Transcript of Proceedings


                          DEPARTMENT OF HEALTH, EDUCATION AND WELFARE



                                                  RI,4PS IZP@VIE@el CO@IMIT'll,]E MEETING






















                                                                        r,ockvii@.1e, Maryland.

                                                                        Friday,, 22 September 1972


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  i 7149          1       DEPART@IENT OF HEALTH, EDUCATION, AND WELFARE
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                  4               RMPS  REVIEW CO@IMITTEE MEETING

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                                                   Conference Rooni G-11
                121                                Parklawii Building
                                                   Rockville, @ll.arvla,-id

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                                                   Friday, 22 September 1972

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                              I                                       C 0 N T E N T.S
         CR 7149
         CRAIG:               2 AREA:                                                                                                PAGE
         paw
                              3 Mississippi                                                                                           3

                              4 Missouri                                                                                              52

                              5 New Mexico                                                                                            95
                              6 Northern New England                                                                                  139
                              7 Texas                                                                                                 157

                              8 Indiana                                                                                               193
                              9 Memphis                                                                                               210




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                                                                                     3
                                                        D i N G S

   CR 7149                     DR.  SCHMIDT:  I  think  probably  we   should   begin.
                 2 We thought that the order of the day would be to begin with
     1
      a          3 Mississippi, which is the last of the demonstration presentations

                 4 for the committee and then stop and talk a little bit about the

                 5 visual aids and the sources of information coming to the

                 6 committee.  Then  go  on  to  a  report  of  the  Missouri  Site  Visit

                 7 and kind of a status report on Missouri.  Them move to my state,

                 8 New  L@lexico,  northern  New  England,  Texas,  Indiana  and  Memphis,

                 9 in  that  order,  finishing  before  coffee  break   this   morning.

                lu             So we will begin then with Mississippi.  Dr. liess.

                11             DR.  HESS:  Thank  you.  I  would  like  to  begin  just
                12 lby giving  particularly  for  the  hew  committee  members  a   little
                13 bit  of  background  on  Mississippi  so  that  you  understand   a

                14 li'--tle bit better what some of the specifics are in our discus-

                15 i sion today.
                16             At  the  April  1971  Review  Committee  meeting,   when

                17 I,,iississippi P14P was reviewed, a number of us were very con-
                18 ceriied because of a program which did not seem to be functioning
                19 Very  effectively  in  a  region  which  perhaps  has  some  of  the
                20 greatest  needs  of  any  region  in  the  country  by  almost  anv
                21 health or economic .-',Iiidex you  want  to  pick.  Mississippi  is  at

                                                                                4-
                   i-hp wnrq@  eantq nf 4-'hm             4- li 4 4- 1, - PC - C CkFl @CA J.

                23 whether it be   physician T3opulation ratio,    whether i-t be neo-
                24 natal mortality, you name it, Mississippi       is at or near -the
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                                                                              4



                             We were very much concerned that rather than

  Reba 2        2 unduly punishing a region, that this region above all else

                3 needed some assistance in order to get itself reorganized to

                4 qualify for funding more appropriate to the    needs  of  the  people
                5 of the region. As a result of that deliberation, an assistance
                6 site visit was scheduled in September of 1971. And a number of

                7 staff and consultants visited the region.

                8            We had two days of frank  --  listening  to  problems  and

                9 discussion.and feedback to the staff, the coordinator, and to

               IV s e I e c t L@- 'Llie members of Lhe R7tG. @id tilde, we re.L-Liciiej Lo -wai-L cti-iLl
               11 see what happened.  Some of us who were on that September site
               12 Ivisit returned again to see what had occurred.
               13            We might just indicate for you some of the -- I
               14 haven't had a chance to look at theih, some of the recommendations
               15 that were made at that September site visit.  Concerning the
               16 regional advisory group,  we  recommended  very  strongly  that  they
               17 review th&ir committee structure and reorganize it more
               18 in keeping with the new directions in which RMP was moving.
               19            At that time it was largely categorical in its
               20 orientation.  And we specifically recommended that they deal
               21 with,questions of planning and evaluation and help the '@ZAG

                  become  mote  in-@iTnatt-l-v  i.n@7olvc-.rl  iri  i-h,-c;t-

                             The core  staff  was.not  functioning  particularly  well.
               23
               24 one of the problems was.they were quartered in a variety o

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           #1  I  and this Dhysical separation did lead to some fragmentation

  Reba 3       2  and lack of coordination of activities.

               3             And we also recognized that there was some need

               4  for better communication and stronger leadership thrust

               5  from the coordinator.  We also recommended that they consider

               6  setting back their time deadlines for their requesting a re-

               7  vision in the time for application in order to allow them more

               8  time to make the adjustments.which we recommended.

               9             We offered the assistance of the regional office

                     At'Lai-ILa,    staff in Washington ana pointed out they had
               IV.

               11 a good deal of work to do. The items that we will report on

               12 and discuss today then deal to a large extent with many of the

               13'changes which have occurred Eince that September site visit  and

               14 Tobert will begin the discussion of that as well as giving

               15 you a little more background on the region, Bill Tobert.

               16            MR. TOBERT:  The Mississippi Regional Medical Program

               17 covers the entire State of Mississippi, serves a population of
               18 about two million two hundred thousand people.  The region

               19 is bordered on the east by Alabama, on the south by the
               20 Gulf of Mexico and part of Louisiana.  On the west by Louis-

               21 'ana-and on the north by Tennessee.

                             So the tipner counti-o-c-z -n-f        "-c  sor-@

               23 shared with the Memphis Regional Medical Program in planning
               24 an coordinating of activities.  There are two distinct geograpl-ii-

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                   al areas of the state. The first area is the north and south
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                                                                                     6



                   Delta which starts in the Tennessee border, goes on down through,

   Reba 4        2  over to Vicksburg. It takes in the whole area. It takes in

                 3  all that portion  of the Mississippi   Plain which lies within

                 4 the state border   and which comprises   what iAsually is referred

                 5 to simply as the   Delta.

                 6            This area is one of the two geographical areas,

                 7 it is by far the smaller taking up about one-fifth of the

                 8 total land area of Mississippi. It is the only section,of the

                 9 state where agriculture still provides more personal income

                 n                                          @l-- S4 S                  -he
               .v  than mantifactur,-ng cr             but          changing due t@-o 'L.

               11  influx of small  industries,  the  inability  of  crop  producers  to

               12 pay a minimum wage and the technological advances in farm

               13 ., machinery.

               14   '         The other area is the East Gulf Coastal plain

               15  stretching in Mississippi from the Tennessee hills of Appalachia
               16  in the north to the Point  Ifills  of  the  south  which  terminate

                   along 359 miles of Golf Coastal shoreline. Mississippi is almost
               17

                   uniformly rural in terms of population distribution.
               18
               19            The basic  urban  structure  is  the  small  town,  often
               20  housing one  or  more  light  industries'but  frequently  few  phy-

                   sicians, nurses or dentists. Poverty  was  and  i@  a  fact  of  life
               21
               22  for too many Mississippians regardless of race.
               23            A total of 154,000 families or 30 percent of all
               24  families in Mississippi earn  less  than  $3,000  per  year  and  are

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                   ranked in a poverty class. The Mississippi @IP
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            #11 headquarters is located in Jackson which  is  also-  the  capital

  Reba 5        2 and is also the location of the University Medical Center who
                3 serves the grantee for RYIP.  There were two  subregional  offices
                4 of the RMP located in Oxford and in Gulfport. These offices

                5 were just recently established, with  supplemental  funds  awarded
                6 to the region for health  services,  educational  activities.
                7           The future plans include a joint  staffing  of  the
                8 Oxford office with staff from the Memphis RLMP  (Slide),  there

                9 are ten economic development areas in the state.

                            The M@Lssis8'opi                  Prograitt recognizes
              10
              11  the fact that health care generally  follows  trade  patterns
              12 lin Mississippi and the ten districts form the  basis  of  any
              13 i, approach to improving health delivery systems as  well  as  the
              14  care people receive in the region.

                            These ten areas are also designed to become the
              15
              16  comprehensive health planning areas of the state. CHP agencies

                  located in Jackson and there are two CI-IPB agencies  currently
              17
                  funded, one in the southwest and the other in the Three Rivers
              18
                  area. Two more have applied for funding, Central and  Nortl-ieast,
              19
                  (slide) and the IIP@IP has been actively involved in the develop-
              20
              21  ment of the agencies and they have a  close  working  relationship

              --  with this staff.
              Z.4
              23            It should also be noted here that Memphis is also
              24  assisting in the formulation or development of  some  of  the

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              25  agencies in the northern part of the state (slide).  This

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                                                                              8

        #1        overlay shows some of the regionalization of some of the

  Reba 6       2  activities they have proposed in the application of the review

               3 today.

               4             Part of this application, the  large  majority  of  the

               5  projects and activities were centered around the university

               6  medical center in Jackson.  During the past year the Mississippi

               7  PJ4P have concentrated their efforts in developing activities

               8  which have outreach to all parts of the state. This simply

               9 (slide) shows the geographical make  up  of  some  of  the  members

                     the --regicnal- -.d-,r,-sory group.

                            There are 37 members of RAG, with an adequate
              12,balance of consumers and providers. The involvement of RAO
              13 members this past year is one of the more positive steps the

              14 region has taken and Dr. fIess will comment more on this a little

              15 later.

              16             (Slide)  This chart depicts the distribution of

              17  funds for the region during the three operational years and

              18  it shows the comparison of what has been and what is to be durinT

              19  the next triennium  period.  Clearly  it  illustrates  the  change

              20  from a categorical program to emphasis on inulti or non-categoricil

              21  activities.

                            This has increased from an averaae of 15 nprcent
              22                                                        L

                  during the first three operational years to 49 percent which is
              23
              24  Pronosed in this current application.  It  should  also  be  noted
  ;e- Federal Reporters,  Inc. that Previously a large percent of the program staff budget
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           #1    I  went  into  the  medical  school  for  supplementing  some   faculty

   P,eba 7       2  salaries.

                 3             This is no longer the case.  All members of the

                 4  program staff are full time employees of the RMP, with the

                 5  exception  of  the  As@istant  Director  of  Planning  and   Evaluations

                 6  who  is  also  a  private  practicing  physician.  During  the   (slide)

                 7  site visit of September 1971 one of the major concerns of the

                 8  site visit team was the organizational structure of the region

                 9  both in the program staff and regional advisory group.

                 IV                                 -rates the cor@,p'
                               rp@ i- c-,cri-y'4"us4t-               Lexi'ty of tl'e  organ@

                    zation  prior  to  September  1971  and  very  clearly   illustrates
                 12 Ithe categorical make up of the region. There were categorical
                 13  coordinates, as you see here, that related directly to the coor-
                 14 dinates of the PNIP, and program staff had very little liaison

                 15 with these people.
                 16            The regional advisory group, the categorical

                    committees  were  composed  of  non-RAG  members.  And  RAG  was  no
                 17

                    more than a reactionary group.  The categorical committees
                 18
                 19 were actually directing the program.   (Slide)
                 20            This is certainly no  longer'  the  case  and  we  feel  that
                 21 the restructuring  of  RAG  and  program  staff  has  been  a  major

                    accomplishment  for  the  reqion.This  reorganization  was   hc-aiin
                 2'@)                                           1                   1
                 23 during a retreat in early December of 1971.
                 24            The  program  staff  are  young,  dedicated,  very   cohesive

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                 c. hard-working group. All of the positions are filled with the
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                  exception of the Assistant Coordinator who they are looking for

  Reba 8        2 now. And the  part-time  Assistant  Director  for  Planning  Eval-

                3 uation I have already mentioned.

                4            (Slide)  The restructuring of the   Regional   Advisory

                5 Group has resulted in total commitments and    involvement of

                6 all RAG members. No longer are@there                of non-RAG

                7 members. Each member of RAG is requested  to  serve  on  at  least

                8one of,the task forces.


                9           Each task force is responsible for one or more of the

              I^v goa'Ls.of Llie region, and members are involved in reviewing

              11 and monitoring the activities and projects that pertain to
              12,these goals.  And the goals of the region are shown in each
              13 li of the task forces, manpower, professional education, health

              14 systems design, EMS and public health education.

              15            DR. HESS:  As you can see from your previous document

              16 there were four staff visits to the Mississippi Region during

              17 the late part of 1971-1972, as well as numerous telephone

              18 contacts and various other forms of assistance.    The  site  visit

              19 team for this visit as you can see included Dr.    Merrill  of  the

              20 Council, Dr. Nichols, who is a black physician    from Susquehanna
              21 @Valley, Mr. Donald Tranto from Georgia @IP who   was a very
              ),) valuable asset to the team.

              23           Mr. Van Winkle of Harvard, Mr. Ashby, Mr. Nelson,

              24 @,lr. Ballou and Mr. Grift. from the regional office in Atlanta.
  e-Federal Repoiters,  Inc. This apT)1-3-cation that we are to consider today includes a reques
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                I for triennial status; Expansion of program  staff,  and  funds

   P,eba 9      2  for additional regionalization, developmental components, con-

                3 tinuation of three previously approved funded projects and

                4 funds for 19 new projects.

