other programs

                           24         weave  seen  today,  was  their  relationship  with  CIIP.    They

                           25         decided  to  start working with  the  various  CIIP  agencies  within

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          em6 3                                                                29 1

                     the State, and they have more or less redefined their

                2
                     mission within -- still retain their goals.

                3
                               Therefore, on Nebraska   Regional Medical Program, its

                .4   mission is toward cooperative work with A  and  B  agencies  in

                5
                     14ol.)raska State Department of Ilealth, in an attempt to match

                6
                     those health care  providers who have a need for service

                7
                     with those resources  capable.of  responding  with  services

                8    with the ultimate purpose of improving  the  health  care,  for

                9    all Nebraska citizens.


               10              So that this  is kind of a redefinition  of  its  own

               11    mission, vis-a-vis the  CHP agencies.  It is not all too

               12.   clear from  the  proposal how well this is progressing.

               13              Several   other projects that we  will  be  talking

               14    about actually came from  B agencies, and in  one  B  agency

               15    right off they said it @,iould be unfair for us to write off

               ].(i  on this, because actually we were  involved  in  gathering  the

               17    proposal and designing the proposal.

               18              There are other sections where there is an absence

               19    of a writeoff or a signoff by B agencies  or  A  agencies,  and

               20    others where the A agencies and  B  agencies  in  particular

                     indicate a very positive vievi toward the projects'.
               21.

                               So it's kind of spotty.  I will try to have the
               22

               23    staff elaborate on this, because, although it's evident they
                                                     e
                     are trying to cooperate, how successful they  are  is  a  whole
               24

                     nother question.
               25

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         em64                                                                292

               I              Now, when you look at the  proposal,  and  it's orobably

               2    the thickest one in this go-around, it seems rather awesome

               3    until you realize that it is a  fairly  simple  proposal.

               4    They put their money on two things, an A  hex  kind  o  a usine s

               5    which they believe should be, like  Memphis,  to  cove  afairly

               6    smallregion, and if you were concerned over tlae  fact  that

               7    some of these area community healtl-l-education  consortia,

               8    as they call them here, or hospitals  in  Memphis,  yo  will

               9    kind some of them are nursing homes in  Nebraska,  be--ause

              10    their primary concern is with that level of traininj.

              11              So, of All the projects we're  talking about, there's
              12,   these two main thrusts, the A hex type thrust, @-zith@,a

              13    nationalized learning -- I mean.a Statewide learning

              14    resource center, and then some one, two, three, four, five,

                    six specific regional agent type outfits.

                              Surprisingly  in this proposal, there  are  eleven

              17    different home health proposals, hone care proposals, some

                    of them defined in one way, home health  satellite  or  the
              18

              111)  day-care service for elderly and disabled;  and  they  have
              20    these scattered throughout the State, mostly based in

                    nursing home type places. They are  trying@to  get-  nursing
              21

                    homes for whatever few little bits and  pieces  of  visiting
              22

                    nursest associations they can find, and beginning to design
              23
              24    a global hone health backup pro4ram, for the elderly in
              25    various parts of the community.

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          em65                                                                 293

                               And of course this is, as I said, these two tjirusts

               2
                     are in line with their Goals No.'2 and No. 3;  and  the  rest

               3
                     of this rather large list of variety  of  programs,  nurse-

               4
                     physician programs in the cities, shared hospital resources,
                     which are not unusual, they are all small.  They run from

               6
                     12 to 33 thousand dollars.  It's obvious they're shoving this

               7
                     money into programs that are in existing institutions.

               8
                               There is  this problem of their renal program,

               9
                     which is the largest  of all these non ---A hex non-home  health
              10                                                        i
                     related outfits.  lqhich I will allow Staff to respond to,

                     because it looks like  afairly shaky business,  all  in  all.

              12.
                               I'd like to hear from staff.  I'm  going  to  use

              .13    him, if you don't mind, as kind of  a  secondary  reviewer,
              14     because my secondary reviewer isn't here,    And let him
              15     particularly elaborate on the problems of the interface with
              16     CIIP's and with the kidney problems, and any  other  comments

              17     he may have on  Nebraska.

              18               MR. CHAIIBLISS: Mr. Zivlavsky,  will  you  comment,

              19     please?

              20               MR.  ZIVLAVSKY:   The Nebraska.application is
              21     576  pages.  Dr. Iless, three years ago, made a site visit

              '-)2   out there, followed up ]3y a site visit approximately a year

              23     and a half ago.

              24               There was a major shakeup out there.  They follu,-;ed
              25     up on many of the concerns from the first site visit.  They

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                                                                                                                .29  4
               em6   6
                              increased their program viability and they were just   as any
                       2      upsweep    to    come     in     for     a     triennial     anniversary     application
                       3      when    our    phaseout    letter    hit    them    right     between     the     eyes..
                       4                    Some   of    the    good    things    that    they    have    been    able to

                       5      do    have    been    their    efforts    in    indirect     costs,     for     example,

                              have been less  than five percent of their total costs.

                       7
                              Over   the   past   two   years   they   have    really    been    able    to    do    a

                       8
                              good job in this  relationship.   They receive a few stars for

                       9      that,  at least.

                     10                      In    the    area    of    minorities,    the    State     has     approxi-

                     11       mately    2.7    percent.    They    have    worked    in'the     area     of     sickle

                     12.      cell    screening    for     the     entire     black     community     of     Lancaster

                     .13      County, which is in the Lincoln area.   They have worl,,ed

                     14       with a mobile cancer bus in terms of screening the Indian

                     15       population.
                                             The program staff has            provided     assistance      to      the

                     17       Panhandle      community.action,      which      involves      the      migrants       and
                     18       Indians but in western Nebraska.   In their phasein they
                     1.1)     have    hired    an    additional    min@rity    --    I    should    say    they     lost
                     20       one    minority    person    in    their     program     staff.     They     were     able
                     21       to hire another minority person on their program                         .staff.
                     22                      I   am   not   sure   --    they    come    in    with    an    application
                     23       requesting no people.   Pres@ly they have 11.5  full-time
                     24       equivalence.   I think they can use a couple of people to help

                              them in the monitoring area.
                     25

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       em67                                                                        295


                                I don't know.  That's  up  for  discussion  or  grabs,

                 2
                     I guess.

                 3
                                I like the comment  on  the  negative  CIIP  comments,

                 4
                 -   and on page 345 of the application, specifically commenting

                     on Mr. Thompson's CIIPA comment, the    reason the CI-IPA  agency
                 6   withheld  comment  was  because  they  developed  the  proposal

                 7
                     and they were actively involved, and I believe they felt it
                 8   was a conflict of interest.     So they backed off, and this

               .9    was one-of the reasons that they did not comment.

               10               The second negative comment is on project No.      47,

               11    and again the  CHP  agency  has  commented  that  this  project

               12.   lacks specificity.

               13               The program staff is following up    on this particular

               14    project, and  it  involves  the  Omaha  and  Winnebago  tribes,

               15    and  basically  there's  a,rnisunderstanding  that  the  outreach

               l(i   from the community health representative in the community

               17    population, the CHR'S.  they  assume  that  you  have  much  more

               18    time than really is available,- she has  a  half  a  day  a  week

               l@)   for outreach  activities,  and  they  didn't  really  get  this

               20    clarified before  they  submitted  the  proposal  to  the  RAG.

               21               The RAG again  is  following  this  up  with'  program

               22    staff and  I think they can negotiate this difference.

               23               The renal project, DPJIPS,.Dr. Mathis, the present

               24    coordinator,  if  he  would  not  seek  out-of-State  technical

               25    consultants,, and he agreed to do this because all the people

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                                                                                29 6
        em6 8
                     within the State of Nebraska  have  been  involved  in  their

                2    project.

                3
                                Yesterday we received a letter from   the   associate

                .4   coordinator for program services, attached to    three@comments

                5
                     basically from the technical reviewers.  All three  ad,
                     negative technical comments,.reducing the budget from

                7
                     approximately $51,920 down to 15  or  20  thousand  do.Llars.

                8
                                These comments have  not been submitted to@their

                9  -regional  advisory  group,  however.  The  Regional   Advisory
               10    Group will be meeting this following Friday',   reacting   to

               11    these negative comments.
               12,              Basically what  you have is a questionabl  e@
                                                                             ,stance.

               .13   We are trying to ask the   community for some suggestions
               14    or recommendations on what to do with this particular project,

               15    I think I have answered,

                                                  My f
                                MR. TIIOMPSOII:       unding recommendation, they ar@

               17    now 502, the target is   868. This  comes  in  at  962.  There's

               18    a possibility of another 150,000, because there is really no

               1!)   slush fund or escrow,  however,  designed  in  this  program.
               20    All the money is carefully  identified  in  this,  these  little

               21    small programs.
               22               It is Very difficult to cut much of this, but I

                     would make the recommendation they be funded at  9       O
               23
                     which is $50,000 less than the" now have, which reflects thei@
               24                                    y
                     cost of that kidney  program, wliicl-i'I have some doubts about.
               25

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       em69                                                                   297

                1   I am  not going to tell them that this is against the kidney

                2   program,, but they've got to read-.  The kidney program has
                31
                    cost 50,000, we're cut 50,000. And they  still  will  be  the

                4   third smallest program in the country if they  get  all  this.

                5             DR. WHITE: 17ell,, in the past @,7c could say thes.e

                6   technical experts came out. If you go  ahead  and  insist  on

                    each of these, inspite of our advice and their advice,

                8   next time around;they can thumb their nose at us  this   time,

                9   because

              10              MR. CHAI@IBLISS:  Would you speak just alittle

              11    louder, please?

              12.             MR. TIIOPIPSON: I think the  technical  comments  on


              .13   this    I can't see how the RAC:,'can step around them.  It was

              14    unanimous, and I tliink the RAG will just drop that.

              15              So I think we,can put a little hint  in  the  advice

              16    letter.

              17              I move, then, $912,000  for the  Nebraska  proposal.

              18              MR. TOOIEY:  Second 3t.

              19              MR. Clik7-IBLISS:  The motion has been properly

              20    moved and seconded.

                              Is there discussion, please?
              21


                              Question.
              22

              23              Those in favor?

                              (Chorus of."ayes".]
              24
              25              MR. CIIAIIBLISS: Those opposed?

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                   em7O                                                                                                                            298


                                                           [No  response.]

                              2
                                                          MR.  CII@IBLISS:                  r.nhe  filayesif  have  it,  and  the  motion

                              3
                                       carries,  at  a  recoruyiended  level  for  Nebrasl@a  of  $912,000..

                              @4


                              5


                              6


                              7


                              8


                              9


                            10






                            12






                            14


                            15





                            17


                            18


                            19


                            20


                            21


                            22


                            23


                            24


                            25

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                                                                            29 9
           em7l

                                   REGIOIIAL IIEDICAL PROCR7UI @VII',@l

                2
                                            NEW MEXICO


                3
                              MR. CliAlIBLISS: Shall we then move to New Mexico?

                4
                    The reviewers here are Dr. Miller, and Dr. White, with Mr.

                    Zivlavski as staff support.

                6
                              Will the record so indicate that IIrs. Jesse

                7
                    Salazar is not a part of these proceedings, and has absented

                8
                    herself from the room.

                9
                             'DR. MILLER:  The New Mexico application is another

              10    of the umbrella type PIIP applications.

              11              It is an extremely ambitious one, and has an

              12,   application for $2.77 million, when the current level of

              13    funding is $1,.2.

              14
                              forever it does not plan to come in with another
                    application in July,, so,,this is its total application for

                    the next year.

              17              The New Mexico PIIP had    has a new coordinator,

                    and who starts, let's see, May lst.    Dr. Gaye, who has been,
                    in my opinion, an able coordinator in the past, is resigning

              20    as of the 30th of June, but will remain-as a consultant to

              21    Dr. Walsh, the new coordinator.

              22              Otherwise, the program leadership seems to be good,
              2tl   and I presume that this arrangement looks like it will still
              24    provide a continuity and a fairly stable-program leadership.
              25              The program staff seems.to be adequate, and capable

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                                                                              300
        em7 2

                     in general.
                2              The original Advisory-Group, I don't quite know
                3    what they did -- why they did what it did.  I  couldn't  find
                .4   it in there, but they recently padded the Regional  1,Advisory
                51
                     Group, increasing its membership to 120 people.

                6
                               And we've seen that in reverse a number of times

                     in the last few years.   I don't know what will motivate

                     it doing this.

              .9
                               But, of course, it forced the developmen  of   sub-

              10
                     committees to then run the program, and at  least i  seems to

              11     be reasonably satisfactory.

              12.              The past performance and accomplishmentsihave some
              .13    bright spots, and some that maybe aren't quite so  bright.
              14     But in general they seemto be satisfactory.    As  I  felt

              15     their objectives and p@@orities were, also.
                               And the proposal is congruent with the   explicit

              17     objectives and priorities as given.

              18               The feasbility is another one  of  these  where,
              I!)    with the tremendous proposal for a year, it doesn't seem ve@

              20     likely that it can carry out well the projects that it

                     proposes.
              21
              22               CIIP relationships apparently are quite good.
              23               So,, over-all, I felt the program is above average.
              24     And I felt that the -- that if P14P was' going to be continued

                     for another three years  this re
              25                                      gion, like two  or  three

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          em7 3                                                                 30 1

                     others we'vb had yesterday and  today,  would  be  really  well-

                2    established for going gung 1-io ahead on  a  three-year  program.

                3
                                Most of the projects  in  this  application  are  really

                A
                     pro3ects for the staff.  There's some confusion in my mind

                5    as to what constitutes a staff  program  in  New  Mexico  and  what

                6    constitutes an extramural project,  since,  in  most  of  the

                7    projects, why, the WIP is th  e,  apparently  the  sponsoring

                8    organization, and many of the staff  that  are  going  to  be

                9    working on the project are staff people of the Regional

               10    Medical Program.

               11               So I interpreted all except two   of these   projects

                     to actually be  essentially  staff  activities.  Which,  in  this
               12.

               13    case, would mean,, then,, that almost the  whole  program  in

               14    New Mexico is a program, staff management  system  of  staff  and

               15    projects run by the same people.

                                There are two projects  that  are  extramural,  which

               17    they list as the lowest priority,  in  which  it  received  some

               18    unfavorable comments.  So that      which are for a neonatal

                     regional program and -- I for'oget what the other  one  was'.

                     Genetics.  Oh, yes, genetics regional program.
               20

               21               There's one huge  emergency medical  service  that  is
               22    an expansion staff project,  continuing  -.r  it's  a  continuation
               23    project, but it's a huge  expansion,  with  a  budget  of  $911,000

                     Same kind of problem we had before.
               24

                                I don't knoi,,, @@7hat it waq last year. Does the  staff
               25

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        em74                                                                  302

                1   knovi?

                2              DR. WHITE-.    ilelte trying to determine that
                3   right now.  That kind of information is not in any of our

                4   research.

                5              I think since the program'is funded to July 172 for

                6   $52OfOOO.

                7              DR. MILLER:    $528,000?  Well, it isn't such a huge

                8   expansion.

                9              DR. WHITE:   Well, that was for two years.

               .10             DR. MILLER:   That was a t-vio-year program.

               11              DR. WHITE: That was two years?

               12.             DR. MILLER:  That was to7o years of funding?

               13              DR. WHITE:  Yes.

                               oh. this is one year  $911,000- and another one of
               14
               15   their projects, health education for the public, was expanded

                    to $303,000, and I don't know what the previous level of

               17   that  was.
               is              MR. VAN WI@ITKLE:  Project 25.

                               DR. MILLER:  No. 25, health education for tl-ie

                    public.
               20
               21              MR. ZIVLAVSKI:  There is another substantial
                    increase.  They had $175,000 in there, and then about 70,000
               22
               23   for the past six months.  And they.put approximately 225,000
                    in  there.                       e
               24
               25              DR. MILLER:  I have sone'philosophical feelings

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             em75                                                              303

                    about health  education for the public beamed through every

                2
                    possible communication mechanism for one year     for  $300,000,

                3
                    as to what are the  cost-benefits,  and  how  would  you ever

                4
                    know?  And if you can't know, what the devil do youldo it

                    for?

                               MR. OIAMBLISS:    Dr. TIiller,, I think in ail candor,

                7
                    with the reviewers, it should be noted that we had     A staff

                @8  presentation of that project, health education  to  -E-ie  publi
                9   during the last  year.  We  were  not  overly  impressed with

                10  what came out of it.

                11             I say tl,.at just so the committee may   know that that

                12. presentation had been made to the staff.

              .13              DR. MILLER: I think  I  can  complete  my  statements

                14  now with the feeling that this is an over-a@itious  largely

                15  staff programs in an @IP that  is  fairly  good,  and  therefore

                    my feeling is that vie ought to hold our funding to the

                17  targeted level.

                18             MR. CHA14LISS:   Dr. White.

                               DR. WIIITE:    Well, I noted that Dr. Gaye was

                20  retiring.  I don't know Dr. Walsh.-  I knoyi nothing about New

                21  Mexico.  This is the first time I've had anything to do with

                    New llexico, other than the site visits as a reviewer.
                22

                23             Dr. Ilalsh is an unknown quantity, to  me  at  least.
                24  The staff  seen to have the credentials.
                25             My interpretation of the Regional Advisory Group is

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       em76                                                                   304

                    that it was  ex panded to 120 people in.1971, at whose behest
                2   I don't know, but possibly to get the  minority  group  in,
                3   or one thing or another.

                4
                               But, in any event, when the  phaseout came  out, they

                5
                    then began reducing by'-   attrition, and beyond  that  they
                6   also began not meeting, to my  interpretation,  in  delegating

                7   their authority to an executive committee and I think this

                8   is reflected in the fact that the proposals, as I   read them,

                9   are enormously impossible.

              10               If they had trouble spending     I think it   says

              11    in here the number of people they trained   in two years   in

              12.   the EL,,IS program for approximately $250,000 a year, they have

              ..13  no earthly hope of spending 900-some  thousand  in  a  year's

              14    time and getting their money's worth out of it.

              15               I think also that health education to the public
                                             Al .
                    is a hopeless proposition by the  avenues that  they  propose.

              17    I don't why we can convince people to take  aspirin  by  using

              18    mass media, but we can't convince them not to take it.

              19               I-IR. TIIOIIPSOII: Viell, you know, Bayer's advertising

              20    budget is  far beyond anything we put out.

              21               DR. WliITE: In any event, beyond that,  I  would

              22    agree with Dr. Ililler. I  would  consider,this  an  average,

              23    neither bad nor good; and I think it's entitled  to  its  fair

              24    share of whatever money is portioned out, and  I  would  agree

                   to the targeted fund minus whatever is   reserved for  July,
              25

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                                                                                                                30  5
   iHD46               1     and let it go at that.
                       2                    MR.  C117UIBLISS:       Dr.  Scherlis.
      WD fls           3                    DR.    SCIIERLIS:    I    looked     at     the     Emergency     medical

                       4
                            Services, which constitute a great part of their budget,  and

                            in    reviewing    it,    I    asked    some    serious    questions    a'"-out    it.    It

                       6
                            looks at what is the easy side of the Emergency Medical
                       7    Service,  the trainee          and the 'Vehicle end of it, but in terms

                       8
                            of looking at a system of care,  there are some serious

                       9
                            questions.
                     10                    Maybe   I   could   just   spend   a    minute    or    two    on    this.

                     11                                                         's
                                           Under    objectives,    it     look     at     training     and     coinmuni-

                            cations, which really consisted of                  developing a st        atewid--

                     13     emergency communications system linking all hospitals and

                     14     ambulances together,  then@-to create a crisis center to inte-

                     15     grate all communication links.

                     16                    I    guess    the    question    I-have    is    something     that     maybe

                     17     they.have not included in this,  although they have about 40

                     18     or 50 pages devoted to it, and I                 would    rather    see     that     than

                     19     all    the    individual    sources,    and    that    is,    are    they    are     talking

                     20     about characterization of care?

                     21                    I see the reference that this is an important aspect,

                     --)2   but   if   you   are    going    to    have    people    talking    to    people,    they

                     23     should talk to them about somethbg aside from the fact:

                     24                           "We're coming in          in a hurry; weave got some

                     25            sick people aboard.

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                                                                              3 0 6


  WlID47        1              I don't know if they provide in there,  and  perhaps

                2   Staff can  comment, whether they have provided medical communi-

                3i' cation at  one end or whether this is  administrative  communi-

                4   cation.

                5              Also, if they are under all of these funds proposed
                6   for centers in the  state  for  treating  more.specificall'y  cer-

                7   tain types of catastrophic  events,  if  they  are  talking  about

                    one or twenty burn centers,  one  or  twenty  trauma  centers,
                8

                    one or twenty cardiovascular centers -- so    what  is  "Training,
                9
               10   and Communication Evaluation," and  I  would  have  to  review

                    tnis carefully,  but I would think one would like a    great

               12   deal more in the  way of evaluation than what they have

                    included, if they are going to get some answers in terms of
               13

                    what they want to do.
               14
               15              Continuity -- they are going to ask the Governor
                                              1.
                    for money, which seems to"me the.b'est  way  to  continue  all
               16
                    forms of care, at least by going through the appropriate
               17
               18   motions.  But I don't see adequate emphasis in here on what
                    I would think seem to be the real problems despite the fact
               19
                    they are putting in an awful lot of money.
               20
                               They are talking about basically   new and.  better
               21.
                    ambulances, about communications, about training, and I think
               22
                    the other end of-it, in terms of what happens when these
               23
                    people get to a center? I don't/  know  if  they  are  talking
               24
                    about bypassing certain  areas,  or  if  they  are  talking  about
               25

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                                                                             3  07



  WliD48        1  really having hierarchy type of care and really a regional

                2  type of emergency system.   It does not seem to    come out of,

                3  at least, the document that we have,    and I question  whether

                4  or not this  is  really  an  adequate  presentation-or  whether

                5  you know more about their plans.

                6             Maybe this does not.do  justice  to  the  plan  they

                7  have.    I don't think that this  warrants  the  price-tag  placed

                8  on it, at  least from the  minimal  review  I  have  giver  it.

                9             Perhaps you can comment?

              10              MR.-CHAMBLISS:  Are there Staff comments i  response

              11   to Doctor  Scherlis's query about New Mexico?

              12.             MR. ZIVLAVSKI:  Why don't I just start from      the

               -13 top and make a few comments?

                              In terms of the RAG and the number  of  the  RAG,  when
              14
              15   Doctor Gaye  became Coordi nator, it was his decision to involve

                   more people  in the decision-makin'g process.  He  increased   the
              16

                   RAG 220 members,  broadly  representative  and  including  minori-

                   ties and parts of the state, and the whole thing.
              18
              19              In this application it  seems  like  a  conflict  of
                   information, but in the RAG report it-mentions 120 still being
              20

                   there, but actually they have decreased it to 73 members.
              21.
                              There is a litUe  confusion  in  interpretation;  it
              22
                   depends on which page you look at.  The       in terms  of  the
              23
                   of Doctor Miller's comments on whether there is confusion over
              24
                   staff projects,  and are  they  essentially  control  projects,
              25

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                                                                           3 0 8


  WHD49        1   four or five of these activities were  out  originally  with
               2   CO numbers.  The last review we had, in a site visit we had
               3   down there, we indicated to them that what  they  needed  to
                   do was to place these projects in  independent  status,  provide
               4
               5   them with a project number and make sure..you give  them  the
               6   -- the information to the Project Directors  that  these  are
                   unlimited activities and they can't crawl back  into  the  wings
               7

                   of the university once the project phases out.
               8

                             Just in the last six months, they have typed these
               9
                   CO type numbers and have been,@able to communicate  these  to
               10

                   the people.
               12            These are free-standing, they  are  centrally  located
                   in the headquarters of the lu4P, physically right in the same
               13
               14  area. However, they are operating  as  project  directors,  100-
                   percent type of activities; when the  project  ceases,  they
               15
                   are going to have to find new employment, whenever that'
               1(;

                   happens.
               17
                             DOCTOR MILLER:  But th ey are staff of the RMP;
               18
                   they are listed under the personnel lists for  each  one  of
               19
                   those things as the New Mexico RMP staff.
               20
                             MR. ZIVLAVSKI: There  is  no  duplication.in  terms
               21
                   of salaries on the Form 6, which is the  core  staff  salary
               9-2
                   budget, as well as the Project Directors'  salaries.    There
               23
                   is no duplication of funding; each  of the moneys are  coming
               24
                   out of different types of activities.
               25

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                                                                            3 0 9

  WHD50        1              You' can look at Project 32, the  community  health

               2   resource development, Project 33,.the health resources
               3   registry, and Project 34, regional health  resource  plan  and,
               4   development; each of these three  projects  are  leaning  toward
               5   the future of health resource planning.

                              These are not in escrow, there is not      these  are
               6
               7   defined moneys and they tell you exactly   what.they  hope  to

                   do in these areas.
               8
                              Staff did    there was a presentation by    Project
               9
               10  No. 25, which is the health  education for the public; .'it has
                   substantially increased their re quests.  This  is  a  statewide
               11
                   project; the former project director of this  is  now  a  Deputy
               12

                   Director of the RMP.
               13
               14             It presents a problem; maybe  the  alternate  sugges-
                   tion is to have a technical review committee, site visit from

                   out of state consultants to  come .in, people that  don't  have

                   a bias, and maybe we could send this message back and     then

                   write an advice letter to the program  to  have  somebody  from
               18
                   out of state come in, let theoRMP pay for  it  with  their  own
               19
                   funds, then give the report to the  Director  of  the  program
               20
                   not to Walsh, not the Deputy   Director, who  is  th6-previous
               21-
                   Project Director.
               22
                              Project Number 18, EMS, there is  a  heavy  emphasis

                   they have  done a lot of things in here; I don't  know  how  to
               24
                   tackle some of your questions, but you  mentioned  the  fact  of
               25

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                                                                           3lu


  WlID51       1   categorization; the Deputy Director, Doctor Ilanratty,  has

               2   been working on a computerized system for it.
               31            Their position is that they are not happy with any
               4   of the national plans for categorization, AIIA or any-,of these.
               5   They would like a modification  of each of these plans, and
               6   they would like to have a computerized categorization of
               7   the hospitals.  And they are working on  that right now; they
               8   started out slightly on their surveys, the form has  been  pre-
               9   pared.  I can't tell you what modifications have  been  made
               10  in the categorizations of all the hospitals, but there is an
               11  obvious gap, because one or two hospitals in  Albuquerque,  one
               12. in Santa Fe, and then you have the rest of the  state,  and
                   they haven't completed this.  They have the survey form
               .13

                   developed.
               14
                             It is a modified form, and what the results   will
               15

                   be have not appeared yet.

                             In area medical communications they  work  closely
               18  with the State Department of Communications.   Everything  they
               19  do there is pretty well basedoon a total effort, because

                   there are a lot of scant resources.
               20
               21            They have done quite a job in  terms  of-training.
                   No P14P funds have gone into the purchase of vehicles; the  @IP
               22
                      Doctor Walsh, by the way,  the  Present Director of  this
               23
                   Program, is also the Director of  the  EMS project.  If he is
               24
                   finally selected as the final Coordinator on July  lst,  his
               25

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                                                                         31.1

  WlID52      I    Deputy Director, Doctor Hanratty, will -- it looks likely
              2    that he will take over as Project'Director.  He has been

              3    Deputy Director on the project for one year.
                             MR. CHP14BLISS:  I wonder if that sufficiently covers
              5    the query about the categorization  and so on?
              6              DOCTOR WHITE:  I migh t point out that if you take
              7    the targeted fund -- I was a little more charitable in
              8    approaching their EMS; I think they do have some compatibility
              9    in terms of their training programs, and by'.legislation th6y

                   are  oing to be uniform.
              10      g
                             Communication as I read it was between am bulances

                   and hospitals, where there are enormous distances to get
              12,

                   to.
              13
              14             DOCTOR SCHERLIS:  The average run can be 50 to 100

                   miles.
              15
                             DOCTOR WHITE,: They need to communicate with the

                   interim  stations along the way just in case something happens.
              18             DOCTOR SCHERLIS:  This is why I asked about-the
              1!)  categorizations, because I don't know how they are going to
              20   react to  passing certain ones if they have to, and this.is a
                   key feature to  astate that large, with a long hafal-.
              21
                             DOCTOR WHITE:  But regardless of the quality
              --)2
                             MR. THOMPSON:  This is rather ironic.  Unless I am
              23
                   mistaken, the first proposal that-ever came in from New
              24
                   Mexico, altogether in the old, old, old, days was on .emergency
              25

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                                                                         312

   WlID53     I    medical services.  They did a rather large study and they
              2    found out that the primary cause of death downthere was  not
              3    heart, stroke and cancer; it was Indians spread out over the

              4    highway in these old cars.
              5              We did not give them any money because they did  not
              6    fit into the categories of heart, stroke and cancer.
              7              DOCTOR WHITE: It still do6sfilt solve the  problem
              8    of the Indians, because they point out in here, there are no
              9    areas in which the Indians are terribly keen about participate'

              10   ing in.
              11             MR. CHAMBLISS:  Is there a motion and a  recommended
              12.  level of funding here?
                             DOCTOR MILLER: I move that they be funded  at  the
              13
                   target level: $1.64 million.
              14
              15             DOCTOR WHITE: 11 Second.
                             MR. CUMBLISS: It has-been moved  and  seconded  that

                   New Mexico be recommended for funding at a level of $1,644,000.

                             Is there discussion on the motion?
              18

                             All in favor?
              19
              20             .(Chorus of "Aye")
                             Opposed?  The level is recommended at  $1,644,754.
              21.
              22             DOCTOR WHITE: They will  get  thIe message @out  staff
                   ,appraisal of educational efforts-,, won't they?
              23
                             MR. CHAMBLISS: Your Concerns will be  passed  along,
              24
                   indeed, regarding EMS and,@education-for the public.
              25

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                                   REGIONAL ME
  ,ID-1                                        DICAL PROGRAM REVIEW

                2                      NORTII CAROLINA.REGION

                                                        we go  on then  to N rth
                31              MR. C@IBLISS:    Shal                       0


                4    Carolina?

                5               Doctor Miller,  Doctor  McPhedran,  and  Staff  will  be

                6    represented by Mrs. Parks.

                7               DR. SCHERLIS:  We should have    Mrs. Salazai-i.  come

                .8   back, shouldnit we?
                9               DOCTOR MILLER:  This   is  another  large   application.
                10   North Carolina has a current funding level of      $1.67    illion,

                     it puts
                11            in an application   for $3.26 million, and pl  s to sub-

                     mit another application in July for $400,000.
                12,
                13              Targeted level  is  $2.78  million,  and  the  composite
                     of the  present  application  with  the  proposed  a.dditions in
                14
                     July-will be 132 percent  of  the  target,  or  $880,000  over  the
                15

                     target amount.

                                The Region is  a good Region, in general, has done
                18   a lot of things in the past that are quite outstanding.  They
                19   have a change in the Project  Director  and  Coordinator,  which
                20   I can not assess.  Perhaps the Staff can help us with that.
                                The new Executive Dire  ctor, Ben Weaver.,.was  Deputy
                21
                     Director for five years, so it is presumed thatlis leadership
                92
                     should probably be adequate.
                                The program staff approach looks     all  right;  the'
                24                                                                   y
                     plan to increase it quite a lot during this      next  year,  but
                25

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                                                                          31 4


  WHD-2        1   they have- a fairlygood nucleus anyway.
               2              The Regional Advisory group assessment is  all right.1
                              The past performance, as I mentioned, is  go!od;
                   their objectives and priorities are good, and the    proposal
               4

               5   fits in with their objectives and priorities.

               6              Their CHP relationships are good.
               7              This, in my opinion,'is one of the extremely needy
               8   areas in this country, where you can hardly design anything
               9   -that would not help, because their needs are so  great,  and
               10  they are really deprived of  health  care.  There  are  any
                          f health care deprivation in  s           and   ey have
               11  areas o                               ervices,        h
                   been working toward these and have  made  some  outstanding
               12,

                   achievements, I think, in this area.
              .13
               14             So I think they deserve a recognition of   those

                   things.
               15
                              They have, in tgi's application, 45 projects.  A lot
                   of them are not very  good in principles of feasibility or per-
               17
                   formance, and are not in my  opinion  justification  for  the
               18

                   costs.
               1!)
               20             One continuation, one which bothers  me  terribly,
               21  but I guess it's just one of those things, is a medical. air-
                   operations, which is $50,000, which is a continuation, so I
               9-2
                   suppose they have been doing it, which is  solely  for  the
               23
                   the money is spent solely for the purpose of flying faculty,
               24
                   students and staff around the state in  private  planes  in
               25

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                                                                       3 15


  IHD-3       1    support of the area health education center project.
              2              Of course, all kinds of.faculty -- as .. well as
              3    students and staff -- would like to fly in private airplanes

              4
                   almost anywhere if you give them that luxury.
              5              Another one, they have a project in here for the
              6    medical foundation they have in the state for a PSRO develop-,
              7    ment for $125,000. I think this is  inappropriate;  PSRO's
              8    are going to be funded, and as near as I can tell from that
              9    application, it is a pure PSRO project development.
              10             Then there.are multiple rural health clinic supports.
                   There are supplementary support to state clinics or  state
              11
              12   rural health clinics, which undoubtedly are.needed, and are
                   supported by the state.  But the-amount of this support amounts
              13
                   to $243,000 altogether.
              14
                             And then another.supportive project for supporting
              15
                   the area health education center activities in the  state,
                   which is funded outside o@ RMP, to develop a library network

                   for $363,000 in community hospit als throughout the  state.
              18
              19   Although I don't question their statement that community
                   hospitals have no library facilities that amount to anything,
              20
                   and when you want to educate health-care professionals  in
              21
                   rural communities, why, one of the things you need is a
              22
                   library, but it seems like an overly ambitious approach with-
              23
                   out any guarantee that it will be-continued.
              24
                             Another of the fundamental things, of course, in a
              25

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  WHD-4        1   place like North Carolina, which I think is probably true

               2   in some of the other similar types of states, there is very
               3.  little guarantee that these -- any of these activities will

               4   be-continued after RMP funding, probably because, ho-,7everf,

               5   that their potential for funding things is so poor that tey

               6   are quite dependent upon Federal funding programs.

               7              In general, I regard this as a superior program,

               8   and it is  a terrifically needy area, where they -- a composite

                   application which is over-ambitious, and some of it  s
               9

               10  inappropriate, and my  recommendation would, again, be a fund-

                   ing at the target level.

                              MR. CHAMBLISS:  Doctor McPhedran?
               12.
                              DOCTOR MC PHEDRAN:  I agree.  I really have nothing
              -13
                   to add.
               14

                              DOCTOR MILLER:  I'll make the motion, then.
               15
                              DOCTOR MC PHED@N:  I'll second that.
               16
                              MR. CM-IBLISS:  It  has been moved and seconded that

               18  North Carolina be recommended for funding at the targeted

                   level of $2,775,522.
               19
                              Is there discussion on the motion?
               20
                              DOCTOR MILLER:  Their present funding for the.
               21
                   current year is $1,175,000, so they will-get
               22
                              MR-. VAN WINKLE:  About $1.1.
               23
                              DOCTOR MILLER:  They Vill get $1,100, 000 more
               24
                   money; they probably can't spend that either.
               25

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  IHD-5        1             DOCTOR WHITE: Well, I guess that  is  what  bothers
               2   me, in terms of losing out on a million dollars.
                             Even though you said it was a superior Region, yet

               4   I look at -- what?  45 new projects, which
               5             DOCTOR MILLER:  Very needy.  How do  you really
               6   decide on deprived areas?  There is no way to  solve those

               7   problems without pouring money into them.
               8             MR. THOMPSON:  They are going  to come in with

                   another $400,000.
               9
               10            DOCTOR WHITE:  Let's not get people used  to  some-
                   thing    why get the poor people out in the hills  used to
               12. something they are going to lose next year?
               ,13           DOCTOR MILLER-.. Reminds me of a site-visit I  went
               14  on a couple of years ago to West Virginia. Have  any  of  you
               15  been to West Virginia?
                             We were questioning d lot of these things,  and one

                   of the physicians said:
               17
               18                  "We depend on Federal money for a living;  we
               19       will do anything -- whatever the Federal money resource
                        requires, because we are totally dependent upon Federal
               20
                        money."
               21
                             DOCTOR SLATER:  They are not the only group that
               22
                   says  that.

                             MR. CHAMBLISS:  Doctor Miller,  may I just ask a
               2,4
                   point here, about the PSRO?  Did you say  that was out and out
               25

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   WHD-6       I   PSRO?


               2             DOCTOR MILLER:  Nearly  as I can tell.  Does the

               3';  Staff have any other interpretation?

               4             MRS. PARKS:  We thought the.same way.

               5             DOCTOR MC PHEDRAN:  I agree.

               6             DOCTOR MILLER:  I think it is totally inappropriate


               7   at this time.


               8             DOCTOR SCHERLIS:  I have some  concern, because I

               9   think in your description of the various   projects, programs anl

              10   so on, I was detecting a certain note of   lack of enthusiasm,

              11   and then I had your conclusions, which reflec ted, in a  way.,

              .12  a disparate approach.

                             You know, the need is there, I think we would agree;
              13

              14   the R@IP has a pretty good track record, and again I would

              15   assume that, given an area that is impoverished  in  many  ways,
                                            1.
              16   these funds might eventual@y-do  some  good.

                             I do have a  significant  concern, though, in terms
              17
              18   of all that money, in view of what  I  think were very apt  cri:-
                   ticisms of the ability to realty spend this  wise,ly, and I
              19

                   would think, particularly in view of the fact that they are
              20
              21   coming back for at least additional funds at  $4OOtOOO,  and  in
                   view of the fact that we doubt very much that all  of  this  can
              22
                   be -- not just efficiently spent, but let's say inadequately
              231
                   spent, that you might then entertain some reduction from the
              24
                   target figure, understanding that they are going  to  come  back
              25 III
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  WHD7         1   for more, although I know that is not a constraint, but I
               2   just have some difficulty, as I view the large array of pro-
               3   jects, particularly the one for, say -- well, I guess    it
               4   would be $362,000 for a statewide network of hospital      librar-

               5   ies.
               6              I wonder if you  might  not  entertain.the  possibility
               7   of reducing that some, because I don't think they could really

                   effectively utilize this support level.
               8
               9              DOCTOR MILLER:  I judge on that library business
                   they are going to staff  those libraries?  I could no  tell
               10
                   in the application, but  they are probably going to set up
               11
                                                                         S!
               12, libraries in every one of these hospitals, which ha  nothing

               13  now.

                              Is that true?
               14
               15             MRS. PARKS:. Right. They will be  tied  into  the  nine
                   area health-education cent,6rs, but I don't think that the
               16
               17  supportive personnel will solely   be funded through the North

                   Carolina RMP.
               18
                              DOCTOR MILLER:  Well,  it costs a lot  of money to
               19
                   set up nine libraries.
               20
                              DOCTOR.IIHITE:-  Doesn't it cost a fair amount  to
               21,
                   keep them going, in termsce personnel?
               22
                              DOCTOR MILLER:   It is a  terrible  problem4  She  says
               23
                   they are going to keep them going; will the hospital undertake
               24
                   the responsibility, or the AHEC, or solely someb ody else, for
               25

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  HD-8         1   the operation.of these libraries after one year, after the

               2   RIAP  is  gone?

               3;i            DOCTOR WHITE:  If  nothing  else,  somebody  has  to  dust


               4   the books.

               5              MRS.  PARKS:  I  am  not  really  sure.  The  only  infor-

               6   mation I  have is what is in the  Form  15,  and  it  was  not  clear

               7   as to how  many would.

               8              DOCTOR MILLER:  It does not    say; there  are  a  lot  of

                   unanswered things as you read these.
               9
               10             DOCTOR WHITE:  Did   you find contributions from the
                   Appalachian  Regional  Commission?  Matching  funds   and   things
               11
               12@ of that sort that  look  as  though  they  might  be  substantial?

                              DOCTOR MILLER:  I don't think they have that in
               13

                   here,d'o.they?
               14

                              MRS.  PARKS:   No.
               15
                              @IR.  THOMPSON:  @at  I  can"t  understand;  they  have
               17  been.working specifically with hospital libraries, hospitals
               18  and quality control for  all  these-  years.  What  the  hell  have..
               19  they been doing?  All  those  snoll  hospitals;  that  was  the  main
                   thrust of the project -- quality control and libraries.
               20
               21             DOCTOR  VAUN:  The  objectives  of  the  National  Library
                           c'
                   of Medi ine   is not to perpetuate  the  old  concept  of  libraries.
               22
                   It does not   cost a lot to build  a  library  that  can  function
               23
                   through the   National Library of  Medicine  network,  and  if  we
               24
                 ii pour this amount  of  money  into  creating  a  lot  of  old-fashione
               25

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                                                                                                     321  :@
   IliD-9            1      libraries, You might just as well flush it.down thedrain.
                     2                    MR. VAN WINKLE:   Staff.had flagged that for that

                     .31    consideration.
                     4                    DOCTOR MILLER:   Well, I think cutting the                   budget,
                     5      even to the target level, will put the pressure on them for

                     6      some of this kind of          stuff.
                     7                    MR. CHAMBLISS:   That is the motion,, to recommend

                     8      funding at the target level.

                                          Is there further discussion?
                     9
                     10                   DOCTOR SCHERLIS:   May I move an amendment                   to the

                            motion?
                     11
                                          MR. CHAMBLISS:   You may indeed.
                     12
                                          DOCTOR SCHERLIS:   I withdraw my motion.
                     13
                     14                   MR. CHAMBLISS:   Those in favor of the motion,  let
                            it be known by the usual sign of voting.
                     15
                                          (Chorus of  "Aye")

                                          Those opposed?
                     17
                                          (No response)
                     18
                                          May we have a show of hands on that vote, please?
                     19
                                          (Show of hands.)
                     20
                                          Three in favor, and the "Nay..'s" have it and the
                     21
                            motion is     not carried.   The Chair will entertain a new motion.
                     22
                                          DOCTOR SCHERLIS:   I would move that the target
                     23
                            figure be     reduced by $400,000, as the level of funding for
                     24
                            the coming fiscal year.
                     25

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                                                                        L-@- A


  fHDll       1    the vast array of projects,  particularly that one, and to
              2    think in terms of what will happen to a statewide systems
              3    when you have libraries in individual hospitals, and what will

              4    occur@-at that time.
              5              I think there is a lot of fat in this budget.  I
              6    don't think this is going to affect their overall program one
              7    iota, and I think to fund them at their target level now,
              8    when they will be coming back for additional funds,  they
              9    aren't bound to ask for only $400,000; I'm sure they will be
                   asking f-or a significant sum more   I'd like to give them
              10
              11   that latitude.
              12             Now, if you asked me if I reached.a rational feeling,
                   I think that Itried to express myself rationally,.but,  I
              13
                   would suggest to you that the input to that was about 95 per@
              14
              15   cent gut reaction.
                             Is that a fair-apprai@al?  That's what you thought,
              16
                 .didn't  you?

                             DOCTOR MC PHEDRAN:  That is what I thought.
              18
                             MR. C@IBLISS:  Shall I call the question again?
              19
                             Those in favor?
              20
                             (Chorus of "Aye"
              21@
                             Opposed?
              22
                             (No response)
              23
                             The motion is carried" to recommend a level of fund-
              24
                   ing at $2,375,522.
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  rHD10       I              DOCTOR WHITE:  I'll second that.
              2              MR. CHAMBLISS:  The motion is now that the recom-

              3    mended level be set at $2,375,522.
              4              It has been properly moved and seconded.  Is  there

              5    discussion?
              6              DOCTOR MC PHEDRAN:  I supported the previous motion,
              7    and I really feel it is important for me to say that this  is

                   another arbitrary choice -- so was the previous  one.
              8
                             I don't really know how you decide, and  it is

                   obviously arbitrary and I don't know how it can  ever be
              10
              11   intelligently decided.  In fact, it can't be  without a more

                   detailed review of the projects.
              12
                             So Ithink that I would like to know whether Doctor
              13
                   Scherlis would acknowledge that this is a really arbitrary
              14

                   amount?
              15
                             DOCTOR SCHERLISt/.Let me tell you the rational  way

                   inwhich I reached my decision.  I sit here and listen to
              17
              is   the reviewer with a great deal of care, because he is going
              19   --.has gone through the document more than any of us have,
              20   and must really have some expertise.  And I get a certain
                   flavor which I file away, I assume, somewhere in-my brain.
              21
              22             Really, it is a gut,reaction, and then as the  dis-
                   cussion goes on and I try to relate what I have heard at
              2.3
                   previous meetings, to a particular state, what I did in  this
              24
                   instance was to look at the sum they have asked for, look  at
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  WHD12        1               REGIONAL MEDICAL PROGRAM REVIEW

               2                    NORTH DAKOTA REGION

               31             MR. CliAMBLISS: Now we will move  to  North  Dakota.
               4              The presenters here will be Doctor Slater and Doctor

               5   Scherlis;  Miss Resnik will represent the Staff.

               6              DOCTOR SCHERLIS: North  Dakota,  Mr.  Chambliss,  is

               7   the smallest budget RMP in the nation,  of  $367,746,  and  are

               8   coming back in with a request for $774,057,  which  is  132  per-

               9   cent of the an@ipated target.

              10              I would like to make a comment that there must    be

              11   some kind  of a leak in this agency, because despite your    pro-
              12,  testations  that they don't know what the targeted figures are,

                   North Dakota is so honest that they said:
              13
              14                   "There has resulted a  grant  application  figure
              15        that exceeds the target figure."
              16              Which doesn t bot er me very much.
                              DOCTOR SLATER:  North Dakota also makes a point

                   which I think will rectify that      and I am  abstracting  here:
              18
              19                  @"We have considerable Idifficulty attracting
                        physicians to North Dakota.  Our image is ridiculous in
              20
                        view of the,national situation."
              21
                              I think the@ have some problems  in this  proposal
              22
                   which reflect that self-image.  Quite honestly, I    am concerned
              23
                   about their priorities, and there is   not a thing,  I believe,
              24
                   that we can perhaps do about this.
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                                                                           32 4

                                                                n the fa
  WHD13         1             The. ir-image, in fact, is based o        ct that
                2   they have about 146 p3?imary care physicians per 100,000

                3
                    population, which is the lowest on the national scene, and
                4   their concern is that  they need to upgrade their medical care
                5   system, primarily going in the direction of producing more
                6   manpower and increasing the education of those individuals,.
                7   both professional and lay, who are already there in    North

                8   Dakota.
                9             As you know, there has been a major press    to develop-
                10  -a four-year medical school,  and I had the opportunity   to
                11  visit North Dakota after the original    feasibility'study, to
                    determine whether they would become a   Region, and  recommended
                    to you -- what?  In '67, I guess; Doctor Scherlis    has been
                13
                    thiare'more recently, so his information is better   than mine
                14
                15  but they now have been accredited for a four-year    school, and
                                             1.
                16  are searching for ways to @implement thisi
                17            Well, to get back to what they have been    doing,
                    they have, from what I can make out, a small, reasonably well-
                18
                    organized, active staff, and I will have to rely entirely
                19
                    upon other people's inputs to determine how effec   tive they
                20


                    are.
                21
                I?            Their program thrust, as I said, was in education
                -2
                    and manpower.
                23!
                              Past accomplishments include Emergency Medical
                24 1
                                  they have been able to
                    Care System;                          produce 1,000 Emergency
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                                                                         325

   WHD14       1   Medical Technicians, which has produced a number of one    per
               2   600 population, which is the highest ratio on the national
               3   scene.  They are proud of that; they feel it makes a    very
               4   effective dent, at least on attending to accidents aid emer-

               5   gency problems.
               6              In the second area of activity, the Univerr)ity of
               7   North Dakota,  working their  EXtension Service through the
               8   Medical School, and working  in conjunction with the
                   Eealth Department, and the.@IP , have really been abLe to get
               9
               10  engaged in a great deal  of data collection and professional

                   education -- continuing  education programs.
               12,            There are  four AHEC areas which are active@y
                   involved in the arrangement of local..teaching programs for
              -13
                   lay and allied health professional teaching people, and
               14
                   associated with this have been the arrangements for a great
               15
                   deal of travel by nurse  educators as well as the bringing in
               16
                   of local physicians to become engaged   as teachers in their own
               17
                   special areas of capability, for   not only lay but allied
               18
               19  health professional people.
                              So that by and large, I think they have concentrated
               20
                   a great deal on blanketing   the state with a.great variety of
               21
                   types ofcontinuing education and special    types of therapy
               22
                   for coronary care, renal, chronic renal disease, problems
               23
                   requiring   rehabilitation of the'handicapped and the like.
               24
                              Now, where  are they going-, against this kind of a
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  WHD-15           background?
               2             They have presented a series of activities here
               3   which -- in which I would like to-indicate to you w here they:

               4   see their priorities, on page 16.
               5             Their RAG is made up of 47 people, with nine repre-
               6   sentatives from Comprehensive Health Planning.  I believe
               7   they work very closely with CHP, but I don't have any direct
               8   evidence of it from this proposal, except in the sense that
                   the CHP people are involved in reviewing and helping set
               9
                   priorities on the proposals that go through.
                             They are askirg for a series of projects, and I will
                   just run through them and give you the commentary on them.
               12.
                             First of all, they are-intereseted  in  feasibility
               13
                   study to look into the development of,a residency program in
               14
                   internal medicine.  This of course is oriented to getting the
               15
                   medical school off the ground.  $13,775; this will put togethe:

                   committees, consultants and site visits.

                             The         ticularly anxious in looking at
                               .y are par
               18
               19  Pittsfield, Mass., Rutgers University, Muncie, Indiana, I
               20  believe it is, who have been able to develop residency programs
                   at community hospitals.  They would like to develop a consor-
               21
               22  tium of hospitals for the residency programs that emanate
                   from the University of North Dakota.
               23
                             The second project, small -- $9,620 -- a feasibility
               24
                   study to look into the potential for graduate programs of
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                                                                        32 7


  11ID16      1   behavioral science related to family practice, and they

              2   are looking to the possibility of developing a Master's
              3il degree in behavioral technology as a graduate  program,  and,
              4   also set up resources for marital counseling, child-rearing,

              5   sex counseling, addiction, dying, and fty will do this

              6   through statewide meetings and consultations and this kind

              7   of activity trough AHEC.

              8             The third type of program is  $400,000,  abiomedical

              9   communications system connecting the  four  AHEC'S, phase  A

              10  and B are to go on during this fiscal  year,  first of all  to
              11  study the feasibility and costs, and  mechanics  of this,

                  and secondly to purchase the equipment.
              12.

                            After they purchase the equipment, by the end of
              13
              14  Fiscal Year '75, they will then present a fiscal  study  to
                  see whether or not it impossible to continue  to  fund  this,
              15
                  and that will go to the legislature, later to be in fact
              16
                  picked up and operated by the University of  North  Dakota.
              17
                            There is really no mention of the --  apart  from
              18
                  microwave connections and a fear general words    there is.no
              19
                  mention of the kinds of equipment, how the  terminals  will
              20
                  operate, what the details are, how the people will  fit  into
              21
                  this -- now many specific types of programs will be function-
              22
                  ing through the learning centers that will be located in these
              2@l i
                  four places.
              24
                            By and large, I don't understand this and  am  very
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  WHD17        I   concerned about this type of expenditure of money.
               2              I bring this up now because it is a tremendous
                 i chunk of money to spend when one could put   this intolthd  pro-

               4   duction of personnel who will go out and improve the    home care

               5   treatment, and so on.
               6              Fourth, they want a  computer  lab.  They  red  y  are
               7   anxious to be able to program the health data that t@ey are
                   pulling together and improve their computer laboratory      capa-
               8

                   )6ility.  That is $36,000.
               9
                              Satellite hemadialysis unit they want      tiey   have
               10
                   one five-bed unit presently, operating at Fargo; ftylwant

                   a three-bed unit put together at the United Hospital in
               12.
              .13  Grand Forks, which would give them two 'in the state.
                              A project review program for North Dakota certifica-
               14
               15  tion.and need  law  a.nd the Federal capability expenditures;
                   $25,000.  They want to bring   in a consulting firm, John, to
               1(;
                   tell them what the capability   of a certification  of  need  law
               17
                   is.  You will have to comment on   that for us.
               18
                              They are talking about  a human services  center, for

                   $41,700.
               20
                              They have developed a medical Pdtk, with two new
               21
                   hospitals going up; I believe it -is in Grand Forks, and they
               22
                   would like to put up a separate facility    in which all  of  the
               23
                   other health and human serviceseagencies    are placed,  so  that
               24
                   everything is   laced in one area there, and they can inter-
                                  p
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                                                                            329
  HD18         1    digitate more effectively. for the coverage of people being

               2    serviced by that area.
               311            It sounds like a good idea; they   put it on  the

               4    bottom of their priorities list.
               5              Number 8 is a data analysis      two of these have
               6    been withdrawn.  The last one is development and tea hing
               7    health data collection forms,.to be done by the Department of

               8    Health in Bismarck; $25,000.
               9              I am very concerned, personally, about the amount
               10   of time that is spent up there collecting data    and a alyzing
               11   it.  I don,t quite understand what they are doing with all
               12.  this data; they were talking about this back in 19671  it
                    seems to me they should have been able to get some kind of
               13
               14   an operational base on.what can   be done in North Dakota, with
               15   all these years of RMP  activity, so someone from Staff or
                    Doctor Scherlis will have-'to fill  us in on that.
                              I would like to suspend   further commentary on this

                    at the moment.  I can't decide whether or not to suggest that
               18
                    we hold them to the targeted funds, or to wack out the
               19
                    $400,000 entirely, as we just did on that project.
               20
                              @IR. CHMIBLISS:  Thank you, Doctor Slat@r.  Mr.
               21
                    Doctor Scherlis?
               22
                              DOCTOR SCHERLIS:  I don't know if I can b'e'helpful
               23
                    in this.  When I was in North Dakota, I guess I share the
               24
                    concerns that other site visitors have had previously; this
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                                                                             33 0

                                                                           has   be
  WHD19        1    has been  a state which, at least in my experience            en
               2    rather unresponsive to suggestions from out of      state.
               31             I remember as I was leaving,   going to the    airport,
               4    a finger was thrust at my chest and I was told that:
               5                    "You people from  Washington  just  don't  know

               6         what we people out here   really need and shoula    o.11

               7    And I only resented it because I wasn't from Washing    ton.

               8              Their Executive Director  makes  this  a  25  percent
               9    effort as far  as his time allotment, and there   is  no  Deputy
               10   Director, so  that is a blank.  And  I.think  this  is  indicated
                    in a way by the type of projects  that  we  see,  because  these

                    do not really indicate  any  homogenous  presentation  in  terms
               12.
                    of addressing what many eople  who  come  to  that  state  feel
               13                            p

                    the real health needs are.
               14
                              When I was there  the  thrust  was  rmre  toward
               15
                    Physicians' Assistants  and  Emergency  Medical  Technicians,  on

                    the bais of what has been there  described  as  faras  the  ratio
               17
                    of physicians to  the population of the state, and it concerns
               18
               19   me that they are  goin g at the  computer  approach  rather  than
               20   through the people approach.
                              Two of  the  projects  have  beenwithdrawn,  two  which
               21
                    were given very unfavorable ratings by their local CHP agency,
               22
                    so this reduced their overall reque,st  by,  I  think  $28,000.
               23
                              DOCTOR,SLATER:  Both of those were data collection,
               24
                    again.
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  WHD20         1           DOCTOR SCHERLIS:  Their staff is small; they have
                2  a 25 percent Executive Director, an Assistant Director for
                3@ Administration -- that's another  -.that is a full-t-..me person,,
                4  and they have two individuals in Program Evaluation,  which  is
                5  a person and a third, and a full-time person in Heal h
                6  Education, who is a nurse involved in health education, so
                7  they do suffer from lack of staff, as a great many o; these
                   projects appear to derive from the university.
                8
                            When we were there there were some hopes o@ having
                9
                10 areas outside of the larger population centers,  and  et's
                11 face it -- North Dakota does not have  many large population
                12. centers by our criteria, but these do not seem to ha e been
                   implemented, and I think -- and are affected in the present
              -13

                   report.
                14
                             As you look at the individual  programs, you can
                15
                   fault them.  I think in terms of'using RDIP funds for residency
                   programs at a medical school, you know,  if you can't get  your
                   money anywhere else, RMP can be approached, and yet  you  could
                18
                   say that in North Dakota, if they can attract  physicians  that
                19
                   come to their state under any guise, this is a wholly worth-
                20
                   while way of improving health care.
                21
                             I am impressed with  the  fact that this has a  little
                9-2
                   different flavor than it used  to  have; at least they are
                23
                   interested in more ways, in health care  delivery, and the
                24
                   North Dakota project, at least in my experience before, was
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                                                                                                   332



  fHDO.21           1
                          very much from the top and not totally physician and provider

                    2     oriented.
                    31                 I am concerned, as Doctor Slater was, about that
                    4     biomedical communications system for $400,000, and also @o
                    5     the application of computer technology, which was another
                    6     $36,000, and this was to have health care professionals in
                    7     the state        as they said it:.
                    8                           ... affect an evaluation of the application
                    9           of computer technology in health care fields.
                    .10   And the way they would do this would be to have the                     physicians
                          apparently located in different communities to have                     access
                    12.   to the computers, in order to improve the delivery of health
                          care, and as I read this, I don-'t quite know what they sa'
                    13                                                                                   Y.
                    14                 The speak of the   selection and implementation                   of
                          process for computer programs or software will require con-
                    15
                          siderable investigation          of computer systems now in.operation,
                          and'therefore considerable travel, study and collaboration
                    18    with other investigators throughout the United States will
                          be necessary."
                    19
                                        And I guess what they will be looking for are pro-
                    20
                          grams   that will help physicians improve the level of health
                    21
                          care.   This is how it comes out, and I would think that,
                    22
                    23    Number 1, the funds         that they ask for won't be helpful in
                          that regard, and Number 2, a lot of these programs are readily
                    24
                          accessible by getting in touch             with other areas and utilizing
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  WHD22        I   the mail, and I wonder how much  acceptance  there  will  be  by
               2   North Dakota physicians in this,.and I don't sense from    this

               31  that the homework has been done.
               4              If you talk about a state  that asks for  th ee  and
               5   a half million dollars and you cut    it down to two a d a halfl

               6   million, I don't feel very badly.
               7              But when  you take a state that is asking for a
               8   relative pittance -- it is already the lowest-funded       and
                   -then you begin carving out big chunks, you  leave  it  with
               9
               10  very, very little, if anything, to move on.
                              So one rational approach that  I  also  should  have
               12  mentioned in my discussion,before is inconsistency,      ich is
                   again, one of my chief virtues.
              -13
                              So I don't feel constraired..to be consistent in
               14
                   any recommendation that I   make, and one thing that this Review
               15
                   Comittee has always impressed me,with is its great ability
               1(;
               17  to be consistent.  This has been, if anything, the most con-
                   sistent feature about it, includ  ing the directions that we
               18
                   get on top, about what RMP means this  year,  at  this  meeting

                   and this has been true of every meeting I have ever attended,
               20
                   and I think that I won't have to defend ca-sistency any longer
               21
                   in tlat regard.
               22
                              So I would support your general comments; I    guess
               23
                   it is a question of   coming up with a sum of money to recommend,
               24
                   and perhaps you could have some discussion before we offer
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                                                                        33 4


                  that motion, if that is within the purview
  fHD23                                                       of the  reviewer

              2             MR. THOMPSON:  Has there been  any Staff input  on
              3!  this $450,000 thing?

              4             MISS RESNIK:  Yes, there is one letter in response

              5   to a question which I asked a Doctor -- did he  need  to  do
              6   all of this at this  time?  It is tied to the four AH@C's at
              7   the four big cities  -- Grand Forks, Minor, Bismark a d  Fargo.

              8             He suggested yes, they probably would not I:ie  in

              9   with All of the facilities as originally planned.  T  e  letter
              10  which I guess I just havenl-t had a chance to duplica e,  is
              11  from the project Director, Doctor Christ6pherson,-who suggested
              12. that he could reduce the equipment by about $80,000,1@and  man-
              -13 power by $24,000, leaving a total of a little over $300,00-0
              14  for the project.
                            That still is Very large, and I  believe what  may
              15
              16  have happened is that they approached the  AHEC's,and  @they
                  couldn't get additional  funding. They are funded  for  five
              18  years out of the old Manpower grant, and so they are just
                  trying to  do something with -this, although tlmy are justifying
              19
                  it on the basis of the educational programs in  the  medical
              20

                  schools.
              21
                            MR. CHA14BLISS:  Doctor Miller?
              22
                            DOCTOR MILLER:  I don't think I have a vested
              23
                  interest, so I think it is all right for me to make  some  com-
              24

                  ments.
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  IHD24                      I have been a big brother to the North Dakota
              2    RI,4P.'s for a long time, and we really need to understand the
                   Dakotas in the center of the country, in a program like
                   this; you know, the Dakota.Territory was a territory  and
              4
                   when they finally became a state, which was a long time ago,
              5
              6    but it was one of the latter.ones, and North and  South  Dakota
                   are typically pioneer American    rugged,  independent  indivi-
              7
                   dualists, everybody doing his own thing now in his own way,
              8
                   and to heck with his neighbor, and they never  could  get
              9
              10   together.
              11             They still can't; they are divided between North
              12   and South Dakota, as different as though  theIy were  arch-
                   enemies, though it has modified somewhatlately.
              13
                             North Dakota medically of course is very small;
              14
                   the population is 500,000, MInnesotals is one million.  They
              15                           1.
                   have 50 hospitals in Nort@ -Dakota,.whereas Minnesota  has  286.
              1(;
                             They have 500 physicians; Minnesota has  5,000.
                   They are arch-conservati.ves, rural America, independent;  they
              18
                   have some justifications for it, incidentally.  They have
              19
                   very small amounts of medical personnel and hospitals,, by
              20
                   population ratio, but do you know where the longest length   of
              21,
                   life is in-the United States?  Northern North Dakota.

              22
                             They have the fewest number of health care facilities

              23
                   in the United States, by population     Northern North  Dakota.

              24
                             So maybe there is something about health that is

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  WHD25       1    more important than medical care.
              2             Now, they are beginning.to change, and the change
              3-   is motivated by the very great need for them to have a com-
                   plete medical school.  Nowadays, their two year school, which
              5    incidentally was a superb one   their graduates cou@d choose
              6    almost any othcrmedical school they wanted to go to n the
              7    United States and get admitted, because they were very, very

              8    well-trained two-year men.
              9             But that is not an option now, and they reFlly
              10   desperately need to develop their own medical school  They
                   have a big AHEC grant, and have these.four units whi6h have
              12.  the potential of developing a clinical tie-in, multi le small
                   places, with the medical school and still maintain quality
              13
                   in medical  education at the clinical level.
              14
                            Now, they need support in every way they can get
              15
                   it in order to carry out -(his rather ambitious plan.  They
              17   also.pioneered in the training of  medic.s, and were one of
                   the first ones, along with Duke   but a different approach,
              18
              19   of trainkg Physicians' Assistants, which has gone very well

                   in North Dakota.
              20
                             So they are moving into a cooperative approach,
              21
                   they are cooperating with each other in their viciously com-
              9-2
                   petitive adjacent towns better than they have before, and I
              23
                   would put in a plug for --- let@s give them a little push.
              24
                             DOCTOR CARPENTER:  Is it really true that people in
              25

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                                                                                            337

   ilHD26         I     North Dakota live longer, or does it just seem longer?
                  2                  (Discussion off the record)
                  3                  DOCTOR SCIIERLIS:  Anecdotally, North Dakota is the
                  4     only place I have ever been to where the home that w&-went
                  5     to, which is o   ne of a series of apartments, instead
                  6                  (Further discussion off the record)

                                     We do have a number we have arrived at.
                  7
                  8                  MR. CHAMBLISS:     IAll right.     We would like to have

                        the recommendation of       the presenters.
                  9
                  10                 DOCTOR SCHERLIS:   I would not be prepared to defend
                  11    it, but that is for a number of $500,000,. which is              midway
                        between, actually, what they have asked and what is                targeted,
                  12.
                  13    and the rationale that we have used, which is not offered as
                  14    a means of defense, is that they now have a level of $367,000,
                  15    they requested $774,000,       1. and actually reducing that by what
                        they have indicated they can, which is $104,000, plus eliminat--
                        ing two projects -- which is not a significant decrease
                  17
                  18    it comes to a total      of $100,000.
                  19                 I would think at thi-,s particular time, with           the
                        medical school coming in, that within the constraints                that
                  20
                        they have-during the coming year, this would be -- I would
                  21
                        assume the values of the programs they are looking at, an
                  22
                        certainly    they can come back in July for          more.
                  23
                                     The major reduction'i.4 what they have indicated they
                  ,)4
                        can take.
                  25

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  WHD27        1              MISS RESNIK:  They are not coming back in    July,

               2    according to their suggestion.
               3              MRS. WYCKOFF:  Can they come in now, or is    it  too


               4    late?

               5              DOCTOR SCHERLIS: Well, even  if  they  are  not  coming

               6    back, this reduction, $104,000 -- what they have indicated

               7    they can make by dropping two projects, again  this  is  not  a

               8    significant reduction but I think it reflects on some of

                    their    well, computer services, that the   other   additional
               9
               10   reductions have made,  so this is $500,,Qoo,  which  is over

                    their present level of funding.
               11

                              DOCTOR SLATER:  It effectively   takes out  the  bio-
               12
                    medical program.  Since the $360,000 was   put  into  microwave
               13
                    sending and receiving equipment, it makes it possible for
               14
                    them, though, still to spend somewhere between $20,000 and
               15
                    $40,00 0 to put in four audio-visual learning packages in the
               16
                    AHEC centers, which could be used locally   to  improve  teaching

                    techniques for various types of personnel.
               18
                              By suggesting this,owe  have  taken  $224,000  out.of

                    the request, so we have effectively killed off  the biomedical
               20

                    system.
               21
                              MISS RESNIK: Yes, they still  have  a  start,  and  now
               22
                    we can go ahead, if it is agreeable,,  to  suggesting  limiting
               23
                    the locations where they are going to try out this       Medline"
               2,4
                    microwave.
               25

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  WHD28        1             MR. CHAMBLISS:  Would the Committee so recommend?

               2             Did we have a motion to-that  effect,  or  was  that

               3   a recommendation?  May we have a motion,, please?

               4             DOCTOR SLATER:  Motion by Doctor Scherlis, seconded

               5   by me.