                5           Going over now the review criteria as  outlined  in

                6 the site visit, as Already mentioned by Mr. Torbert the

                7 roles and objectives of the region have been revised and are mole

                8 in keeping with the new directions of RMPS.  The  coordination

                9 between the university medical centers and the Mississippi R.@4P

              IV  appears to '"e extremely youd, there always has been good working

              11  relationships there and these continue.

              12            The Mississippi PIIP has moved into new  categories

              13  outside of the medical center,  This has accomplished several

              14  things. First being that the staff are all toget er now

              15  physically, where they are able to communicate and  work  more

              16  effectively together.

              17            And it also has removed any -- some of the questions

              18  that existed about undue influence and too close liaison with

              19  the medical center. Ile found no problems of real concern in this

              20  area. Some of the statistics which reflect hopefully  in  part

              21  the impact of the Mississippi R14P are shown here in the  site

                  visit- rppnrt.

              23            Some of them are very dramatic. In 1968,  the  neo-
              24  natal death rate was 28 per hundred thousand live  births  in
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              25  ITolmes County. This was reduced to 19.8 in 1970, and 7 in







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          #1 1 1971. This reduction  is  so  dramatic  you  almost  question  the

  Reba 10      2 statistics. But the people there feel  that  there  is  no  question

               3 but what the Pediatric  nurse  assistance  and  midwife  program

               4 and  so on has had some influence in reducing   the  neonatal  death

               5 rate.

               6            The regional satellite units have been set up around

               7  the state.  They have a very well organized and smoothly

               8  functioning renal disease Program there as near  as  we  can  tell.

               9  One of the important accomplishments of this program is to

                  reduce the cost of d4-lysi,- for th@-4r pa4   -s.

                            They bring families and  patients  into  the  medical
              12,centers, train them in the use  of  dialysis  and  then  through
              13  the use of trailers which have been set  up  around  the  families,

                  a.member of the family can come in with a patient and perform
              14
              15  the dialysis for the patient.

                            Heart clinics have been set up  around  the  state  which
              16

                  have been -- have resulted in care being given to patients who
              17

                  previously did not have access to this type of care. The
              18

                  existence of the stroke care unit in the medical centers    has
              19
               0  resulted in the treatment of a large'number of patients,    the
              2
                  training of a number of physicians and nurses from various parts
              21

                  of the state who are now better qualified and equiT)Ded to

              23  provide higher quality care to patients with this type of
              24  problem.

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                            Pulmonary training programs and inhalation therapy
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           #1  I  has been established in a number of inhalation therapy

  Reba 11       2  aids trained who can now provide this type of service in hos-

                3 pitals outside of the medical  centers  located  throughout  the

                4 state.

                5            The coronary care unit which  initially  was  funded
                6 and operative at the university medical center has trained
                7 120 nurses in coronary care and they  now  are  functioning  in
                8 various areas throughout the state to provide a more sophi.sti-

                9 cat6d and effective type of care  for  patients  with  coronary

              10  heart disease.
              11             Through the efforts of the Mississippi  PIIP  program
              121 for training of dental hygienists was  initiated  and  this  has
              13 11 had more spin-off, in that there is now discussion of the
              14  possibility of initiating a dental program there. But through
              15  the use of the training of these additional people, additional
              16  dental services are now available.
              17             They have been giving attention to  the  question  of
              18  continued  support and an example of this is the Hollandale
              19  midwife project in which through the fees which are being
              20  collected for the services to patients, medicai.d  and  so  on,
                  these fees are being put back in to help  support  the  cost  of
              21

              21  the program.

                             There was some concern about what withdrawal of
              23
              24  some of the support to the Medical  School  faculty  might  mean

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                  in terms of their availability to participate in M4P programs
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          #1    I and continue education and so forth.  And  the  Dean  indicated

  Reba 12       2  that there was some uncertainty as to how much of the time

                3 of the medical school faculty might be      he might be able
  is
                4 to fund and pay for out of other sources in order to continue

                5  some of the thrust which they had begun in earlier times.

                6           The region is giving  attention  to  the  improvement

                7 of health care delivery for  underserved  minorities,  this  is

                8 a major area of emphasis for the region, and all of these

                9 projects that have been conducted in the  past  have  had  very

              'IC) 'Important       an--' cmp.lxas-'Ls on the care of uiiu'erserved

                  Minorities.


              12            The needs are tremendous in this area and what has

              13  been done is onlv beginning then to scratch the surface, but

              14  the region is certainly very conscious of these needs and
              15  appears to be taking appropriate actions. As far as minorities
              16  on the staff, currently they  have  one  minority  professional

              17  and one minority secretary, and this is an area that we.gave

                  additional emphasis to, on the site visit, and they expressed
              18
              19  their intent to employ additional minority people in unfilled
                  positions or as new positions open u'
              20                                        p-

                            One of the outstanding programs which has been
              21

                  conducted there is one in which thev are-  seeking  to  attract

              23  black medical students who are going to school outside of the
              24  state to come back to t-l-Lssissippi and practice.
  e-Fedeial Reporters,  Inc. As I am sure most of you are aware there is suddenly
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        #1     I a nationwide competition for qualified black  medical  stuents,

  Reba 13      2 and many of the best students, black students,  in  Mississippi

               3 are being actively recruited by medical schools from  all  over

               4 the country, and are going there to continue  their  education.
               5           Through the black physicians in  Mississippi,  Mississ-

               6 iPPi RMP, these students have been, many of these  students  have
               7 been contacted and brought back and discussions were held  in  an

               8 effort to show them some of the changes that are happening and
               9 to develop in them a desire and commitment to return to  Nliss-

              10 issippi and.pract4-ce Cohen their training is com-leteA-.
              11           I was going to take sometime now -- now it  is  going
              12 to take sometime to know how effective this effort will be
              13 L)ut it certainly seems to be an appropriate one. Along with this
              14 is a much greater awareness in the University of Mississippi
                  tself, of the need to admit black students within their
              15 1
              16 own state and they seem to be making progress in this area.
              17           Going on to the coordinator, the -- Dr. Laraton has
                 been coordinator since January 1971, and we found  evidence  on
              18
              19 this-site visit that he indeed is beginning to exert a much
              20 stronger leadership role than when we' were there in  September
              21 0f 1971.
                           At that time he was relatively new and feeling his way

                 but'after the site visit and the report which came back he has
              23
                 not hesitated to take the recommendations seriously and  to  move
              24
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                            There seems also to be a much better working relation-

  Reba 14       2  ship between he and the staff. And whenwe were there in September

                3 of 1971 we were getting all k inds of informal feedback  in  the

                4 hallway and so on of some of the communications programs

                5 and leadership problems which existed.

                6           This time we pickedup none of that kind of thing. And

                7 there were many indications that the working relationships

                8 have improved.  His relationship with the RAG seems to be

                9 cordial and. effective and we found no evidence of  any  discord

              10  in that area.

              11            The program staff has been strengthened, they have

              12  hired A number of additional people who seem to be quite

              13 capable., Some of them are young and not too experienced as

              14 yet, but appear to have good potential. One of our concerns,

              15 however- was in this area, in that the Assistant Director
              16 for Planning 'and Evaluation is a practicing physician.
              17            He is an internist, hematologist, gynecologist who
              1 8 has a private office and exactly what this  half-time  means  we

                  are not sure. But it was evident to us that this is an area
              19
                  that does need strengthening, and one of our recommendations is
              20
              21  that this be made a full-time position, and that the new

                  neonle that thev bave brou-ht onto the   staff )De -even some

                  additional training and orientation so that this  area  of  core
              23

                  taff might be further strengthened.
              24  s

  e- Federal Reporters,  Inc.
              25            They have a new person in the area of evaluation.

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         #1     I           From our discussions with him he seems to be a

  Reba 15       2  competent person, a lot of good ideas and a good approach to

                3 evaluation and we are honeful that the evaluation might improve

                4 over the next year or two. Regional advisory groups represent

                5 the key health interests in the region. And as indicated by

                6 Mr. Tobert's presentations now much more actively involved

                7 in planning and decision-making for the region. Attendance at

                8 the RAG meetings have been running over 50 percent, they have

                9 requirements that if more than three meetins are missed then

                  L,',-ie irt@tiber is dropped from the RAG.

                            The grantee organization is performing its function
              12jeffectively as we could tell and we have no questions about
              13 that. The major health interests are participating and there are

              14 a wide variety who are involved and they always seem to be in

              16 full support of the objectives, and -- of Mississippi lu4P

              16 and what it has accomplished to date.

              17            Mr. To)-)ert-indicated the -- how the state is divided

              18  into subregional areas for health planning and   IUIP has been

              19  instrumental in helping to facilitate this development and

              20  they'are working closely inthe dovelo pment of these,local

              21  Planning areas.

                            Acti-17             -rc go4.ng on Concerning Oi:ydll.LZdt3.011
              A.@

              23  in nine of the ten areas, and five of these are in the active

              24  Planning stage at the present time. There is an adequate

  'e- Federal Reporters, Inc.
                  mechanism for obtaining CHP rev.@Lc.,,vi and comment.
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               1           The Mississippi @IP has participated in and/or has
   Reba 16
               2 available to it a rather large data base documenting the

               3 health fields and resources of Mississippi. However,  there

               4 has been thus far an apparent lack of the expertise  needed

               5 to move from available data to program development. This'is an

               6 area we emphasized to them a number of times and we Are hopeful

               7 that there might be some immediate and further movement on this

               8 and we-have a recent letter from Dr. Landon indicating they have
               9,already begun to take steps to address this  issu'e.
             io           All the current projects in the current triennial

             11 application were developed concurrently with re-thinking
             121of the goals and objectives and restructuring of the RAG and
             13 program staff. Consequently the projects have not evolved as

             14 a-result of the re-thinking which has gone on during the last

             15 few months although several of the projects are compatible

             16 with that expressed by the.new goals and objectives.

             17           Coordination program staff has improved substantially

             18 and they have developed a plan for systematic monitoring  of

             19 individual projects both by written reports and site visits,

             20 by project monitoring teams which will include program staff,

             21 RAG members and other consultants.  Written project progress

             O)n eno--r--c -nnid f4----@a" repoKLs ai-e also a standard requirement.
   0         I- Z- I-

             23           We have already mentioned about the new  full-time

             24 3valuator for whom we have a good deal of hope.  He did not have
  e -Federal Reporters,  Inc. an opportunity to have much influence on the evaluation aspects
             25





                                                                               19


                  of the projects which are submitted in the triennium, but he
  Reba 17       2 does hope to have some influence  on  their  functioning.  And

                3  we were assured they would have an active role in reviewing

                4 and participating in the development of all new projects so
                5 that adequate evaluation is built in from the very beginning.

                6            We identified some problems in their documents,

                7 differences in evaluated criteria between the 8tated objective,

                8 the project development guidelines, the technical review cri-
                9 teria, and developmental component priorities, the RAG rating

              1 0 'Loi:ics aria Lile Iitoyrwtt @vai-uat.?Luii statement.

              11             We felt these all have been developed at different
              12 1times and  with somewhat different people and we felt, we
              13' recommended that they sit down with all of these now and try to

              14  make them consistent and uniform with  one  another  to  avoid

              15  some potential confusion and improve the baiss for carrying

              16  out their evaluation.

              17             The region has  established  priorities.  This  was

              18  accomplished during the retreat of the Regional Advisory
              19  Group in December of 1971 and they are congruent with national

              20  goals and objectives.
              21             They have begun a School of Allied  Health  at  the

              99  Universitv of Mi,ssissinni          Centc-ri and. this i--q On i-+--c
              23  way@now.   The initiation of this school has been attributed to
              24  a signific at degree by the P14P, and the@-are actively on

  oe- Federal Reporters,  Inc.
              25  their way now in recruiting faculty and students and hopefully







                                                                              2 0

                  this will begin to supply a gap in health manpower in the regior.

  Reba 18      2             Now getting down to'the recommendations of the site

               3  visit team I am going to save, wait on the    financial   recommen-

               4  dati.ons until last.  We did feel they were   ready  for  triennial

               5  status.  There was no question that they had addressed all of tle
               6  areas of concern raised in the  September  1971  site  visit.

               7             And they were in  a  substantially  better  position
               8  as a region to manage their own affairs and to more effectively
               9  address the needs of the people  although  there  are  still  a

               C) number of important arom=cz -Flmn+- the-%7 -- x@7here they need further

              11  improvement.
              12             We recommend that there be a  full  time  director
              -13 ot a P.'Lanning eva'Luat.-'Lon staff, and that this section snoula
              14  engage in a good deal of training and  we  suggested  as  one  part
              15  of the training of the staff some  @IP's  which  they  might  visit
              16  to learn the methods and techniques  that  would  help  them.

                             We emphasized the need for developing consistency
              17
              1 8 with the statements having  to  do  with  evaluation  mentioned
                  earlier. lie felt that their applications, their projects, needed
              19
              20  better documentation of need and this went back to the need for
              21  strengthening their planning section.
              22             We also felt that.they needed to improve their technical
                  review input to the RAG, that there were some projects that
              23
                  we looked at, as examoles, where we questioned some of the needs
              24

  :e- Federal Reporters,  Inc.
              25  as far as the equipment and budgetary  items  and  felt  that they





                                                                             21



               I  could well benefit from some qualified experts to work with

  Reba 19      2  them in reviewing these project requests and determining what

               3 was actually necessary and the methods that would be most

               4 effective in addressing the methods of the project.