               6             MR. CHAMBLISS:  It has been moved and seconded

               7   that the level of funding for'North Dakota  be  at  the  level

               8   of $500,000.

               9            :Is there discussion?
               10            DOCTOR SLATER: I  would  like  Mr.  Thompson.to  refer

                   briefly  to that ques@n before we go on.

                             MR. THOMPSON:  There are 24 states that have certi-
               12

                   ficate of need legislation.
               13

                             DOCTOR SLATER:  To  spend $25,000?
               14
                             DOCTOR VAUN:  The  importance of certificate of need
               15
                   legislation in a state that is      that has only  two  dialysis

                   units escapes me, but what I wanted to  make  was  the  observa-
               -17
                   tion that the knife seems to be getting  sharper  as  the  day
               18
                   wears on, and I am especially sensitive of  this  when  we  have
               19
                   been dealing with other Regions whose requests are in t   he
               20

                   millions.
               21
                             We have arbitrarily landed on the target     figure,
               22
                   and when we are dealing with a small state'like this, that has
               23
                   a very small -- $80,000 makes a iot of difference, and in lighi.
               2,4
                   of Doctor Miller's comments, I really would  like  to  see  us
               25

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                                                                      34 0

  IHD29       1   give them  at least the target figure.
              2             MRS. SALAZAR:  Mister Chairman, I endorse that.

              311           Is discussion still in order?.

              4             MR. CHAMBLISS:  Certainly.
              5             MRS. SALAZAR:  I used to have some administrative
              6   responsibility for the state of North Dakota, and of all the
              7   Regions I have ever dealt with -- and.I have dealt with quite
              8   a few    the state of North Dakota has a-long history of being
              9   very penurious in their applications. They spend money  -
              10  wisely and they spend it well, and they are very fiscal,
              11  they are very accountable to every dime...
                            I am looking @down the list of the RAG and I see
              12.
                  a lot of old familiar names, and,I also see some on the
              13
              14  staff, and I also note that they are try ng to recruit  a
                  Deputy Director, which is one of the things that I recall is
              15
              16  an old problem, and I am wondering how much we would damage
              17  the.program if we reduce it by a relatively small figure?
              18  How attractive this would be to somebody they are trying to
                  recruit for leadership, which-is very much needed in this
              19


                  area.
              20
                            DOCTOR SCHERLIS:  We would like to withdraw  our
              21
                  motion and suggat that it be the,.targeted figure.

                            MR. CHAMBLISS:  The amount mentioned in the motion
              231
                  is withdrawn and the target figtre is substituted, and that
              24  11 figure is $582,217.
              25 11
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                                                                            3 4 1


  WHD30        1               DOCTOR SCHERLIS: I would  also  like  to  just  note
               2    for the record -- it is interesting  to  note,  and  we  should
               311  have mentioned this in what I think  is  a  very  active  motion
               4    on appeal -- they never ask money for overhead.  Isn    It  this
               5    true? They are the only state  in  the  Union  that  refuses  to
               6    ask for overhead of RMP,    and.m,aybe this is a way of refunding

               7    some of that overhead.
               8               MR.  CHAIIBLISS:  Question? Those in  favor of  t  e

                    motion?
               9

                               (Chorus of "Aye")
               10

                               Those opposed?
               11

                               (No response)
               12.
                               The "Aye's" have it; the  motion carries.

                               DOCTOR-SLATER-.. Will the Staff advice going back on
               14
                    this indicate the concern over the   priorities of communication


                    and  so  on?


                               IIR. CHAMBLISS:  Yog.


                               @R. THOMPSON: And the  certificate  of  need  thing.>
               18
                               MR. CI@IBLISS:  And'the certificate of need thing.

                               DOCTOR SLATER:  This concern is coming from people
               20
                    who have spent time in the-rural areas.
               21
                               MR. CHAMBLISS:  Will the Staff note that?
               22
                               I would now like  to ask the Committee to make a
               23
                    decision as to  how we could  proceed during the lunch hour
               24
                    here.   We have completed the review of eight regions      this


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  IHD31               morning, we have eight left; we could, if you wish, complete
                 2    one more and then -- Nor,thlands, and that would free Doctor
                 3    Carpenter, and then after that immediately start in on Texas,

                      and that would clear Doctor Slater.
                 4
                 5                I stand open for.suggestions from the Committee as
                 6    to how we   should proceed.
                                  MR. THOMPSON:      Let's  get going on Northlands.
                 7


                 8


                 9


                 10





                 12.


                 13


                 14


                 15


                 16






                 18


                 19


                 20



                 21


                 22


                 23


                 24


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                                                                         343


  IqHD32      1                 REGIONAL MEDICAL PROGRAM REVIEW

              2                       NORTHLANDS REGION

              31,           MR. CIIAMBLISS:   All right, let's move forward  to,

              4   Northlands, and let the record show that  Doctor  Miller,  the

              5   former Coordinator of Northlands, has absented  himself   from


              6   the room.


              7             The reviewers here are -- is Doctor.Carpenter.

              8   Staff support will be provided by Mr. Jewell,  on  Northlands.

              9             DOCTOR CARPENTER:  Well, this is a     sort  of  the

              10  same problem. The Coordinator, as is  perfectly  obvious  to
              11  everyone here, has left, and I think he left  quite a  hole.
              12.           The Region has given up its own  priorities,  or  if
              -13 it hasn't, at least it doesn't mention them  in  the  applica-

                  tion.
              14
              15            The stff is --,.it simply lists the Federal  words
              16  and then says what it might do after that.
                            The staff is tiny.; there are four people, with three
              17
                  professionals.  They  have in mind enlarging to five, I believe.
              18
              19  But I see no evaluation of ari7y significance, and again,  the
              20  projects don't seem to me to,have any specific goals.
                            They are talking about area health education centers
              21
                  but it is not clear that there is local support  for  these,
              22
                  and it seems more a question of bringing in Mayo-produced
              23
                  software to be displayed to hospitals and staffs who undoubtedly
              24
                  will be busy elsewhere.
              25

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                                                                        34 4


  IHD33        I             They don't have any activity in primary care,  and
               2   I was pretty concerned at that point.' That was my  first
               3   time through, and I -- after I went back through it again, it

               4   is a triennial application; this is the third year.

               5             Their mechanism, except for the staff, I  guess

               6   teir mechanism is intact.  The RAG was inactive for a while,

               7   but it seems to be back again.

               8             The man who took over was the Deputy  Director  for

               9   a.number of years, and he puts together a very mechanical

                   application. It is beautiful, you know?  All  the  --  every-
               10
               11  thing is color7codod, and you can find your way through it
               12. very nicely, but I just don't find any substance there.
                             The contracts through CHP and the state agencies
               13
                   will apparently lead to the designation of Emergency Room
               14
               15  facilities by classification and a better  comanuhications
                   system between the various agencies'providing emergency care

                   in the state, and this will be something which I believe the
               18  original Coordinator started, and it is going to  leave  a
                   legacy that I suspect will be useful.

                             The definition of levels of training for various
               20
               21@ kinds of emergency personnel and performance  standards  have
                   been elaborated, and-for the continuation and development of
               22
                   this emergency project, they are asking for $140,000 for local
               23
                   plans, and $120,000 for the state coordinating mechanism.
               24
                             Then there is this network of community-based healthi
               25

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  WHD34        I   education centers; they do have local councils,  and  at  least

               2   a part-time staff now, in each of-the areas.
               3             Continuing education was     has'-always been, I guess
               4   of importance to them, and they have continued  that.  'They
               @5  are  -- they have a series of these AHEC'S; they have a
                   standard description on each of the projects,  which  is  goals
               6
               7   that I think were set sometime ago, and then.on some of the
               8   projects, there is typed in with a  different  typewriter  some

                   additional ideas.
               9
               10            For instance, some of  the    they.have a management
                   training program, and some of the AHEC's,, but not all of them,

                   will take advantage of that.
               12.
               13            One of them is going to get involved in  public educa-
                   tion, but no particular information about exactly  what  that
               14


                   means.
               15
                             Altogether, this program for the  community  based

                   health-education centers will  cost about $636,000-$640,000.
               17
                             Then there are -- they are interested  in  the  PSRO,
               18
                   business, and they are not coirLing at it in a way which I
               1.0
                   would think -- or, I would think they probably  should  have
               20
                   not started this way; they are interested  in  quality  evalua-
               21
                   tion, and they know that they are laying the groundwork for
               22
                   a PSRO, but I am not sure that they are going to --  I  am  not
               23
                   sure how you look at it.
               24
                             They are going to  set criteria, but they  are  going
               25

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   WHD35       1   to develop nine pilot programs, too.  And all in all, they
               2   will invest $190,000 in  something.called  the  "Foundation  for

                   Health Care Evaluation," and I hope

               4              MR. THOMPSON:  It sounds like a PSRO to me.
               5              DOCTOR CARPENTER:  I hope we can have some descrip-

               6   tion of what that organization is.
               7              They have managed to pull together  some  People  who
               8   don't ordinarily work together in quality care;  they got the
               9   Medical Society and the hospital group together, and that
               10  must have been a challenge, and then they   got the Mayo Clinic
                   to go along, too, so there has to be  something  good  going  on

                   there.
               12
                              Well, we have a state -- they want  to  coordinate  a
               13
                   state hypertension  control program, and that will cost
               14
                   $133,000 for clinics -- for a clinic in one hospital, and
               15
               1(; then $87,000 for software for public education programs.
                              There is $120,000 to sell the idea of organ procure-

                   ment to both the public and the professionals, and a p   art  of
               18
                   that program  is to find out why heptatitis is a problem in
               19
                   transplantation.
               20
                              There is $69,000 to start  the last two CHP's that
               21
                   the state thinks they need.
               22
                              Some of the projects are to  vaguely  described  that
               23
                   the state  A agency expressed concern in regard to  two  of  the
               24
                   projects,  involving the specificity-of the plans, and I guess,
               25

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   WHD36           that I am on CHP's side.
               2              Can we hear particularly from Staff  about  the  nature

               3!@i of that foundation for health care evaluation?

               4
                              -MR. JEWELL:. Doctor Carpenter, I questioned'Mr.

               5   Wilkins when he was in here, on this, and  it  is  a  fund-holding

               6   company. No, not a fund-holding company;  I  am  trying  to  think

               7   of the words he used.

               8              I really can't answer your question; I  could  not  get
               9   a satisfactory answer  at the time he was in  there,  and I did

               10  question him on this.

               11             DOCTOR CARPENTER:  All right.
               12             The number of that project -- well, it,is   hard to
                   find the projects because they are u  nder,several categories.
               13

                              MR. CHAMBLISS:  Is that 107S?
               14
                              DOCTOR CARPENTER:   We can find it by the dollar
               15

                   value.
               16
                              MR. CHAMBLISS:  107S  and 107?   Would that be the
               17

                   activity?
               18
               19             DOCTOR CARPENTER:  Ifiiat is, probably.
               20             MR. JEWELL:  That is the hospital association.
                              (Discussion off the record)
               21
                              MR. THOMPSON:  They say there is $326,676 in
               22
                   quality assurance; how did that number get arrived at by
               2.3

                   Staff?
               @.4
                              DOCTOR CARPENTER:  Well, it is hard., I'll tell you.
               25

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  WHD37        1   I spent a long time last night trying  to  do  that,  but  you

               2   can add up the various projects in that area.
               31             MR. THOMPSON:  Well, there  is 17S, which i@
               4   $158,000;  then there is 107, which is another $73,0011,    so
                   evidently  Staff, or whoever made up this briefing sheet,    .must
               5
               6   have combined those pro3ects that had something to d  with
               7   quality assurance, to come up'with the fact that 20 percent
               8   of the budget is on quality assurance.
                              MR. JEWELL:  That.is from their words, Mr. Thompson.
               9

                   It is on the purple sheet in the front.
               10
                              MR. THOMPSON:   I only got the yellow  sheet

                              DOCTOR CARPENTER:  There  is  some  blurring,  too,
               12
                   because there is a hypertension program that was       well...
              -13
                   there are several of them.  One of them is a quality assurance
               14
                   program in hypertension.
               15
                              So some of this quality  assurance business, I think,

                   has a little bit of pizzaz to it.  There is a guy from the
               17
                   Mayo Clinic who is working pretty hard at it, and he started
               18
               19  with a single disease and  worked  out  criteria  and  applied
               20  them, and now wants to expand  Iit to a couple of others.
                              MR. THOMPSON:  Beverly Payne did that a-couple of'
               21
                   years ago in Michigan. You  know,  and  he  started  out  with
               22
                   more than one disease.
               23
                              You know, it  is awfulfy difficult; these guys are
               24
                   just rediscovering the   wheel.
               25

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     WHD38                  I                           DOCTOR CARPENTER:  It is awfully difficult to match
                            2        and meet these.  lie is matching the relationship between
                            3        the ability to meet the criteria and the outcome, or trying
                            4        to in a hypertensbn project.
                            5                           And I think that -- you know, that is a                                       significant
                                     area that          requires more innovation.
                            6
                                                        Let me             you want'a            funding level, or do you wan
                            7

                                     to talk a          while?
                            8
                                                        MR. THOMPSON:                Go right ahead.
                            9
                                                        What about the               kidney thing?                   Is    that      going to         be
                            10

                                   legit?
                            11
                                                        DOCTOR CARPENTER:                     I don't think,               very;      'no.
                            12.
                                                        MR. THOMPSON:  I'd                    like to pursue               legitimate pro-
                            13
                            14       jects here; I've got 20 percent, wrapped up in quality assur-
                                     ance  and  I'm  not  sure  that  is  not  a  PSRO  basis.

                                                        I have $149,000 or 9 percent of the total budget

                                     wrapped  up  in  kidney  disease.
                            17
                                                        Then I have the payoff to CHP, which I'll roll
                            18
                                     by.
                            19
                                                        MR.  CHA14BLISS:    Let me  speak  to                          the  CHP  issue.
                            20
                                                        MR.  THOMPSON:    I               didn't  include               the  CHP.

                            21
                                                        DOCTOR  CARPENTER:    The  quality  assessment,  there  is

                            22
                                     about  $190,000  going  into what might    be  a  PSRO,  and  if  it
                            23
                                     is  not  it  is  so  vaguely  described  it  would  be  impossible  for

                            24
                                     me  to  support  it.

                            25

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                                                                          35 0
  WHD39        I             The rest of that $326,000 -- you know, I think it
               2   is not unreasonable to suggest something will come of that,
               3!1 and it certainly will not be a complete PSRO; it will be,
               4   you know, an opportunity to try to lead people beyond  Beverly
               5   Payne's criteria, which I believe is terribly important.
               6             The renal project, I don't think, is very good.
               7   Are you suggesting though, John, that,we are-not supposed to
               8   fund renal projects at all?  And I guess the issue   then is

                   this is not a catinuation.
               9

                             MR. VAN WINKLE:  That is hot a fact.
               10
               11            The only  ting we need to do  is'flag  the kidney so
                   it can be discussed  with Doctor Goodman in the end-stage
               12
                   renal program,.  We have to make sure that they are in compli-
               13
               14  ance, and this sort of thing is not something you fund without
               15  checking.
                             DOCTOR CARPENTER:  The  main thing with  that kidney

                   program is that they.are talking about procuring   organs, and
               17
                   they don't tell you for what.-
               18
                             I assume they  don't plan to bank them indefinitely,
               19
                   but I don't know.
               20
                             MR. VAN WINKLE: Could  I  speak  to  that?
               21
                             Doctor Fred Shapiro is the Director of the Renal
               22
                   Program in Minnesota and probably one of the leading nephtol-
               23
                 11 ogists in the country in terms of setting up what we con-
               24
                   sider to be one of the better programs that   we have  seen.

               25

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  WHD40                       HE does have true regionalization; he has been
               2   taking care of the Dakotas, too,. as well  as  Minnesota,  and
               3,  those satellite units you see basically are coming oLt of

               4   Shapirols units.
               5              DOCTOR CARPENTER:  Does he do enough trans:) ants  o

               6   have an impact on things?
               7              MR. VAN WINKLE:  Absolutely.
                              MR. THOMPSON:  I  gues.s my concern is  the  k@nd  of
               8
                   field you have for the project which is not matched #ith at
               9
                   least my idea of the  resources that are available in the
               10

                   state.
                              DOCTOR CARPENTER:   You mean you think the@ could
               12.

                   do more with what they have?
              -13
                              MR. THOMPSON:  I am talking about -- you know, there
               14
                   are some very good people in that state.
               15
                              DOCTOR CARPENTER:' Well,  you know, I  can't  argue

                   with-you there.

                              M. VAN WINKLE:  Mr. Thompson, I don't think there
               18
                   is any".question that after Doctor Miller left,  most  of  the
               19
                   other staff left also, and at one time all we had was Mr.
               20
                   Wilkins, his Deputy, and I believe one other person.  Is that
               21
                   correct?  And one part-time individual, and I -- Mr. Wilkins
               '22
                   is excellent; I am not  questioning  that  whatsoever.  It  is
               23
                   just so th-in.-'
               24
                              MR. THOMPSON:  In  the old-days, we used to get some
               25

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  IIID41       1  real flaming projects out of there.

               2             MR. VAN WINKLE:  That is right.  Their RAG and

               3  their Executive Board are excellent. They  are  very  good,
              @4  but they went into -- as I heard someb ody mention e@rlier

               5  irto neutral, and they informed.us at that time that  hey were

               6  making no moves  or any decisions or moving forward  i  any
                                                                       1
               7  way until they  got some answers from us, and we informed

               8  them back:  "You  may have a considerable wait,"  because  we

               9  didn't have any  at that time.
              10             So there was a period of time there was ve y little

                  happening.
              12.            DOCTOR CARPENTER:  Our idea now, at a $1,2 0,000;
                  the target is $2,170,000, the request will, by July, amount
              .13
              14  to $2,500,000, and I would think we might start now  at  some-

                  where around $1,600 000.
              15
                             DOCTOR WHITE:  Can I interject a comment?
              16
                             According to the yellow sheet, at least, all but
              18  $226,000 is for on-going activities. They  only  ask  $226,150
              19  for new projects. I don't know what  percentage  of  continua-
                  tion projects are being augmented, financially, but if  You
              20
                  cut them too drastically you may noteven allow  them  to  con-
              21
                  tinue what has already been started.
              22
                             DOCTOR CARPENTER:  Well, it is not too clear.
              23
                             tR. THOMPSON: They mdy be supporting  them,  but
              24
                  their annualization funds now
              25

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  7HD42         1           MR. CHTAMBLISS:  Did you have a comment on that,  Mr.

                2 Jewell?

                31!         MR.  JEVTELL:  Well, Doctor White, I don't know  if

                4 it is unusual but it is  probably unique. For  example,'on  EMS
                5 they will set a limit of  perhaps $25,000, which are funded
                6 through the CHP B  agencies.  You don't -- it isn't grab-bag'
                7 here; tey set a fund and if you can comply-- they set a fund
                8 for a certain amount, and if you can comply with  what  they

                9 set out as their goals and objectives, then that-set  amount

                10 is all you get.

                            MR. THOMPSON:  I think it is too drastic.
                11
                            DOCTOR CARPENTER:  Do you?  All right; I had $1,700,0)0
                12.
              .13   I was anywhere., all over the map.  If you were to say  --
                14 well, give them what -- there is no way that those three  guys
                  are going to bring home the bacon and a $1,700,000 worth  of
                15
                16 projects, even if some of them are now under way, I don't

                  think.
                17
                            But I don't know; what do you want to do?  Give them
                18
                  half of their new projects, an& what they had before?
                1!)
                            DOCTOR WHITE: Does anybody know at  what  percentage
                20
                  their old projects have been inflated?
                21
                            MR. CHAMBLISS:  Do you have any idea?
                22
                            MR. JE@QELL: It is not a great amount. I  am  sorry,
                23
                  I don't have that figure, but au 'entation of $10,000 would be
                                                  gm
                24
                 la lot.
                25

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  HD43         1              DOCTOR CARPENTER:  It has to be augmented in a      bunch,.

               2   doesn't it, because they    went from

               3i                     ELL:  Well, I meant on t                        re
                              MR. JEW                           he individual.    The


               4   are some  of them, Doctor Carpenter, that are larger.
               5              DOCTOR CARPENTER:  $60.0,000 increase; their reque,=+-
               6   is $600,000 larger now than what their annualized amount is,
               7   and they are reduced in staff,' and they have $200,00@ worth

               8   of new projects, so there must.be a $400,000 increaSE in

                   their continuation      $300,000 or $400,000 or someth ng like
               9

               10  that.

                              MR. CH2UIBLISS:  All  right.  Are You   prepar    to
               11

                   make a new recommendation, or    does your former recom  ndation
               12.

                   hold?
               .13

                              DOCTOR MC PHEDRAN:    I have an observation to make
               14

                   that may be  beside the point;   it is on a matter of detail.
               15
               16             I think that  this  matter  of  developing  standards  for

                   care of common problems in different hospitals and office prac-
               17
                   tices and so forth, that it is to    me an argument of no effect
               18
                   that somebody else has done it in the past,@Beverly Payne or

                   anybody else.
               20
               21             I really think  that  people's  behavior  in  the  manage-
                   ment of these things will never be changed.until they are doing
               22
                   it themselves on a  local  level.  I  think  that  it  is  worthwhile
               23
                   to avoid the duplication of efforts in various parts of the
               24
                   state.  I don't   think it is an inappropr@e expenditure of
               25

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  WIID 4 4    1    money.
                                                    r it is within R14P guide-
              2             Now, I don't know whethe
              31  lines; I haven't really gotten that  far in thinking about it.
              4    But I really think, from what I have seen since I ha@e  moved
              5    to Augusta, it makes me feel that the efforts which are being
              6    made the staff of this community hospital to develop
              7    they are doing GCAH types of preparation for audit  parposes,
              8    is probably going to be of more value to us than  almost  any-
              9    thing else you may have done, and it really did not aelp them
              10   a lot to know that somebody else had made some reco  endations

              11   in the past.
                            I know it sounds  like God and Motherhood"  ut I
              12.
                   really think it is true; I don't think there is any point  in
              .13
                   bringing anybody else's recommendation in except as it guides
              14
                 you in making your own.
              15
                            MR. VAN WIIIKLE: I/ tqell,-that is certainly  something
              16
                   that,,can be checked-out by Etaff.
              17
                             DOCTOR CARPENTER:  I don't think if that is the
              18
                   start-up project that that is a problem.  It is this non-
              1 9
              20   s.pecific -- whatever it is   $190,000 for the foundation for
              21   health care evaluation, that we just know mothing-about..  I-
                   don't think that is the problem.
              22
                             The other half of that money is for quality  assur-
              23
                   ance, and I agree with you.  I think it is the best thing
              24
                   they are doing, and ought to be supported.
              25

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  IHD45          1                 So--- would you believe $1,700,000?  That is a

                 2    motion.

                 3                 DOCTOR VAUN:  Seconded.
                 4                 MR. CHAMBLISS:  It is moved and seconded that the

                 5    level be   set for Northlands at $1,700,000.
                 6                 Is there discussion on the motion?

                 7                 Those in favor.@

                 8                 (Chorus of "Aye")

                 9                 opposed?

                 10                (No response)
                 11                The motion carries.
                                   The Committee has done all its       work assigned    for
                 12.
                 .13  the morning, and I would say we can have          lunch and come back

                      and start with Texas.
                 14
                 15                (Whereupon, at  1-12:45 P.M., the Committee recessed
                 16                for luncheon, to 1:30 P.M.)

                 17


                 18






                 20


                 21


                 22


                 2.3 i


                 24


                 25

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                                          TEXAS REGION                        @357

               1                MR. CHIU-IBLISS:  May I call the panel to order and

               2    indicate that first, I have b  een-in contact with the Chairman

               3    of the other panel and they are moving along with speed.

               4                We ate looking forward to the joint meeting of the

               5    two panels so that we can have a view  of  what  they  have  been

               6    doing and they in turn can see where we  stand  and  we  are  not

               7    at the moment certain as to whether this group can meet eithex

               8    this afternoon or tomorrow.  I am more or less inclined to

               9    believe that it may be in the morning.

               10               I would then suggest to the reviewers     that you
               11   may begin to consider amending your plans with    that  in mind.
               12               I do know that doctor      let's see,  who has to

                    leave today     Dr. 14cPhedran.
               13
                                DR. SLATER: I  am  sorry,  I  am  irreversibly
               14
               15   committed to leave.
               16               MR. CHAIIBLISS:  Dr.  Slater  has  already  indicated

                    previously.

                                Will you leave today, Mr. Thorqpson?
               18
                                MR. THO@4PSON:  Yes, I have an important meeting
               19

                    to make.
               20

                                MR. CHAIIBLISS:  Dr. Vaun?
               21
                                DR. VAUN:  I have an appointment tomorrow    after-
               22


                    noon.
               23
                                MR. CHAI-IBLISS: I think  that  willnot  be  aproblem.
               24
                                DR. SCHERLIS:  Would it'be advisable that we meet
               25

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                                                                             358


                I  at 8:00 o'clock instead of 8:30?


                2              MR. CHAl,4BLISS:  I will get that to the other

                3!1 parties.

                4              MR. TOOMEY:  What is the purpose of the other

                5  meeting?

                6              MR. CHPIIBLISS: Since we have been split  in  two

                7  groups to coordinate the  work of both of them, so that we can

                8  have the joint  recommendation covering all of the   all   of

                9  the funding levels opposed b  the two panels known to and
                                                -Y

                10 enforced by the entire  review committee.

                               DR. McPHEDRAN:  Is that something that you   need

                12.  as a pro forma matter?

              .,13             MR. CHA!,IBLISS:  It is a pro forma thing.
                14             DR. McPHEDRAN:  We can't just give you a blank

                15 check?
                lfi            MR. CH7U4BLISS:  Since Dr. Indicart has said that
                17 this should be a quality review, I think  whatever  semblance
                18 we can maintain of making sure that all of  the  requirements
                19 are met for such, I would hope that as many as can stay over

                   would do  so.
                20
                21             I would call to your attention also the fact that
                221we have a new Reporter present.
                               Shall we then begin with a review of the apoli-.
                23
                   cation from Texas and.the reviewers
                2411
                               DR. WHITE:  I hope you all will know I am excused.
                25

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               1               MR. CH2UIBLISS: Mrs. Salazar and Dr.  Slater  and,

               2   for the record, we note that Dr.-White has absented himself

                   from the room.

               4               Miss Murphy, Miss Mary Murphy, one of our

               5   operations people will be the staff person on this  region.

               6               MRS. SALAZAR:  At the outset, I must say at the

               7   time of the New Mexico deliberations were 19 minutes, so  I

               8   am making a push for equal time and a little beyond that,

               9   I hope you will bear with me.  I am eager not to be

              10   discriminatory towards sexes. I thought it  would  be  helpful

              11   to go into a little more detail because I found the application

              12.  extremely hard to understand and perhaps some of you have

              i3  'had the same difficulty.

              14               Texas is rounding out its first year of trienniurrt

              15   status, funded at $775,832, which covers 14 project activities,

                   a co-staff of 7 professionals, 5 commercial.

              17               This request continued funding for six on going

              18   programs and five new areas of health education, health

              1$)  economics and systems demonstration, health  manpower,  health

              20   care quality, and management of major diseases,  amounting  to

                   $3,239,000.
              21

                               There is also a staff development component
              22

                   requested in the amount of $287,000.  The.present  director
              2 tl

                   has served his capacity since November 1973.  However, he has
              24
              25   had PD..IP experience since 1970, having served as a deputy

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                              I        director  from  June  1971  until  August  of  last  year  when  he

                              2        became  acting  director.

                              311                               The  remainder  of  the  corps  staff  has  wide

                              4        experience  from  1-1/2  to  4-1/2  years.    The  total  number  of

                              5        staff  was  reduced  from  the  time  of  phaseout  from  32  to  the

                              6        present  14.    And  the  various  disciplines  are  impressive.

                              7                                But,  I  do  have  some  concern  about  the  region's

                              8        ability.  to  mount  the  very  ambitious  program  that  they  now

                              9        propose  without  active  day  to  day  surveillance  and  participation

                              10       by  physicians  or  more  immediately  related  professions.

                              11                               I  have  other  misgivings  about  the  region's  ability

                              12       to  deal  with  the  broad  State-wide  medical  programs  as  they

                              13       propose  in  the  application  with  a  delegation  of  authority

                              14       and  responsibility  through  the  project's  contract  conditions.

                                       Especially  since  these  issues  are  addressed  in  the  oroposed
                              15

                                       very  highly  sensible  position,  access,  utilization,  organi-

                                       zation,  manpower  and  so  on.

                                                               The  regional  advisor  group  and  the  board  of
                              18

                                       trustees  of  the  Texas  PJIPL  Inc.,  which  is  the  grantee,  appear

                              20       to  have  excellent  lines  of  communication.    Although  it  is  the

                                       same  time  noted  that  the  executive  committee  met  only  onc                                                  e
                              21

                                       in  1973.
                              22

                                                              This  committee  of  RAG  which  I  will  hereafter  refer
                              2t3
                              24       to  as  RAG  has  added  two  minority  members,  one  of  rural  and  one

                                       urban  base.
                              25

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                                                                            361


               1               It is interesting to note that although the

               2   program committees were only reactivated in early April   of

               31  this year, meetings are already scheduled in June with  only

               4   three replacements out of the 70 members requiring  space.

               5   think this is a test to the continuing interest  in the State

               6   and especially in the RAG-IUIP affairs.

               7               The RAG has obviously been very participative

               8   in the program development which evolved into  this  present

               9   application.  It had a special planning committee in November

               10  of 1973 and it met subsequently three times to  address internal

              @ll  and external health influences and significant  le  islative
                                                                     9

               12, thrust.

              -13              The RAr@ is also moved into the direction of

               14  strengthening relationships with the health planning.aqencies

               15  and has met with medical,-agencies as well as other  Federal

                   and other related associations.   Several of the projects seem

               17  to emanate from these sources.
               18              As a result of the joint Arkansas Council, a
               19  proposed rate for high new born death rate is under the
               20  Texas @MP for joint funding. This is I think a real break-
               21  through for Texas in view of the fact that they seem  to  be
                   responding better to local needs and demands which cross
               2->

                   traditional State lines.
               23
                               With the CHP involvement in the application, there
               24
               25  is some very familiar names withI longstanding experience in

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              1    health planning, are rather obviously alert and  informed  to

              2    the new thrust of Texas IU4P.


              3                I notice that Sister  Marian Strohmever is
              4    actively involved.  She has been  involved in the hellth

              5    planning in the lower Rio Grande  valley, which is one of  the

              6    depressed and under-served medical areas of the Stuce.
                                                                        1
              7                However, the time frame for the  Dreparation  and

              8    submission-of this application imnosed very serious

              9   -limitations in MY view on community involvement  and  review.

              10   And to me it at least created a vacuum in the appli  ation  in

              11   order to review the CHP report. It appears  planned-.  It  is

              12,  so planned that it is almost meaningless to  me.
              .13              There were four letters of endorsement  with  two

                   to follow and there was some expressed reluctance  from  local
              14

                   groups to comment on Statd-wide  programs.  They  felt they
              15

                   didn't have a bearing, that they'were not  capable  of that.
              16
                               There is also an element of inconsistency  in  this

                   vacuum.  In February of this year, the second  annual  meeting-
              18
                   of health planners of 22 councils of government  was  sponsored
              19
              20   b-y the Texas P14P. The nurpose of this meeting was  to  solic3t
                   assistance in information about successful  projects funded
              21.
                   by the Texas @IP since 1968. Another such  meeting  is  Dlanned
              22

                   for next month.
              23
                               I think that perhans@ it is time to inquire  about
              ?,4
                   present status and cooperative efforts in view of this, as
              25

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                                                                             363

                   well as other pending proposals and  the  RAG  reports.  That

              2    they are under consideration like the Arkansas-Texas    joint  I

              3@l  council.

              4                AS to feasibility, the contract  approach to these
              5    proposals seems to have some advantage  of  concise  l@nguage

              6    and subject presentation, the goals and objectives are clearl@,

              7    defined, easy to read.

              8                However, the same economies of languaae do impose

              9    specificity and detail.  I have no criticism of contracts

              10   per se as a mechanism but,I have some problems with     e

              -11  personal non-human approach to fulfilling the provisions of

                   the contracts.


              -13              There is a quality throughout here  of   saneness

              14   of the language.

                               It is comm6rL-to all the projects and it is
              15

                   difficult to determine the inter phases and the -- the network,

              17   in other words, of the relationships of one  project  to  the

              18   other.
              19               The.language is good and it is lofty  and  it  is

              20   worthy and it sounds like they can do it.  But once again, the
              21   impression that these views that vou are looking at, all

                   of these throw a thin layer of professional systems who are
              22
              23   unquestionably skilled in such presentation and I have trouble
                                                   e
                   with the understanding of it.  I have trouble with understandi:,Ia
              24
              25   the programs commitment to addre Iss themselves to these

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                                                                           -364


               I   problems.  They don't come through in these little

               .2  descriptions of the request for contracts.  That is,mv  own


               31  bias.

               4               There is an intangibility about it that,I  find

               5   is very difficult to deal with.  Let me just quote  ne

               6   little paragraph.  Description of one of the programs.

               7               To develop and demonstrate educational  pnroaches


               8   for barriers to health care.


               9               So much of the contracts and the  effectiveness


               10  of the contracts, I believe depends on the language, that  I
             .11   find it impossible to get an understanding from whatlI  read

               12. in this application of what Texas is going  to do with tl-,ese

              -13  contracts. I have some concerns  about  giving contracts  to

               14  profit organizations and who will nionitok them and 1 will

                   spell those but later.
               15

                               I would not at this time like to make a recommenda-


               17  tion until we hear from Dr. Slater about that.

                               MR. CHAIIBLISS:  Thank you, Mrs. Salazar.
               18

               19              Dr. Slater?

                               DR. SLATER:  I thought you were going to be going
               20

                   for 19 minutes?
               21

                               I would like to say, Mrs. Salazar and I met just
               22

                                                                icated on Texas.
               23  briefly at lunch, is the first  time-we  commun
               24 'And I will simply reiterate for you what my statement was for

                   her.
               25

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                               1 was deeply impressed with the objectives as
               2   she has quoted them of the Texas,nrogram and felt that as
               3   long as looking at health education, quality State-wide
               4   disease projects, health manpower concerns, that clearly
               5   there is plenty of room to move.
               6              And that one cannot fault  under any circumstances'-
               7   this kind of -- the set of objectives.
               8              TAlhat I simply cannot get ahandle on, readina
               9   Texas, was what was really coming out of it and Icame

              10   prepared to say that I am impressed with the range of
              11   activities that are going on and feel that, from what I read,
              12.  that they apparently do have very good review by an involve-

             @13   ment of the comprehensive planning group. But I still  could

              14   not understand it because there is too much, there is too

              15   broad a range of activity explained into few words, which I

              16   believe you say lack any color whatsoever.

              17              I think that perhaps Ilrs. Salazar put a figure
              18   on it by saying there doesn't seem to be any medical pro-
              19   fessional input into this that gives the sense of the priority
                   within the framework of the humanity aspect of it and I am not
              20

                   saving that that comes through that strongly in the other
              21

              22  proposals but this is a little too perfect in some ways.

              23             What I am saying is that I am impressed with  what
                   they are attempting to do and if one takes a look at paae 24,
              24
              251  the project status report, contract No. 73-1, continuing

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                                                                          366


              1    education for reaistered. nurses providing community health

              2    services, is on  schedule.

              3!i.             Comments:  Extended 60 days for additional effortli

              4    Progress excellent.


              5                That is  fine.


              6                And there is two Dages of this type, or 2-1/2

              7    pages of this activity and we simr3ly-have to.accept the fact
              8    that evervthinq except the two projects is on target and doin-@

              9    well.

              10               on-the basis of that, there is a request for

              11   continued activity of, I can't get here, I would say some-

              12.  thing like, maybe $300,000, $400,000 extension.

              .13              Now, when one goes beyond that one gets into the

              14   matter of what do they plan to do in the future?

                               As Mrs. Salazar pointed out, because they are in
              15

              16   a tight time frame, they have decided to follow the general

                   guidelines of their thrust, their objectives and sent out
              17

                   proposals for, send out requests for proposals.
              18
              19               Do you want me toogo on with this?

                               Mrs. Salazar.  Yes.
              20
              21               DR. SLATER:  And let me, if I can find my way in
              22   again, let me give some sense of what they are doing here.

                               They have an access committee of their RAG,
              23
                   oriented, an access committee concerned about getting into
              24
                   the health T)rogram. It is asking for $286,400 for what is
              25

              c
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                                                                              367

               I    called the Texas health education project.    Within that

               2    there are a whole series of objectives  which  are  fine.

               3    Objective 1 is develop and demonstrate a coordinated approach

               4    to individual health education in a selected area.

               @5               Then there are Work  Activity  A.  Apply  those

               6    guidelines developed in IU4PT Contract k@o. 74-14 through a

               7    coordinated approach to individual health  education  in  a

               8    specific community, town,  county,  multi-county  region.

               9            is available for that.

               10               Two, determine health education requirements and

               11   develop effective means of meeting those needs.

               12               There are four work activity suggestions here

               13   sent out, widely distributed  throughout  the  State.  They

               14   range from Work Activity A, analyze  cultural  barriers  to

               15   adequate health care and,,d                     overcomin
                                              ,7yelop methods for           g.the

               I(;  'barriers through education at $48,000; Work Activity B,

               17   develop an outline form that can be used  in  rural  poor

               18   communities to assess health status and informational needs

               iq   at $40,000.

               20              Work Activity C, study the legal barriers    to healtl

                    care as perceived by the consumer and provider and recommend
               21

                    educational approaches to overcoming  those  barriers  at
               22

                    $63,400.
               2tl
               24              And Work Activity D, demonstrate and evaluate the

                    use of upper division nursing and medical students as remote
               25

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                   area community health educators during  non-school  periods

                2  at $35,000.

                               Objective 3 is improve health care  and   reduce

                4  overall cost through education.

                5              Work Activity A, analvze areas of greatest
                6  cons umer abuse in the health care system and suggestieducatio@al

                7  programs aimed at overcoming  same at $55,000.

                8
                               All of those activities add up to something like

                   -$@86,400.
                9

                10             Then, under the general rule book  of the utiliza-

              -11  tion community, the Texas Health Econorqlcs an  Systems

                12. Demonstration Project are indicated.  That is a figure  of
                                                                         1

              -13  $636,340, and I think I would lose you if I read over all,

                14 the objectives and work activities.

                15             Needless to say

                16             MR. THOMPSON:  That is a five-year project

                17 conservatively speaking.  I just reviewed it just for you,

                18 Bob.

                19             DR. SLATER:  Thank you.  I didn't even speak to

                20 you about it.
                21             Health Manpower Committee of the RAG is to a8s3st,

                   coordinate and cooperate with those who wish to perpetuate,
                22
                23 expand and improve the quality and output of health manpower
                   in Texas for $160,000, and a very laudable group of objectives
                24
                2  laid out here. I don't think anyone is  finding  any  fault

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                                                                                                                                                 it:)9



                            1        with  this.


                            2                               The  report  on  current  distribution                               and     trends  in
                            31,'     Texas  is              work  activity,  none  is  required  at                              this     Itime.
                            4        They  were  satisfied  at  a                          excuse  me,  that  appears                      to  be

                            5        in  here  under  what  they  were  going  to  fund  and  I  have  been

                            6        misled.


                            7                               But  they  have  a  series  of  objectives  und  r

                            8        attempting  to  define  better  health  manpower.                                         Here  is  a  very

                            9        specific  one.

                            10                              Encourage  the  development  of  a  resnonsiv    and

                            11       timely  State-wide  health  manpower  data  base  for  use                                           by  health

                            12.    educators,  r)olicy-makers  and  others.

                            -13                             llork  Activity  A,,  a  six-month  study  for  this

                            14       purpose,  with  Governor's  office  of  Information  Services,  is
                            15       nearing  mid-point.    This,.is  already  under  way.

           (2)                                              Continuing  Education  Committee  is  wanting  to

                                     identify,  encourage  and  assist  those  health  care  professionals

                            18       interested  in findling  new  and'more  effective  methods  for
                            19       providing  continuing  education  in  the  region,  and  they  require
                            20       $308,700  for  that.

                                                            MRS.  WYCKOFF:    Is  that  PSRO?
                            21

                                                            DR.  SLATER:    I  don't  think  so.
                            22
                            23                              MR.  THOMPSON:    There  is.a  quality  that  is  laying

                                     the  base  for  that.
                            24
                            25                              DR.  SLATER:    Can  you                identifv  that?

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              I               MR. THOMPSON:  Project No. 111.  You mention PSRO

              2   specifically in the project, but.although it doesn't make  it
              3 I!; directlv

              4               DR. SLATER:  Objective 1 is assist in the.

              5   developr..ient of new approaches to upgrading quality health

              6   care in response to identified needs of the professional

              7   conlnunitv.

              8               Ilork Activity A, establish a quality review   task

              9   group comprised of physicians and other health   professionals

              10  to provide leadership and decision-making functions for the

              11  project.
              12.             Work Activity B, select a technically   qualified,
              -13 unbiased organization capable of providing research, analysis,
              14  evaluation and other work support to the task group.
              15              The analysis evaluation, in other words.
              16              MR, THOMPSON:  I was'on the PSRO task force and
              17  I can take this and lay it out and say to  the  PSRO,  here  you

              18  are, go.
              19              DR. SLATER:  The final one is just for $6500
              20  I don't think I dropped a zero -- I  did,  $65,000,  excuse  me,

                  regional disease management program.
              21
              22              That is oriented to the management of major
                  categorical disease awareness and treatment program in Texas.
              23
                  And the goal is to design and test effective mechanisms for
              24
                  developing and managing State-wide disease programs.


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                               Now, they have several objectives.

              2                To document the methodology in Texas for a

              3!i  coordinated State-wide response to major disease aw
                                                                      areness


              4    and treatment programs.

              5
                               Work Activity A, to evaluate the major disease

              6    programs supported by MIPT since 1960, heart, cancer, stroke,-

              7    hypertension, renal, to identify successful and unsuccessful

              8    features.


              9                Now, that is evaluating the major d'
                                                                  lseas


              10   supported by PJIP since 1960.  That is a lot of work.

              11               Deve lop a methodology for a comprehensive,

              12.  coordinated State-wide approach to major disease. programs.

              -13  That is to be sublet to somebody or maybe multiple people-

              14   for $65,000.  There are some other objectives here.
              15               Monitor the jnajor disease programs currently being

              1(;  funded through IU.IPT.

                               objective 3, recommend to the regional advisory

              18   group concerning the efficiency of participating, or continuin3
              19   to participate, in major disease programs.

                               I am saying that t support this type of activity.
              20
              21   I think it is very necessary and we have to move increasingly
              22   to it in this country.
              23               What I don't get a feel.for, either from this
                                                   11
                   brief description as it appears here or of the more extensive
              24
              25   write-ups that appear in  the  boo.k and they are not that much

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                                                                                372


                    more extensive, they are simply  almost  the  same  thing  laid

                 2
                    out on the dollar street activities, required    pages,required

                    by RMP.  I  can't get a feel how long it   takes  to do these.

                 4  l@ether there are groups in Texas to do    them and what is

                 5  the quality of the work that is going to be done.         canit

                 6  seem to get a profes sional sense of this.

                 7               I am concerned that they are  asking  for  a  great

                 8  deal to be'done in a very short   period of time.

                 9               Now, I gather against this background        t.they

                 10 expect many, many proposals to come in and in    fact  aving

                 11 something in the  range of  90 or 100 from which  they  wish  to

                 12 choose about 25,  and I am  anticipating  obviously   thait  their

               .13  staff and RAG group are going to  screen  out  those  that  are

                 14 technically capable of being done in one year.

                 15              I come back to the concerns that Mrs. Salazar

                 16 had, which I believe should be reviewed here and that is the

                 17 matter of what kind of assurance do we have of the monitoring

                 IL8 that can be done by essentially nonprofessionals, non-

                 I!) physician professional staff and it may be that they need

                 20 other kinds of professionals on activities that are essentially

                 21 contracts.

                 22              The question I have is  when  one  nuts  contracts
                 23 out, are they all to profit-making organizations?
                 24              Does the contract carry any concern for the
                 25 conflict of  interest between those who are on a profit-making

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                                                                               f  -D



                1  basis in providing the kinds that we  want  in  comnared  to  the

                2  usual grant system?

                3               I think that     I don't want to go  any   further

                4  at this point.

                5               Do you have any follow up?

                6               MRS. SALAZAR:  No, except for this letter.

                7               MR. CHA14BLISS:  Yes, let me introduce the letter.

                8               There has come to the attention of Dr. Pahl


                9  what  is marked as an urgent'piece  of  correspondence  from.

                10 Texas.   It arrived during the break  and  the  reviewers  have

                11 had a chance to  read it.

                12              I would simply submit that the  panel  may  wish to

                13 know of its  contents.

                14              DR. SLATER: Yes, I  think  the  Texas  people  were

                15 concerned that they had put a proposal  into  us  in  which  they

                l(i were really asking us to take on  faith the fact that they were

                ii going, following the program  thrust  that  you  have  described

                18 and had submitted a request for  proposals  to  be  submitted  to
                19 them and that these proposals are now 3ust coming in and that

                20 they are planning to have their  RAG  staff  group  act  finally

                   on those proposals on June 28  or  something  like  that,  which
                21

                   is something more than a month after  we  would  have  funded
                22
                23 them to do it.
                24              So that we are in fact funding,them in advance of
                25 the time that they actually make a decision for the proposals.

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                                                                           374


                               Miat they are suggesting is.that their proposal

               2   as submitted to us, be modified to the extent that they take

               3
                   their 25 top priority proposals and  submit them to the  R-T..IP

               4   staff here who would review them and  make a decision on

               5   whether or not these satisfy, in essence, the  goals of @IP

               6   and the thinking of this Committee is the staff cou d

               7   interpret  that.

               8               Is that a fair display of what they say?,

               9               MR. POSTA:  -Yes, sir.

               10              DR. SLATER:  They are  concerned that

               11              DR. SCHERLIS:  Could you translate that?

               12.             MR. POSTA:  lqhat their picture is, that y going

              .13  the contract route they would like to have as long a period

               14  as possible, meaning 12 months.

               15              If they hadto wait until July 1   to get their

               1(; 15's and 16's in more specificity, by the time it got through

               17  all counsel, they would have a maximum 10 months to do the

               18  activities Droposed and their whole concern is, on the

               19  contracts that they had funded in the past, through their

               20  evaluation process according to Texas representatives, the

                   ones that have been funded in the least amount of time, have
               21
               22  not been as successful as those that were given a full year's

                   duration.
               23

                               MR. THOMPSON:  Do we have any idea to whom these
               24
               25  contracts are going to be let?

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                                                                                                                                                     375

                            1                               MR.  CHAMBLISS:    Miss  Murphy,  can  you  comment  on


                            2        that?
                            31'                             MISS  MURPHY:    I  think  in  the  Drimary  and

                            4        secondary  review,  a  summary  of  contracts                                   funded  from            1972

                            5        through  1974,  and  just  reading  down  to  the  people  that  they

                            6        were  contracted  to:


                            7                               Texas  Hospital  Association                               these  are  the  past

                            8        ones  and probably  some  of  these  same  will  be  included  in  this

                            9        round.

                            10                              Texas  Hospital  Association.

                            11                              Texas  Medical  Foundation.

                            12.                             Chamber  of  Commerce,  Ty  er.
                            .13                             Coordinating  Board,  Texas  College  and                                 University

                            14       System,  Austin.
                            15                              Scott  and  Ilh,ite  Memorial  Hospital  and  Scott,

                                     Sherwood  and  Brindley  Foundation-Temple.
                            16
                            17                              Human  Resources  Development  Foundation-Houstoni
                            18                              Bexar  County  Medical  Foundation-San  Antonio.
                            19                              Cameron  County  Boaord  of  Health-Harlingen.
                            20                              Texas  Hospital  Association,  Austin.
                            21                              Texas State-Department of Health, Austin.

                                                            St. Paul Hospital-Dallas.
                            22
                            23                              Texas t-,Iedical Foundation, Austin.
                                                                                                  e
                            24                              The University of Texas Health Science Center at

                                     San Antonio.
                            25

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              1                Southwest Research,Institute, San Antonio.

              2                And I could go on.

              3 1              I have another page and a halt.  Those are  the

              4    types of people that they were contracted to. They  sent  them

              5    to a very select group.

              6                I have the sheets where they are checked off,

              7    how they had selected them and according to thei r expertise.

              8    Five hundred.

              9                MR. THOMPSON: -I am concerned myself, only  faiklv

              10   knowledgeable in the,area of health care economics, that

              11   this project that they have laid out here is very well done,
              12   but the problem is that work, the way it is-laid  out,-work
              13   activity A has to be completed before work activity B can

              14   be begun and C.
              15               When I said.it would take five years, I was  being

                   slightly facetious.  It would take three years.
              17               But, I don't know where they are going to  find
              18   the people down in the hospital association, because I know
              19   the people down there who are going to be able to do  this.
              20   This is a fantastic -- it is a well laid out, fantastic  idea.
              21@              MISS MURPHY: They are only going to let 30  to  35
              2,,' contracts out of this whole group.
              23               DR. SLATER:  I assume they are going to operate
              24   in the future on the basis as they operated in the past.  If
              25   one takes project status reports and accepts their very  brief

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                                                                           377

               1   indication  o-f how they are proceeding, one says they are

               2   satisfactory, I just don't have a feeling for this and  all

               311 we can do is assume on how they are going to operate in the

               4   future as they have in the past.

               5               MRS. SALAZAR:  They seem to be convinced that

               6   the contract mechanism is the way they are going.,

               7               MISS MURPHY:  That is the only way they feel they

               8   can go.

               9               MRS. SALAZAR: They feel  that  their,experience

               10  with the contract is verv good.

               11              DR. SLATER:  I will accept that.-

               12              MR. VAN WINKLE:  They have 130 letters of intent

               13  out.

               14              DR. CARPENTER:  Did the regional advisory group

               15  approve this?
                                            Al
               16              MISS MURPHY:  Yes.

               17              DR. SLATER:  I think it is difficult to have done

               18  more than this, because of the reporting that will be

               19  necessary to get a grasp of the renorts.  Either that or.
               20  they might have been able to give us an appendix of their
               21  status reports which would give us some indication of  what
               22  was coming out of the projects that are already funded  and

               23  the implications.

                               MISS MURPHY: This is what the form  I  referred
               2 @4
                   to do    summary of contracts funded.  Very small print.
               2

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                                                                                                                                               378


                            1                               MR.  CHIV-IBLISS:    There  have  been  some  concerns


                            2        on  the  part  of  staff  expressed  about  the  16's  and  the  fact

                            3        that  they  have  not  gone  into  anv  detail.

                            4                               We  would  certainly  want  the  views  of  the                                  committee

                            5        on  that  asnect             of  the  application.

                            6                               MRS.  1,7YCKOFF:    Does  this  mean  that  they  are  goina@

                            7        to  reach  out  beyond  the  walls  of  the  great  elite  establishment

                            8        in  Texas  and  try  to  get  into  the  uncovered  areas  that  really

                            9        been  touched?

                            10                              MR.  THOMPSON:    These  are  the                        same  old        boys.

                            11       These  are  the  same  old  boys.

                            12.                             DR.  SLATER:    I  would  like  to                       take      exception  to

                            @13      Mr.  Thompson.

                            14                              They  really  are  making  an  effort  to  look  at  the

                            15       mortality  rate  in  the  area.

                                                            MRS.  IIYCKOFF:    I  think  the  physicians  are  reallv

                                     on  the  job.

                                                            MRS.  SALAZAR:    It  is  very  difficult  to  say,  @Irs.-

                                     X@ckoff,  from  the  reading,  the@  kind  of  thing  Dr.  Slater  has
                            20       indicated,  it  is  very  difficult'from  the  reading.
                                                            This  is  why  I  have  problems  with  the  application
                            21
                            22       being  completed  that  it will  indeed  begin  to  cover  these
                            231      areas.
                                                            Mary,  maybe  you  can  tell  us  at  the  time  of  phase-
                            24
                                     out,  where          did  Texas  go?    How  far  down  the  road  did  it  go
                            25

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                                                                              379


               I   back?

               21               Maybe I can get some  meaning from it.
               3tl              MISS MURPHY:  They went  from 35 Deople and  now
               4   they have 7  professionals, 8-1/2

               5                MRS. SALAZAR:  I am not   speaking so much of staff.

               6                MISS MURPHY: They  closed  all  of the sub-regional

               7   offices.  No more sub-regional offices.

               8                Like these RMP's were sent  to  El Paso, so many

               9   of their old staff th at they had, that  they knew were distri-

               10  buted throughout the State to try to get a good coverage --

               11               MR. THOMPSON:  I don't think-seven ,oeople  can

               12.  monitor these.
               13               MISS, MURPHY:  Say that you pick a good  project
               14  director, why would some person have to go out and    do it?
               15               MRS. SALAZAR:  How can you monitor yourself?
               16               DR. SLATER:  I think'what needs to be clarified
               17  is whether or not there is functionally any difference between
               18  a contract and the traditional form of grant mechanism that
                   the @.iP follows in the sense (yf professional quality and
               19
                   monitoring and judgments that a  re made.
               20
               21               I think if the committee can satisfy itself, that
               22  contracting  is just as good functionally.
                                MR. VAN WINKLE:  Dr. Miller has had some experience!
               2.3
                   with that methodology.
               -)4
                                MR. THOMPSON:  Before you go, because you are goin


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                                                                             38c)


                   to have a lot more to say about this than I, when we had a

                   project we had a man, an identifiable person who we sometimes

               3   were disappointed but we knew his background, we knew what he

                   was good at and bad at and we could judge the contract, I

               5   mean the project.  The contract, we don't have   the man.

               6               DR. MILLER:  It depends on how you do it.  It

               7   depends on how you do it and my experience with it was

               8   essentially halfway between what you traditionally think of

               9   as a  ontract and what we traditionally think of  s a r)ro
                        c                                             a       ject.

               10              And by that mechanism, why you know not only the

               11  man but you know the institution, you know  what you want

               12  them to do and you have a lot better control over it than

               13  you have over a project.  All the way around.

                               MR. THOMPSON:  It takes a good monitoring system
               14

               15  to get  that.

               16              DR. MILLER:  It takes  a good system, yes.  But

               17  it is not an open-bidded contract  kind of a thing.  You don't

               18  just publish.it and give it to the lowest bidder without reg@rel

               19  to who it is.  You can do

               20              DR. SLATER:  They are not going to do that here.
               21  They are obviously going to look for quality projects or work

               22  and then contracts.

                               So would you agree to that in terms of what I
               23
                   understand the system here to be, they are simply using the
               2,4

                   contract method to finance?
               25

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              1                DR. MILLER: It hasn't any positive  attributes.

              2    I am thoroughly sold on the contract approach to project.

              3    It really puts vou in the driveris seat with regard to

              4    management.

              5                MRS. SALAZAR:  llhy did Texas elect to go this


              6    route?


              7                MR. CHAMBLISS: That had to do with the  change  of

              8    organizational structure.

              9                Will you clear that up  Mike?

             ..Io              MR. POSTA: I guess it was December of  '72.  un

              11   to that time the Texas system was the grantee agency which

              12. was composed of 17 educational institutions.  Then  they  broke

              13   away and formed,a name and a board of directors and of  course

              14   by that time we had gotten word that Febrtary 173, that we

                   were going out of business'.
              15

              16               So the regional advisory group got together  and

                   said., if we are thinking about feasibility, short-term pay-

                   offs, we had better think in terms of a period of a year.
              18
              19   Their whole administrative mechanism was to build a device
              20   whereby they could call the shots, set up the instructions

                   for the contracts, choose the neople and pay them for the  job
              21

                   done and they, qtoting verbally, "have felt that thev have
              22

                   done a better job especially in short runs."
              23 1
                 I             They probably would not agree if they had a three-
              24
                   year  funding period.  But I think their whol.r.,@  remise is based
              25

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                                                                          @82


               1   on that approach.

               2               DR. CARPENTER:  Did they use the contract

               3   mechanism to get the grants written?

               4               MRS. WYCKOFF:  You mean the Pj4P?


               5               MR. THOMPSON:  I think I know who wrote some of

               6   these grants.  I think that is a facetious question.

               7               DR. SLATER:  llell-, I think again, given the

               8   material that we have in front of us coming from a program

               9   that has been site visited and has been a part of  the

               10  endeavor here for years and for which many peo le  have Dersonal
                                                                  p

               11  knowledge of the individuals, one has to give the  benefit of

               12  the doubt.


               13              I think there is another major question that

               14  comes uD and that is whether or not we feel it is appropriate

                                              or some of the monies for the new
               15  to consider allocating all,/,

               i(i projects which have been requested prior to the time that

               17  those projects have been chosen.  They have requeste  t at

               18  they do this with the proviso that we, appropriate the staff

               I() here, the responsibility of reviewing those 25, and

               20  representing us and the advisory council, that it is appropriate

               21  for them to proceed to carry out.

               22              MR. VAN WINKLE:  I believe I am correct.  Larry,
               23  they cannot spend any monev until you have 15's or 16's, is

                   that correct?
               24

                               DR. CARPENTER:  What is the 15 and 16?
               25

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      (3)      1               MR. VAN WINKLE: The  budget  forms.

               2               DR. SLATER: They won't be  able  to start Until
               31 July 10. As soon as you clear the  air  and  the money will be

               4  in the bag.

                               Otherwise, they won't get through until the
               5

               6  Advisory Council meets in August, which is too short and

               7  will

               8               MR. THOMPSON:  Are they talking about this or

               9  the next one co-ming.down the pike?

                               MISS IIURPHY:  They are sending nothing else in.
               10

                  otherwise the contract will have to be ap
                                                          ...proved and met in

             .12  July.

                               DR. SLATER: To get something  done.
               13

                               MR. THOMPSON:  We are examining this one right
               14

                  now; is that tigh4.-.@
               '15
                               DR. SLATER:  @at is-right.  We don't know what
               1(;

                  the 25 projects are going to be.
               17

                               All we know, are the guidelines being used by
               18
               19 applicants who already submitted 130  proposals?

                               MR. THOMPSON:  If they can do it, why can't every-
               20

                  body else do it and we don't meet in July?
               21.

                               DR. SLATER:  Well, I think
               22

                               DR. MILLER:  Isn't this a slush fund?  That is
               23
                  what we turned down yesterday.
               24
                               MR. CHA-MBLISS:  We need the judgment of the
               25

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                                                                                 384


               1    reviewers here.

               2                 I would say there is.a fundamental issue     here   and

               ,i   that is, I think Dr. Pahl would be    very much concerned   here

               4    and so will the Council, and that    is  the  local  decislion-makin

               5    Process has not had a chance to.work its will on wh t you

               6    are being asked to make a recommendation on today.

               -1                MRS. 1,7YCKOFF:  It is a blanket request.

               8                 MR. CIIAIIBLISS:  I would -- I wanted to, wanted

               9    -the discussion to go forward as it has, so that we       u

               10   thread out of here some advice for counsel and     for D

                    Pahl,

               12@               MISS MURPHY:  Could I ask    something?

               -13               I-IR, CHAIIBLISS:  Yes.

                                 MISS MURPHY:  Each one of these proposals as
               14

                    they'are being worked out before they are submitted to the
               15
               16   @IP, are to  be brought to the attention of the CHP.  A comment

                    is going to  be made prior  to coming to the RM  P.
               18                MRS. VIYCKOFF:  Did they  make  the  comments  on  the-

                    lU4P that went ott?  Or on what comnanies?

                                 MISS MURPHY:   They have  companies  on  all  of  this.
               20
               21                DR. SLATER:   I think if the usual history of all
               22   the other Projects were being followed by.this one, we woul
               23   have 25 more clearly identified, ve@ briefly described
               24  @projects which Iwe would look at'and we would say, yes, that
                                                                                        I
                    is what they are going to do next vear and they only requested
               25

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                                                                                                                                                         385

                              1        7 percent of the funds that are targeted for them and it

                              2        sounds good because they have been producing in the                                                         past       and

                              3        so let us go ahead with it.

                              4                                 I think that is what we                           are likely to say as                       we

                              5        pick holes in the taraets.

                              6                                 MR.  THO!@IPSON:    We  would  have  some  evide  ce  that


                              7        CHP


                              8                                 MISS  MURPHY:    You will  have  it.     They  will  have

                              9        -reviewed  them  before  they  get  to  the  RMP.

                              10                                The  proposal  is,  you  know,  that  is,the  direction.

                              11                                MR.  THOMPSON:    What  is  to  stor)  it  even  i    thev

                              12.      get  an  unfavorable  review?

                              13                                DR.  SLATER:     I  think  what  they  have  done  is  wire

                              14       us    and  put  us  on  the  record  and  said  that  the                                      25  projects

                                       that,they  send  up  here  would  only  come  on  the                                          basis  that
                              15

                                       they  went  through  the  usual  process  and  then                                          they  put  this

                                       staff  in  the  position                           put  us  in  the  nosition  of  defending
                              17

                                       on  the  staff  to  legallv  or  to  put  their  names  on,  agreeing
                              18

                                       that  these  are  avnronriate.
                              19

                                                                MR.  THOMPSON:    This  is  going  to  come  up  in  South
                              20

                                       Carolina.    The  same  kinds  of  business,  although  not  so
                              21

                                       blatant.
                              22

                                                                I  just  have  a  vague  feeling  that  I  am  getting
                              23

                                     -had.
                              24
                                                                DR.  SCHERLIS:    The  question  is,  for  how  much.
                              25

     HOOVER  REPORTING  CO,  INC.
      32OMassachusettsAvenue,N.E.
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                1                 DR.  CARPENTER:  There  are  certain  things  which  I


                2   will not put.

                3                 DR. MILLER:  You have been getting had all       day.

                4                 MR. CHA14BLISS:  I would assume those comments are


                5   off the record?

                6                 DR. SCIIERLIS: No, sir,  I  would  like  those  to  be

                7   on  the record.


                8                 MR. CHIU-IBLISS:  All right.

                9                 DR. SLATER:  I think it clearly breaks all

                10  precedent,   the past, as  well  as  good  operations,  to  approve

                11  this kind  of thing without some committee review inDuts.

                12                Mrs. Salazarts question is whether or not it would

                13  be sensible   in this case to have a site visit    by  some  of  the

                14  review committee and the staff to take a look      at the situation

                15  here in view of the -- in view of the problem.
                1(;               MR. CHAMBLISS:  I would recognize Dr. Scherlis

                ii  fi rst.
                18                DR. SCHERLIS:  You are obviously looking for
                19  some way out.  Perhaps we could give a tentative approval,

                    giving their ap
                20                   proval by July 1.
                21                I for one, Although I  know  that  a  great  deal  of
                    what we are   doing at this session is really looking at
                22
                    inadequately  submitted  proposals  and  making  what  in  time  may
                23
                24  be inadequate decisions, I stilf think we      should  go   through
                    the opportunity that I think we must have and that is exercise.
                25

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                                                                               3@7


                    ing our right of approval or  disapproval  and  not  telling  the

               2    region, you can do what you want'on, any basis that you choose

                    to and I for one am not that  overly  impressed  that  any  region,

               4    including Texas, once it receives this sum of money will

               5    decide that it is going to  do  anything  more,  is  minimally

               6    necessary to have the project operate.

               7                Novi, my faith may  be less than  others  because  ovex

               8    the years that I have been  had,  including  site  distances  and

               9    I would sug est that we have, tentative approval but only
                                9

               10   contingent that we have approval in July to review    the

               11   contracts.  I offer that as a contract.


               12.              DR. MILLER:  This contract   is a bit of    semantics

                    as a sort of semantics. It  is  trying  to  get  approval  for

               14   slush fund projects  without  approving  the  project.  By  calling

               15   them contracts.

               16               So I support what you   do, that we  not  fund  it

               17   now but give them the opportunity   to come in with their

               18   proposals in July for how many ever contracts, projects,

                                                                                 'tted
               19   whatever they wish to call them, as long as they are subm-i

               20   in the usual way.

               21               DR. SLATER:  I don't understand what has happened

                    here. I thought you said  you  would  find  it  provisional  unon
               22

               -9   the  receiDt?

                                DR. SCHERLIS:  I offered Potential ways of trying
               24

                    to meet this.
               2.5

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                               I think we need more suggestion on this.  I  most

                   strongly  do not support the concept of giving them  funds at

               3   this time for what they have asked for and I am trving to

               4   seek a way out.

               5               Any suggestion as a wav out

               6               DR. SLATER: The question at  this  point  is  whethe

               7   we will guarantee some sum of  money up to what they   requested

               8   that will be held in escrow here until our requirements are

               9   satisfied, which is their submission of  whatever  the  proposal

               10  they want as a result of these requests that  have go;ne out

               11  and the ratification of those proposals by  the  staffiand  now

               12.  we are adding to that, either a site visit or some members

              -13  of this committee to get these proposals and  talk  on  the

               14  conference, call or come to Washington and do  so.

               15              Such things that keep our process  intact.  If   we

               16  do that by July 10, we will  avoid another whole  review  cycle

               17  which they want to avoid in  order to be able to do  the  work.

               18              MR. THOMPSON:  One of  the beautiful  rhinos  about-
               19  a  contract, you can specify time. Therefore if  it  is  l@O
               20  months or 12 months, they let the contracts.  TIhat is the

               21  difference?
               22              DR. SLATER:  Because the only way we can do it
               23  is to  bring it back for the next review cycle and  it  will  be

                   later part of August, and it will add two months.
               24

                               MRS. TIYCKOFF: They add it to  the  other  end?
               25

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                                                                              389



                                MISS @IURPIIY:  No, they can't.

               2                MR. THOMPSON:  They change the contractl@and

               3i               MR. CHMIBLISS:  T@Te have known for some time that

                   this application presented something of a    dilemma.  I  have

               5   just talked with Dr. Pahl on -the T)oint.

               6                Dr. Pahl, would you care to make an expression asl

               7   it relates to -- the contract activities coming in about the


               8   20th of June after this committee


               9                MISS MURPHY: No, the  28th.  The  RAG  are  goina

               10  to meet and  aor)rove them and he said they would be  ip  here

              @ll  by the 10th  complete.  The 30thlof July.

               12,              MR. CHIU,.IBLISS:  of July, that is worse.