               5            We recommended that they should work to obtain both

               6  CIIP and state funding of on-going health planning data collections,

               7  There was one project in this group which is directed toward

               8  improved data collection, and apparently no one is in a

               9  position at the moment to undertake this activity, yet it is

                  a very 4.
              10          mportan' and essei-iticil act!-vity for all health planning

                  in the state.
              12i  -        And we agreed that this would be a worthwhile
              13  thing for T4P to initiate but it should not be looked upon

              14  as a major on-going activity. Another question which came up

              15  during the course of the site visit was the staff salary scale

              16  which is determined by university salary scales.

              17            And we recommended that the salaries should be reviewer

              18  with the medical center administration to see if the mechanism

              19  can be developed for more adequate program staff compensation.

              20  Our concern was that this might be a liability to the program

              21  in that they may not be able to retain qualified people and,

                  herefore, continue to build a strong -rogram.  1          cn--'
              22  t

              23  my comments at this point.

     end      24
  @F@de@l R,ers, Inc.
        FrS   25






                                                                                 22
     42

       arl                    DR. SCHMIDT: I would  remind  the-committee  that

               2  in front of them are these blackbound books  that  are  computer

               3  printouts, and some of the questions yesterday that  had  to  do

               4  with funding levels and money going to projects  and  so  on,

               5  are very efficiently and effectively answered  in  the  computer

               6  printouts, and I personally find them of great  value  and  would

               7  recommend them to the committee for funding information.

               8  Secondary reviewer is Warren.

               9             DR. PERRY:  I believe in a characteristic way

              10  Joe has done a tremendous job in reviewing the program.

              11  My greatest interest in the program, I have not been in the
              ]2i region, it's been only through application review  in  the  past,
              13  has been this tremendous concern and development in manpower

              14  potential. Educational programs have  really  moved  in  this

              15  state. It 'is a state that has not had that  level  of  expertise

              16  and such to do this. They have been calling  in  in  the  allied

              17  health area, I know three of my dean type  colleagues  have  been

              18  down there in consultation.  They have been moving ahead, as

              19  has been said here.

              20             A member of our staff in Buffalo  has  been  there

              21  in the dental school and dental hygiene program and moving.

                  'iiley're doing a tremendous job as they iook at their  needs

              23  in that state.  They recognize the importance of all levels

              24  of health care personnel in therei and I think this is a

  e- Federal Reporters, Inc.
              25  tremendous development here.




                                                                                23


      ar2


                              My only concern is going to be in some of the

               2  recommendations on the level of funding here  which  I  would

               3  like to turn right back to Joe to make.  There is no question

               4  but this state has made a major turn and is moving in a most

               5  positive way.

               6              DR. SCHMIDT:  Bill, was anything left out that

               7  should be -- all right, Joe, can you put a  proposal  on  the

               8  table   then?


               9              DR. HESS:  The site visits team had some difficult

              lu  in arriving at a funding level recommendation.  I will place

              11  that before the committee at this  time.  There  was  another
              121 wide variety of opinion as to what it  should  be.  I  suppose
              13  that I ought to express to you some of my personal reservations

              14  about   this.

              15              This came as a sort of compromise, the team

              16  recommendation@:ls a compromise. And I  happen  to  personally

              17  be on the lower end of the scale concerning  the  spectrum  of

              18  opinions of the team for funding recommendations, but neverthe-

              19  less the recommendations which we ended up were  in  order  to

              20  leave and catch our plane.

              21              DR. SCHMIDT:  The suspense is killing me.
   0            1                 UVVO:  "ou can see here oi-i your: age, 11 of
               2                         L

              23  the report  the total figure&  On the sheet over here.we have

              24  broken these down.  We agreed that with the expansion in

  :e -Federal Repofters,  Inc.
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                                                                            24


      ar3
              I   that the program staff planned to get into and so on,  that

              2   the increase in program staff budget was justified.

              3              We felt that they were ready and could effectively

              4   use in the first year developmental component of @6,315.  The

              5   total for operational projects we felt was somewhat high.

              6   There were three specific projects there totaling about

              7   $200,000 that we had some serious reservations about in terms

              8   of their appropriateness when one considers the total  health

              9   needs of Mississippi, and we reduced their -- our recommendation

              iO  was something about $230,000 below that requested by the

              11  region for operational projects.
              121            So the total ends up with 2,110,138.  They had
              13  already received approval for, through supplemental  funding,

              14  183,634 in kidney, so if you subtract that, it comes down  to

              15  1,926,504, which is the first year recommendation.

              16             The second and third year, you can see on the

              17  sheet the kidney money will be included in that, 2.2 and  2.4

              18  million the second and third year.

              19             So I will place this recommendation on the table

              20  in the form of motion, but also say I have some reservations,

              21  particularly considering the fact that the first year is  a

                  10-month year for them. I ha@.,-- so.-..c pcrsonal. reservaL-.'Lons
              2 z@
              23  about whether they can effectively use that 1.9 million during

              24  that first year.
   -Federal Reporters,  Inc. DR.  SCHMIDT: All  right. Dr.  Hess  then  moves
              25



     ar4                                                                     25

                   with some reservations, then, the team report.  Is  there  a

               2   second?

               3              Warren, do @6u second this or not?

               4              DR. PERRY:  Yes, I am going to second it, to get

               5   it  started here. I -- not having been there,  not  having  a

               6   chance  to, you know, really be a part of looking at the new

               7   projects and such, it is a -- really a, more than a promissory

               8   note.  It is really an accolade in this funding amount.

               9              I would like to ask Bill in relationship  to  his

              IC)i knowledge of the reai,on of your feel for thei--- ability to
                                      I

              11   handle this increase.

              12              MR. TOBERT: I share with Dr.  Hess  the  10-month

              13   o-,aage-L. at that ievei.  I had no qualms on the second and third
              14   year at all.  But I think there can be some justification in

              15   reducing the first year.

              16              DR. SCHMIDT:  Before I call on Dr. James, Mr.
              17   Griffith, the regional office representative, 3s here, an  I

                   had asked Ted if he has any comments.
              18
              19              MR. GRIFFITH: No comments at  the  present  time.

                   I go  along with the proposed activities so far.
              20
              21              DR. SCHMIDT: Obvious and  maybe  stupid  question
              22   is if you are worried about the 10-month thing, why not give
              23   them ten-twelfths of that amount for the first year?
              24              DR. HESS:  Personally I think that would be more

  'e -Federal Reporters, Inc.
                   reasonable.  I figured it several different ways, and I think
              25







         ar5

                  that would be an appropriate way to go about it.

               2              DR. SCHMIDT: Well, the  chair-won't  intrude  on

               3  the workings of the co@ittee.

               4              Dr. James?

               5              DR. JAMES: As a new member of  this  committee,  I

               6  get a gut reaction from the report as given and as stated.

               7  in the site visit report. My gut  reaction  relates  to  the

               8  fact that we have seen a state that has long been known to be

               9  without, use its own resources to develop a  kind  of  program

                  that seems to be evolving with the profe--si-onal help  that
              IV

                  came about in December of 171, demanding new direction.
              ]2i             And I think I would like to emphasize  the  fact
              13  t:LLat tney nave not nad the professionalism and expertise prior
              14  to December of 171, apparently shows that the  efforts  of  --

                  of funding apparently have been -- has resulted in the train-
              15
              16  ing of personnel which in the long run has  affected  a  net
              17  change in direction of what I have heard  all  day  yesterday,
                  that is, in fact, the people have apparently been the
              18
              19  recipients of the funding of the efforts  of  the  Mississippi
              20  regional program, if this is in fact what  is  absolutely  the
              21  case, as seems to be written in this program.
   0                          And I, for one, would want to  re-emphasize  the
              23  fact that sometimes when you don't have enough money to go
              24  on, you don't have the .expertise and professionalism which
  e-Federal Reporters, Inc. in turn helps to cloud an issue and really you do not get the
              25





                                                                               27
        ar6

                I  services to the people, maybe this is what it is  all  about.

                2             And I would strongly suggest that the expertise

                3  and professionalism be'-6ffered these people on a  higher

                4  scale so they can use their basics, their abilities to
                5  continue their efforts to train more people in Mississippi
                6  which net results in services to the people.
                7             The fact that infant mortality, this is an
                8  absolute fact, it does sound, you know, almost fictitious,
                9  doesn't it?  But if this is an absolute figure, can we

                   duplicate that samt- ficriirt- in any other re(,-ion across the

                   country?
              12              I think if the regional medical program did nothing
              13   eise nut to re-uuce -Lne infant mortality rate, it has servea
              14   a very useful purpose.

                              DR. SCHLERIS:  I was wondering if I could see -that
              15
              16   overlay to show how the direction has changed in Mississippi?
              17   I confess by saying I always, in driving, have  been  tolId  by
                   my family of a very poor sense of direction.  And  in  trying
              18
              19   to review briefly, I do have some questions to ask about
              20   specific projects.
              21              I am trying to discern what is really  the  change
              2'-) in direction. The multiple is probably where  there  is  some
              23   reason for my questioning this. I am sure  heart  disease  is
              24   probably about 13 percent. But if I look  at  heart  disease,

  'e-Fedetal Repotters,  Inc.
                   cancer and stroke, I would think that the numbers really don't
              25







      ar7

                I reflect some of the changes here unless these are put into

                2 multiple, because as far as some of the new pro]ects coming

                3 along the line, those to be supported, some  of them appear

                4 to be very much what we have been looking at for  a  long  time.

                5 The ongoing projects to be supported,$122,000.  They put in

                6 some projects, I don't know what you  did,  electrical  hazards,
                7 that probably went under multiple, but this is a  set  of  a

                8 model electrical hazard safety program, and the hospital

                9 then to put it through the community.  This  is  about  $80,000.
              i 0 This has now been used in Tost communities as t.L"Jc respons'Lb-L'L.LL..,@

              11  of the hospital itself.
              121            Radiotherapy is coming in as a  new  project  for
              13  $80,000.
              14             Education of radiologists, setting up of peripheral
              15  centers, is coming in again at a significant level of support.
              16             PulmonaIry therapy as a model  project  is  coming

                  into a 50 to 100-bed hospital to treat pulmonary disease and
              17
                  cystic fibrosis, stroke system to be set up for $58,000.
              18
                             My concern, as I look over these projects, is   that
              19
              20  many of them are what we have been used to seeing over the
              21  past several years, and my concern is that they are isolate
                  projects related heavily to heart  disease,  cancer,  stroke
              2-41
              23  and related diseases, rather than being a part of a new direc-
              24  tion.
  :e-Fedetal Reportefs, Inc. Some of the new directions concern me a bit.
              25





                                                                                  29

       ar8


                1  $39,000 for educational program for mentally retarded

                   children is something that I am sure is necessary, but I

                3  again think that this is the RMP picking up things that

                4  should be done in other ways.  Controlled in effect in

                5  hospitals, to set up a model unit  and  then  if  other  hospitals

                6  are interested, help them, is $32,000.

                7              I have only looked at a few of   these, but those

                8  that I have looked at would suggest very  much  a  good  deal  of

                9  what,has been going on in the past.  Now if the change of

               I v %A Arec:-L".Lon is in the @Lnterest of core, that's one thing, but

               11  I don't see it reflected at all in these projects, and

               12  there are myriads of them and just scanning them quickly, I

               13  wanted to know how you define the change in direction, admitting

               14  that I have a poor sense of direction.

               15              DR. HESS:  Well, I had commented on that in passing,

               16  in that their rethinking occurred at the same time the
               17  projects were being developed aid consequently, particularly
               18  the first year projects do not reflect that, so that it is
               19  kind of a phasing problem that we have seen in many other

               20  regions.
               21              And this, the very questions  you  are  raising,  are

                   some of the thinas that bothpred me and raise -uesti---ns in  m-t,

                   own mind as to how much of a favor we  are  doing  the  region  to
               23
               24  get -- give them enough money to  get  started  and  obligated  on
  ce - Fedetal Repoiters,  Inc. some of these projects that I, in  my  own  mind,  thought  ought
               25





                                                                              30
       ar9

              I   to be low priority.

              2              Now some of these we    site-visit team -- we

              3   felt strongly ought to really be looked at very  carefully.

              4   We told them so in feedback session, that we just  questioned

              5   whether these were consistent with the needs and so on of  the

                  region, and that they needed to go back and rethink that whole
              6

              7   business and look at those projects again.

              8              Now, I think they are developing the mechanism

              9   and the wherewithal to do that, but this application does  not

              io, reflect that kind of thinking, you see, and it is a question of
              11  how much faith we collectively have in their ability to  go
              12, back and look again at these projects.
              13'            My own feeling is that there should be enough
              14  restriction on funding that they can be very selective  about
              15  which ones they choose and which ones they choose to fund  --
              16  which ones they choose to fund and which ones they choose  not
              17  to.