               13               DR. PAHL:  I really feel -- I don't need the

               14  microphone     I really feel that we prefer a definite decision

               15  not based on staff cadabil@t  early  July  for  the  following
                                                y



                   reasons:


                                Normally I think we would be happy to accommodate

               18  that kind of recommendation but we  are  laboring  under  some

               19  difficulties internally, namely as soon as legislation is

                   passed and none of us know when that is going to be, the
               20
               21  department is then going to make its decision as to just how
                   many of our staff are going to be departing on the decentrali-I
               22

                   zation basis and I am not sure who is going to be here in
               23

                   July to do the.work, very frankly.
               24

                                I think that it is rather clear issue in the
               25

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                                                                               390


               1   sense that Texas has had and does have as much of a lifetime

               2   as any other IB@IP.  It happens to be  a  free-standing  organi-
               31  zation, it is not the only one that   we have.

               4                I think that they have  chosen to go  a  certain

                   route and that is,their choice, but the other RMP's have been

               6   under the same time limitations and  are  under  the  same  time


               7   limitations and I would suggest that   you not'treat them

               8   speci,al.than from the other RMP'S.

               9                If you can find it appropriate to  arrive  at  a

               10  decision on the basis-of the information provided, which

               11  leaves you comfortable, we  will  take  that  recommendation  to

               12, Council.

                                But I do not prefer to have it come back to
               13        1

               14  Committee     the staff, because I really don't know our
               15  capability to manage thi,Fesponsibility and it would be

                   really a disservice.

                                The other thing is: I am  and  you  should  know

               18  this, working with the Office of the Administrator to try to-
               19  get an agency policy statement  developed  which  will  be  sent

                   to granteem pointing out  what  the  Federal  responsibility  is
               20
               21. for monitoring activities which go  beyond  the  lifetime  of
               22  PIIPIS, just trying to look to this eventuality and Dr.
                   Margolis is very sympathetic.
               23

                                Vie have drafted a statement and if  this  were  to
               24
                   occur, for example, then some   of the time  pressure  would  be
               25

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                                                                           391

              I    off of free-standing organizations. You have to realize

              2    that the Government always has programs terminating and

              3    continuing activities within those programs.

              4               All I am trying to do is to formalize a Federal

              5    responsibility at an agency level which would assure Texas

              6    and its affiliates, as well as all other grantees, that shoul@t

              7    another monitoring device beyond the RMP be necessary, perhaps

              8    it could be this agency or the regional offices that could

              9    assume that responsibility.

              10              If that were the caset then-the fact that an'

              11   activity got started later, that would not be so detrimental.
                                                                    i

              12.  Because that is the thrust of Dr. Ferguson's point of view.

              13              In essence, I don't believe that we can  accept

              14   those kinds of workloads T)rojected into the future with what

              15   I know to be our own situation.  I feel Texas has a tight

              16   to choose its method of handling its funds and grant appli-

                   cation.

              18              I do not believe that it is in any other position

              19   than any other PI.IP or will be treated differently.

                              To that extent then, we leave you to your own
              20

                   considerations.  But perhaps it does give you some guidelines.
              21

                              MR. CHZXIIBLISS:  Thank you.
              22


                              Dr. Vaun?
              23

                              DR. VAUN:  I think we are playing semantics here.
              24

                              It is unfortunate that Texas picked the word
              25

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                                                                                                                                               3 -02


                                      ficontracts."    I  think  we  awarded  slush  funds  in  the  last  day
                              2       and  a  half  and  I  don't  see  any  reason  why,  because  they
                                      selected         the  word  "contracts,"  that  we  should  treat  them  any
                              4       differently.
                           .5                               We  talked  about  slush  funds  up  to  $800,000  up  t6
                              6       this  point,  with  very  ill  definition  of what  was  going  to
                              7       happen  to  that money,  besides  it was  being  tucked  away  for
                              8       future  legislative  proposals.
                              9                             DR.  SLATER:    May  I  make  a motion  to  get  something
                            .10       on  the  floor  and  that  is  that  we,  I  find  it  possible  to  mak
                                                                                                                                                        e

                           11         any  decision  on'  how  to  cut  back  on what  they                                  suggested,  so
                           12.        I  make  the  motion  that  we  fund  them  to  the  amount  that  they

                           13         requested  and  that

                           14                              MR.  THOMPSON:    After  all  this,  you  are  going  to

                           15         do  that>


                                                           DR.  MILLER:    Go  ahead.


                           17                              DR.  SLATER:    Subject  to  the  contingency  that  the

                           18         proposals  that  they  submit  are  reviewed  by  a  technical

                           19         by  the  staff  and  bv  a  technical  site  visit.

                           20                              I  think  the  point'is,  I  don't  think  that  we  can

                           21         bypass  this  committee  if  the  committee  will  have  to  give  the

                           22         responsibility  to  some  members  of  the  committee  and  staff  to

                                      go  to  Texas  and  it  is  just  one  da                           to  get  a  grasp  on  this,
                           23                                                                     'Y

                           24         to  see  if  we  are  fulfilling  our                       Federal  mandates.
                                                                                 t
                                                          I  don't  see  this  as                 a  slush  fund  for  Texas  project
                           25

    HOOVER REPORTING  CO,  INC.
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                    I think that the technique used has just been delayed   bring-

               2
                    ing projects to look at.
               31               MR. VAN WINKLE:   Who would the site visitors

               4    report back'to, doctor?  This group or Council or to whom?

                                DR. SLATER:  Back to this group who will be

               6    sitting here in July.

               7                MR. CHARABLISS:  I. think Dr. Pahl has, if I may

               8    make the point, has stated that  we are uncertain as to the

               9    status of our staffing after the first of July and we have

               10   no indication as to what our staff availabilities will be

               11   to help decide this question.

               12               DR. SLATER:  You have another round of      you

               13   have another review cycle to handle.

               14               MISS MURPHY:  July and August.

               15               MR. VAN WINKLE:  Another group has laid on us

                    that visit here, right?

                                DR. PAHL:  I think there is a different question

               18   than what I heard coming up before.

               19               We do have a July meeting of this committee, an

               20   early August Council meeting.

                                If what you are doing is recommending approval
               21

               22   subject to your reconsideration in July and then notification

               23   of the region and if the Council would buy that, they would
               24   thereby in reality have a mid-July approval from you for the

                    full amount.
               25

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              1                DR. SLATER:  We met here on July 18, which is one

              2    week after they are going to submit it.

              3                DR. PAHL:  That gives  them three weeks.

              4                1 understood you to say that staff to d6  it July

              5    20.  You  may recommend approval with -- contingent upon it

              6    coming back and confirming it at the July meeting but basically

              7    that does not give the money to  Texas  and they canit go ahead

              8    and spend it until July 20  or  thereabouts which is  three

              9    -weeks different than if they take more time to describe  it

              10   in their July 1 application.

              11               I don't know whether that  is a good thi    or

              12,  not.
              13               DR. SLATER: Is it technically possible  for  thi-s
                   to be approved by the Council and not have to go back  to  the
              14

              15   Advisory council?
                               Could they give this-review committee final right
              1(;

                   of  approval?
              18               MR. THOMPSON: If we  make  that  recommendation.
                               DR. PAHL:  We would take that recommendation to

                   the Council. If thev accent it, then we  could  implement  it.
              20

                               DR. CARPENTER:  It seems to me that we can.
              21
              22   accomplish the same thing in a much more  Istandard wav.  I
                   suppose that if we are right, that these people do have the
              23
              24   opportunity to develop a good selection of projects, and we
                   want to get them started on that, we can approve  an  amount
              25

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                                                                        39-@


              1    of money now'.

              2                For instance, we viould want to support their

              3 11 corns  staff right away.  We could sunnort something around.

              4    $1 million which would get them well past July and  if  they

              5    have the confidence that their program is  reasonable,  they

              6    can assume that when we have a complete description in July

              7    we will approve such addition al funds'as will  be  necessary

              8    to carry out the program.

              9                I think what we have is a region that  is now

              10   operating $348,000 worth of Projects, a very small  number of

              11   projects.

              12              They are saying that within a  ear they can
                                                            y

              13   productively spend nearly $1.5 million on new projects.

              14               I think that I will require additional convincing.

                   So, I  think that you get.-them started and they have  Dlentv

                   of money  to go on, until we have a chance to see their detail-

              17   ed  proposal.
              18               MR. THO.IIPSON:  May I ask a question, because I am
              19   confused  at this Point.
                               This damn telegram that keens zip ing in, we
              20                                                p

                   should have taken it up this morning.
              21
              22               We are talking about 25 additional projects, is

                   that correct?
              23
                                                   e
                               DR. SLATER:  No.
              24
                               MR. TIIOMPSON:  You are talking about these?
              25

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                                                                                 39b


               I                 DR. SLATER:  They requested the nrogram staff

               2    money and then they have also requested in this package'.

               3    money to continue and  complete  that  which  is  already  under

               4    way.  Something like $348,000 there and then they said we

                    need about $1.5 million for  new  studies  but  we  haven't  got

               6    the projects yet. We have the  areas  and  we  put  out  to  bid

               7    but we don't have the project.yet because we haven't had

               8    enough time to get them in.

               9                 We would like you to live  us  the  right  to  spend

               10   up to $1.5 million which is  what  the  budget  boils  down  to,

               11   to support these contracts when we,    when our RAG has  received

               12   them and decided what are the high    priority.ones and  bv

               13   some mechanism this review committee likewise approve       them.
               14                tqe are simply being asked  to  approve  in  advance
               15   what they are behind in.,. I don't see it as a slush fund

                    because it has to be reviewed   by their  RAG  and  reviewed  by

               17   us in some way.
               18                MR. THOMPSON:  Let us just take this crazy, damned
                    economics of the whole delivery system.  $656,000
               20                DR. SLATER:  Those are guidelines for proposals.
               21   Those are not the projects.  you haven't seen a project
               22   description  there.  You  have  seen  guidelines  for  proposal.
                                 MR. THOMPSON:  O.K.  Then I understand I buy
               23
                   .Dr. Pahl's proposal that we  request  Council  to  permit  us  at
               24
               25   ou.r next meeting to review some of these contracts.

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                                                                                397



                                DR. SLATER:  O.K.


               2                DR. CARPENTER:  They'haven't even chosen      sites

               3 1  for these projects.

               4                You look at the  site  selection  sheet,  they  are


               5    blank.


               6                DR. SLATER:  Because they have come in.  The

               7    whole reason to come in now instead of the next route is

               8    based on their argument that they have one year leftilike

               9    everybody else in the program and they haven't..asked this

               lo   question about any other projects.
              .11               They said, we really need a whole area if we are
                                                                          .1
               12, going to contract and try to  do  what  we  are  doing.  So,  we

              '13   would like to give you a new advance.

                                MR. VAN  WINKLE:  Dr.  Pahl  indicated  that  three
               14
               15   months from now or four months from now, contracts for a full

                    12-month period.

                                It is just that  the end product will be monitored

                    by somebody else.  They can  let a contract.
               18
                                DR. SLATER:  They can do it up to the last minute

                    as far as the monies are spent.
               20
               21               MR. THO@IPSON: 14hy can't  we  separate  the  thing
               22   out?  Give them a certain amount of money-, writing WIP's
               23   and then request counsel to permit this Committee to review
                    the hard proposal at the next meeting and approve or disapprove
               24
                    them without going through Council.
               25

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                                                                            398


                               DR. SLATER:  That sounds like a good idea.

              2                I just had a question strike me like a bolt'of

              3i   lightning.

              4                This is the first time  it has happened.  1%7ho.is

              5    going to monitor any of these things?

              6                All of this work that we are farming out, Dr.

              7    Pahl, who is going to be looking at the reports that are

              8    coming in?

              9                DR. PAHL:  That is what  I was alluding to.

              10               MR. T80MPSON:  We brought this up yesterday,  about

              11   what is the

              12,              DR. PAHL:  In practical terms, it may  not be as

              @13  bad as it always appears to be.

              14               For example, the chronic disease  control  program

              15   disappeared, but I remember @IP for about 3-1/2 years matching

              -16  contracts as a result of the Federal  commitments.  The  whole

              17   kidney activity that.we have been doing, is the fold-over

              18   and so forth of that activity.
              19               I sat with Dr. Mar"golis about -- well, a  week.or
              20   more aao and again pointed out to him that it would seem nice
              21   if we could set this agency kind of policy statement which
              22   could be sent to all grantees and we now have drafted  one  at
              23;  his request which will be looked at.every carefully and I
                   am not sure what will eventually happen to it.
              24 ii
                               But it would be nice if we could tell grantees


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                                                                          99


                   that we recognize the program and that there are continuing

              2    operations and that the Federal Government, hopefully this

              3i   agency or regional offices, will monitor and that w  won't

              4    all have to get out contracts again.  I can't make  he commit

              5    ment.  Ile are trying.  That is not a problem.. It will

              6    happen.

              7                DR. SLATER:  We  can pass this over to th  nex

              8    review-cycie.

              9                There is only one problem.  When they are oneratirg

              10   by contracts, they withhold  acertain Percentage, I think

              11   20 percent of the funds  until the contract is completed and

              12   then they make the final payment.  If they start. late on

              -13  a one-year contract, then we are past the fiscal year ending
              14   and they will have. to pay out the funds for the remainder of
              15   the contracts before the.-contract is completed and therebv

                   lose whatever leverage they have on the contract.

              17               MR. THO@IPSON:  Miv don't we just hold the thing?

              18   Why don't we just buy

              1!)              MRS. 1,7YCKOFF:  Put it in escrow.
              20               DR. SLATER:  I would like to hear from Mrs.

              21   Salazar, Mr. Chairman.

                               MRS. SALAZAR:  I don't feel that that is a real
              22
              23   factor in that the Texas EUIP has a board of trustees, so I
                   assume that will have some fiscal responsibility to hold
              24
                   these people accountable; am I correct in that?
              25

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                                                                             40o


               1                MR. POSTA:  Yes, but at the uresent time thev

               2   plan to terminate it.

               3                DR. PAHL:  You are in  the never, never  '-and of

               4   grants,  Federal legislation, and there is no one in this

               .5  room who can honestly state what will happen next J    ne 30

               6   and there are a lot of people concerned and working and nobod'

               7   in this agency can tell you and I really say that i  all

               8   seriousness, because we lived with this whole activ ty, this

               9   is the same set of discussions we had internally   la t year

               10  when the program was going to end, Jerry Gardell,   Larry
              -11  Parker and others have been concerned  Iabout it a year ago

               1.2 and we are in the same position this year and somehow R-@IP's

              -13  are here and as a Federal manager, I am trying my best to

               14  smooth the,way to,get a transition but I can't get a-cornnit-

               15  ment.


                                I would say, make your decision on the merits

               17  of the case  and don't worry about the tail end payments of

                   contracts.   Somehow it will work out.

               19               Do what you think is appropriate for spending

               20  the money effectively in Texas on the basis of the information

               21  you have.  And you have to arrive at that decision.  But we

                   will worry about the continuation.
               22

     JR(4)fls
               23


               24


               25

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    ,ogers/nii                                                                                                                                   4ol
    ape 4
                            1                        DR. MILLER:  I submit, -in antagonism, I guess,

                            2    against the motion, that it isn't going to make that much

                            3    difference with these activities, whether they start the 20th

                            4    of July or when does the council meet after?

                            5                        DR. PAHL:  9th of August.  Awards would go out

                            6 effective              September 1.

                            7                        DR. MILLER:              It isn't. going to ma[re that much

                            8    difference, and I fail to see a reason why we should make a

                            9    special procedure for Texas.' Even though, I know they are-

                            10   accustomed,.to such treatment.

                                                     DR.  SCHERLIS:    What  was  the  motion                           you made an hour

                            12   ago?

                                                     MR.  CHAMBLISS:    Was  that  a  motion?
                            13
                            14                       DR.  CARPENTER:    A motion  with a  second  on  the  floor.
                            15                       DR.  SLATER:    I  will  withdraw  my motion.

                                                     MR.  CHAMBLISS:    The               motion  is          withdrawn  and  the  chair


                                 will  entertain  a  new  motion.


                                                     DR.  CARPENTER:    What  I  was  suggesting  is  that  what    -
                            18
                            19   I  move,,  is  that  we  fund  Texas                       whatever  the  suin  of  $319  and
                                 program  existing,  plus  the  continuation  project,  $348,000,,  plus
                            20
                                 another  $350,000  to  give  them wiggle  room.
                            21,
                                                     So  that  is  $700  --  $1,100,000.
                            22

                                                     MRS.  tTEIKOFF:    I  second  the  motion.
                            23,                                                                   e
                                                     MR.  CHAMBLISS:    It  has  been moved-and  seconded  that
                            24
                                 Texas  be  funded  for  this  round  at                            the  level  of  $1,100,000.
                            25

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                           Are you ready?

              2            Is there discussion?

              3 1
                           MRS. SALIZAR:  Yes, does your motion, Dr. Carpenter,

              4
                 include the rest of your first condition?
              5            DR. CARPENTER:  No condition, and I ho'pe they will

              6  be back in July

              7            DR. SLATER:  We have'another cycle to consider.

              8            MRS. WEIKOFF:  Let them come back in July.

              9            MR. CHAMBLISS:  With the provision that they will

              10 come back in July with a clearer application.

              11           DR. CARPENTER:  No provision, but just recommend that

              12,they tell us all the good opportunities that they have in the

              13 July meeting.

              14           DR. @fILLER:  I will second the motion.

              15           MR. CHAMBLISS:  It has been moved and seconded.

                           Is there further discussion?

              17           DR. MILLER:  Could I ask the question from the staff's

              18 viewpoint, the fact that they said they were not going to come-

                 back in July does not mean they can't now change and come back

                 in July.
              20
              21@          MR. CHAMBLISS:  They still can come in July, yes.

                           MR. TOOMEY:  Question.
              22

                           @IR. CHAMBLISS:  All those in favor?
              23
                           (Chorus of ayes.)
              24
                           MR. CIII@IBLISS:  Those opposbd?
              25

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                                                     (No response.)

                            2                               CHAMBLISS:  There is.no opposition and the

                            3 motion is              passed.

                            4                        DR. SLATER:  The next round, all we are gO3-tig  0  0

                            5    is take a           look at the 25 projects if they do it.  We. in

                            6    essence, covered the basic text,                               of this Texas program,

                            7                        @IR. CHAMBLISS:  Let us take a short recess.

                            8                        (Recess)

                            9


                            10






                            12.


                            13


                            14


                            15












                            19


                            20


                            21


                            22


                            23


                            24




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                                                                             4o4
                                             OHIO VALLEY


                            MR. CHAMBLISS:  Shall we resume?

               2
                            our next region for review is Ohio Valley.
               31
                            The presenters for Ohio Valley will  be  Dr.  Vaun
               4 and Mr. Thompson, backed up by Mrs.  Parks  from  the  staff.

               5
                            There are, in this region, a  couple  of  nuances,

               6
                 having to  do with the two regions formerly in Ohio that are

               7
                 no longer  in existence.  There  have been.some  special arrange-

               8
                 ments made permitting activities from Ohio to    be incorporated

               9
                 into the Ohio Valley application.
               10           I wonder  before the reviewers make.their-  presentation
               11 if you would just like to highlight those  issues,  so  that  it

               12 may be before the ConuDittee as a whole.

               13           MR. VAN WINKLE-. What has happened is  that  the  two

               14 Ohio's had been phased out, and, as  this  revival  came  around

               15 we started getting inquir3'-"e@ from there, where can we  apply?

               '16 We don't have an organization, grantee.

               -17          ArrAngements, were made with the Ohio Valley Regional

               18 Medical Program to entertain such  proposals,  having  them  act

               l@) as a grantee agency.

               20           I want to call your attention to the fact that   I

               21 Delieve Dr. Paul made assurances to them that in no way would

               22 affect their funding level, Ohio Valley's.  'I  mean,  it  would

                 -iot work to their detriment.
               23

                            MR. THOMPSON:  But, nothing in this particular request
               24

                 reflects that change.
               25

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                            1                       MR. VAN WINKLE:  I can show you where it is and that

                            2    is what  we         want to point out.  It                        would be on page 200, under

                            3
                                 "Discreet  Activity  Summary."

                            4                       She  indicates  the  feasibility  st                           udies  from  this

                            5    study  were  conducted  on  four  potential  sites  in  the  region.
                            6    Dayton,  Ohio,  Southeast  or  Harlan,  Kentucky,  South-Central  or

                            7    Somerset,  Kentucky,  and  Southwest,  Georgetown,  Ohio..

                            8                       There  are  two  Ohio's  in  there  that  are  not,                                 fully

                            9    developed  yet.

                            10                       Now,  it  may  even  extend  on  to  include  Lima,  Ohio,

                            11   and     as  far  north as  Toledo.

                            12,                      NR.  'TRQM.F$-GN*':            I  guess  I  do  not              know  about  the

                            .13  previous  geography  about  that  craziness  in                                      Ohio,  which,  if

                            14   remember  correctly,  we  tried  to  contract  before.

                            15                       So.  in  other  words,  Miami,  where  the  Ohio  University

                            I.(i is,  and  the  new  medical  school  is'going  to  I:,e,  was  not

                            17   Originally  in  the  Ohio  Valley.

                            18                       MR.  VAN WINKLE:    That  is  correct.

                                                     MRS.  PARKS:    Dayton.

                            20                       MR.  '.THOMPSON.-.,    Miami

                                                     DR.  '.VAUN-.:':    Where  was  Cincinnati  before?.
                            21,
                            22                       @a.  VAN WINKLE:    Ohio  Valley.
                                                     MRS.  PARKS:    Actually,  what  happened,  or  is  happening
                            23
                            24   as  far  as  the  Toledo-Lima  areas  are  concerned,  they,  of  course,

                            25   'lave  expressed  interest  in  some  kinds  of  activity with  the  Ohio
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                                                                                4o6

               I  Valley Regional l@ledical Prooram.  Part of it was through this

               2  particular activity that they are interested in,, simply because

             .3 lit is a priority in that area.

               4            There are three CHP "b" agencies within that  area.

               5  One.in.Dayton, one in Lima and there is another one in  Ohio.

               6  But there are three of them.

               7            They have expressed an interest in coming  together

               8  to form a consortium and once this is done they will apply to

                  the Ohio Valley RMP for funds for the development  of  a  sub-.
               9

              10  regional organization for health., manpower and training.
              11  The application has not been developed yet.  There  will  be  a

                  meetin- tomorrow in Dayton at the Health Planning Council
              12.       C)
              13  office and it will include representatives of the three CHP "b"
              14  agencies within that area, representatives  from  the  academic
                  institutions, health service institutions,   Halt agency,
              .1(; Dr. Milligan will be there, and program staff  from Ohio  Valley
                  and I think several of the regional  advisory  council  members

              18  from the Ohio.area, Dayton, Ohio.
                            And the purpose of the meeting is to discuss this
              19
              20  arrangement with the Ohio Valley and if they  are  interested  in
                  it, then they will make an application to the region for-fundin(-
              21
                            It will still be subject to the  Ohio  Valley  Regional
              22
                  Advisory Council's approval.
              23
                            They do not envision th"at it will be ready  for  the
              24
                  Ixt meetin- of the council, which is'July.  They figure October
              25

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                                                                                   f


               I which is when the council meets again, will be too late.

               2             MP,. VAN WINKLE: You are'talking about the third

               3. council.

               4             MRS. PARKS:  The Ohio Valley council, RAG, they call

               -5 it,

               6             So what they are aiming for is to, with the assistance

               7  of the staff from Ohio Valley, help in developing a project and

               8  have it ready by August, and it is a possibility that the

               9  RAG.will empower the executive committee to act and either-

               10 approve, or. whatever.

               11            But the RAG, back in 1972 and 1973, developed      some

               12,specific guidelines for the development of these sohniets., and

               13 this is the reason for the meeting tomorrow.

               14            They are going to inform this group of what these.

               15 Guidelines are, and if they can conform to the guidelines,

                  then their application will be entertained.

               -17           MRS. WEIKOFF:  Is this,the 27(a) through'(h) or just

                  @7(d)?
               18

                             NU . PARKS:  The funds budgeted   in 27(d) will provide
               19

               20  funding if the application  is  approved  for  the  Dayton,  Lima

               21 and Toledo area.


               22            MR. THOMPSON:  You said two Ohio programs went down

               2.3 the   tube?

               24            MRS. PARKS:  I beg your pardon?

               25            MR. THOMPSON:  Did you say two Ohio programs went dow

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              1 the tube?


              2            MR. CHAMBLISS:  Were phased.

              3            I,,IR. VAN WINKLE:  Cleveland and Columbus.


              4            MR. CHAi4BLISS:  Known as Ohio State.


              5            MR. THOMPSON:  What about Toledo?

              6            MR. VAN WINKLE:  Toledo was phased out earli3r.

              7            MR. THOMPSON:    I will be danined,

              8            MRS. PARKS:  And it only covers certain partB.

              9            MR. VAN WINKLE: @This is the only way that we can

              lo accommodate any requests from the State of Ohi o.

                           MR. CHAMBLISS:  Now that you have been  informed on
              12.future project activities in Ohio., may the presenters  @ommence?

                           Thank @ou.
              .13
                           DR.  VAUN.::  I thought you were going to make.our   job
              14

              15 easier Dy introducing tl@,.Ohio comments, but what you have done

              ,i(i  is make it more difficult.

              17           I don't think it has changed one iota, my comments,

              18 and one iota on the budget, but it is an enlightening thing.

              19           What it is goin(, to do is compensate the leadership

              20 for the Ohio Valle  program which, in my view, seems complicated
                                   y

              21 now. That is, it would appear that the leadership  of  this  @NiP

              2-;) is somewhat of a coordinator of a troika, and I am not sure

              23 how this new partner is going to alter that situation.  To wit,
                                                   e
                 it would appear that the leader of this pro-ram has been an
              24


                  architec
              25           t Of sustainin- an isosceles trianole and  making  sure
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               1 that all the angles remain the same, and now you introduce
               2 another angle and this is going to-foul up the whole niess'.
               3 This v@ill come  out in the proposals.

               4
                           The reason I say your comments are not going   to

               5
                 interest me is because the proposals are not  going  to  be

               6
                 altered one iota by another group, and my criticism will,

                 I think,, remain valid.  It would appear that RAG has  sustained

               8 its effectiveness.

               9           I am a little  surprised, in looking it over.  I

               10 shouldn't be surprised from the nature of the
                                                                 projec@t, that

               11 there are six of the 40 identified as medical center  officials.

               12 There are nine also that I would identify as medical     there

                 are probably several others who  are  quasi-medical  center

               14 officials, so that the program is, although adequately

               15 represented, it is heavily,.oriented to the' three  medical

               1(; i)enters.

                           It would appear that their CHP relationships have

               18 Deen okay.

              .19          Jean was good enough fo fill me in on some staff.

               20 chan-es and she may want to comment  further,  because  the

               21 numbers on our yellow sheets were incorrect, and I was a'litt e

               22 startled by thinking that they were expanding and they are not

                  eally expanding.  Their full-time professional staff is going
               2,3
               24 Crom nine to fourteen,.and these are primarily vacancies and

               25 iot new positions.

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                                                                               41o


               1            Their full-tiriie others is cooing.to 47, so it would

               2  be a total of 21.  There are fourteen now.  Most of   them are

               3  unfilled vacancies and not creatinc, new positions.

               4            Jean, you also indicated to me that their deputy

               5  director position has been filled?

               6            MRS. PARKS:  Yes, I learned several davs ago that

               7 a former member of the program  core  staff  has  'been  approached

               8 by the Executive  Committee  to  assume  duties,  effective  August

               9  1  -as deputy coordinator, Bill Fox.

               10           DR. VAU'li--'-  I think that will help with@the  increase(]

               11 amount of money that they are asking for  in the funding.

               12.          With regard to their proposals,  my criticism  is  that

               13  the pro'blems in Lexincton, Louisville and Cincinnati, seem

               14 amazin-ly alike, both from the point of  view  of  level  of  fundin@
               15 and typo of problem.  To @'i@: I really can't understand how

                 they would have the guts to  apply  for  three  colcimetry  centers

               17 in Louisville, Lexin-ton and Cincinnati, almost  to  the  identical

               18 dollar figure.

                            I mean. that is a slap in the face that  I  just  don't

               20 understand how they could do that to us, but they did.

                            In any eventI just took the worst  of  the  ones  without
               21

                 o,oin- down to indicate that almost all of the other projects
               22


               23 area  third for Louisville, a third for Lexington  and  a  third

               24i
                  or Cincinnati. Whether it is ambulatory  care,  it  is  a  third,

               25
                   third, a third; that is why, I   think, the leaders are  going,
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                                                                                                                                                                                   4,11



                                        to be in a difficult position when.tlie3r introduce the                                                                          fourth.

                                   2
                                                                I am not -- I should not be                                        too critical because,

                                   3
                                   . I apparently., this program has been able to move with this

                                   4
                                        problem, and in ottierareas, this influence has parali ed                                                                               other


                                        areas.,
                                   6                            I might point out that I arrived at my deduction in

                                   7
                                        a rational way. I think the nature of this proposal reflects

                                        their leadership. They are heavil involved in ambulatory
                                                                                                                        y

                                   9
                                        care, they               are heavily involved in the ad hoc                                                  proposals and,

                                   10
                                        Jean,, unless you would want to add something more at t is

                                        point about what I have said before I give a figure, I am
                                   12'ready   to  pass   it  on  to  my  fellow  re-viewer.

                                   13                          @S.   PARKS:     I  agree  with  what  you  say  about   the

                                   14   iierjical-  centers   bein-  funded.     They  seem  to  come   in   threels.

                                   15   But,   I  don't   feel  that   they  have  created  quite   the   severe

                                   l(i  problem  as  you  have  discussed,   and  maybe   this   is  my  biased

                                   17   Dpinion.

                                   18                         As   far  as   the  activities  are  concerned   that   they
                                   19   iave  developed,   I   thinlt  most  of   them  have   been  developed,   really
                                   20   )ased  on  study  after  study  after  study  within   the  region  and
                                   21   .-hey,   the  activities,   were  developed   from   these   studies,   based
                                   22   'In   the   needs  of  particular  areas,   and.they  have   sort  of  moved

                                   2 t3 n  the   basis  of   that.

                                                              DR. ".'VAIW-.I-:               Tt
                                   24                                                               is  a   simple,'  technical  fact.   that
                                   25   rne  dolcimetry  center                             could  handle  all   three  States   put   to@ehte
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                                                                           412


              I  okay.
              2            MRS. PARKS:  Well, I wouldn't argue with the

              3            DR. VAUN:  As I worked through the projects

              4  considering the nature of the overall project, I have arrived

              5  at a figure that I am happy with production, that comes pretty
              6  close to their targets, $514,900.

              7            MR. CRAMBLISS:  Is that  our recommendations
                                                   y

              8            DR. VAUN:  That is mine.

              9            DR. MILLER: -What is the amount?

              10           DR. VAUII: $514,900.
              11           DR. MILLER:  For what?.

                           DR. VAUN:  Off of their request.
              12.

                           MRS. PARKS:  That is a minus.
              13
              14           DR. VAUN:. You didn't think it was an add-on?

                           MRS. PARKS:  I t:h
                                            'ought it was a recommendation.
                           DR. VAUN:  Their request was $2b2,536.  @fy identified
              16
              17 reduction was $514,900, making recommendation $2,507,63'0.
              18           MR. CHAMBLISS:  Mr. Thompson.
              19           DIR. THOMPSON:  I agree 100% with my primary reviewer.
                           I will say that although there were many  etters
              20
                 from CHP agencies here,, it is obvious that they are playing games
              21
                 because om letter here did not receive a proposal ifi time to
              22
                 review it.  They didn't endorse it. 'They said they wouldn't
              23                                  11
                 turn it down but they would not comment on it.  So, it happened'
              24
                 to be that dolcimetry bit, which is tairiy wild.
              25

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                                                                                               413


                  1               There was also a problem here about one of  their

                  2  home car programs, that the primary purpose of whictiiif                  I

                  3   am not mistaken  was to stimulate the coverage of home care

                  4   by Blue Cross programs.  This stimulator had been in :he

                  5   works for four years.

                  6               It seems to me about       time for them to     fish  r

                  7   cut bait on whether or not Blue         Cross will pick     up home   care.

                  8               Now., there happens to      be a national policy for        Blue

                  9   CrQss  to do that, as much as there can be a national [)Olicy
                  lo  for  Blue  Cross  but  that  looks.  like   a   little   bit   of   a@long
                  11  time to prove out that something is val          id before some8ody else

                  12, takes over.

                                  They have requested continuation.
                  13

                  14              DR.. VAUN:. That was     one of the largest, too.        That

                      fourth  year project was a,.$200,000 request.
                  15

                                  DR. SCHERLIS:   I    just wanted to ask some questions.

                                  The home care, as I add it, it comes to well over,
                  17
                  18  well,, it  is  about  $491,0001,  is   the   sume   requested   for   home
                      care,  a  great deal of which is developmental, at least $200,00j,.

                                  I am wondering what plans they have once this amount                1
                  20
                      of money is withdrawn as far as what will happen to the need
                  21
                  22  that they have stimulated within the conmiunity?  It seemed like
                      a rather short time.
                  23
                  24              1 have Iother questions.   Perhaps I can get some
                      Eeeling on that.
                  25

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                                                                              414


                1           DR. VAUN:  I think this is what John was tr@l g to

                2  raise in his point.

                3           Now  they  have been four years in the process and

                4 they are asking $200,000 again.  So, the likelihood ill: that

                5 much of this is going to remain under-funded at the end of

                6 this  year.