                             And they are going to need some continued help  and
              18
              19  supervision in order to get things organized and  consistently
                  moving in the direction that we would like them to be.
              20
              21             DR. SCHERLIS: Well, my concern is that  once  we
              -A)2 gave them developmental component, it should be on the basis of
              23  our knowing that they have indeed demonstrated a change  in
              24  direction, because in looking at the projects, I have a feeling
            tefs,ln of deja vu  as far as what we would have a few years ago of
  ,e- Federal Repot C.
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                                                                                31
         arlo

                I  seriously challenged as being bits and pieces of projects

                2  coming in from all over.
                3              I am sure they will  do something, but I don't know

                4  if they really demonstrate any   program, you know; our concern
                5  should really be program, we shouldn't be talking projects,

                6  and our chairman has been most kind in letting us talk
                7  projects, because I don't see it as a  program,  but  as  bits

                8  and pieces of unrelated projects.
                9              My immediate reaction is I question whether we

               in  have had a  demonstration of their change- in ciirf-ction; but

                   rather   what we have been shown is that they recognize there

               12  should  be  achange in direction, have given us a list of

                             tnat wniie they wili do good, 'L' am  sure,  doesn't
               13  '-Ojccr-s
               14  really reflect a level of maturation to demonstrate that they
               15  are ready to go in the developmental component.
               16              I would like to have some other points of view on
               17  this.  I know this is not the view of the site-visit group.

               18


               19


               20


               21


               22


               23


               24

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     mea-1                                                                32
     CR 7149

     #3

                              DR. LUGINBUHL:  I would like to summarize my
              2     views on what-I have heard.  It seems to me this is an area

              3
                    of desperate need.  We would like to give them as much
              4     funding as they could well use.
              5               Also it seems if they had made real steps toward

              6
                    developing an organization, that we are all concerned that

              7
                    they are still pretty embryotic in their development; they
              8     are still focused on projects that aren't very well
              9     coordinated, and if we give them too much funding, they are

              -If% I
                    likely to commit themselves very deeply to projects that will
                    not readily be pulled together in a coordinated program.
                              From that basis I wonder if it wouldn't be wise

              13
                    to take a hard look, particularly the first-year budget,
              14    with the thought in mind that if indeed'they do set

              15
                    priorities, that they do move towards a coordinated program;

              16
                    that funding could be increased more rapidly in the second

              17
                    and third quarter.
              18               Spedifically it is not clear to me from the yellow
              19    sheets as to whether their first-year requests,indeed for a
              20    ten-month period or is it for a 12-month periodi if it is

              21
                    for a full-yeat period,, I would think this would reinforce
                    the suggestion that that be reduced to five-sixths of the
              23    amount suggested over here which would be about $1,5O5iOOO.

              24
  ,e -Federal Reporters,  Inc. Can someone tell me, is that first-year request
              25    for ten months or 12 months?

                I





     mea-2                                                                 33



                               MR. TOBERT:  It is for ten months.

              2
                               DR, LUGINBUHL:  That would seem to me to be a
              3     rather large increase and I would like to move an amendment
              4     if that is in order.
              5                DR. SCHMIDT:  The Chair will accept a move to
              6     amend.
              7                DR. LUGINBTHL:  To reduce the first year to
              8     five-sixths of the amount up there. I will leave the  exact
              9     calculations to someone else. I did it very quickly; it  is

             IV     about a million and a half dollars,and to omit the
             11     developmental component for the first year.
             12                DR. SCHMIDT:  There is a move to reduce the amount

             13
                    to five-sixths and omit the developmental component for the
             14     first year, leaving the second and third years at the
             15     recommended level but with obvious interaction between staff
             16     and the Review Committee prior to the funding of the second

             17
                    year.
             18                Do you accept that total restatement of your
             19     amendment?
             20                DR. LUGINBUHL:  Yes.

             21
                               DR.,SCHMIDT:  All right.

                               Is there a second?

             23                MISS KERR:  I would second.

             24                DR. THURMAN:  Joe is afraid to ask you what you
  e -Federal Reporters,  Inc.
             25
                    thought.  You said you compromised upward for the plane.




     mea-3                                                                      34




               I    What would you really think?

               2               DR. HESS:  Well, my feeling  was that they  could

               3    effectively utilize somewhere in the neighborhood of 1.6,

               4    1.7 million.  This would cut out about $400,000 worth of

               5    projects and if I use my priority system, the ones  left  in

               6    would be ones that are truly helpful and directed to some

               7    very urgent problems there.

               8               But I share the concern which you expressed.  The

               9    infections in hospitals, electrical hazards and so  on  were

                    ones which obviously came up -- we  were  verIy surprised that

                    they got through their review process and this is one of the
              12,   things that gave me some concern.
              13               The nurse or I should say the cancer  project  is

              14    just a one-year; this is the final year or I should say,

              15    the stroke care demonstration is a final year  for  that

              16    project so that 122,000 only appears in  the  first-year

              17    budget and I think they are obligated to  continue  that

              18    previously approved -- but taking all these things into

              19    account, it is my feeling that they could have quite  a  bit

              20    of money to play with and, not to play with but  to  use

              21    effectively, and still show them that we had  confidence  in

              I-/-  wliat was happening, give them the support which they need to

              23    begin moving more strongly in directions which I am convinced

              24    they will move in and not do damage to the program.

  e - Fedeial Reportets, Inc.
              25               DR. THURMAN:  Mr. Tobert, what is your feeling




                                                                            35


                    about staff reaction to the business of cutting them, this

              2     level or lower?
              3               We heard a--lot yesterday about how if we did not
                    show our faith, hope and charity that we might seriously
              4
              5     hurt somebody.
              6               MR. TOBERT:  No, I don't think this would affect
              7     the operation at all.
              8               DR. THUP24M:    What I am really asking is 1.5
              9     or lower.  Let's look at both of those, 1.5 and then also
                    the lower because I share every concern that Dr. Scherlis

                    had.
             12               MR.,TOBERG:  If it is any lower than 1.5 without
             13                     p--o.-onent, I     it m4-ght ha-.,.e some
                    concern on the staff.
             14
                               DR. SCHMIDT:  The move to amend was so
             15
                    inconclusive that it is a substitute motion and so really
             16
             17     the motion we are talking about right now is the lower

                    amount.
             18
             19                John, first.
                               DR. KRALEWSKI:  I am in sympathy with cutting the
             20
             21     thing back.  I have mixed emotion over developmental
                    components, whether we give it to them in program-. and
                    help them organizationally to do this or whether we give it
             23
             24     to them as a pat on the back.
  e-Fedetat Reporters,  Inc.   Organizationally sl3eaking I had been inclined to
             25




      mea-5                                                                        36



                I    say the program would be better of  if  you  would  reduce  the

                2    budget in the area of projects and   gave them some developmen-

                3    tal money to play with.  I think I   would be inclined to

                4    believe though that ending up with   220,000 which must be

                5    one of the larger developmental  components  ever  given  to  a

                6    program would be fair.  But I would think that developmental

                7    component in terms of perhaps somewhere in the area of that

                8    first year's program,going up perhaps  around  'a  hundred  for

                9    the second two years, with the  cutbacks  to  bring  the  total

               I.v   budget down to a million and a half, taken out of the
                     projects, might be more helpful to  a  program  such  as  this
               12i   and give them more running room and  give  them  a  chance  to
               13    turn it around if they are trying to turn it around.

               14                DR. LUGINBUHL:  Is that an amendment to my

               15    substitute motion?  If it is, I will accept it as a change.

               16                DR. SCHMIDT:  I will accept that as an amendment

               17    to the substitute motion.  The seconder was Elizabeth.

               18                MISS KERR: Yes, and I .would accept it.@

               19                DR. SCHMIDT:  All right, the motion now includes

               20    a developmental component of  96,000,  which,  for  the  first

               21    year then.  How about the second and third years?

                                     KRAL-@WSXI% 1 suggested a liuiidre-d  thousand

               23    isn't much  of an increase but suppose we say 90,000 the first

               24    year, a hundred the second two?
  @e-Fedeial Reporters,  Inc.
               25                DR. SCHMIDT:  All right, 90,000 the first year and




    mea-6



                I   a hundred then for years two and three.  So that is the motion

                2   that is now on the floor.
                3              Further discussion?  If not I will call, "Question."

                4              Bill?
                5              MR.-TOBERT:  By reducing the developments
                6   component for the second and third year does this in effect

                7   reduc- the total amount you are  awarding for those two yea.-.
                8              DR. SCHMIDT:  Yes, it would be a reduction of 1
                9   110,000 year two, 120,000 in year three.  Year one, it would

                            ou@ calc            O-r   Ac: a a-& aurcnue4@, are you
              I v   be, w-'@4,44  J- u at-ng ccn- -gra%@       A&   A& @ L.
              11    going to take five-sixths of the  amount  after  the  subtraction
              121   or before the subtraction?  Oh, developmental component
              13    isn't subtracted.  So it is five-sixths of what?
              14               DR. KRALEWSKI:  What I was suggesting is a total

              15    budget of one and a half.
              16               DR. SCHMIDT:  Including developmental components.
              17               DR. KRALEWSKI:  Developmental component is 90.
              18               DR. SCHMIDT:  That clarifies it.
              19               Does the staff understand the recommendation?

                               All right.  I will call for the
              20                                                 vote  then.  All  in
              21    favor please say aye.  opposed no.
   0          2 'Z'.           I hear no dissent,
              23               I would like to just take a  few  minutes  now  before
              24    moving on to a report. on Missouri to ask the committee to
  e-Federat Reportefs,  Inc. exprp-:-@s themselves concerning the staff efforts at  presenting
              25




     mea-7

                                                                               38


               1    information to you about regions as part of  the  review  and
               2    triennial applications, that backgrounds the regions a little

               3    more,

               4                You have seen the slides that  have gone up.  You

               5    have heard two presentations by staff as   part of the committe::
               6    review.  One of them was done by John, I   believe, as part  of
               7    his review.  fie used the visuals that were prepared by staff.

               8                And we have talked in the past about  the  informa-

               9    tion that comes to the committee, the amount   of it, the

                    detailed na@@ure of it and so on.    I called your aLLeiiL-A.oi-i

              11    purposely to these books because they do have some of the
              121   budget breakdowns that are most handy.
              13                You have the applications now in their new form.

              14    And you have the reviews of these three regions that were

              15    done by staff.  So could we have some guidance from the

              16    committee on what  they  think?  Dr.  Ellis?
              17                DR. ELLIS:  Mr. Chairman, I would certainly like
              18    to express great appreciation for the work of  the  staff  in
              19    setting forth these audiovisual  presentations.  I  think  they

              20    have been very, very helpful.
              21                many times in trying to describe a region  it  is
                    inst impossihlp to do so  so that People li-c4-en and hear
              22    1                                            --

              23    what  it is all about when we are talking.  But they get our
              24    attention; we understand exactly what the region  is  like  and

  e -Federal Reporters,  Inc.
              25    I am just very regretful that I wouldn't have it when I




     mea-8                                                                      39



                I    present this complicated region today.

                2               DR. SCHMIDT:  Elizabeth?
                3               MISS KERR:  I would also  commend the staff for thi

                4    and I would further make a comment  and then a request.
                5               As I review regions which I intended and plan to
                6    visit and also which I review for reporting, I have done the
                7    same thing with my own little feeble handwriting on the map
                8    that is produced for me on the materials trying to identify

                9    locations, centers and so forth.
              10                This is very helpful 1 found but my request would
              11     be, could this kind of material be developed and -- and
              121    included in the review materials prior to the review, the
              13     site visit even?  I think they are that important.
              14                DR. SCHMIDT:  I think that would be a goal to be
              15     achieved.  Certainly the maps of the regions could be done
              16     for all regions that were coming up for triennial review and
              17     some of the funding history  and  particularly  things  like
              18     these pies that show that the whole  yellow  thing  was  the
              19     medical school and now the medical school has been cut down
              20     to a little piece of pie and I think  that  these  sorts  of

              21     visuals are great, and could be done in advance.
              22                MISS KERR-. For exarrp"Le Te.-&-as, as '.'Large ar, it
              23     I had to get some idea of locations of agencies and so
              24     forth prior to having a meaningful review from the applica-

  e -Federal Reporters, Inc.
              25     tio,-i.  So this would be very helpful.



      mea-9                                                                     40



               I               DR. SCHMIDT:  Let me -- I almost feel a   consensus
               2    of the group.  Let me ask for crit icisms; assuming  that  the
               3    committee does favor these, let me ask for criticisms of
               4    what has been done either in length of it or detail of it.
               5               This doesn't include the Rochester  one  which  was
               6    a 30-minute special but I am talking about the  five  to  ten-
               7    minute quickies and particularly for  other  information  that
               8    you would like to have that might be help ul.
      CR 7149
      End #3   9                Bill?





              12


              13


              14


              15


              16


              17


              18


              19


              20


              21
      0       /^- 2

              23


              24

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      CR7149


    #4 .-ter-1
                I             MR. HILTON: If overused  in  our  initial  enthusiasm
                2 with this kind of a "B" approach, it can probably, I think
                3 envision a'time it might become monotonous.  I think it is
                4 possible to guard against that if we are  aware  at  the  outset.
                5             1 would suggest restricitng the use of the particu-
                6 lar approaches in the overhead8 to the background data.  We
                7 have 50 local RMPs and even though we have been to the place
                8 before, individual members may have been there before, it is
                9 a good idea to have  that  background  refresher,  geoqkaphy-kind

                  of display of territory, Perhaps consider bui-I.di,n,a tip a ],,ibrary
              1.0

                  of that kind of data for each region.

                              I suggest, too, perhaps some variety, like for
              12
                  Hawai.'L, we hdd -- in add@-'on to the overhea@ we had the  l-ttle6
              13                           I L.1  L.                           L
              14  plastic what do you call it, topographical models.  That     kind
                  of variety and other approaches to variety would help minimize
              15
              16  the boredom of this kind of approach, I would think.
              17              DR. SCHMIDT:  I was hoping for some flowers, myself.
                              MR. HILTON: Yes, I would too, like  to  applaud  t  e
              18

                  staff for the effort and I think it is great.
              19
              20              DR. SCHMIDT:  All right,  Leonard?
              21              DR. SCHLERIS:  We had planned some really spectacula
                  events for  Hawaii. I can tell you we shared  every  bit  of  the
              23  Aloha spirit at our presentation yesterday, that we had in
              24  Hawaii.  Only those of you who were there will really appreciate
  ce- Federal Reporters,  Inc. what that alludes to.
              25





     ter-2



                               I think these are  excellent.  I  would  make  one  sug-

                 2 gestion, that is the value  of  putting  specific  numbers  that  we

                 3  are talking about on the wall chart that we    have.  It is really

                 4 a great help and I would  suggest  that  this  be  done  previous

                 5 to the meeting, perhaps, someone  on  staff  could  write  down  for

               -6  each of the regions, what has been the previous level of

                 7 support and what is being  recommended,  because  we  can  all  look

                 8 at the numbers together, and it furnishes a great deal of

                 9 value.

               IV              When you use a wall chart, just use a rougn draft

               11  on the over head, where someone  can  cross  it  out  and  modify

               12  it.

               13              DR. MARGULIES:  For one thing, as you have pointed

               14  out, these presentations are all on prime time, so the

                   question of durations is significant.  Certainly, the kind of
               15

               16  overlay and in-depth analysis for the beginning of a triennium,

               171 I would imagine is a first priority in putting this much effort

               18  into it.

               19              It emphasizes two things,  however,  and  I  would  hope
               20  that the review committee would help to guide us in one of
               21  them, rally, both of them; as much as possible.

                               There is always the risk i--n- presenting data 'in  a
               ?3  particular way as a  preparation  for  a  triennium  review  that
               24  we will begin to influence your thinking by the way in which

  -e-Federal Reporters, Inc.
               25  we put it together.





     ter-3



                             It was quite obvious for example, we were  making

               2 a point in presenting the Rochester regional  medical  program

               3  as a case study.  You could also see we could have picked other

               4 programs for that purpose. We are not  going  to  deliberately

               5  do that kind of thing,,but in the selection of data and present-

               6  ation, there is the risk that that will occur.

               @7            There also is a constant problem which will  grow

               -8 in time in selecting data with the knowledge that no  matter

               9  what we present, it is rather incomplete.  A case in point, I
               lu think of Te-u3         down a-L the end of the table representin

               11 the HEW REgional Office.
               121           It would be fine if we could, in some manner, have
               13 a concept of what else is going on in other kinds of  health
               14 activities within the region. To do that is  without  really
               I5 innundating you with materials extremely difficult.  But,  we
               16 are going to have.--to do something about how that might be

               17 achieved.

                             It would be very helpful if one knew that, what is
               18 going on in X areas or is not related to a lot of other things
               19
               20 which are underway or are intended from other origins.  What I
               21 am suggesting is sort of reorganizing the whole  Governmental

                  svstem in presentation,  We cannot do that.
               '12
               23            The other thing I would like to mention, we  have
               24 brought up and which Bob Chambliss spoke to you about,-yester-
               I
  ce- Federal Reporters,  inc. day, is the significance, under the circumstances, of the staff
               25






      ter-4


                  Anniversary Review Panel, because.if we are-to'continue  with

                2  the kind of staff review for those programs, which are not

                3 undergoing intensive review, by the review committee, it  will

                4 give us a greater quality of differentiation for what  really

                5 requires full-time by the review committee; what needs to  be

                6 referred to, and what does not present major problems so  that

                7 it can be kept in some kind of balance.

                8            Obviously, you are being burdened with some  heavy

                :9 responsibilities, and you will have to accept our kind of

                io discretion -@n developing for you wha-L. rieeL'As Lo come th'LS way,

                11 and what requires that kind of time.

                12           DR. SCHMIDT: I would like to comment on  the  Staff
                13 Anniversary Review Panel reviews from my perspective and  see

                14 if there is the consensus of the committee.  If not, we can

                - discuss the Staff Anniversary Review Panel  reviews  further.
                15
                16 To me, these have been very high-quality efforts by the  staff

                  and the reporting of these, the information that is in the staff
                17

                  summaries, the written word that comes to the committee that I
                18
                  look at gives me such a good feel for what went on with  staff
                19

                  in their deliberations that I can very quickly be  satisfied,
                20

                - or dissatisfied with what went on by my review of these reports.
                ?I
                             In the last number of vears, T ha-k7e detected no
                2
                23 dissatisfaction on the part of the Committee with this  Staff
                24 Anniversary Review Panel process, or the information it  gets

  kce- Federal Reporters, Inc.
                25 to the committee.






     ter-5


                               I think the Committee must  have  the  perogative  of

                2  asking for explanations for actions if they do not understand.

                   But, I don't think there is any need, right now, or any desire

                4 on the part of the  Committee,  to.@change.that  process,  or  the

                5  process of reporting the information to the Committee.

                6             That was what I expressed to staff during the past

                7  few weeks, and would ask  if  the  Committee  members  disagrees

                8  with that at this point?


                9             Warren?

                              DR. PERRY: I think, although we %@Ao A-LoL@. iieed,-You

                   know, no further approval, if we  all  agree  in  the  importance

               12 of the audio-visual, from  one  of  the  comments  made  yesterday

               i3 that indeed, the review process  might  be  more  open  and  less

               14  involved.
               15             This is another important reason to have this qualit),

               16  and kind of material. If  there,  we  can  anticipate,  you  can

               17  anticipate other people  around.  That  would  be  most  helpful

                   to have those kinds of thinas around, so that each person can
               18
                   respond in relationship to it.
               19

               20             Also, I think that there can be judicious choice on

                   the part of the staff as  Harold  has  said.  Perhaps,  for  the
               21

                   -triennium.  For the important ones.  Let us not get in the

                   habit of doing it for everyone, let us do it for those that are
               23
               24  really significant and.we need for the review.

  'e-Fedefal Reporters,  Inc.
                              SISTER ANN JOSEPHINE:  I would join the other members
               25








      ter-6
               I  of the Committee in complimenting staff on their presentation.

               2  And, as I have had an opportunity to function on this committee

               3 I begun to realize that the diversity between  the  regions,

               4  not in the area of needs.  That is quantitative rather than
               5  qualitative, but the diversity is rather in where individual
               6  programs are at the present time, as compared with other
               7  programs in an awareness of how to go about meeting the object-

               8  ives of the program.
               9             And I would think that this type of review, carried

              .^, on as part of the program should be very helpful to sL@.a-cL-Lc,,
              I u

                  because in putting myself into the role of a member of staff,

                  and sitting there and listening to this, I might well say, You
              12

                  know, in these two programs, that I am responsible for, these
              13
              14  efficiencies have been met very effectively and I need to

                  communicate them with those who are working with the other
              15

              16  programs.

                             And in this way we can really begin to share resourCES
              17
                  that are resources of the regional medical program. And  I
              18

                  think we have not done that as effectively in the past as we
              19
              20  can do it, now.  We,have reached a p6int'in,-E-ime, and it is
              21  really sharing facilities.
               11            DR. SCHMIDT:  Let me end this bv askina staff if
              2,L
              23  they have any questions of the Review Committee about the
              24  information or whatever?
  ce-Federal Reporters, !pc. If not
              25




                                                                            47
    ter-7



                I            DR. CHAMBLISS: I might say on behalf  of.tt&ff  that

                2  we do appreciate your words of approval for these efforts in

                3  the visuals.  Especially in the staff of the division of

                4 operations and development and DPT, but I think this  committee

                5 should know who has spearheaded this effort in terms o  t e


                6 visuals.

                7            I would like to just say Miss Judy Flasher, over herc

                8 at the door, has spearheaded this, and also with equal  assist-

              19  ance,"Mr. Frank Schniowski, who has provided the data for the

              10  visuals.  !,'rank is over here and you all know him.

              11             Thank you.

              12             MR. RUSSELL:  I would like to say one thing.  I

              13  think it would be helpful to the staff when on a.site-visit,

              14  if the site-visitors feel, if a particular visual would be
              15  helpful then this would give us direction, we would  appreciate

              16  it.

              17             DR. MARGULIES:  That picks up what I wanted to
              18  comment on, Dick, and that is that in the interest of  express-
              19  in  the kind of diversity which you spoke and Sister Ann,
                   .9
              20  everyone has recognized, if I get the sense of this  committee,
              21  you,will accept the idea that the development of the visual
                            a--'    -.ianner o4 4- is some-h'ng w@'cl- might conlinu4@
              2,4 &tl@ @@    &,-            -L L %.     I-L    A.A LaiLLi    t-
              23  to be left to the style, to the interest, to the motivations of
              1
              24  the staff people connected with the program.

  ce - Fedeial Repottefs,  Inc.
              25             I think that would be better than.to say, we have




     ter-;J





               I  one single format which we want to follow.  This will g ive  them

               2  a greater sense of involvement and I think, they can probably

               3  do better that way.

               4             MR. SCHNIOWSKI: Dr. Schmidt, as part  of  the  experi-

               5  ment we had one presentation given by staff, another one that

              .@6 was a ]oint-type, Staff Review Committee and a third one,

               7  by the Review Committee members.

               8             The Review Committee has commented on  the  audio-vis-

              @@9 uals. I wonder if we could find out if they  have  any  preferenc

                         -O,,tur-, as -Lo @l-,B                             to
              IV                           -ype of delivery they would like

                  see?


              12             MR. HILTON:  I would go for that second  approach.

              13  Specifically, with staff though there would be opportunities
              14  as Merle has already suggested, to someway propagandize present@

              15  ation to some degree, I think we will guard against it,

              16  particularly the staff covering those things that are of a
              17  geographical and demographic objective, reporting kind of
              18  nature with regard to the region, and with committee handling,
              .19 the other kinds of concerns were here to address.
              20             DR. SCHMIDT:  I like the quality of interchange
              21  with staff being part of the presentation.   I see all the  heaas

                  are aoina like this.

              23             DR. KRALEWSKI:  I have always liked to use slides

                                      While I agree, I think the background data
              24  in a presentation.
  ce -Federal Reporters,  Inc. is well presented bthe staff; I think it is useful as an
              25                     y





                                                                                 49
     ter-9



                  introduction.

                2             I think it is useful during the presentation  to  have

                3 the use  of slides, also,@:though, so really,@what we are  saying

                4 is part  of what I am suggesting is part of  each of these

                5  approaches we have previously outlined.

               @6             And I think that the site-visit is the tiffs to  out-

                7 line the kind of, kinds of slides, that you will  need  for  that

                8 presentation, because then, you can highlight some  of  the  parts

               .9 of the program you feel are necessary.

                              I think this gets away from the fact then,  that  the

               11 staff may be worrying about their slanting it in a certain

               12 direction.
               13             DR. SCHMIDT:  We will want to bring this to a closer

               14 quickly, then.

               15             DR. JAMES:  Yes, I have a very, very quick comment

               16 to make.

               17             Again, being new, I certainly enjoyed the audio-

               18 visuals yesterday, and I would concur that  the  joint  presenta-

               19 tion by Staff and site-visitors of the committee, make it a

               20 presentation; I also would like to comment that this kind of

               21 presentation with the broader presentation of actual figures
               22 on     '"card, helps one to L-'AeL@ e, rrLtine w'l-iere file leve'L o'L funding
               23 would be, because sometimes I see coming  about,  ceiling  figures

               24 that may apply to a funding, and I believe this would help to

  :e - Fedeial Repoftefs,  Inc.
               25 deter -the use of ceiling figures.





                                                                               .i v




     ter-10
                              A fiuke,out of the ceiling.

                2             MISS KERR: One other quick request, is  if  it  were

              .3  so that we  could have t'hese graphs prior to a site-visit,  and

                4 then if there were such changes as  were dramatic enough to show,

                5 could this suggestion be made by the visiting team to the

                  staff member, and the staff member, at  his  discretion,  then
                6

                  develop the second audio-visual for comparative purposes.@
                7
                8             DR. SCHMIDT: We will accept that  as  a  suggestion.