                7           DR@ SCHERLIS:  The other two items that trouble me,

                8 ambulatory care, again, a.developinental  component  of  @150,000,
                9 and developmental for one of their sohmets or'for at    least  the
                10 five additional sohmets.  Their suborganizational res   onse  for
                11 health, manpower care and training, I think they have   the
                  very interesting, very long and  very:varied  list  of  proposals.
                12
                13          But my concern even more here  than  elsewhere  is  what
                  happens when that year ends?  They will have built up needs
                14
                  people and no vestige of opportunities, I think, for a great
                16 many of these to be supported,  particularly, home care.
                            We have all been involved in the home care projects
                17
                18 for a limited period of timL-.  When they die, they die.  There-
                  is nothin- to fix them up and they were going down the road with

                  $500)000.
                20
                            IIR. THOMPSON:  Except management of the projects
                21
                  that we picked up in the past.
                22
                            DR. WHITE:  I am still 6ot   sure about this fourth one.
                2:3
                   here is some money that would be earmarked for them.
                24
                            @IRS. PARKS:  For what?
                25





                                                                                        415



                               iMR. CHA@IBLISS:  For Ohio-.

                2
                               @IRS. PARKS:  Toledo, Ohio.  The      funds   requested   in
                3   !'2 7 (d) .
                4              DR. WHITE:  That is the developmental complex.
                5              l@IRS. PARKS:  Yes, it is to provide funds for the

                6
                    development  of  sohmecs  in   certain   defined   georgraphic   areas.
                7              They included in here some potential sites!,
                                                                                  that they
                8   plan to start them.  The Toledo-Lima-Dayton ones would also be

                9   included, but they do not have the application from that

                10  particular group of people, as yet.

                               DR. WHITE:  This $150,000     is again   an escrow account?

                               @fR. CHAMBLISS:  It is for    future -project activities.

                13             DR. VAUN:  But., it would appear on the basis of some

                14  Commitments by -- that is not totally an escrow.  They were led

                15  to believe that they would     have some access to the Ohio Valley

                l(i program.

                17             I  am  asking  it  again.  Suppose  it  is  awarded  at  the
                18  level you  recommended instead or what they asked?  Isn't there'

                19  :)ption to say  to  these  other  people,  sorry,  we  didn't  get  all

                20  4e asked for, therefore, you are out of luck?

                               ,LNa.  CRAMBLISS:  We  would  have  to  give  them  specific
                    instructions  on  that  and  we  wotuld  await  your  judgment  on   this
                22
                2.3 oint.
                               DR. IFILLER:  i4r. Chairman,   there  are   three   projectsI
                :),4 11
                    .,am asking the reviewers, there are    three projects that are listed
                25  ii                                                                        t




                                                                                416


                1  developmental awards.
                2           Are these projects      is'this another way  of  having
                3 $500,000 of a developmental fund which   they can use as they

                - choose?
                4

                            one of them is home care develo  ental   awards,
                5                                            PM
                  $200,000.   One of them is sohriiet, $150,000, and one is
                6
                7 ambulatory care and developmental components, $150,000.
                  $500,000 of developmental funds.  Is this all open?
                8
                            DR. VAUN: It is not open and  that  is  how  I  arrived
                9

                  at some of.my reduction.
                10
                11          DR. MILLER:  You are saying, essentially, that those
                12. are things that we disapprove of in engaging in?
                                        That $200,000
                13          DR. VAUN.                 care thing  as John pointed
                  out, this is the fourth year.  Now,  how  developmental  can  you
                14
                  be?
                15
                            MR. CHAMBLISS:  Is  their  specific  recommendation  on

                  that particular part of the application from the committee?

                            @..THOMPSON:  I don't think we can tell them that
                18
                  we were concerned about, but if they want to give that, that is
                if)
                  their prerogative.  We need instructions to the re@ion.
                20
                            I think we can say that we  were  concerned  about  the
                21
                  odd coincidence of equal requirements for the same kinds of
                22
                  desperate towns, and the second thing we ought to tell them,
                23
                24 we just really don't know how developiiental'the -fourth year
                25 agreement can be..  But that is up to them.

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                                                                                  417



                 1            MR. CIIAMBLISS: Thant<  you.  We  will  note  your

                 2  concerns and we will entertain a motion,.

                              DR. VAUN:  I move that the request of the Ohio

                 4 Regional  Program be reduced by  $514,900,  to  a  figure  of

                 5 $2)305,C)36, with instructions to the region that the specific

                 6 project that involves development components         is  that

                 7 27(b), Jean?

                 8            MRS. PARKS:  Yes.  Is that the    solimot activity


                 9 yes.
                 10           DR. VAUN:  @lay not be less'than     $100,000,,may not be

                 11 less than $100,000.

                 12.          \IR. CH@IBLISS   Is there a second to the    motion?

                 13           DR. @1ILLER:  Second.

                              MR. CHAMBLISS:  It is moved and seconded that the
                 14
                 15 level be for the Ohio Valley,  $2,305,636, with the additional
                 16 provisions cited by Dr. Vaun,  applying to the region.

                              DR. @4HITE:  This 27(b), I understand, has not been
                 17

                   throu-h a  review process.        p
                 18
                 1.4        -DR. VAUN:  No. it has not because this region phasing
                 20 out of one regional medical program has been given access to
                 21 this regional medical program, and I guess.they just didn't have

                   @ime to do it.
                 22
                              @IRS. PARKS:  No. that is' not -- the process of handlin
                 23
                   evelopments of activities has been approved by the re-ional
                 24
                   dvisory group.     They do have some areas identified that they
                 25





                                                                            418


               1  intend to fund.  The Toledo.-Lirna situation, now' that',has not
               2 lbeen approved by the RAG, simply because they do   not I
               3
               .ijapplication yet.  But, the process of  providing  funds to
               4  certain areas, provided they meet the  guidelines, has  been
               5 approved.

               6            DR. WHITE:  My point'is, therefore, we cannot say

               7 no less than $100,000, unless we appended that, and ttey

               8 approve it as being a project, they would otherwise undertake.
               9            The regional advisory group has to have the preroga-

               10  tive of approving thi@.

               11           MS. PARKS:   Yes.

               12.          DR. VAUN:  That is why I indicated no less than

               13 $100,000.

               14           DR. WHITE:  If they say it is no good, we don't want

               15 to do it

               1(;          DR. VAUN:  How are  you going to protect this region

               17 which is out in the cold ri-ht now, having been told they
                                             0

               18 haven't access to this program?

               1!)          DR. VAUN:  And they would not be penalized because

                 they  were doina this out of the goodness of their heart and
               20               ID

               21 they  also handled two arthritis proposals, !and they agreed to

                 monitor  evaluate and carry on all grantee activities for those
               22

                 ?articular projects.
               23

                            MR. CHAMBLISS:  As add-on  S.
               24
               25           DR. VAUN:  There is a way to obviate the criticism.





                                                                           419


                1          That is to guarantee the $100,000.
                2          1 think if they do not award up to $100,000@tO'this

                3 project, their request will be further reduced by  $10  000.

                4          DR. IQHITE: This $100,000 can be used for  t  t  or

                5 no thing.

                6          @aS. PARKS:  I am sorry, let me get this cl ar.

                7          In- other words, the mone  that you are appr ving for
                                                   y

                827(b) can only be used for the Toledo-Linia projects,  f  it.

                9comes in and is approved?

                10         DR. VAUN:  Right.

                           MRS. PARKS:  They cannot use it to start a p

                 activities in some other sites?
                2.

                           DR. VAUN:  No.
                13
                14         MR. VAN WINI@LE:  Would you award them 2205, whatever
                 it is  and in the other,ma@e-an additional award if it comes
                15

                 throuc,h?

                           DR. VAUN:  If you tell me that it the best  way  to
                17
                18 say it, that way, and I will say it that way -- tell me what
                 the rules are, and I will subscribe.
                20         Now, I think you know what I am trying to say.
                           DR. CARPENTER:  I guess if I understood, he said let
                21
                 us award them $100,000 less in July than if they come in with
                22
                 this sohmet up north, and we will,give them another.
                23
                           DR. VA UN:  Is that what you are saying.?
                24
                           MR. VAN WINI(LE:  Your c6ncern seems to be over this
                25






                                                                                 -420



                  solunet9  $100,000, whatever' it is.'

               2             Let us say, in the award, that the 22 is for Ohio'

               3
                 !,Valley and the X amount is for the other.

               4             MR. CHABIBLISS:  Making a total of.$2,305,000, just

               5  as you have proposed.

               6
                             DR. VAUN: I will  revise  my  motion  to  accommodate

               7  that statement.

               8             DR. SLATER:  I wonder if Dr. Vaun would revise    h'
                                                                                3-S

               9 position since he is  within  $10,000  of  the  target  figure, and

               10 in view  f all the criticism, why are we g   iving  them  more than
                            0

               11  100% of their target ficure?
                                          C>

               -12.          DR. VAUN: Because I thin[,, I have  arrived  at  my

               13 fi-ure   in a far more rational way than they arrived at their's.

               14 I  have  no way of knowing how they  arrived  at  their  target

               15 figures.

               16            DR. @fILLER:. Which is the correct target figure?

               17 lqe have two.

               18            MR. CHA@IBLISS:  The one on the long sheet  is   the-

               lq  laid-up  one and the more correct one.

               20            DR. iNaLLER:  35291 -- which is 45,000?

               21            MR. VAN WIINKLE:  I would like to'point out that the

                  taraet figure is for Ohio Valley.
               22

                             DR.  MILLER:  Their  developmental  project  includes
               2 i3
                  @i.;hat they are going to give to Ohio Valley.  So it is all in
               24
                  @l@here.






                                                                           421


                            NR. VAN WINKLE:  I am only saying

               2
                            NR. CHAMBLISS:  Your point  is viell taken, but the

               3!
               -fmotion as  presented by Dr. Vaun includes not only Ohio Valley,

               4
                  but the additional $100,000 to take care of Project 27, is thatl

                  correct?


               6            MRS. PARI@S:  Yes.

               7            MR. CHAMBLISS:  Now, question from Dr. Scherlis.

                            DR. SCHERLIS: As I recall, we had a great deal  bl'.

               9  fun@. and games in all of our previous review committees
              10  designating the various quadrants, or portals, in which we

              11  place various regional medical programs.
              12.           Could you refresh my memory and tell me  where  Ohio

              13  Valley was?

              14            MR. CHAMBLISS: If I recall  correctly,  Ohio  Valley

              15  was in the upper quadant.

              16            NR. VAN WINKLE: You know,  this  particular  project

              ii  you are speaking of is $150,000.
              18            MR. CHAMBLISS:  We understand that.  It has been

                  reduced to $100,000.  That is the point that he is making.
              20            MR. VAN WINKLE:  I thought he said not less than that
              21            DR. VAUN:  You are satisfying rae.if you leave it the

                  way it  is.
              22
              23            IvaS. WEIYOFF: Not less' than $100,000.
                            DR. VAUN:  The award to this re-ion..  My reconunendati n
              24
              25  is $2,305,000, with additional $100,000 for 27(d), if the RAG

  i4nnUrRRi:PnRTINrrn  lNr.





                                                                         422


              1  of the Ohio Valley approves it.
              2             MR. CHA@IBLISS:  I think that is of sufficient clarity,

              31 Doctor  to be understood.
              4             If they don't request that amount, then the principle

              5  of reversion tat-,es place.
              6             DR. SCHERLIS:  Call for the question.
              7             NR. CHAMBLISS:  All riaht, the.question. 'Those in

              8  favor of the motion?

              9             (Chorus of ayes.)
                            MR. CHAI.-IBLISS:  Those opposed?
              10
              11            (No response.)
              12.           D@IR. CHAMBLISS: The motion is carried.
              13            Let'us now turn our attention to the application

                 from Oklahoma.
              14


              15





              17


              18


              19


              20


              21









              -24


              25

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                                                                                                                                                     423



                                                                                       OKLAHOIIA


                             2
                                                    MR.  CHAMBLISS:    Oklahoma  will  be  reviewed  by.

                             3.
                                Dr.  Scherlis  and  Mr.  Toomey  with Miss  Resnick as  staff  repre-

                             4
                                sentative.
                             5                      DR.  SCHERLIS:    For  those  of  you  who  are  iDerhaps  not
                             6  familiar with  Oklahoma,  perhaps  I  can  give  a  brief  history.
                             7                      Oklahoma  had  been  very  heavily  oriented  toward
                             8  professional  education,  and  for  sometime  the  feeling  was  that

                             9
                                this.v)as  not  only  its  main  th@ust,  but  almost  its  only  thrust,
                          10    This  posed  some  problei-a..

                          11                       It  has,always  been  very  much                          procedure-oriented  and

                          12    this  is  apparent  when  you meet  with  both  of  the  regional

                          13    medical  program  advisory  groups  and  when                                   you  review  the

                          14    programs  that  they  had  over  the  years.    They  have  had  a  change

                          15    as  far  as  leadership  is  concerned.

                                                   Their  present  director  is  Albert  M.  Donnell    and  in

                          17    his  letter  of April  30th,  with  his  grant  request,  I  think  he

                          18    indicates  some-points  that  I  would  like  to  refer  to  because

                          I$)   it  at  least  gives  some  orientation  to  the  rest  of  their  appli-

                          20    --ation.

                          21                      As  he  points  out,  the  budget  request  which  he  s'uiDmits

                          22    Ls  based  upon  how  the  money  can  best  be  invested  wisely  and

                          2tl   I)roductively  in  achieving  the  maximum  cost  effectiveness  for
                                                                                                   I-
                                !thort-run  and  also aids  in  the  long  run.
                          24

                          25                            I  think,  and  it  is  an  important                          statement,  because,

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              1 as you review their request, a great deal is based on cost

              2  ef fec tiveness.

              3            When they put together their application, they did

              4  it in A way that I think will merit some discussion. .,They saic'

              5  their program development began with a consideration of the

              6  past and present DRMP mission, including guidelines and

              7  priorities with anticipation as to the most probable cause

              8  of action Con@ress would take in formulatin- remedial  legisia-

              9  tion. ORMP structure was then closely  examined,  including.its

              10 RAO organiation, past and present program activities, the

              11 staff structure and personnet.capacities, and the roles

              12. relationships and functions between the grantee institution

              13 OUHSC and ORIIP.

              14           The program then evolved and was further structured

              15 to demonstrate the willingness and ability at the State level
              16 for health planning, devei'opment,,implementation and regulation

                 to co-exist and function effectively, although under  different

                 or-anizational entities.
              18   0

                           They submit this as bein- their new  game  plan.  l@t

                 they have done is to put to-ether a series of projects and
              20
              21 plans which relate to, I think, a great deal of emphasis on
              22 provider base and also. on consortiunis of hospitals to reduce
              23 costs as far as the various services which they give.
                           There are a few points which I want to make in this
              ,)4
                ilregatd.  They state they developed a program, the Ot@lahor4ia
              25

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                                                                                 425


               1 iledical Program did not      I want to  emphasize,  did  not  announc@

               2  an open invitation to bidders to regional support funds for

               3 development of fiscal year '75 program.. Since the regional

               4  health development area program, which they referred to

               5 officially as RHDAP, and has been adopted as the'base program

               6  for 1974.

               7             The program content was   related to the question where

               8 to expand,, which development induced them to existing RHDAP

               9 staffs and what supports are utilized in makinc, the cost and

               10 quality effective.

               11            What they have moved into, as best    I can determine it

             .12.a structure called Re-ional Health Development Area Program,
                                        0

               13 and., therefore, have developed  several  such  areas  throughout  the
               ,4 State, and have built their futur.e.programs on this, basing

                   art of this on the fact that they are not quite sure which
                  p

                  direction RIIDAP or CHP will @o, so'they are loo[ring to an overall

                  area type of programorganization.
               17
               18            They say that the major program thrust will include

                  their continuation of remote coronary systems.
               20            This has been areas where they have been quite success-
                  ful in attracting a well-trained ca0i,(?-Iog'i@-t to assist  nei-hbor-
               21                                                               0
                  Ln- hospitals.  I might add that he is one of my fellows and
               22
                  ,-.hat is a very effective program from what  I have  heard  from  him
               23
                   s well as other people in the area.
               24
                             They have emphasized I,,idney-centers, as part of the
               25

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                                                                           426

              1 programs that they wish to continue.  They have been involved
              2  tlirouch their reaional health development groups, non-profit
                      C>
              31,icorporations known as @ledical Profit Systems,.Incorporated.
              4 These are ways of sharing joint purchasing of druas,  I .V

              5 solutions, various other services.
              6            This has proved to be, according to their cost
              7 effectiveness analysis, helpful as far as reducing hospital
              8 costs,, and becomes apparent as you go through their program,
              9 that a great deal of their emphasis continues  to  be  on
              io hospitals or providers working together as far  as  more

              11 effective cost mechanism.
              12.          In reviewing some of the things  that we would
              ,13 like to do and their staff, I think it is important  to

              14 emphasize a few things.
                           One, their e),-ecutive director  Dr. Donnell  has been
              15
              16 their for a year and four months. 'They have associate director,
              17 director of telecommunications, program director, program
                 assessment  manpower development, placement service, emphasis,-
              18           y
                 ac,ain  on education and, I guess, that which speaks most to
              19
              1>0 what you can do through provider orientation.  They do have
              211 significant vacancies on their staff that I calculated out as
                 bein- approximately $56,000 a year and some of these are at
              22
                  ignificant levels.
              2LI
                           In terms of what they w'ould like to do with their
              !,4
                 ,Fl.aone they have asked for several re,-ional health development
                     y


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               I  programs, that, as I total it, come to something l-'[-e $500,000
               2 for the total number of  five  or  six  which  they  have  requeIsted
               3 'and perhaps to give you a flavor of what these would like to do!,,

               4
                  I can read from one of them, and many of them are pul@--together

               5
                  just exactly the same way.

               6
                            This concerns one of their  medical  product  service

               7 groups which is under regional,liealth development program.

               8 This was-created for the purpose of achieving the following

               9  long-range goals:

               10           Promote area-wide  participation of  hospitals,  other

               11 health care providers and consumers, in exemplary programs for

               12, effective cost containment.

               13           Improve the availability,  accessibility  and  quality

               14 Of health services throughout the area through a more sophisl-i-

               15 cated health care system in concert with  State  and  area-wide

               16 health planning efforts.

                            Attract and better utilize health  manpower  in  rural

               18 communities.

                            Promote expansion of shared services voluntary

               20 hospital organization concept.

               21           They are the -eneral ones.

               22           Cost containment services will be pursued through the

               23 following activities: -roup  purchasing  to  initially  include

               24 drugs, I-V's and selected  hospital-supplies-  shared  services
                                                               i
               25 to include micro'Li@ing and printing;  shared personnel,,
  HOOVER REPORTING CO, INC.
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                                                                           42b


              1 commencing with dietary and medical record consultants.

              2            They put them into each one of these areas.  A
              3  whole wide range of programs which, if effective, would

              4  obviously accomplish a great deal.  They point to a complement
              5  to their pharmaceutical, drug costs, 50%, I-V equipment by
              6  40%,and so on.  In each one of these areas where they have

              7  planned or existing systems, they point out that they have

              8  been able to reduce costs  or will reduce costs.

              9            They have stated specifically in their general
              10 description that they are provider-oriented and certainly this

              ii has been one of their main thrusts, has been in that area.

                                                            is
              12.Other projects include program staff which    $317,000, EMS
              13 @raining, $100,000    so they are asking for a total of
              14 approx@iately $1,380,000. This exceeds their  estimated  140%
                 tar et, $1,000,000, by a total of $350 000. They have,  as  I
              15    9
              16 pointed out, successfully developed some remote coronary
              17 programs.  Their emphasis is obviously now on their  regional
              18 health development area programs, which, if these work, can be-

                 very effective.
              19
              20           Much of the effort appears to be in really reducing
              21 costs by mutual purchases, the hospitals, and the others,  as
                 I have indicated, appear to be essentially.continuation of the
              2-@
              23 projects.
                           I will withhold any motion until there is further
              2,4                                           1
                 Jiscussion,, and we have had staff comments on that.
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                                                                               429


               1            MR. CHAMBLISS: All right, than[.-, you.

               2            Mr. Toomey?

               3            MR. TOO@Y:  I think it is interesting that the thrus@

               4 of the Oklahoma program has moved  from  their  early  cooperative

               5 programs in the clinical field and  evolved  as  cooperative

               6  efforts in the management and the hospital operation.

               7            I suppose the three major -- three or four  of  the

               8  major efforts in the hospital field today have to  do  with

               9  shared services, mergers, contract management and  this  ki nd

              io  ofoperatio,n. The people in the hospital business  look  --  they

              ii  look at this kind of evolution as being  something  really

              12, tremendously desirable because it talc-es many of the problems

              13  and many of the isolation factors related to  small  hospitals

              14  operating as autonomous individual institutions  that  are

              15  essentially uneconomic,bec,ause with small hospitals havin-

              16  to purchase things that they purchase and hire  the  kinds of

              11  People that they hire, in a small hospital  and  expensive --

              18  for example, a dieticians or social worker in a  small  hospital-

              1!) may not have enough outlet for her capabilities or  her  capa-

              20  'Dilities in that one institution alone.  Whereas., the sharing of
              21  people, the sharing of resources, whether they  be  financial
              22  resources or personnel resources or equipment  resources,  has
              2.3 to be, as far as I am concerned, it has to be the move of the
              24  future in order to create some kind of  an  institutional  health

                  ,are system.
              25

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                           Now, I really only differ with them in the use  of
                2 some words. For instance, to call-it a health delivery  system,

                3@
                 I think it is probably wrong.  I do agree, certainly, that it il@

                4
                .an institutional kind of melting of services and  sharing  of

                5
                 services.

                6          I look upon it really as a thrust in two areas.  One

                7is economics and the other is the enhancement of the manpower

                8or the professional personnel who are basically in short

                9supply and-certainly if theycan be shared  it  is  desirable.

                10         SO, I can't help but be very much in favor of this

                11 kind of move in terms of the service s. it enhances the  services

                12.rendered to the people; it enhances the problems, the cost of

                13 containments. It has a very strong economic thrust in terms of

                14 value to the community and value to the institutions and value

                15 to the patients who use these institutions.

                16        I think that it  is an extremely desirable  kind  of

                17 thing and I think that it is certainly interesting,  that  it

                18 springs from the initial sharing going on in the heart  disease,

                 :ancer and stroke and they moved over into the institutional

                 .:, ields, and I suppose part of the reason  I don't know whether
                20

                 J)onnell, however, you pronounce it, is a physician, if you call
                21

                 Lim a doctor
                22

                          MR. VAN WINKLE:  He is a hospital  administrator.
                23
                24        M. TOOIEY:  Well, I remember that-, he was Donnell,@il.H.A.

                25

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                               1 which is a @las-ter's decree in hospital administration, so I
                               211 think it is, perhaps, just as logical                                 .  for this guy as a
                               3  hospital administrator to move his R i" in that direction as it
                               4  is  for a  physician Ri%M  directed  to move  his  RAG  in  the

                               5  direction  of  clinical  services.

                               6                     In  either  way,  I  think  there  are  values  to  be  gotten@
                               7  and  Oklahoma,  as  a  rural  State,  as  far-as  I  am  concerned.,  with

                                                                                                                                                       the
                               8  this  kind  of  thin                   is  a  very        large  degree,  I  would                   say,  at
                                                                  9
                               9  present  time,  you  could  look  upon  them  as  almost  a                                        model.
                               io What  could  be  done  from  the  institutional.  point  of                                        view  with

                               11 other  institutions.
                               12                    So,  the,only  other  question  that                                   the  only
                               .13 question,  really,@tt-iat  I  had  was.the  --  it                                 is  a  small  staff,  bu-
                               14 if  you  put  it  on  a  percentagewise  basis,  it                                   is  about  a  70%
                               15 increase  in  the  staff  that  they  are  asking-
                                                     This  is  one  place,  Mrs.                    Resnick,  where  I  think we  l@vc
                               16
                               17 to  lean  on  you  to  find  out  if  that  increase  in  staff,  with  the
                               18 fact  that  their  programs  are  under  way,  and  they  are  just
                                  expandino,  them,  rather  than  bu@ding  in  a  lot  of  new  ones,.
                               19                C>
                                  whether        that  is  justified.
                               20
                               21                    I'FISS  RESNICK:    I  think-  they  need  some  strengthening
                                  of  staff.    But  I  felt  at  first  it  was  a  little  too  much  at  this
                               22

                                  time.
                               23
                                                     The  regional  health  development  programs  are  well
                               24
                                    lon@  as       far  as  the  models  are  concerned,  because  Enid  and


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              1  Bartlesville have been successful.  Enid and Bartlesville

              2  were initiated just as a pilot last spring Keith '74 iaonies, an

              3 1 they do want to expand and probably will follow the

              4  Bartlesville approach.  They are getting very good  reactions

              5  from the communities.

              6            You are right, they feel this is an excellent

              7  mechanism for the rural area outreach and that is what it

              8  will prove.-

              9            As for this new.st.aff, I can't speak to it axactly-

                 I haven't been in the area and talked to Mr4  -Donnell.  I think
              10

                 he needs some strengthening, but I am not sure that h -needs
              11                    C>

                 that many people.  Seven new positions are proposed .  Four
              12.
              .13 professionals and three clerical,administrative and that

                 sort of thing.
              14
                           MR. THOi'4PSON:  Have you had any more definite

                 relationships with CHP?  When you-get these programs, then
              16
                 CHP usually starts screaming.
              17
              18           NISS RESNICK:  There are four funded eastern area
              1!) CHP "b" regions which were extremely laudatory of the program.
              20           One of the projects  if you will notice, is to
                 assist in western Oklahoma.  Actually, it is  two programs in'
              21
                 western Oklahoma will eventually go on their own, but right now
              22
                 it is a very weak area and they have had a rocky history with
              23
                 the CHP a-ency and even the "a" agency.
              24
                          I,lr, DonneL4:1 think,was with the  a  agency and he is
              25

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                                                                             433
                  well aware and sensitive to this development in connection with

               2 the CHP  "b.

               3
                            He feels that it is helping to strengthen the

               4 relationship.
               5            Now,, if that answers the question
               6            DR. SCHERLIS:  I have tried not to put too much
               7  a qualitative feeling when I presented it.  I come away quite

               8  co6l to this.
               9            I think a good many of these projects should have
              .10 been done by the Oklahoma Hospital Association without having
               11 any semblance of involvement whatsoever, of any consumer

               @12 groups or other regional cooperative ventures.
               13           I d"Ld-.nbt know that he was a hospital  administrator.
               14 If I had, perhaps I would have so identified him in the
               15 presentation and it would'.1-iave been covered fully by that.
               16           1 say it only because  .I'don't think this reflects
               17 a regional cooperative venture. I thin[,, it reflects  the  swing
               18 away from what they used to have.   When they formerly were
               11) heavily oriented towards education, who was it, Dr. Dale Dromes,
               20 and I was very concerned because it was totally professional
               21 education and we spoke then rather prosaically of  this  or  that
               22 medical prograri., having turned the corner,.and Oklahoma  seemed

                  at that time never to find t e correct  corner or a correc
               23

                  corner to turn.
               24
               25           Now., they have turned and are still  heavily  provider

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                1 oriented, but now it is a different  group  which  is  providing

                2that and that is  the  hospital-based  need  and  they  are  spinning

                3 loff cooperations which are looking at what I.thin't-, are very

                4im ortant aspects of  mutual  purchase  of  equipment,  sharin-  of
                   p

                5facilities  and I see that the thrust that they .point to

                6under proposals, are one thing.  When they  get  progress,  they

                7can point to the facts that they are now reducing the  cost  o-P
                8I-V equipment and now have joint microfilriiing,and so on,  but

                9these are -the progress notes.

                10         Under their whole area health programs, much broader

                11 thrusts are envisioned.  But, I think they are doing first

                12 things first.  Everyone does his own thin-, and I thin[-, he 'is

                13 doing his own thing very effectively.

                14         I would like you to react to that.
                15         MR. TOOMEY:  I react two ways.  One is, you could
                 conceivably say either the medical'societies or the various
                ,7 medical schools, and all of the States have been involved  in

                 the contribution or dissemination of medical information to  the
                18
                 outlying rural areas before RMP came in with its medical thrust.
                20         You say the hospital association should have done  it.
                 Well, the hospital association is a collection of  individual
                21,
                22 Institutions just as the -- just as the medical society is  a
                23 collection of individual physicians, and I think that each one
                 ias its own thing to protect.
                24
                25         I think that they are trade'associations, either  way,

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                                                                              435


               I  and to say that in the profession of institution management
               2  the hospital association should inflict its desires for great
               31 development of an' integrated health delivery system utilizing
                I
               4  all physicians is any different from saying that the hospital
               5 association should indicate all hospitals, so that you have

               6 hospital systems.

               7            You can argue one way and I think it is just as

               8  inappropriate, really, for me to say about that, about the

               9  medical association, just as it is for you to say it about the

               10 hospital association.

               11           I think it is a major breakthrough  in institutional

               12 management, which is for the benefit of large numbers of

               13 individuals.  Granted it really is to the benefit economically
               14 and in terms of quality of care.  It provides these things

                  hat were not provided befor
               15 t                          'p..

                            It is in a different context of clinical -- but it

               17 does provide an excellent, an increase in enhancement of the

               18 2aliber of care within those institutions, and I think that., I-
               19 think you are going to be interested in what medicine does,
               20 i@hat nursing and dieticians and x-ray technicians and what the

               21 other people do.  Because each has a bearing.

               22           So, I think that, we are both talking from different

               2.3 points of view, but from my point of'view, this is great.

               24           DR. SCHERLIS:  I don't mean this to be a debate.    it
               25 is obvious we didn't get together at lunch.

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              1           l@. CHA14BLISS:  A brief comment by Viiss Resnick.
              2           MISS RESNICK:  The origin-of these area development
              3. corporations was a manpower development device to begin with.
              4- It is not emphasized quite as much in this presentation as it
                was the last time and that is still a component of their
              6 operation.  It is not just sharing costs and containments.  It
              7  is manpower seminars, workshops', development of -- they will
              8 have a conference that is b eing spread out throughout these
              9 hospitals, so it is a little more than meets the eye.
              10           I don't think it is exclusively a hospital management
              11           MR. VAN WINKLE:  You wouldn 't believe the community
              12  involvement in this program.  Never saw such enthusiasm.
              13           MRS. WEII@OFF-.  This is just a piece of the whole

              14  tt-ii ng.
              15           14R. CHA@IBLISS: -I wonder if the representatives
                 are ready to make a motion?
                           DR. SCHERLIS:  Recognizing that hospitals are
              18 important, I would move that we fund them to the level of their
                 tarc,et  which is $1,033,000.  This reduces what they asked by
              20 $150,000, which I do without coneciencereally.
                           M. CHA@IBLISS:  If you will look at your spread
              21
                 sheets, you will see the more current target figure-is
              22
                 $1,062,337.  Would that be covered in your recommendation?
              23
              24           DR. SCHERLIS.:  I would"move -- yes.
                           MR. CL@MLISS:  Is there a'second?
              25

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                                                     MR. TOOIE@Y: I will second it, and then just                                            as an
                            2 aside tell you that you gave $62-000 more than I was                                                         goina, to

                                 ask.

                            4                        @IR. CHAMBLISS: All right, it has been movec and

                            5    seconded.

                            6                       Is there further discussion?.

                            7                       Dr. White?

                            8                       DR. tiHITE:             Is there some concern on the yellow page

                            9   about the           duplication? EPS activities?

                            10                      DR. SCHERLIS: We have been assured                                     this is ot a

                            ii  factor.


                            12.                    1,4ISS RESKICK: It is just a continuation of what
                            13  they have           been doing. Very little additional money, training,
                            14  3nd,  apparent           ly,  it  is  acceptable.

                                                           CHAMBLISS:    C
                            15                                                      all  the-question.

                                                   MRS.  I-IEII@OFF:    Question.

                                                   MR.  C@IBLISS:    Those  in  favor  of  the  motion?
                            17

                            18                     (Chorus  of  ayes.)

                                                   MR.  CHA@FBLISS:    Those  opposed?

                                                   (No  response.)
                            20

                                                  14R.  CIiAl@fBLISS:    The  ayes  have  it.
                            21

                                                  I  would  simply  wish,  if  I  may  indulge  in  the  preroca-
                            22
                            23 tLves  of        the  chair,  maL-,e  the  observation  that  not  only  is  the

                            24    coordinator  of  O'L@laho                 i-na  an  administrator,  I  understand  that

                            25    his  RAG  chairman  is  a  hospital  administrator,  one  of  your

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                 reviewers, @ir. Toomey, is a hospital administrator.

              2            Your staff assistant is a  hospital administrator and

              3 i
                 so is your chairman.
              4            And, I would  say it is about time that  hospital

              5  administrators became more involved.  We have sought to oet
              6  their participation over the years, and it now comes  it  a

              7  rather late date.

              8            DR. SCHERLIS:  Nothing succeeds like success.

              9            DR. CARPENTER:  Could I ask one questi on7

              10           Is Mr. @ysor involved in the regional program in

              11 Oklahoma?  You didn't see the name in the application

              12.          IIR. TO@IEY:  No, I didn't notice.

              13           la. C@13LISS:    I would like to note one thing  for

              14 the record if I may that at this late date  in  our  review

              15 process, that all of the reviewers,are still in  the  room.