                              Sister Ann?
              '9

                              SISTER ANN JOSEPHINE:  Some of the regions are beg.
              10

                  ning to develop their own visual material, and it may well
              12@ be that some of-the visual material they have developed  could
              @13 be usea for this type of presentation, without  a  duplication

                  of effort.
              14

                              DR. SCHMIDT: I think Staff will  be  sensitive  to
              15
              16  that.
                              MR. TOOMEY: I would like to comment  on  the  fact
              17
                  that seems  to me that we are, -- we have been asked  to  look
              18
                  rather specifically, precisely, and indepth, at the    program
              19
              30  problems of the organizations that we visit and with  which   we
                  are concerned.
              21
              22              Then, in the course of our discussions,  we  begin
              23  to focus on projects that are part of that. Yet,  it  is  very
              24  incidental.  I cannot help but feel that the projects are
  ce - Federal Reporters,  Inc. extremely important in terms of ananlyzing the  congruence  of
              25





    ter-11



                   the project to the_program.  And, I am going back to Staff

                2  Anniversary Review Panel, because I think those reviews are

                3  great.

                4              I think, perhaps, the  most  effective  presentation

                5 on your charts have been the  changes  from  the  categorical  to

               ,,6 the multiples-kind of projects. And,  I  think  if  one  further

                7  facet of Staff Anniversary Review Panel  could  be,  because  we

                8  are not taking the time to review the  projects  in  any  depth;

                9  that they probably know them better than anybody else, and if

               10  they-could spend just a little bit of time on, or at least

               11  a comment in relationship to the project), itself, to the pro-     I

               i2  gram that we are most specifically concerned with.

               .13             Do I make myself clear?
               14              DR. SCHMIDT: Yes, everybody says,  yesit-and  it  is

               15  captured and-While you have your microphone on, let us turn
               16  then to Missouri and a brief status report from the site-visit.1
  -4/s-5                       MISS KERR:  I am assuming we need not do anything wi@h
               17
               18  that on our evaluation sheet, right?
               19              DR. SCHMIDT:  That is correct.

               20              This is for information.

               21




               23


               24

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               25




      CR   7149                                                               52


           4  -B
   follows   4-A
      by  TER  I             MR.-.TOOMEY: I visited Columbia a'month,  in  company

               2  with Dr. Thurman, Dr. Pellegrino, Dr. McPhedran, Donna Howseal,
         kar   1
               3  Dr. Farrell, and Judy Si-lsbee.  There has been a kind  of  major

               4  problem in the Missouri RMP.  Frankly, it has been a program ane

               5 'organizational kind of structure problem.
               6             For instance,. at the top level there is a problem with
               7  the regional advisory group.  It was initially established
               8  under Dr. Wilson in three parts.  It was a tri-part RAG.
               9             One part was an advisory council, the second part wa!
              10  project review committee, and third part was a liaison commute(
              11  which was project oriented. When these three  groups  met,  they
                  in a sense, represented the regional advisory group.
              12
              13             however, they met separately as well, and w4L$I-h the
              14  advisory council being only 12.people and with the project revi(w
              15  committee and liaison committee being made up  predominantly  of
              16  the prior groups and most specifically, of the University of
              17  Missouri people, it was a very closed kind of corporations
                  rather than an open advisory group with input from much other
              18
              19  than the University.
                             When this problem was called to their attention, their
              20
                  made the decision that the advisory council with 12  people  was
              21
              22  in fact their RAG.  In fact, it does not meet the requirements,
                  the legal requirements of a regional advisory group  because  it
              23
              24  does not have all of the representation,  even-the  legal.repre-

  e -Federal Reporters, Inc.
              25  sentation, Veterans Administration group, and I think  some othe;








          kar 21 Bill, what was the other?  'CHP  Agency?  In  addition  to  which

               2 it had only one minority  or  consumer  involvement.  It  was  one,

               3  one lead who was black and who was a   housewife, and  she  repre-

               4  sented the female, the black and the   consumer, all  by  herself.

               5              Their focus in the past had beeon on, naturally, the

               6  extremely categorical nature of the projects.  They had been --

               7 they had  been  very  equipment-hardware  oriented.  They  didn't
                                                               6

               8  have adequate goals, subgoals or priorities and within the past

               9  year, they have had a group headed by, I think it is Dr. Mare

              In  who has worked, 1 guess                        -nd c.-.tl.-.us-,--

                  in developing a set of goals and subgoals and priorities.
              I I

              12             However, they felt that the objectives that should

              13  oe established -Ln order to achieve these goals  should  not  be

              14  established by their goals committee and it should not be

              15  established by RAG, but in order to allow the local regions

              16  covered by the Missouri IZMP to give to the establishment of their

                  projects and their objectives, the local flavor that was necessary
              17
              18  they left the objectives out.  They felt very strongly   and
              19  organizationally they have six  or  seven  subregIions and they  haVE
              20  a part-time-"coordinator in each of these subregions and    they

                  felt-that each of the subregions was geographically so different
              21

                  and the needs were so varied that for a central group to establish

              23  the objectives for these regions  was  undesirable.  So  they  did

                  not -- they did nothing other than establish the major goals,
              24


  ,e -
    Federal Repofteis,  Inc. the purpose, the major goals and some of the subgoals.
              25




                                                                                   @54



          kar  31             Their major goals  are  the  enhancement  of  the  avail-

                2  ability and accessibility of health resources, enhancement of

                3 quality care and  the  moderation  of  costs.  And  they  have  under

                4  each of these major goals,,they--have sqbgoals to the.total of

                5  13.  Frankly, they have done an excellent job.  Their goals and

                6 subgoals are great. And  if  you  can  accept  the  fact  that-the

                7 regional area should be able, through its own input,-to establi,@h

                8 the objectives for that area to determine what its major objective

                9 would be, then it is not an inadequate or it is not an undesirable


                  approac4&.

                              The program staff was      had not had its organizational

              12  structure changed   from the time that it was categorical in,

              13  nature.  And I think I would put it in another framework.  They

              14  have  an  organization  which  is  inadequately  structure  to  carry

              15  Out the goals  and  subgoals  that  they  have  established.  They

              16  did not have an evaluative mechanism.

              17              A committee was established,  but  it  is  a  little  bit

              18  hard when you have no objectives to evaluate whether or not whal

              19  you are doing is being  accomplished  as  it  should  be.  So  the

              20  evaluation committee really exists in the same kind of a void

              21  as the specific,objectives exist..

                              We were concerned wi,tb the part-time rerlional
              22

              23  coordinators, and really  it  wasn't  until  we  had  an  opportunity

              24  to meet with these gentlemen, four or five of them being

  L,- Federal Reporters,  Inc.
              25  physicians, and retired   or semi-retired kind of situation.  And




                                                                                55




        kar   4   when we did meet with them, we found that they were; in my

               2  opinion, a very dedicated group of people.  The pro blems   that

               3  have existed really are the fact that they  were  part@time  and

               4  there it did take them a considerable amount of time  to  travel

               5  through the region for which they were responsible  to  relate  to
               :6 the priors and other people in that region and to  begin  to  draw
               7  out of the region the things that the region might do.
               8             They felt that they would be better if  they  had  some
               9  part-time help themselves-in terms of secretarial help  or  data

                  gather4-n,- or kind of -cople who were -- these with all physicians

                  and they felt they needed some nonphvsician help in  the  --  in
              12  their work. As part of the  organizational  structure,  I  think

                  that we looked ver hard at the coordinator,, and I don't -- I
              13  11
              14  think I would feel more comfortable .when I would say  that  they,
              15  and I quote from a review of their fifth  year  application,  site
              16  visit report in 171, "The site visitors  find  the  organizational
                  effectiveness of the coordinator weak.  The doctor is not- as
              17
              18  forceful an administrator as he could be.11@ And in"72  the rema.k
              19  is, "Other leadership is still considered weak.  Not  only  does
                  he exhibit through the lack of organization within  the  program
              20
              21  staff itself, but in addition to which he is  director  of  health
                  program for the University extension division and he is director
              2
              23  of a HSMHA contract in consumer education, and to  compound  the
              24  weakne.ss which seems quite apparent, he is now devoting only
  e -Federal Reporters,  Inc. 54 percent of his time to the direction of  the  Missouri  RMP."
              25








         kar   51            Now, the explanation for this is that  the  consumer

                2 project is operated through the University and  the  University

                3 has said this is congruent with the RMP program which is operated

                4 @throqgh the University and therefore, we will put it in RMP  and

                5 make Dr. Rickley the director.

              -6             These, I think, with the organization problems, the

                7structural  programs,of the organization, the lack  of  specific

                8objectives  even though the goals were considered to be --  in  my

                9opinion they have done an excellent job. I  think  each  of  these

              10 items      re-ortc--' d4---cc--'-,- L--o -their group.
                                            Y

              11             I would like to ask Bill if he would like to contribute
              12@anything to this, IBill Thurman?
              13             DR. THU@IALN: I think that I would just add  a  couple

              14 comments. Bob has outlined most of  the  concerns.  One  of  the

              15 members with us from council indicated, said this was    nothing

              16 more than a day-long feedback session which is really   the feel

              17 you got for what we did because it was at times very sticky,

              18 uncomfortable and at times they kept coming back to us with

              19 questions like, what is the difference in definition between the

              20 advice you send and the recommendations that you send.

              21             And we tried to respond to each of these and it was a

              22 long,-drawn out tyT)e of feedback session.  T tbi.nk that one
              23 thing that concerned them the most was whether or not review

                 committee and councils handling of the VAS situation should
              24
  ;e -Federal Reporters, Inc. have been clearer to them than it was, and Dr. Pellegrino's
              25







        kar   6   statement about that, and one of the reasons I have  been  con-
              2   cerned today and yesterday about out patting people on  the  back

              3
                  who haven't turned the corner is the Pellegrino statement that

              4
                  they have had hit in the head with a 2x4 and still haven't
              5   changed.

              6              So I think this was a  very worthwhile visit,  I

              7
                  wonder if we could have one word about  councils  feelings  about
              8   not concurring with'our recommendation last time  around  about

              9   triennial status for this group and I think the only other poin:

              10' 'O"- h a #@- 'rL would ad-"' to wll-,a,@ Bob 14-tan sa@" -1-c c-@ord4Lnatc--
              11  problem represents a significant problem and lead to our ultima:e

              12  recommendation.

              113,           MR. TOOMEY: I donit know if the  council  is  ramliiar

              14  with the fact that after the VAS proect, which  is  a  computer
                                                       I
              15  project, and Dr. Billy Jack's offi ce related to the medical
              16  school, council of the advisory committee had recommended  it  be
              17  funded no longer; then@a separate contract was signed with

              18  HSMHA in order to continue.

              19             DR. SCHMIDT:  Bill, what did you mean by your ultima,.e

              20  recommendation?

              21             DR. THURMAN:  Bob is going to present our recommend-,

              22  itioh in iust a minute. I am sure.
              23             MS. IIOUSEAL:  In response to your council about why
              24  council decided that, they felt withdrawal of funds in the amouit

  e - Fedetal Repoftefs,  inc.
              25  of a hundred thousand and the site visit would be strong enough,








         kar  7   and they though it would be too harsh to withdraw triennial
               2  status.
               3             DR. SCHLERIS: What will be the  result  of  this  site
               4  visit, I gather it is information only, or are there specific

               5  recommendations?

               6             DR. SCHMIDT:  I was a little puzzled, obviously,,

               7
                  again I am hanging on tender hooks because there was some

               8
                  recommendation made.

               9                                                        go
                            .MS. 'HOUSEAL:  The site visit team was to     out  and

                  carry.the message from  last time.  The recommendation had alrea y
              11  been met or set by review committee council-at:itheir-last
              12, meetings.  The program recommendation, those Mr. Toomey gave
                i
              13 regarding settling the RAG issue,  making  the  coordinator  full-

              14  time, making objectives more specific, evaluation section on

              15  core staff, the site visit made no funding recommendations.

              16             With regard to the computer contract, there was

              17  another site visit held by HSMHA officials this summer and con-

              18  tract funds of contract will not be forthcoming from RMPS for

              19  this activity, but will be supplied  by national centers for

              20  tesearch-and development.

              21             DR. THUF*IAN:  I didn't mean to leave the Chairman

              1)  IL-Langing in mid-air..  L 'L-.h-Li-ik -Uoiiiia has outlined our recommencti-,

              23  ations.

              24             A very specific request was made by the site visit
  L,- Federal Reporters,  Inc.
              25  team which Bob outlined to have a letter forthcoming  from  P14PS






        kar 8 1  outlining these specific forms.  My apologies to the Chairman.
               2             DR. SCHMIDT:  No.  Any  other  comments  then  before

               3  moving on?

               4             DR. SCHLERIS:  Does this  go to  council with a   re-
               5  affirmation of our recommendation from before, or is it     just
               6  where it was before, because I don't see where this is really
               7  more than,.YOU know, it might be well if you did this.  Funds
               8  have been our means for having some impact, however transiently

               9  on a region.
                             MRS.            I th4-k Dr. P,6-lle-rino, who used to bs-
              11 on the review committee  originally  and  council,  descrived  it
              12  best as a therapeutic site vis it.  There were indications, not
              13  only beforehand,, but at the time of the site visit, that letters
              14  that had come and advice that had come from the review committe@
              15  and the council, again, the site visitors looking over the
              16  material could not understand how the region could have failed
              17  to have gotten the message, but when we got there, we realized
              18  there was a filtering process and they had  failed  to  get  the

              19  message.
              20              So this was an opportunity to  have  a  face-to-face
              21  discussion, to make sure that  what  the-committee  and  council
              22  had been saying was understood by the regional medical program.
    E   4-B                   DR. SCHMIDT:  All right.  We will move on.
              23


              24

  e-Fedeial Repoiters,  Inc.
              25





                                                                             60


   CR 7149
               I               DR. SCHMIDT:  We will go onto Bi-State before
  iake 5
               2 coffee.
  .or 1
               3               'I guess we are still with Mr. Toomey.