              16           I would like the record to show that.  And, it shows

              17 certainly the commitment that our viewers have had to this


              18 process.

              19           We do, indeed, appreciate the support that  you  are

              20 givin- us in this review  and I will say that I hate to spoil.

              21. what Ihave said.  Off the record.

              22           (Discussion off the record.)

                           M. CHAIIBLISS: Now, we,are back  on  the  record.
              23
              24           Our last region -- our next.region for review is
              25 South Carolina. After South Carolina., we will have  only  one

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                            1 additional re--ion to coi-,ie before this panel

                            2                        DR.     14ILLER: You have two.,

                            3                        MR.     CHAIIBLISS: Thanlr, you for correcting me, we

                            4    have two after this.


                            5






                            7






                            9


                            10


                            11



                            12


                            13


                            14


                            15


                            16


                            17


                            18


                            19


                            20


                            21


                            22


                            23


                            24


                            25

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                                                                               44o



                                     SOUTH CAROLINA RE@GION

               2
                            MR. CliAMBLISS: Let the record show that Mr. Toomey

                 has left the room for this review.
               4
                            The reviewers here are Mr. Thompson and Dr. Vaun,
               5
                 supported by Mrs. Kyttle, who represents the staff.
               6
                            MR. TflOMPSON:  South Carolina contains many of
               7
                 the problems that we have been  discussion here today,  such  as:

                 slush funds.
               9
                            Previous approval of contracts have not been
              10
                 completed  and so let me just start out with a  positive point.

                            There is on page 'Qb of the application, a thing
              12
                 entitled a.chronology  to boggle the mind.  That reviews the
              13
                 history of the poor South Carolina project  from 1972 back up
              14
                 to 1974, and it is true, it was @ chronology to boggle the mind
              15
                            The program wasin the first year, I think, its

                 triennium review program when the axe fell.  Its RAG   has
              17
                 maintained itself, although I have many problems  with  the  RAG.
              18
                            I went through it and I find out that the  RAG,  there

              19
                 is a total of 58 people, 24 of whom are physicians, ten of

              20
                 whom are educators., four of whom are nurses, four of whom are

              21
                 hospital administrators, ten of whom are other professionals.

              22
                 one dentist and there are four civilians on their RAG.
              23            Now, whom they represent. Eight  represent  the  State
              24 educational system' seven the voluntary  health  agencies,  three

              25
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                                                                           441

              I official health agencies, four of them public State agencies

              2   two in health plannin-
              3            Down on the bottom, after you go throu-h  s@ven from
              4   hospitals and medical centers and, finally, six public
              5   representatives which makes one kind of wonder what kind of
              6   direction this pro-ram has @one into.
              7            The proposals, then, are very clear and logLca  y
              8   presented.  I will try to sum up what this is.
              9            The objectives are in six Roman nlmberals.
                           The regionalizati6n of service, health manp wer
              10
                  development improvement, strengthening of quality ass  ance
              12, efforts, special categorical interests, primary h-ealt  care
             .13  and advanced resources planning.
              14           These reflect both inputs from the national and
                  some inputs from the localsqene.  Each operational project
              15
                  is hooked directly, or indirectly, to one of these Roman

                  numerals of overall priority areas.
              18           However, do not be misl-,ed@ by the logic of this
              1!) presentation.  Because when one looks at the budget proposal
              20  which, by the way, this is now,funded at $1.,250,000, their
              21  target is @2444.  Their request for this is $3,000,000 even
                  and they have put us on notice that they are going to come
              22
                  sliding in with another $500,000  which is a pretty big growth
              2t3                                 I
              ?,4 for a program that has been operatin g at a rate of  1250.
                            When one examines their request, one finds that
              25

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                                                                                  442


                  Roman, numerals, six Roman numerals, and the staff accounts for

                2
                  67% of the total requests.
                3            Npw, in their defense., they   have indicated several
                4 future projects that are in the pipeline of each one of the

                5
                  Roman numerals  and   they are  not.  They  did  not  like  Texas
                6 saying, "Give us some money and we will put some of these thin-s

                7
                  into effect."

                8
                             on the other  hand,  they  have  asked  an  inordinate

                9
                  amount of money for the support of these Roman numerals, which

                10 are not connected at this time to specific programs.

                             When one looks at the specific programs, even thouch
                                                                  C2

                12.they only require     only consist of 33% of the total budget,

                13 they are.consistent with the main goals and they are consistent.'

                14 ;iith wLiat little I know of health problems in South Carolina.
                15           In other words    tL-i@-te is -a nurse @iifbry project'

                  L@or example.  There is a great deal of attention to quality

                17 -ontrol.

                18           As you probably  know,  prenatal  quality  is  a  real

                ii) )robleni in South Carolina and the prenatal death rate is very

                20 high, and they have paid attention to it.

                21           I have some problems that some of the other quality

                22 control or mecical evaluation systems.  They are institutionally

                2t3 based.  Those hospitals that have@been doing their -'ob should

                24 have paid attention to Quality Control lon,- before this word

                25

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                                                                             443

                  became stylish to PSRO or to any other kind of way.  But,  I
               2
                  can't argue with this specific project.
               31                                                      ''
                            ,Now, as far as the CHP relationships, something very
               4
                  interesting has happened.  Evidentally, the CHP agency and
               5
                  the P@IP agency got together and.said, "What are we going to
               6
                  do with this unknown legislation that might be comina sliding
               7
                  down the pit-,e.

               8
                            So., they decided to get together.to talk about an

               9
                  advanced health@resource planning group.  They are supposed
              10
                  to have the "b" agency, the 'a  agency and PLIP and $164,000.
              11  was allocated to this advanced health resources group.
              12            Evidentally, they were going along when one "'D"

              13
                  agency, I think it was the "b" agency of Gharleston, zipped
              14  in on this proposal.  Since it seems peculiar that one a-ency
              15  would scream, and the other didn'E scream, I tried to find out
                  from the staff if there was a funded MO down there.  That somehc@@i
                  that "b" agency was the fault of the DRMP  because Dr. Margolis
              18  signed that grant and although they were no longer with RMP,
              19  it might have helped-.  We are very much in a problem then
              20  that they are requesting to approve what is roughly $1,092,000,
              21  in these six Roman numerals, which really represent a lot of
              22  specific projects that have not been advanced.

              23           Now I understand they have told the staff that if we
              2,4 -ive them this money, they will not come back in the next round.
              25           In other words., they would take the money that we woul

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                                                                           444

                 give,  for example,  to  quality assurance,  and  give  it away,to
                 some  of  the  projects  that  they have  in  the  pipeline of  quality

              3
                 assurance.,

              4            I am very reluctant  to  do  this,  although Ican  see
              5  the  rationale  of  it,  because  I  think we  would,  in essence,be

              6   ivin-  them one  hell  of a  big  slush  fund.
                 9
              7            It  isn't  that  I  don't  trust  them,  but we haven't  had
              8   anybody else  recently  tried  that  big a  structure, Let me  close

              9  then,

              10           It  is  a well-written  project.    Probably  the  best
              11 written  project  I  have  ever  seen  from South Carolina.    The
              .12! priorities  are  carefully  spelled  out.    The  projects  do  relate
              13 to  priorities. They are making a  real  attempt  to get  together
              14 with CHP and  solve  this.    The  health authority  problem.
              15           But I  can't  see  civing  them all  this money  for  proj'ec:s

              16  that are still unapproved.

              17           I will close.
              18           MR. CHAIIBLISS:  Thanko you, Mr. Thompson.

              19           Dr..Vaun?:

              20           DR. VAUN:  I don't think there is much doubt that the

              21  eadersl-iip orogram has come through on this, very well. I'think

              22  ohn has identified the makeup of RAG.. I am not sure that it
                Texas made any difference in the thrust of the pro,,ram, at least
              23
                as I surveyed the pro4ects.  They don't meet too o'ten, but
              24
                 Poarentl . they seem to cret the job done.  The staff, in my
              25          y





                                                                             1145


                1  opinion, looks good@ and I think it couches the realization

                2 with CHP, in eneral  terms.  It  is  difficult,  at  this  point,

                3 jto forecast whether the divergence  are  good,  whether  they

                4  are checks and balances or forceps that may prove to be

                5 counterproductive.  That may say a lot of it may not say

                6 too much.

                7            I must admit that I was more  conformable  with  this

                8 propos,al.before Texas    and I mean that very sincerely.

                9 I thin[-, I could have been very comfortable  coming  up  with

                10 some kind of recommendation before I saw wi-iat,we did specifical-Y

                ii with regard tokxas, and'that is even more so here because two-

                12 third of the request is in this never-never   land of   advanced

                  health resources plannin,-.  $164,000.  Primarily, health care
                13

                14 to b                   cts                                 0
                      e defined in contra       that is 194.  The  other  was  1'4.

                15 Special categorical inter6's@,  $404,000, etcetera.
                16           1 think John has identified this.  There   is no

                - need for me to belabor it  at  this  point.  I  think  perhaps
                17
                18 Mrs. Kyttle could help us.

                             MR. CHAMBLISS:  Miss  Kyttle,  would  you  proceed?
                1!)

                20           MISS ICYTTLE:  Going back to RAG, RAG has evolved

                21@ and is still evolvin- into what it is now.  It was a 72-mem'Der

                22 c)ody with '0'3 physicians on it, not too long ago, and  they

                2t3 listened to get that RAG in a better balance  and as memberships

                24 @irote it, the balance is coming, it is not there  yet,  but  it

                25 is coiiiin-.

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        Ro,,ers/ml                                                                446
                 1            But) South Carolina is and has been for some time
                 2Idivided into ten very precise medical districts,  They are
                 311
                  planning districts.  They are economic     districts, and.they are
                 4Nqell-settled'districts for many matters.in the States.

                 5
                              14hen regional:medical programs began, it had a very

                 6
                  touryh time gettinc, off in South Carolina, until it assured each

                 7
                  district that a physician from each district would sit on

                 8
                                                                           ,but
                  iqhat they thoucht would then be the governing.body,l         which

                 9
                  turned out tc,  'L)e,-the re@ional advisory group and they have

                 10
                  notmdved away   from that promise.

                 11
                              So, whatever evolves from    the RAG, you are goin- to
                 12, have ten representatives  one  each  from its medical district.
                 13           They call  them  civilians  down there, too.
                 14           1,T,. THOMPSON:   I know, I took it ri-iit off your

                 15  checklist.
  end tape
     6           16
  .ontine on
   taoe 7        17


                 18


                 19


                 20


                 21


                 22


                 231


                 24


                 25


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                                                                            .447


    JR-7       I                 MISS KYTTLE: The  actual  submission,  that  is  not
    1 dm
               2    quite right in that they have   not promised us  that  they  will

               .3   not come in.  But we put the regions on a bit of a spot.

               4                 Before they heard words  from  this  review  cycle,

               5    we asked  them to look what the next cycle would like and

               6    South Carolina dodged and said,  depending  on  what  comes  out

               7    of this cycle, we will do this,or this or this.

               8                 We had their proposal and it  sort  of  boggled  our

               9    minds and we hit the middle, the $500,000 is a middle

               10   contingency and for the purposes of producing this right,     but

               11   not correct list here,'We hit $5,000 out of all of the

               12   contingencies that  South Carolina proposed right back to


               13   US.

               14                If they get full funding they do not plan    to come
               15   in. If they don't get fiiIA.funding,  and  it  is  this  or,this
               16   or this and that is the kind of  contingency  this  July  1  is.

                                 With respect to the  kinds  of  institutions  that

               18   they are dealing with, South  Carolina  had,  about  two  years
               19   ago when its hospitals  got  into  accreditation  and  certifica-
               20   tion trouble and that has fostered  some  of  this  activity  in
               21.  some of the categories that you mentioned.  CHP, the comments
               22   on the vellow sheet do not relate only to CIIP.
                                 In South Carolina there@are  at  least  five  forces
               23
               24   that have been active in their   own rights:and  very  active  in
                    watching everyone else.  It is   Appalachia,  well-funded   and
               25

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                                                                                 448

    dm 2         1  strongly provincial.  CHpf 1.)oth'A and B, external and internal

                 2. problems.  P-TIP, the State Health DeT)artment in which the

                 3  "A" is seeded and the Governor has created a Health Welfare


                 4  and Environment Council which is   beginning to move State

                 5  money around from  .everyone into everyone else and into the

                 6  Governorts Office.


                 7               And South Carolina is politically, healthwise,

                 8  in quite a turmoil right now.

                 9               I don't know whether it is  that  they  are  farther

               .10  along in.some States and they are getting to the range like

                 11 that other States will get to or  whether  it  is  the  approach,

                    I just don't know and that is why I  say  I  don't  know  whether
                 12.

                 13 they will be good checks  and  balances  or  counter  productive.

                 14 There is a lame duck Governor.

                 15              This Council that he.has created has made two

                    attempts, neither Of which was successful, to get legislative

                    life. It is just a dotted  line  out  of  the  Governor's  office

                    and   everyone wonders when the Governor goes, will the Coundil-
                 18
                 19 go.  It is a political arena right now healthwise in South

                    Carolina, to have pulled as much constituency together as
                 20
                 21 South Carolina did, is remarkable.

                                 MR. VAN WINKLE:  Doesn't Westmoreland sit on that
                 22

                    Council?
                 23
                                 MISS KYTTLE:  No, not on the Council, he is runnin@
                 24

                    for  Governor.
                 25


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                                                                              449


      drn3      1                 MR. THOMPSON:  ily official recommendation      was

                2    that $2.2 million which is just under $1 million more       than

                3    they have.now,  but  is  some  $800,000  less  than  thev  requested

                4    and most of that money, I would suggest could be       turned   into

                @5   the second review when some of these programs in       the   general

                6    areas were more specific.  I am not making this      as  a   motion.

                7    I am just saving this is what I came out with.

                8                 I would not be adverse to recommending the

                9    $2.4 million-, but I don't think  that  we  can  give  them  in  all

                io   due respect, all this money, these     slush  funds  that  they  are

                11   requesting.

                12@'              MR. CHATIBLISS:  All right.
                .13               MISS KYTTLE:  I  alerted  you  that  the  pages  of
                     the application d6.show  the  people  with  whom  thev  will  be
                14
                     doing business with, the sites'with whom thev will be doing
                15

                     business with and the money that will be involved.
                17                Unlikd Texas, these have been received, identified,
                18   negotiated,  some of the budgets have already been negotiated.

                     down.
                19
                20                There  have  been  preliminary  studies  by  CHP.   CHP
                     promises and that is part of the hang up there, their staff
                21
                     has to get through   things that require the time, some even
                22
                     said we won't even   need 30 days'--   some  of  the  submitters
                2t3                                                I
                     are B's and they  can  get  by  late  June  their  internal  process
                24
                     finished  on  these  specific  applications.  They  could   have
                25






   dm 4         1   put a 15 in for everyone of them.  They could have --ut     a 16

                2   in.for everyone of them but they.are not through their      final

                31  review process and South Carolina is very precise about their

                4   review process with respect to their regional advisory'

                5   group.

                6                They would not put the 15   in this  ap
                                                                       .placation be-

                7   cause it hadn't gone through the second round     through RAG.

                8   It has,been through the first.

                9                MR. THOMPSON:  My problem is if it ain't in.the

                10  book, I can't grab it.

                11               MR. CHZLNIBLISS:  Are there further points of

                12.  discussion?


                                 Dr. Miller?
                13

      (8)       14               DR. MILLER:  Dr. McPhedran and I, after yeat
                                                                                er-

                15  day's discussion and much discussion about slush funds,

                16  discussed about whether   we should put a motion in that would

                    establish the principle   of the review committee not to approve

                18  anv slush fund components of applications and we discussed

                    it a little bit and decided maybe it wasn't going to come up

                    and maybe there wasn't much point in putting up a motion that
                20

                    wasn't going to come up again and I just commented to him, I
                21

                             has been inappropriate.  It would have been a good
                22  guess it
                23  idea to have the motion put in, because it seems to keep

                    coming back, doesn't it?
                24
                25              MR. THOMPSON:  In their-defense, everybody is

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    dm 5            laying  $2  on the horse race and covering all

               2                MR. CIIAt4BLISS:  Is there further discussion?

               3
                                Dr, .1,7hite?

               4
                                DR. WHITE:  Miss Kyttlon-, you are implying that

               5
                    if this money was restricted at this time, in these numerical
               6    categories, that they would by July have these things in
               7    form which we could see, is that correct?

               8
                                MISS KYTTLE:  Yes, they were trying to obviate
               9    the necessity to come into the July cycle and come in

               10   September.

               11               DR. WHITE:  Thev were trving to save us a trip?

               12               MISS KYTTLE:  They were trying to save themselves

               -13  two months, too.

               14               They have made inroads with MUSC on contracts,

               15   affiliation agreements are tough for a year.  Not too many

               I(;  of us have sat around and said that.


                                That is one of the beauties of a contract.  In

               18   addition to it, contracts as Cr.-Miller said, give you

               19   opportunities to do things that when South Carolina discovers

               20   the control of the contract, they like it, they have used

               21   them sparingly through MUSC, because they.had to educate their

                    grantee.  Having done that, they propose the contract method
               22

               2tl  with these.

               24               These are   and in that, it is merely a physical
               25   mechanism and I think the group got hung up on the differences





                                                                          41- 2


                   between agreements and a nroject and a contract and   they are
    dm 6

               2   all the same thing.  Thev wanted   to let them as  of U.L-,r. L.

               3                Also in their application they said the   would

               4
                   hope for  July 1 beginning dates on the use and theylwill be

               5   ready to  go by then, they tell us, because  they  will have

               6
                   had the opportunity to  capture  several  things.  They will hav
               7   their full sta                                      a@ full
                                  ff complement to monitor them  for  th

               8   year in South  Carolina and they do that precisely too.

               9                They will have the opportunity to  . come rough

               10  the.review group here with the staff at its highest cornnlement

               11  here in DPNIP because they see the erosion coming to  staff

               12. that Dr. Pahl mentioned, later, and they see the bodv that is

               13  meeting here today that they are not so sure that there will

               14  be the continuity'of it in Julv.

               15               MR. TIIOMPSON:,/ -TA7hat is the incidence of hyper-

               16  tension in children, does anybody know what the incidence

               17  of hypertension is in children?

               18               Dr. Scherlis, do you know?

               19               DR. SCIIERLIS:  No, I would assume vou would be

               20  dealing with blacks as opposed to whites. -You would have a.

               21  much higher incidence but I don't know what the incidence

               22  would be.

               23               MR. TIIOMPSON: They,have a specific orogram for

                   hypertension in kids.
               24

                                MR. CH@IBLISS:  I can comment briefly on that.
               25

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    dm 7            That is the incidence of hypertension in black chil,:--,@@ does

               2    not seem to increase until the stress mechanism gets to work-

               3
                    ing and that is towards adolescence and above.

               4                 DR. 14cPIIEDRAN:  I think it is quite significant

               5    in black adolescent children.  I don't know how    high it is.

               6                 MISS KYTTLE:  Part of the interest of that

               7    activity is to nab  beginnings  of  renal  disease.  As  using

               8    hypertension in children, female children considerably.

               9                 DR. WHITE:  What is a  special categorical interest?

               10-  Have you 'an idea what thev mean by that?

               11                MR,. THOMPSON:  The priority areas.

               12,               DR.  WRITE:  No,  special  categorical  interests


               13   for

               14                MR. THOMPSON:  That is IV.

               15                DR. WHITE:  lkpow what it is called.

                                 MISS KYTTLE:  Because the others deal with heart,

               ii   stroke

               18                MR. THOMPSON:  Hypertension,  is  their  big  one

                    because they have a high black population.

                                 MR. CH&NIBLISS:  Yes, but they don't develop the
               20
               21,  mechanisms to take care of the hypertension once it is

               22   discovered.
               23                DR. SCIIERLIS:  Just !screening.
               2,4               MR. CHA,14BLISS: The  mechanismis  not  there,  I
                    think in all candor, that should be said.
               25

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                                                                              454

    dm          1               MR. TFIO,IIPSON:  Diabetes is another one taat  is
                2   specifically mentioned in this,  emphysema, arthritis, heart
                3   disease, cancer, they cover the  whole categorical @ing that
                4   they had in hypertension, that in the pipeline there are

                5   some peculiar ones, esophogean cancer.

                6               MR. CHAMBLISS: I would like to  get  a  sense  of
                7  the.committee's feeling,on this application and  call.  for  a

                8  motion if I may.

                9               MR. T11014PSON:  My second reviewer has a comment.
                10              DR. VAUN:  Jesse, in the Texas write up,l how much
                   did you see where these contracts were going to and    here?

                               MRS. SALAZAR:  None.
                12,

                13             DR. VAUN: My mentioning Texas,  I  think  was  un-
                14 fair.,

                               Miss Kyttle,    think-you did mention  the who and

                16 where?

                               MISS KYTTLE:  And the budget and that is import-
                18 ant.

                11)            MR. CHP-1,4BLISS:  The basic thing, would this
                  con-mittee in its judgment wish to approve these before these
                20

                  issues are in fact settled there?
                21@

                               MR. TIIOZ.IPSON: That is why the recommendation
                22

                               MR. CHX,,IBLISS:  Would you put that in the form of
                23
  Index           a motion>
  " Recor(im-   24
  Bndation"                   MR. TIIOJ.IPSON:  $2.2 rfiillion.
                25






                                                                            -455


     dm9                        MR. CIIA.'-IBLISS:  The recommendation for a level
               21@ of funding   for South Carolina is $2.2 million.
               3ii              DR. SCHERLIS:  I second that.

               4                MR. CIIN,@IBLISS:  It'has been seconded by Dr.

               5   Scherlis.


               6                Is there discussion?


               7                Dr. Vaun?

               8                DR. VAUN:  John, I don't understand  yo ur sub-

               9   mission.  This is the award for South Carolina,   period.

               10               MR. CHPC@1,BLISS:  They can still come in.

               11               MR. THOMPSON:  There is $500,000 coming in.

               12.              MISS KYTTLE:  There will be more than the $500,000.

               13               MR. CH2V-.IBLISS:  There will be funds available

               14  at that  time.

               15               MR. THOMPSON:-The  $2.2 million is arrived at by

               16  taking out some but not all of  these non-program areas.

               17               MR. CH2UIBLISS:  Would you like that instruction

                   to go to the region -- all right, we have a motion, we have a'
               18

                   second, we have discussion.
               19

                                Shall Icall the question?
               20

                                Those in favor?
               21

                                (Chorus of "ayes.")
               22

                                MR. CHXIBLISS:  Those opposed?

                                (No response.)
               24

                                MR. CH@-IBLISS:  The ayes have it and the level is
               25





                                                                                1.@56


    dm 10       I   set at $2.2 million.

                2                I would call upon the Committee again to, ask

                3   how we should spend our time for the balance of the after-'

                4   noon?  I  am given to understand that the other panel     will

                5   coRplete  its work today.  They will met at 8:00 o'clock, they

                6   will be available for a joint meeting with this Committee at

                7   9:00 o'clock and I would like to  know  if  you-would  like  a

                8   break for a moment or would you like to continue?


                9                DR. McPHEDRAN:   9:00 a.m.?


                10               DR. SCHERLIS:  Do we have any reason to meet


                11  from 8:00 o'clock to 9:00 o'clock if  we  complete  these  two


                12, regions?  ','That would we do if we meet at 8:00 o'clock?

                13               MR. CHA-@IBLISS: We would have  no  basis  unless

                14  the Committee wished to look over what  it  has  done  and  we

                15  would have a listing of,all the actions  that  we  have  taken

                16  and a showing of the current  levels  annualized,  the  taraot

                17  amount, the request and the actions coming out of this group.

                18               I-le can look at our work product as a whole.

                J!)              DR. MILLER:  Let us finish un.

                20


                21


                22


                231


                24


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    dm 11                                 SOUTII DAKOTA

               2                MR. CTIA-14BLISS: All right, I would then  ask,vou

               3    to turn your attention to South Dakota.
               4                The reviewer there is Mrs. Salazar, staff supporti

               5    by Miss Resnick.

               6                Mrs. Salazar?

     (9)       7                MRS. SALAZAR: In  the  interest  of  movin  along,

               8    I will.try-to shorten this.  I promise not to do as

               9    I did on Texas.


               10               MR. CHMIBLISS:   A little louder, please.

               11               MRS. SALAZAR:   The application is  requesting

               12.  6 continuing activities and  the RAG has 11 of  th em, ith 5

               13   new ones.

               @14              Perhaps it would be better if I start in the back
               15   of the summary that I see as a summary  of  this  application.
               1(;  That the RAG and the staff are obviously addressing the
               ii   peculiar needs of this State,.very large rural area with
               18   limited man and woman manpower and resources in various remote

                    locations.
               20               They propose a consortium  of  educational  insti-

                    tutions and health institutions to very innovative and
               21,
               22   creative approach to South Dakotals health needs.
                                Regionalization of the core of the center concen@.
               23
               24   is what they are proposing, is @iell supported and the region
                    is making every effort to bring supported  activities  to  the   i
               25

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                                                                           458

   dm 12           point of self-sufficiency.

              2                As most of you remember., South Dakota -TUIP pulled

              311  aviay from Nebraska-South Dakota which was the original

              4    planning grant as far back as 1969.  The first program for

              5    South Dakota as a.separate entity was extended through August

              6    of 1972.  It gained operational experience immediately and

              7    submitted its first triennium application effort last year

              8    but because of pending phase out, it was never reviewed;

              9    is that corr6ct?


              10               MR. CHAMBLISS:  That is correct.

              11               MRS. SALAZAR:  It was extended again in March of'

              12   1973 through January of 1974 and approved through June of

              13   this year.

              14               I am telling you this because South Dakota  seems

              15   to have an awful lot of tt
                                            ,Arting and stoppina and yet there

                   is a great deal of continuity through the whole  application,

                   which is amazing.

                               At the time of the staff implementation crisis
              18

              19   this year, a couDle months ago, the region was found to be

              20   viable and energetic and it was certified, I believe it is

                   excellent in its review criteria and procedures.  It naturally
              21
              22   has a great emohasis on rural out reach with a focus on man

                   and woman power development through'the process of  regional-
              23                                  e

                   ization.
              24
                               There is an integrated nrocess with CHP  planning
              25

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                                                                                459



   dm 13            which is very remarkable, in th'at the CHP board is the RAG,

               2    the one and the same body.

                                Manpower training,  the  distribution  and  utiliza-

               4    tion of manpower are primarily important to the region and

               5    these elements are found throughout all  of  the  projects.
               6                I find this proposal a very exciting and well

               7
                    organized Western Plains, no  nonsense  language.  It  sets

               8    forth what it wants to do verv matter of  factly  into  two

               9    general categories of projects.

               10               One,  thos.e that are designed to achieve their

               11   objectives within the 1975 framework of funding and;

               12.              Two, those with interim  RMP  support,  and  I-think

               13   that is very significant that they  specifically  say  this

               14   interim report can be given impetus beyond  175  to  attain

               15   their specific goals or tcvachieve permanent status either

               I(;  independently or under other funding sources.

               17               The staff appears ready to  move  into  new  avenues

               18   of health.resource planning.  There is already good chemistry'

               19   that exists between  the  other  health  agencies.  Coordination

               20   of efforts and cooperation with other agencies is very

               21   apparent in the application.

                                A quick review of the  projects  did  emphasize  the
               22

               23   South Dakota commitment to improving health services that are

                    not now adequately covered. Yet at  the  same  time  the  apdli-
               24

                    cation is realistic, it is very local, it is very regional and
               25

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                                                                                 460



    dm 14       1   in response to the Geographic handicaps and that ver
                                                                             y rugaed

                2   climate.that exists   out there.


                31               The in tandem onera4@-ion of the CHP aqency    is

                4   quite visible in a State of    600,000.   of course the social

                5   and Dolitical and business interrelationships is more apT)aren-0

                6   than in under-nonulated areas.


                -1               The regional medical proaram there is bl        d i,7 th

                8   a capable and dedicated   staff and it has verv enthus'  tic

                9   and energetic support and I believe ongoing continuing

                10  supDort through the University of South Dako4--a.

                11               The application states that this will be augmented

                12, by two Additional nrogram staff nersons who have plannina

                13  and evaluation expertise.  It v7as a little unclear to me why

                14  the a    ication, in the application, whv the Indian 3    nvolve-
                         .Ppl

                15  ment in the corps staff, Aen so.many of their programs are

                    based, have Indian populations, very large Indian populations

                17  in the State and out-reach.  There is no more active involve-

                18  ment of Indians on the staff.  Especially in view of manv

                19  significant Indian problems in South Dakota4
                20               MISS RESNICK:  Staffing with Indian personnel
                21  well, they are  using  their  Indian  outreach  through  their
                22  RAG.  There are four members representing the Indian reservation
                    population and they are taking the service out to the reserva-I
                23  tion in those corps   components, working very closely with the
                ?4
                    Indian area office in Aberdeen. 'It is Vermilion and I think
                25







                                                                              461


     dm 15       1  their resources would be extremely limited.  That is      where

                 2  the program is based.

                 3@i             That is the onlv explanation I can give for it.
                 I
                 4  I think  they take it  out to the reservations rather than try

                 5  to bring an Indian professional in  where  they  have  so  few.

                 6               MRS. SALAZAR:  they have some very talented Indiar

                 7  people in that State and that is why I was wonderin 'why

                 8  they-weren't involved more at the coriDs level.-'
                                 IIISS,RESNICK:-' I think it.comes through only at
                 10 the RAG and they take it  out  to  the  reservation  area  from

                 11 what I can judae.

                 12              MRS. IIYCKOFF:  The staff out there.,  there is other

                 13 area staff.
                 14              MISS RESNICK:,,!rhere is eight components from the
                 15 staff and three or four deal with    Indian reservations,
                 .16 preceptorship, allied health, a summer training program and
                 ii they are very close to the Indian program.
                 18              MRS. TqYCKOFr: I  think  Mrs.  Salazar's  question

                    is, who is  getting  the  jobs?
                 19
                 20              MISS  RESNICK:   Iknow she asked if  there  is  an
                    Indian  person,   professionals on the staff in Vermilion.@ The
                 21
                    answer is "No,"  but  the  only explanation I can give that there
                 22
                 23 are few resources around Vermilion  and  thev  carry  on  their
                 24 activities right on the spot in the Indian reservation areas.
                                 MRS. SALAZAR:  They are used, in my estimate, for





                                                                                 462


      dm 16         instance, are using some Indians   as consultants to come   in
               2    when there are deliberations that involve projects and

               3
                 I  planning for Indians.
                                 It is very important to have  an  Indian  trhere  to

               5    find out if  he wants to be planned for.

               6                 MISS RES14ICK: There are  four  Indians  on  the

               7    RAG and it is through them that they are having the    direct
               8    contact., as-I understand it,  with  the  Indian  reservation

               9    problems.

               10                MRS. IVYCKOFF:.- The,,., do the planning.
               11                MISS RESNICK:  One or two have made certain
                                                                          II
               12.  proposals but thev have come  from  the  Indian  reservation  or

               13   hospital orogran,.
                                 I thought you meant staff.  There   was    there is
               14

                    no Indian staff.
               15

                                 MRS. SALAZAR:  Yes
               17                MISS RESNICK;  They are very much involved.  The
               18   Indian health facilities and programs are very much involved-
               I!)  in the Chair's activities and they  have  asked  for  help  from
               20   the Oahe and the Lewis and  Clark,wherever  they  happen  to  be

               21   close.
               2-@               MRS. SALAZAR:  I don't mean to imply that the
                    program leadership is not energetic and well motivated.
               23                                    e
                                 I-ii.ss RESNICK:  I think thev are actively engaged
               24

                    with them.
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                 1              MRS. SALAZAR
     dm 17                                      The RAG is also verv  strong  and
                 211 active and has organized into several, what is obviously  verv!
                 3! productive committees.

                 4              The Chairman, interestingly  enough  is  an author,

                 5  rancher, farmer.  He is well informed of State    Drobi ms and

                 6  involved in many community and  educational  health  ef forts,
                    which  is probablv one of the reasons in the health education

                 8  community concept.  He is an active facilitator and   I gather

                 9  gets great respect throughout the  entire Stdte:.

                 10             At the same time he is very adequately saccessfull@,

                 11 '-reoresenting all of their interests, of the CHP, as  ell as

                 12. the  MLP.
                 13             MR. THOMPSON: Is he on the  CHP  board  as  well?
                 14             MRS. SALAZAR:  Yes, it is the same board.  Forty-

                 15 one  members.
                 16             MR. THOMPSON: Fifty-one  percent  on  the  board?
                 17             MRS. SALAZAR:  I think it is interesting to note
                 18 that the executive committee of the RAG met six times in the.
                 1.1) last 12 months with almost 100-nercent participation in
                    spite of that rugged winter out there, weather and the climate
                 20

                 21 too.
                 22             They seem to be very proud of the fact that their
                    members also serve without remuneration.
                 23                                  F
                                MISS RESNICK:  They have project consultants who
                 24

                    serve without reimbursement.
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                                                                                464


    dm 18                          Manv of them in this Particular Program4

                2                  MRS. SALAZAR:    Just to wind up,   the highest-

                3    priority'rating   of the RAG   was assigned  to  the   emergency

                4    medical services.    That program   the,y have  is very small  and
                5    they are only asking for    th(@, training efforts, about $50,000

                6    for that.

                7                  I presume that  this  means  that  there  will  be

                8    another. application in emergency medical services ar,ter thev

                9    try this one out.