               4               MR. TOOMEY:  The visit to Bi-State was in regard

               5 to an application for triennium status.

   xxxxxx      6               A review,'of the problems that existed with the

               7 Bi-State, Bi-State RMP, indicated first of all that the

               8 Regional Advisory Group had been relatively inactive;

               9               That there was a Scientific Educational Review

                                     L L
              10 "ounc-L-L, and an administrative liaison council made up of

              11 representatives from three medical schools, Washington

              12 University, St. Louis University, and Southern Illinois

              13 University.

              14               And the indications were that these two

              15 committees which review all of the projects made the basic

              16 decision and. made their recommendations then to the Regional

              17 Advisory Group.

                               And the record would indicate that the Regional
              18

              @ig Advisory Group met seldom or perhaps three, perhaps four
              20 times a year, and never for more than two hours at a time, and

              @21 with only approximately one third of the RAG members present.

                               This led i-nto the problem of the grantee
              2.4

                 organization, which was a joint organization, a so-called
              23
              24 consortium, made up of these three universities, who, as a
  e -Federal Reporters,  Inc. consortium, handle the grant funds for the Bi-State RMP.
              25







    dor

                                Another problem apparently was  the  internal".

                2  organization of the program staff, which was structured

                3  in such a way that all of the members of the staff reported

                4 to Dr. Stoneman, the coordinator  of  the  Regional  Medical

                5 Program.
                6               Additionally, because it was a Bi-State area and
                7 covered the area around St. Louis, Missouri, and, in
                8 addition, covered the southern part of Illinois, which
                9 included the state capital in Illinois, Springfield, where

               I  r% there was a concern hf-c-aii-,t-. f.-,he R-MP,, whi-,--.-h- -as a
               IV
               11 growing organization and more aggressive, increasingly

                  aggressive organization, was  concerned  because  the  state
               12
               13 capital O@L Illinois was rjeing covered by a Bi--State RiviP,
               14 rather than the Illinois RMP, as an expression of the

                  either of the agressiveness of the Illinois RMP.
               15
               16               They had just recently funded a project in
                  Southern Illinois which theoretically was in tetritory'.",.@-,,
               17

                  covered by Bi-State RMP.
               18
               -19              Finally there was a,concern about the relevance
               20 of goals and  objectives tothe  region's,health  care  needs.
               -21              The specific issues were -- with which we were
               91) concerned were the organizational  structure,  the  role  and
               23 influence of the  consortium,  the  internal  organizational
               24 problems of the program staff, the dispute over the Southern
  @e-Federal Reporters, Inc. Illinois area with the Illinois RMPL the role of the program
               25







     dor 3


                            committees and the adequacy of proposal development and review

                       2   process  and relevance of goals and objectives  to the Region's

                       3   health care needs,

                       4                          In the establishment of               the go&ls  and objectives

                       5    which  came  about March 1971,  their objectives  and priorities

                       6    were  groupd around six major areas.

                                                  @"Their first was manpower;
                       7

                       8                          The  second,  the health care delivery systems,

                       9    rural and urban;

                      in I                        Thikd.continuing ediir-ationi

                                                  Fourth,  medical  care,  primary,  secondary and

                            tertiary,  and the cardiovascular,  cancer,  stroke,  and other
                      12


                      13

                      14                          Fifth,  demography and statistics;  and,

                                                  Six,  medical information.
                      15
                      16                          And their priorities  followed this  ranking.
                      17                          We were  concerned about the categorial orientation

                            of the objectives,  recommended that there be deemphasis  of
                      18
                      19    the traditional categorical  interests.
                      20                          The objectives tended to reflect highly pre-
                      21    determined assessment of regional needs.
                      2?                          During the categorical period,  let m                    e say this:
                      23    one of the problems that had previously existed before the

                            Bi-State RMP came into being was the inability of the two
                      24
   ,e-Fedetal Reportets,  Inc. medical schools  in St.  Louis to relate to each other in
                      25





                                                                           63
   dor 4


               I  carrying on programs in an effective manner.

               2              The RMP during this categorical period brought

               3 these two medical schools together and their cancer and

               4 cardiovascular program seemed to be particularly successful.

               5              Their other projects that they had accomplished

                 were in the training of coronary nurses, and in a library
               6

               7 network which utilized the services of both Washington

               8 University and St. Louis University and spread through  great,

               9 I think, in terms of about a hundred hospitals throughout

              1-0 the region.
              11              During the past year the Bi-State RMP became
              12,linvolved in developing a major medical service emergency
                 project which was funded this past spring.
              13
              14              In the area of continued support, the radiation
              15 therapy program has become self-supporting.  However, it is
              16 being continued and the nurse coronary care unit is continuing.
              17              One of the projects that had been established

                 under the old RMP was a -- under the categorical phase of  the
              18
              19 RMP, was a project, Pruitt Sago, which is a housing section in
              20 St.. Louis.  There they had made an effort to establish a
              21 program and project which would provide health care services
               2 through the utilization of medical students and training  home
              23 health aides at that center to provide care to six thousand
              24 residents of the Pruitt Sago area.

  -e- Federal Reporters, Inc.
                              With the exception of thatproject, and  beginning
              25





                                                                            64
   dor 5


               I  to look at the problems in East St. Louis, there had been no

               2 indication of minority concern4or minority  interest  on  the

               3 part of the Bi-State RMP.  They  are now concerned  with  it,

               4 not only the urban health care,  but the rural health care, and

               5 they have -- part of their consortium  is  Southern  Illinois

               6 University, which, in its new medical program has adopted

               7 the -- its prime interest, that of developing delivery of

               8 health care services to the people in the rural areas in


              ,9 Southern Illinois.


                              And they now have five new pro'ects of the

                 Bi-State RMP directed toward the underserved.
              12,i            Dr. Stoneman is the coordinator of the Bi-State
              13 RMP, and I think we agreed that Dr. Stoneman was a very,

              14 very dedicated and very, @ery  fine,  dedicated,  intelligent


              15 person.

              16              However, it was our feeling that  he  was  over-

              17 stretched  in terms of attempting to relate to not  only  all  of

              18 the areas  in the two states, but he was on the  faculty  of  the

              19 St. Louis University.

              20              He carried, continues to carry on a practice in

              21 surgery to  Aminor degree, several hours a day, two or three

              2,) hours a  day, is what he has stated.

              23              And in light of this -- and he  also  is  president

              24 elect of  the St. Louis Medical Society.

  e-Federal Repoiters,  Inc.
              25              Consequently, he is in a position  where  in  light




                                                                             65
  lor 6


                 of his desires to relate individually to every person who

               2 works on the program staff and the outside activities, we

               3 felt that, as much as anything, that Dr. Stoneman deserved

               4 a deputy coordinator, somebody to work with him in the internal

                 organizational matters of the program staff.
               5
               6              The program staff, individually, as we  met  with
               7 them, and talked with them and listened to them, seems  to  be

               8 quite an excellent group of people.

               9              They had one organizational structural problem

                                                  -time assoc4---*- co-rdin-4--rs
              .o which related to the use of part

                 at each of the universities in each of the categories  and  in

              12 Southern Illinois, in their rural health care delivery system.
              13'             hnd it was our feeling that these part-time

                 categorical coordinators should be phased out and  that  full-
              14

              -  time associate coordinators, who would have an interest in
              15

                 the organization rather than in the category of medical
              16
              17 care, should be added to the staff, or should  be  substituted

                 for the part-time people.
              18
              19              As mentioned earlier, the RAG met just  three  or
              20 four times a year, and then for only approximately two  hours.
              21 Their attendance was minimal, only averaged about a'third.

                              As businessmen, which is where it seemed their

              23 greatest strength lay, they felt that they were in a  position
              24 where they should delegate to the universities, to the SERC
  -e- Federal Reporters, Inc. and the administrative liaison committee the work of developing
              25





                                                                               66
   dor 7


                  program policies  for  that particular' organization.

               2               And  they  did not feel that it was their

               3  responsibility to take  6-S active apart as we felt they

               4  should.  Consequently,   as we looked at both the RAG  and  the
               5  grantee organization, it was our feeling  that  the  influence

                  of the universities should be phased out of  that  program  and
               6
               7  one of our recommendations was that the SERC  would  be  phased
               8  out entirely and that the Regional Advisory  Group  would  be
               9  made more representative with more consumer interests and

                  minority involvement at the core !6vell
              IV
              11               And as part of our looking at  the  mechanism  by
              12  which our projects came through the various committees to
              13  the Regionai Advisory Group, Dr. Mitchell  awnd  Maria  Flood
              14  reviewed, they did an audit-tra'll, if you will, of two of  the

                  projects, and I might interrupt and ask Maria  Elena  if  she
              15
              16  would like to comment on the trailing of the projects?

                               MS. FLOOD: There was some concern  by  the  siz:e
              17
                  visit team that the university had  exerted  some  tremendous
              18
                  pressures to be assured the projects were named  only  at  the
              19
              20  medical school emphais but,.-'indeed, as we went through  the
                  review process, we didn't find this to be '-.true and  rather
              21
                  found that perhaps the medical schools, the universities,, had
              23  lacked support in helping them develop  mechanisms  for  proper
                  review, but there were some glaring deficits  in  the  review
              24
  :e-Federal Reporters, Inc. process we encountered.
              25






                                                                               67
  ,,or 8
                                We were not provided with the  cover  sheet  that
                2  the regional Advisory Group meeting, page-one of the Regional
                3 Advisory Group meetings'--that we reviewed, which  carried  the
                4 names and attendance records.
                5               We were -- all three meetings,  the review
                  started with page two.  It could have been an oversight.
                6
                7               The review process reflected some deficits in the
                8 fact that if  the reviewer felt that there were conditions
                9 to be met by  project proposals, there was no documentation
              10  that this information ever got back  to  the  project  proposer
              11  or that, indeed, funding was not approved until these
              12i conditions were met.
                                We thought of two studies, one be-Lng a  medica!L
              13
              14  school oriented,three-pronged nurse-physician assistant type of
                  concept, which was originally rejected and then subsequently
              15
              16  resubmitted with a little different approach and was approved

                  on the second review4
              17
                                The other project was a  very  poorly  documented
              18
                  project from a minority impact area, had to do with t e
              19
              20  educationallvfacilities for allied health training, and it was
              21 one of the problems we encountered in this, that there was
   0              no formal development of a format for submission to projects.
              23                Our opinion reflected some deficits in the
                  management capabilities of the staff  in  developing  a  format
              24
  e- Federal Reporters,  Inc. for proposers to follow and formal  structure  for  the  review
              25





                                                                             68

   dor 9


                I  process.

                2              MR. TOOMEY:  Thank you.

                3              Certainly,-'the prior groups were involved,

                4 including the comprehensive health planning agencies.

                5              As a matter of fact, the  relationship  was  be-

                6 ginning to be so close and PMP  was  sufficiently  interested

                7 in continuing this and working closely with the Comprehensive

                8 Health Planning Agency that they recommended to  us  at  the

                9 time that we arrived there that, or  they  didn't  recommend,

              10  thev requested that wp ai.vp                to a funding  to
              11  strengthen and to allow the  Comprehensive  Health  Planning
              12  Agency to continue to become more and more  involved  in  the
              13  In A-lelp@Lng in Au-'ne assessment of needs and in t'l-le planning

              14  for the  area.

                               They used the Comprehensive Health Planning Agencies
              15
              16  to the extent that it is possible to use them now.  They see

                  that it is possible for further developments to take effect
              17
                  with the Comprehensive Health Planning Agency and they would
              18
              19  like to make them an-&ctive ally and provide them with some
              20  funds to enhance that whole record.
              21               As a matter of fact, as they  assess  the  needs
              22  and resources, they felt that this continued active
                  cooperation between RMP and CHP should be encouraged.
              23
              24               Their program staff monitors all projects.  They
  ;e -Federal  Reportets,  Inc. control the financing. They monitor the fiscal affairs.
              25





                                                                                   69

   dor 10


                                Another problem that  they  had  was  the  planning

                2 and evaluation was in the  hands  of  one  person,  a  one-person

                3 department, and they felt that even though this person was

                4 a well-qualified Ph.Dj that this perhpas should be split.

                5               Bi-State RMP has developed an action plan and from

                  the application and  presentation  of  the  visit,  appears  sound
                6

                7 and includes several excellent components.

                8               The RAG has  assigned  priorities  to  the  objectives

                9 and they rank health  manpower  and  health  care  systems  highest.

               ,tf%,Continued education and catogor4-----l disease strategies  were


                  lowest.