                                   MISS RESNICK:    They are plannin  to   and Ithev are
                10                                                    9

                11   also going to come in here     again in July 1.

                12,                The thrust is manpower development     again.

                13                 MRS. SALAZAR:  That is the next one.  The two

                14   health  committee based centers.

                                   I believe basied-on the r)ast experience of South

                     Dakota, that the goals and program      Are achievable and the

                     current momentum of the program indicates that thev have a
                17
                     fairly good chance  I believe, a fairlv good chance of settina
                18                        01                                              -
                     out what they set out to do.  Laudable, I think the CHP joint

                     efforts are corlmendable.
                20
                21                 I think that their efforts toward trying to bring
                     Indian populations more actively into the program also are
                22
                23   very commendable efforts  and  I  recommend  --  may  I  make  a
                24   recommendation, Mr. Chairman?
                                   MR. CHAMBLISS:  You'may indeed, Mrs. Salazar.
                25

                IMP




                                                                             4b@



       dm 19                    MRS. SALAZAR:  That we approve this application

               2    as requested.

                                DR. SCHERLIS: That would  exceed  their  target  by i

               4    $531,000 by $198,000.

               5                MRS. SALAZAR:  Yes.

               6                DR. MILLER:  Being  a neighbor and havinc  had

               7    much to do with the Texas, I thought it might be worthwhile

               8    to say -a little what 1 know about the South Dakota  program.

               9    and its relationships.

               10               As it started-out with South  Dakota  and  Nebraska


              .11   together, incidentally, the reason  Northland  was  mentioned
                                                                        I I
               12.  was before I ever came on board our  big  medical-centers  in

              -13   Minnesota figured that we would have the Dakotas in Montana

               14   and a good deal of the upper Midwest and so I have  had  a  lot

               15   to do with them    it is,-a different story.

                                But they have, they couldn't join with North

               17   Dakota because thev never get along so they joined with

               18   Nebraska, but they couldn't get along  with  Nebraska  either

               19   because Nebraska tried to dominate them.  So thev are impeding

               20   movements which could have gotten started  in  South  Dakota.

               21   But then Dr. Haves, who was the South Dakota associated'
               22   coordinator of the South Dakota-Nebraska  program  moved,  left
               23   the PI.IP to become Commissioner of Health in the State and
                                                    I.
                    although I don't know, I suppose he is "- is he?
               24

                                14ISS RESNICK:  Yes, very actively involved.
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                                                                                -466


      dm 20                       DR. MILLER:  He is completely attuned to this

                2
                     whole movement.  And Mr. Brecken is     an  outstanding   leader,

                3    staff leader and so forth, so that actually this re ion would

                4
                     if it had gotten going sooner, would have had the p tential

                5    to Achieve much further than it has now and we wouldn't have

                6    this limited target estimate which is based on this very

                7    late start.-

                8
                                         -NIBLISS:  All right.
                                  MR. CH@


                9                 MISS RESNICK:  The target estimate     is $571,000.

                10   I am sorry the y ellow sheet was not updated.

    (10)        11                MR. CHA.MBLISS:  We have a recommended fund of

               .12   $571,000.  The requested level of $724,417.

               .13                I don't have a motion vet to that effect.

                14                MRS. SALAZAR,;  I said it was requested.

                15                MRS. T,7YCKOFF:  $729,714?

                                  MR. CHA!-IBLISS:  Would vou restate your motion

                17   since there  is some question  about  which  figure  vou  had  in

                18   mind?

                19                The targeted figure?
                20                MRS.  SALAZAR:  $729,714  as  requested.   That   is

                21   my motion.

                                  DR. VAUN:  I will second it.
                22
                23                MR. CHA-MBLISS:  It has   been  moved  and  seconded
                24   that the level for South Dakota be     'Set at the requested amount,
                     of  $729,@liz.
                25




                                                                                 467



    dm 21        1               Is there a discussion on the    motion?

                 2               DR. SCHEI@IS:    Yes.  At the  risk of  antagonizing

                 311 people who like m-,?--elf are hungr,,,, there are two sv-----@

                 4  programs that  I  have  question  about.

                 5               One is  the  PSRO  activitv of $100 000.

                 6               I was wondering if that is what we really want to

                 7  support?

                 8               The next question relates to the medical genetics

                 9  program which is  a  total  of  $46,000.

                 10              As  I-read  their  nrogram, which 'isa verylambitious

                 11 one, in States  many  times  that  size, I was wondering whether

                 12, that is one of the prime needs for the State of South Dakota.

                                 IIISS RESNICK:  They reduce the number of possible
                 13

                 14 trainees and this is tied to the medical school, a po    int

                    which I think Mrs. Salaza@failed to make.  A four-year
                 15

                 16 medical school  recently approved by the State legislature and

                 -17 now going up for approval'bv the National Association.

                                 We met this professor and doctor in genetics, she,
                 18

                 19 has had support from a number of sources including a little

                    bit from @NIP last year to get  started on this genetics
                 20
                 21 program.  She is looking for other funds and at the moment
                 22 nothing is coming through.. They think the States will support
                 23 it within a  year.
                 24              It is for this reason that they would like very
                    much to have  this continued and not lose what she has already
                 25
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                                                                           4'o- 8


    dm 22          accomplished and she is getting.a lot of sunnort from  the

               2   medical Profession.


               3
                               MR. CHX,4BLI8S:  Ilhat is the purvose of the

               4   project per se?

               5               MISS RESNICK:  It is a primary care, re lly,

               6   activity with a referral, a resource for referral of patients

               7   to professionals and to specialists.

               8               MR. CHAJIBLISS: That are they looking for?

               9               MISS RESNICK:  They are starting with
               10              MR. CII@'%IBLISS: All the chromosomes where you

               11  screen for genetics are abnormal?

               3.2.            DR. SCHERLIS:  I think it is one of the programs

              .13  in looking at many States, I would put as not high on a
               14  priority listing particularly as one looks at the needs of

               15  South Dakota.

                               I am not addressing myself to the needs of Dr.,

                   Virginia Johnson who is in charge of genetics at that school.
               18  I am trying to look at it from the point of view of what are
               19  some higher Driorities in any of the projects that they

                   submitted.
               20
               21              This is one reason that I wouldn't be able to
                   support the motion because I would not particularly attach
               22
               23  significant priority to that.  X4hat was their rating of

                   that?
               24
                               MISS RESNICK:  The ftAO rated that among the ton
               25




                                                                              469


    dm 23           three.  And'it had a lot of visibility.

               2                DR. SCHERLIS:  I don'.t,know what they are going

               3 ti to do with this when they get it.

               4                MRS. IIYCKOFF:  We hire all their products from

               5    California.  We will hire them all  in California.

               6                You needn't worry about  whether they need them  in,

               7    South Dakota.  Ile need them in California so-there  is a place


               8    for them.

               9                MR. THOMPSON:  I would remind you that California

              10    is putting in for $8,017,000 and let them have their own

              11    -genetics.

              12                MR. CH;V.IBLISS:  There has always been some policy

              .13   questions about RMP support in this whole area of  aenetics,

              14    including sickle cell and the like.

              15                I probed a bit just to get a chance to say that.

                    We have, as a matter of policy, suggested that projects

                    dealina  with genetics and sickle cell should go to the NIH

              18    for  support.
              19                We will probably, althouah the committee has.

                    acted on some other genetic applications, there have been
              20

                    one or two in some of the packages, we will probably look at
              21@
              22    those before they, before they are recommended for funds.
              23                DR. SCHERLIS:  Comment on the PSRO.
              24                MISS RESNICK:  It is identified as PSRO by our
                    old options.. It is actually a continuing education activity
              25

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    dm24            which thev started last spring at a very     low level and  it

                2   is to develop guidelines, I guess,,and examine criteria

                    which will be essentially'a base for the PSRO organization

                4   which the State eventually hopes to organize.

                5                MR. CHA,?,IBLISS:  The other policy issue, that is

                6   there are funds from other sources other than     R14P. That is


                7   for strict PSRO.


                8                MISS  RESNICK:  it is not a

                9                DR. SCIIERLIS:  I will differ with you-for one

                10  reason.   As I read their description of that project, it

                11  goes along the lines of saying the Federal Government will

                12,  be funding sometime in the near future.

                13               Vile are going to be geared un to ask for the

                14  funds when they come out.,/
                15               MR. CHAI-%IBLISS:  Yes, pure and simple.

                                 DR. SCIIE'RLIS:  Ur) to the present time --
                16

                                 MISS RESNICK:   It is going to be a medical
                17

                    research foundation eventually and I think this is to enable
                18
                19  it to get off the ground.
                20               But I don't get the impression       we have to

                    restudy it.
                21
                                 DR. SCIIERLIS:  A minimum of 25 percent of oractic-
                9-?                                   e
                  I ina .11-ID's to soonsor for this T)rogram as it goes throuah.
                21 1   -                            -                         -
                                 MRS. SALAZAR:  I   get,the feeling that since the
                24
                    grant of the project is directed by the medical association,








    dm2 5      1   it seems to me that it is kind of a selling job.
               2                MR. THOMPSON:  Let them sell themselves   @or,

               3 1 PSPO.

               4                MR. CHA.NIBLISS: We do 4ave prohibitions  a  nst

               5   directlv funding operational activities in a PSRO.       would

               6   hone the committee would  take  that  into  consideratio

               7                DR..SCIIERLIS: Mav I suggest  $100,000  ofF  the

                   suggested level.  That we don't have to specifv   that it be
               8

               9   reduced as a matter of policy.

               10               MRS. SALAZAR:  I feel that there is  a  kind  of

               11  schizophrenia here because  we have  done  some  similar  PSRO
               12  activities in regions that  we have kind  of  glossed  over.

                                MR. THOMPSON:  Not today.
               1 3
               14               DR. VAUN: Apart from the  PSRO,  I  don't  hear
                   anythina in  there that tellis me there is going to be an
               15
               1(; operational  PSRO.  This is develonmental PSRO.
               17               There has been a lot more than 40,000 that has
               18  slipped through on PSRO.  As far as genetics, it would apnear
                   to me if there is no genetic facilitv  within  the  State  of
               19
                   South Dakotai then I don't think establishing one in a medical
               20
               21  school, and the only medical school,  is  something  that  we
                   ought to turn down.  With,an  Indian  population  like  that,
               22
                   there is probably some genetic  counseling  that  should  be
               23
                   going on and if there is no.other g@netic counseling in the
               24
                   State, and my guess is there is hot, I would be awfully
               25





                                                                             472


    dm 26          hesitant to turn this down.

               2                Tlaybe some advice should go to the  department

               3 i heads that they should try to conceal   this money in some
               4   other way in other departments other than to try to@itrain

               5   20 technologists.

               6                I think the money is worthwhile.

               7                DR. SCHERLIS: I.am going to  make  a  comment  which

               8   may be_pertinent or not Pertinent.  I really think     e get  the

                   States that are asking for small sums of monev.-, out  tendencv
               9

               10  is to really use what is.a double  standard  in  evaluation  and
               11  when a State like South Dakota or North Dakota or Oklahoma
                                                                        . I         1
               12. come in and requests are made, our t(--ndencv is to say the- are
               13  only 4skinq for small sums anyway.  Let us   ask  for  additional

               14  sums.

                                I would think@hat other  criteria,  that  we  would
               15

                   question individual projects that they are doing, working,

                   if this is the best way for the State to go in its overall
               17

                   program and strongly urge that some individuals ao there to
               18
               19  the site visit to see what they are doing.
               20               I have never approved the idea.of  funds  from  TIP
               21. going to medical schools unless there were strong needs
               22  expressed by other segments, for these  services,  and  I  think
                   to use funds for that ourpose, I would put  it  at  a  subsidiary
               2t3

                   level.
               24
               25               I think to take a p@ogram which is now  at  a  level

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    dm 27           of, let's see, $428,000 and to talk in terms of their

                 2
                    handling $300,000 more, is proportionately a large      differ-

                 3
                    ence.


                 4
                                 Novi, I would  like South Dakota  to  be  ab] e  to

                 5  utilize funds of a  much  larger  nature.  But  I  would  have

                 6  hoped more Droductively  than  this.  Even  if  we  reduce  it

                 7  by $100,000, they are still getting over $100,000 over the

                 8  targeted figure.

                 9               I don't know if this is the wisest    use that we


                 10 can recommend for it.

                 11              MISS RESNICK:   Their base  is  also  a  planIning base.
                 12. Unlike the other  orograms  they  were  the  onlv  plannin g program.,

                 13 that is olanning status; and they just became     operational.

                 14 It was a fact of life in the calendar.


                 15              So that base  is'a  little  bit  unrealistic  but

                 16 they seem to indicate  that  they  could  use  the  additional

                 17 amounts.

                 18              DR. SCHERLIS:  I would rather thev put it in to

                 19 developmental or planning than into projects which they will

                    have very little to do i-iith.
                 20

                 21              DR. WHITE:  I would like to voice a difference     of

                    oninion.
                 22

                                 Since we are second-quessing what is best for
                 23

                    South   Dakota here in Washington, D.C. -- I am not through
                 24
                 5  we have heard  from both primary reviewer and someone who is
                 2



                                                                                 474



    dm 28      1    familiar with the.,rngion, that-this is a quality program

               2    and would have been farther along if not for certain political.

               3!   problems.

               4                 We have in the nast two days reviewed other

               5    programs,granted them  what  they  have  requested.  Sometimes

               6    it has been less or more than the target.

               7                I can look at  consultants  for  hc;spital-medical

               8    training units.  Again, I don't  know if that is appropriate,
               9    but I am not going to  second-guess  them.  They  know  better

               10   than I do what serves their purpose.

               11               DR. MILLER:  Just one comment.  The   comment that

               12   has been made about action with regard to these, I drew the

               13   analogy to affirmative action and I think we do have a double

               14   standard.  We want to support the have-not's.  It is an
                    affirmative action program.. Reverse Drejudice, if you like.
               15

                                DR. VAUN:  Question.


                                MR. CHNIBLISS:  Those  in favor of the motion of
               18   funding South Dakota at the requested level of $.729,417,
               19   please let it be known by the usual sign of voting.

                                (Chorus of "ayes.")
               20

                               MR. CH2VIBLISS:  Those opposed.>
               21

                                (No.)
               22
               23              MR. CHMIBLISS:  There   is, one in opposition,  Mr.
                    Thompson
               24
                               It is  approved.
               25

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   dm 29                             TENNESSEE MID -SOUTH


               2               MR. CHA-PIBLISS:  The last one for review is


               3   Tennessee Mid-South.  The reviewers are Mrs. @7yckoff and

               4   Dr. Miller with Mrs. Kyttle supporting staff.

               5               MRS. IIYCKOFF: This is a request for  $2,282,972

               6   which is 72 percent of the target of which $370,000 is for

               7   program staff and $1,094,000 is for 18 continuing activities

               8   and $81.8,000 is for 21 new activities.

               9               The present staff consists of 12 total, and

                   proposed staff is increased to 18 with 2 added  professional

                   and 4 for support staff.

               12,.            The former staff was approximately 36.  Their

               13  present annualized rate is $1.5 million now.

               14              The Tennessee Mid-South @IP coordinator is Dr.
               15  Richard Cannon, who has behn on duty as such since last-

                   September, 100 percent of the time; but has been in the  RMP


                   since 1968.

               18              Ile came on board when Dr. Teschan left.
               19              Perhaps we ought to have a little background  on
               20  what happened there. Dr. Teschan had a difference of opinion
               21  with the grantee and technically 1 guess was fired by the

                   grantee.  He is a Vanderbilt Medical School man who has tenure
               22

                   and is still there in Vanderbilt,.
               23
                               The new man, Dr. Richard Cannon, the coordinator,
               24
                   is also a Vanderbilt man with tenure. The big  problem  that
               25


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                     arose w
    dm 30                    as the communication of  this  P-1@4P  by  Vanderbilt.  It

                2    was very -- the board, the RAG was regarded by Vanderbilt

                3
                     as its creature and they @,7ei7en't about to let go until there       1

                4    was some  pretty strong urging    from  T@;IP that this had to  be

                5    more of a  tripar4l-ite-type  program  with  the  RAG  independent

                6    of Vanderbilt and with the coordinator independent.


                7                 So there was a big paroxysm and I      think the  R@IP

                8    went down there and gave  the  parties  a  Dutch  uncle,  talk  and

                9    the act, the results were described in      the report  when   the

                10   recent -- this report says on September 9, 1973 in a

                11   magnificent  maneuver  of  Parliamentary  procedure,   the   RAG

                12.  dissolved itself,  reorganized  a  new  RAG  and  adopted  new  bv-

                13   laws,,all in the same meeting.

                14                They formed  a  smaller  RAG  of  36  members  with

                15   broader representation limited to one three-year term and

                16   elected  an  executive  committee  with   broader   representation.

                17   And the grantee responsibilities were closely defined.

                18                This was the real Droblem with trying to get all

                                                                             ce.
                     of these people and organizations in the right Dla

                20                The new chairman is a University of Tennessee
                21   man, Dr. Cannon, and they have on it the president of the

                     university at the  South,  he  is  the  vice  chairman,  of  the
                22

                     University of the South at Sewanee.  I was not able to identif@
                23

                     much more than three consumers or four consumers that really,
                24
                25   if you can call  them  consumers  on  that  board,  all  the  rest

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                                                                                477


     DM31      1    providers, so  in a sense it has not been a very great chanae

               2    in the character of the board.

               3                Their past performance has been good in-a sense,

               4    they have carried out their five priorities,   access, regionall-

               5    zation of health services and the sharing of   scarce resources

               6    high quality of health care at reasonable cost; community-basdd

               7    health manpower consortium concept; and the promotion of more

               8    effective utilization of health care resources.  These are.


               9    the principal goals.

                                In the past two years they funded 68    separate

               11   activities totaling $2,246,165 as follows:

               12               Primary health care and emergency medical

               13   service, 15 projects, $443,629,.using for example nurse

               14   clinician and nurse Practitioner primarily in rural and urban

               15   disadvantaged areas.
               1(;              They have launched seven emergency medical

               17   service projects.  $173,241 on that.
               18               They spent $447,753 in new projects such as the

                    nurse mid-wife teleconference program.

               20               They have spent $414,392 on secondary care.
               21-  Seventeen projects in hypertension,  Icidney disease with
              @22   special emphasis on dialvsis and organ-donor procurement.
                                They have had five projects of $560,264 in
               23
               24   strengthening of quality assurance efforts.
                                They have done regionalization, five projects,
               25






                                                                               478

     dm32         1  $206,886.
                  2               For example high risk new borns to the medical

                  li 14 centers for coTnp
                                      rehensive care.

                  4               They summarize all this by saying .they have taken
                  5  care  of 634,681 iDeople  --  634,681  neoDle  received  emergency
                  6  service or aDnroved access to Drinary    care and 626,178 Deonle-
                  7  received secondary  or tertiary  care.   And  758  newlv  trained

                  8  health personnel.
                  9               They take all of the credit for   the R-.IP, which
                  10 I guess is legitimate in telling the story which they did.
                  11              The budget now in the application, 49,nercent is
                     budgeted for continuation  activities  and  37  percent  for  new
                  12.
                  13 projects and 14 percent for staf
                  14              They give     well, I don't know, it is getting
                     kind of late, I don't knots/ how much you want of this.  There
                  15
                     are eight new Drojects, six  of  these  relate  to  rural  appli-

                     cation health districts.
                  17
                  18              One concerns a disadvantaged area.  There are
                     eight new oro3ects in secondary care and regionalization.
                  19
                     They focus on cancer, hypertension, renal dialysis, venereal
                  20
                     disease, pneumoconiosis surveillance and rehabilitation.
                  21
                     There is excellent distribution of projects throughout their

                  23 region.
                                  Now, we have of-the seven continuing projects,
                  24
                     two have received State-wide attention.  These projects, one
                  25


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    dm 33           at the University of Tennessee memorial Research Center and
               2    Hospital, Knoxville; the other at Childrenis Hosnit   if

               3
                 il Vanderbilt medical Center, Nashville, are concerned@with a
               4    coordinated regional high-risk, new  born service.  The
               5    service provides transportation in  specially equipped
               6    vehicles, of high-risk new bornis to respective medi,6al

               7    centers for intensive secondary care.  These'two pro'ects,
                                                   .A

               8    when combined with a similar project funded by Memnh   s PIIP,

               9    provide the State with a'netN%,ork of high ri8k,;nev7 brn

               lo   secondary care.

                                There is other Projects that  they emphasize is

               12,  very important in the monitoring of hiah  risk obstetrical

               -13  Patients at Vanderbilt Universitv Hospital v7hich is being

               14   expanded from 5 to 10 hospitals in the recTion.

                               Then they have 5 projects concerning the develon-
               15


                    ment of health manpower.


               17              One relates to the maintenance man in the small

                    community hospital and Provides in-service training in basic

               19   biomedical engineering and safety procedures.

               20              Another under the.direction of the Tennessee
               21   Hospital Association coordinates health manpower needs in the
               22   region with production by education and includes the State
               23   Commissioner of Higher Education's Office in the program's

                    direction.
               24
                               An innovative Program submitted by Aquinas Junior
               25

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   dm 34        1   College,  Nashville,  attacks  the problem of hospital trained

                2   allied health  personnel,  for  example  radiology  technologists,

                3   respiratory therapists, dental  hygienists  who  desire  to  move

                4   uD the career ladder  by  taking  additional  educational  courses

                5   and receiving the  associate degree.

                6                This is a planned work-study program which can

                7   be extended  over a Period of several vears.


                8                I would  try to.condense this.

                9                In July they are coming in for a total       let

                10  me see,  $658,127 in  additi-on.  There will be $189,746@'in

                11  primary  care, $130,774 in secondary  care;  $88,463  in  manpower

                12.. development and $249,144 in quality  of  care  and  cost  contain-

                13  ment.

                14               So that will bring them over the 105 I think it

                15  is percent limit.

                                 I have  been  throuqh this enormous  number  of  small

                17  projects and I  must  say,  having made a site visit there, I

                    really was very  thrilled  to  see the development of some of
                18

                19  these projects  that  started  out as just a little  urge  on  the
                20  part of a small ar.ouD  of  little students or some little

                    effort to get something going,, esneciallv out in the Apnalachihn
                21
                    Region where the needs are so great and the terrain is so
                22

                    difficult.
                23
                24               I think they have done a  job  in  cooperation  with
                25  the Appalachian Regional  Commission  and  with  that  incredible





                                                                                 481



                                                                       4-
      dm 35         health organization that they have up  there,  tha.  is  reallv

                2
                    remarkable and I do give them credit and I would    like to give

                3   the students of Vanderbilt credit  for  keeping  the  nressure

                4   on and getting these things  done,  really  remarkable  things.

                5   The faculty has cooperated, sometimes reluctantly but has

                6   cooperated to make these things become a reality.

                7               There were only two projects that I raised a

                8   question about.  One was a project in kidney health education

                9   in which they wanted to make a film for home dialvsis.     They

               10   wanted $125,000 for this and it seemed to me that there     are

               11   plenty of films on home dialysis that have been made.  I    know

               12.  we have made some in California and I think   there  have  been

               13   quite,a few films that have been made on  this  and  I  wonder

               14   if this was a legitimate expenditure  and  there  was  $24,000

               15   for a program on life ad'@@@ment to  cancer  which  seemed  to

               I(;  me that they could refer to  the  national  cancer  situation,

               17   which those two would make a total of.$149,000.

               18               Those are the ones that  I  thought  perhaps  ought

               19   to be either deducted or I would like to hear some more

               20   discussion on these before making a final recommendation.

               21               MR. Cl@@IBLISS:  All right.

               22               Dr. Miller.

               23               DR. MILLER:   I have verv little to add.    I agree

                    almost entirely with what she has said.
               24
               25               This is a very needy region, there have   been

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                                                                                482


    dm36       1    problems.  I think a lot of their projects look like passive

               2    funding enrichment for organizations to do things that      are
                                                                           1
               3    or should be doing anyway, but nevertheless the needs are

               4    great and I share her views.

               5                 DR. 14cPHEDRAN:  Are the two projects th t you

               6    question, do vou think that they are W-,IP guidelines


                                 MRS. liYCKOF
               7                             F:  The kidney educational   iml I

               8    -think someone ought to take a look at that and see if it is

               9    legitimate 4.- pe of film.
                                 y
               10                MR.  THOMPSON:   Ther.e is no  reason,  unless  thev
               11   want  to  put it to country music or something.

               12.               MRS. L@IYCKOFF- Life adjustment  cancer,  I  just-

               13   think that  perhaps
               14                MR. VAN WINKLE:  There are certainly grant ranage-i

               15   ment regulations that they have to  comply  with  in  making  a

               1(;  film. If they meet them  there  is  nothing  to  preclude  then

               17   from makina the film.

               18                But they do have to meet certain regulations.

               19                MR. CIIXIBLISS: There is an O!..IB clearance  that

               20   they have   to

               21                MR. THOMPSON:  Tell them to buy one or rent one.

                                 MRS. '@7YCKOFF:' Yes. I would  like  to  recommend
               22
               2tl  that their  budaet be set at $2,133,000,  a  cut  of  $150,000.
               24   $2,133,972,  which is '?150,000 below'the amount that they
               25   requested and it is even belong the 73 percent of their target.
                                              I





                                                                              483


                                                             oriing back.
     dm37        I             DR. SCHERLIS:  They will be c

                 2             MISS KYTTLE:  They requested $2,283,000.

                 3             MRS. WYCKOFF:  This is $2 million

                 4             MR. CH)VIIIBLISS:  There is a motion on the floor.

                 5             DR. MILLER:  I will second it.

                 6             MR. CH)V,,IBLISS: Is there a  discussion?


                 7             Dr. White?

                 8             DR. WHITE:  I have been laboring  on the  question

                 9 of ignorance. Before Dr. Scherlis says I know  it,  I  thought
                                                                      i
                 10 there was some formula in determining  this  taraet.

                 11            MR. THOMPSON:  There is.  It is 140 percent

                 12, divided, assigned out by the average dailv budaet for the

                 13 past 15 vears.
                 14            DR. WHITE:  Why would theirs be $3 million?  That

                 15 is 200  percent.
                 16            MR. THOMPSON: But thev went back and  p  cked  un.
                 17            DR. SCHERLIS:  Tell us about that bookkeeping,

                 is will vou?
                 19            MRS. WYCKOFF:  That  is an odd thing.  It is

                   $3 million.
                 20
                 21.           MISS KYTTLE:  I don't understand their target
                   level.  I didn't set it or commute it.
                 22
                               !.IRS. WYCKOFF:  I used what was on the yellow
                 231-                              e
                 i sheet.
                 24
                               MR. TH014PSON:  They took the oresent mix of
                 25

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                                                                                   484

     dm38        I   monies and got how much of  the  total  part  they  are  g@ting

                 2   now and then assigned that as a percent.

                 3                MR.:CHMIBLIS:  There must be an error there.


                 4   There must be an error there.


                 5                DR. MILLER:   It must be $2,718,000.

                 6                MR. CHIU-IBLISS: This is a computer error as

                 7   @opposed to being a


                 8                MRS. TIYCKOFF:  Human error.


                 9                MR. VAN WINKLE:  If you look at

               10                 DR. SCIIERLIS:  It should be  about  $2.5   million.


               11                 DR. MILLER:  Yes.

               12,'               MR. CIlAiMBLISS:  Giving us 40 percent of what the

                     annualized   level should be.
               13

               14                 MISS KYTTLE:  I think   the annualized level    is

               15    wrong.  When   the 6.9  was  distributed,  Tennessee  Mid  South

                     didn't come in for any of it  because  it  did  not  mee-t the

               17    logical base on which the 6.9 formula was developed.

               18                 Well, when the money  stayed  out  there  in  escrow

                     for so long and was not permitted  to  be  used  for  the  reason

                     it was Drorated, the  lonaer it  stayed  out  there,  the  less
               20
               21    rationale there was to,the base and so it    was    redistributed

                     and Tennessee ',,-lid South came in for almost $200,000 in the
               29

                     last days of its grant  year  that"I  don't  think  is  reflected
               23
               24    in its current annualized level of funding.

                                  MR. CIIAMBLISS:  I would suggest
               25






                                                                                485


   dm 39        1                DR. SCIIERLIS:, I always feel that you are so

                2   clear and that I should understand you, but somewhere along

                3   the lineiI know you are right, but

                4                MR. CHP-T,4BLISS:  Let me suggest to the committee

                5   if you  have  discomfo.rt herei we can clear this issu6 uD

                6   overnight and present this to you in the morning.

                7                There is a motion on the floor that has@@been


                8   properlv moved and seconded.

                9                I am at a loss to     in light of this., low we

               10   should dispose of it.

               11                DR. VAUN:  That fiqure is related   to thei request

               12,  and not the target date.  So why don't we go ahead and vote.

               13   Then if there is a gross error

               14                MR. CHA-MBLISS:  If the committee  is comfortable

                    with that, we will certainly rest)ect vour wishes then.
               15

                                 Shall I call for the question?

                                 DR. SCHERLIS:  Question.
               17

               18                MR. CHP2@IBLISS:  Those in favor?
               1!)               (Chorus of "ayes.")

                                 MR. CHI@IBLISS:  Those op osed?
               20                                         p
               21                (No response.)

                                 MR. CHMIBLISS:-  The level has been recommended
               22
                    for the Tennessee Mid-South Regi"onal Program at $2,133,952.
               2:3
               24                DR. l@IOIGIIT:  I would like to pursue this a little
                    further if I may, Mr. Chairman.
               25





                                                                                486


    DM 40      1                 It is important to me because when I was not able

               2    to make a judgment in any other way  I figured it was     no

               3    worse or better than ten others that we looked at.  Thinking

               4    that somehow or another there seems to be some.disparities

               5    on whether our decision-making was based on error in the

               6    last two days.

               7                 MRS. WYCKOFF: It  is  a  very  disturbing  thought.

               8                 DR. MILLER:  Their targeted funds is more than

               9    they asked for.  We never gave anybody more than     they  asked

                    for.

                                 DR'. WHITE:  Their target funds may have been    in


               12,  error.


               13                MR. THOMPSON:  Whenever we did that, the way

               14                MR. CHP-MBLISS: Is there  further  concern  on  the

               15   part of the  panel?

                                 DR. MILLER:  What time do we meet in the morning?

               17                MR. CH@IBLISS:  Let me close out by saying one or

               18   two things here.

               1!)               First, you have handled your charge in a very

                    commendable  war,-.
               20

               21                I think the committee should know that Miss Kyttle
               22   who has transferred from IIMP to the Health Services Administra--
               23   tion Division of Review, viill no,longer be with P24P.  As a

                    matter of fact, she has already transferred and I would like
               24

                    to take note of the great work that she has done over the
               25

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                                                                           487

               I    vears as a member of the RMP staff.
     dm4l
               2'               DR. SCIIERLIS:  I.would do nothing other than to

               3    second that,

               4                MR. CHA14BLISS: I would like the committee also
              \5    to note the  fact that Mrs. Edith Leventhal, who has been over
               6    the years one  of the strong workers behind the scenes, has
               7    given me  support here today and yesterday and has provided
                   RMP with a good  amount Of staff support over the years..
               9                I would like you simply to note her participation
              10               I would like to sall), that Iknow I express on
              11   the part of Dr. Paul and the Health Resources Administration
                   and the Bureau of Health Resources Development for the sunnort
              12,

              13   of and participation of this panel, and I would say that vou
              14   have been very patient in tackling this job.

                               Finally, I think you would like to know that
                   the other panel is still in the process of completing its

              17               DR. PAHL:  They just started their last one a
              18  minute ago.   This panel won.

                               MR. CIIMIBLISS:  It has been agreed that we would
              19

              20  meet at 9:30 in the morning in the joint session in this

              21  room.

                              DR. PAHL:  The arthritis meeting is meeting at
              22

                  8:00 o'clock.
              2tl

              24              DR. t.IcPHEDRM@:  How long do you expect that meetinc
              25  is going to take?




                                                                               488


    dm 42       1                MR. CIIX,-IBLISS:  l,qould you have an estimate on

                2   that, Dr. Pahl?

                3                DR. PAHL:  I would guess it would perhaps onlv

                4   be for an hour and a half because the purpose of the    meeting

                5   is more basically the two groups and chairmen to see    that

                6   similar topics have been handled equitably and to trv    to

                7   grouo the applications into a,master sort of three-leveled

                8   tier, jtst these seem to be above average and these are good

                9   solid ones and these are perhaps weaker,, but nonetheless-
               10   satisfactory, but not'trv to do anything within the grou,
                                                                               ps

               11   but this will be of help as we go to Council after this

               12,  lengthy period of absence and make. sure that similar problems

               13   have been handled equitably between the two panels.

               14               I would see perhaps mid morning, get together at

               15   9:00 o'clock, it seems to me that vou ought to accomplish

                    that in that period.
               I(;

               17               The word that I  received from the  other panel

               18   would be 9:30 as opposed to  9:00 o'clock.

               1!)              DR. PAHL:  I-Ihy don't we trv to head for a taraet
                                                            I                   I

               20   period of around 11:00, if 9:30 is the time for the other

                    group?
               21

                               MR. Cll2U4BLISS:  Do you feel that this panel should
               22

               23   meet for any further review activity in the morning?'

                               DR. PAHL:  Have you clustered your own aoplication@.
               24

                    into three grouDs?
               25

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