               12               Their immediate priorities include data base

               1.3 improvement, primary  care  strategies  and  medical  information

               14 systems.

                                We believe that  the  REgional  Advisory  Group  needs
               15
               16 strengthening and they need to direct, need to direct themselves
               17 to do a more adequate job of meeting the needs of the

               18 region.
               19               Now, much of this sounds,  in  a  sense,  it  sounds
               20 negative and I think, I suppose it is easier to pick the
               21 program apart than it  is  to  promote  its  strengths  but  they
               ),)Ihave done an excellent job with the development of their

               23 goals and their objectives.
               24               They have disseminated  these  goals,  they  have  A

  -e- Federal Repofters,  Inc.
                  mailing of 8000 organizations, and institutions and individuals.
               25





                                                                             70
  Lor


                              In addition, to the dissemination of this

               2 information they used an interesting mechanism  of  requesting

               3 back from the people to whom they mailed this  information

               4 requests for projects and programs and specific  areas.  T  ey

               5 felt they coudl establish a program of providing, if you will,

                 it was mentioned yesterday as "mini-proposal,"  but  these
               6

                 are a little larger than the five thousand  dollar  proposals,
               7

               8 these would be $25,000 proposals, and at the end of the  year,

               9 they would have, through their evaluative mechamism,  they

             lo  would be able then to.focus in other ones which were  most

                 promising and most desirable.

             12               The staff, as I mentioned before, was  excellent.
             13' They have one tanker of the staff, a Black professional, wno is
             14  extremely interested in the problems of the innercity  and  is

                 working with groups in East St. Louis and in the Pruitt  Sago,
             15

                 and in the .@tqhole Bi-State area, to develop projects which
             16
             17  would be of assistance to the minority groups, their health

                 service education activities, the non-AHEC, if you will.
             18
             19               The AHEC which is non-AHEC, is in the hands of

                 a new person, who is a Ph.D. in education and has  begun  some
             20
             21  programs in this area.
             22               Their work in the emergency medical services  was

                 excellent.  They received, I believe, about a quarter of a
             23
             24  million dollars to carry on this, or to initiate more planning
  e -Federal Repotters,  Inc. in this and the development of a larger program in  this  area
             25




                                                                                                                                                          71

       dor 12


                               I  then.

                               2                             Their review of projects has certainly

                               3  improved, also.

       end 5                   4


                               5


                               6


                               7





                               9


                            in





                            12


                            13'


                            14


                            15


                            16


                            17


                            18


                            19


                            20


                            21


                            22


                            23


                            24

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  CR 7149                                                                 72
    6
   eak
                             In brief, it was our feeling that the organization,
              2  while it does exhibit some weaknesses, that with the addition
              3  Of a coordinator, deputy coordinator -- let me go over it
              4  this way.  We feel that Dr. Stoneman and his staff have the
              5  capability, professional qualifications and interest to build
              6  a first rate RMP.  The goals, objectives and plans were rele-
              7  vant and sound.  It has some organizational problems which
                 presently hamper its growth but with a deputy coordinator,
              8
              9  the reorganization of RAG and broadening of the involvement of
                 -,--ople in the area, we think it has a great potential.  We also
                 felt triennial status should not be withheld because of the
             121 weaknesses but rather it should be approved on a tentative
             13  one-year basis -- if it is triennial status, but with the
             14  recommendation that it be'reviewed-.at the end of the year.
             15  The recommendation for the request for funding was for a
             16  million four, the first year, a million 463 the second year,
             17  a million five the third year.
                             Our recommendation was a $lil5O,,OOO be approved
             18
                 for the first year, $1,230,000 the second year, $1,316,000
             19

                 the third year.
             20
             21              This includes funds for a deputy coordinator
                 and a $50,000 discretionary fund for Dr. Stoneman.  Dr.
             22
             23  Stoneman's concern as far as the developmental component as
             24  opposed to having his desire for developmental component
  !-Federal Reporters,  Inc. was in order to contend with the problems that existed in
             25





                                                                             73

   e -ak 2
                 the fact that Illinois RMP had developmental funds and he had
              2  none and he wanted to be in a position to handle new projects

              3 as they came up when they came up.
              '4             DR. SCHMIDT:  Thank you.  Secondary reviewer,

              '5 Dr. Thurman.
              6              DR. THURMAN:  I will have very little to add to
              .7' what Bob has said.  I think just because of the fact that the
              8  Missouri site visit came on at the same time the turf question
              9  will become a major question and we heard some question of
              --I --n-ern .7hen we       Missouri because of their interrelation-
              lu
                 ship with Bi-State.  I think the question of the coordinator
                 probably needs discussion by the whole Review Committee because
              1 2
                 of the points that Bob has raised.  And I don't think any of us
              13
                 would disagree that if he is to continue in his present
              14
              15 action, that a very strong deputy director is needed.  Lastly,
                 my concern, as already reflected by Bob, is the continuing
              16
                 project-type orientation.
              17
              18              It would appear that this tripartite of'RAG.
              i
              19 basically and their appointment of associate coordinators,
              20 if this is not constantly monitored by staff, will perpetuate
                 this-type of categorical approach.
              2 1
                              MR. TOOMEY4  I might ask Maria Elena if she wants
              t- 4
              23 to add anything to this?
              24              MS. FLOOD:  Well the only comment I might add is

  'e- Federal Reporters, Inc.
                 that we got  the feeling the first day that there was a strong
              25




                                                                                   74


    eak 'I


                I  staff capability and this was definitely reenforced as the

                2 visit progressed.  But  the  management  problems  are  acute,  and

                3  there has been comment here at this committee that you can't

                4 correct a weak coordinator with a  strong  deputy  but  in  this  case

                5 Dr. Stoneman is not really weak.  It has just been his insecurity

                6 without someone under him to allow the staff to develop

                7 the mechanism of interrelationships.  They come to him, they

                @8 answer to him, they report to him.  If he were gi   ven  a  strong

                9 deputy that could  pull  together  the  management  trends  necessary,

                10 I feel strongly personally that this particular staff,

                11  under the leadership of Dr. Stoneman, could indeed develop the
                12,lprogram and follow the recommendation that we made to begin
                13 a trend towards an improved  RAG  commitment  and  RAG  participation

                14 in policy planning and in goals,objectives, and also broaden

                15 the scope of the program to really become a program and

                16 deemphasize this mini-project advertising that they have used.

                17             DR. LUGINBUHL:  It is, of course, difficult to

                18 judge a program without having visited it and just from

                19 hearing discussion and  reading  the  documents.  I  hope  my  remarks

                20 are not overly critical but I can't help but raise a number of

               -21 questions from the comments that I have heard and from the

                      'ew ol @'e material Li-iaL we liave-.
                22 revL      t-IL

                23             First of all, it appears to  me  that  there  is  some

                24 problem with this consortium, and I  wonder  who  is  minding  the

  @e -Federal Reporters,  Inc.
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                                                                                75



     eak 4        in this.  I asked yesterday specifically who has the authority
               2 to replace a coordinator that is inadequate and I was told
               3 that it is the grantee.    I am not quite clear, who is the
               4 grantee in this case, and  who has the authority?  Who makes.
               5 the decision?  You have got two vice-presidents of health
               6  affairs at large medical schools, another developing medical
               7  school involved, but who.actually makes the decision, who moni-
               8  tors this program, that is question number one.
               9              Secondly, I can't help but have some question about
              I-- the coordinator.  After a day and a half, I am beginning to
                  think that the terms hard working and dedicated are euphemisms
              12 for incompetence and I can't help but think that the suggestion
              1'3 that a deputy coordinator be appointed is simply a way of
              14  patching a very worn tire.  I may.be wrong in this but
              15  I can't help but raise this question.  From my point of view,
              16  a strong coordinator, a good coordinator is not necessarily a
              17  person who is a strong individual or who has a great deal of
                  personal dedication.  I think one of the most important
              18
              19  qualifications of a coordinator is the ability to delegate,
              20  is the ability to organize and motivate staff and when I hear
              21  the coordinator has not developed staff, that he does reserve
              221 judgmeInts for himself, then that.to me raises very serious
                  questions and I think that is a very serious deficit to try to
              23
              24  correct with a.deputy..

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                              If he hasn't seen this need himself and developed
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                                                                             76
    eak 5



                 the ability to delegate, I think that it is difficult to

               2  force this by the appointment of a deputy.  Finally, I would lika

               3 to raise a question about-the budget.

               4             I see that the coordinator is listed as  93  percent

               5 effort but I read in the narrative that he is a practicing

               6 plastic surgeon.  I can't help but ask,.what is the control that

               7 we have over this man's total income?  I don't know what the

               8 relationship between this program and the consortium is, but if

               9 there is simply no limitation on his outside income and the'  93

              10 percent figure means very, very little, then I can't help but

              11 be worried about the amount of effort he puts into  the  program
              12iand the amount of time he puts into his private practice.
              13             In summary, I would like to know who runs the

              14 consortium; I would like to hear a little  more  conversation

              15 about the real ability of this individual to run this

              16@ program.  And I would like to have some further insite into the

              17' financing.

              18             MR. TOOMEY:  The consortium has agreed that

              19 Washington University will be the grantee agency.  And they have'

              20 an arrangement through which Washington University is the,

              21 really, grantee agent,  although the three do work together,

              22 but -Lt -'Ls Wa:61iington University. Dr. Guzzi, I believe,  was

              23 the name of the man from the medical school who  is  responsible

              24 as far as Dr. Stoneman is concerned. You know,  as  a  fellow

  -e -Federal  Reporters,  Inc
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    eak 6                                                                   77



                 circumstances.
               2             However, there are some circumstances and this I
                 have seen, that people have varying-degress'or varying kinds
               3
               4 of abilities.  Dr. Stoneman's ability is one in which he became
               5 a participant in the program as a volunteer member of the
               6 faculty when he was a member of the faculty of St. Louis
               7 University.  He is thoroughly dedicated to its goals, even its
               8 present goals.  He is, I would say, an extremely capable person,
               I although to be honest with you, he would be better off if he
               9
                 were trained in management rather than in surgery.

                             But he has been trained in surgery and within, if

                 you will excuse me, those limitations, he does a rather
              12
                      -u- 2-.1-1 ol job. "e does     surrteljij'y wi,@ L--Zi-neu
                 f lul-
              13
                 in administration who understands the kinds of things that you
              14
                 are talking about to work with him.  He relates well to all of
              15
                 the universities.  He relates well to a3.1 of the other
              16
                 physicians.  He relates well to his own staff.  They are
              17
                 extremely loyal to him, I think in every way, by every
              18
                 indication. @He relates extremely well to the, if you will,
              19
                 the power, the financial and economic power structure in
              20
                 the community.  They have a great deal of faith in him.  Perhaps@
              21
                 too much


                             I think this is orie of the cases unlike the
              23
                 neighbor that he has in Columbia, Missouri, where I think the
              24
  @e- Federal Reporters,  inc. administration does not have these abilities. As far as the tim(.
              25




                                                                           78


       7
              I  is concerned, we did ask him about this and he, his work
              2 is done basically at night and on weekends as far as his  home
              3  surgery is concerned.  I know it is aproblemand I don't
              4  know any way around it but he says that in order to supplement
              5  the income that he receives from the RMP, that he continues
              6  a small private practice.  He also does continue with his
              7  teaching at the St.Louis University.
              8             DR. PAHL:  Doctor, I would like to comment on
              9  Point 3. You raised the question about what the control  is
              10 O-,7er tt'te total'. inco,-,,e c@4 coordinators.  At the -resent
                 there is no policy within RMPS, HSMHA, or department that I
              12 know of that provides any control over total income, other
                I
                 than the usual ones of not being reimbursed twice for presumably
              13
              14 the same time expended.
                            However, there is increasing concern being expressed
              15
                 and much more so in recent weeks from both RMP and also the
              16
              17 department andwe have been interested in this matter for quite
                 a while ourselves.  Not so much the total salary as the matter
              18
              19 of part-time direction of RMPS programs and whether  programs
                 which are running at $2.,million a year can, in fact, be
              2 0
                  ffectively conducted without the full-time direction of
              21 e
   0             the chief executive officer.  It is almost impossible for
              /^- 2 1                                         -            - 1
              23 any single program in HSMHA to write a grant management
              24 policy about salaries because you are very familiar with  all
  :e- Federal  Reporters,  Inc. the problems involved with time and effort and we just get into
              2 5





                                                                              79


               I  atremendously complicated activity.  But  I should  say  that
               2  there is very serious concern on the part of people within
               3  RMPS and at higher levels about the costs of managing a program
               4  and the results for the monies being expended, and what consti-
               5  tutes good management.  And I think therb.are continuing
               6  efforts that are partially underway now.  We have some
               7  analyses going on now and I think we will be trying to develop

                  some reasonable kind of statement so that we can improve
               8
                  the management of these programs without at the  same  time
               9
                  trx,ing to impose nonworkable definitions of-ti-me and effort that'
               ^v  .1 -

                  NIH and others have found so impossible to@implement.
               12             DR. SCHMIDT:  We have two or three issues on the
                1
               13 floor.  One other one that has been brought up is whether this
               14 region really is ready for triennial status given the stated
               15 efficiencies in the review process particularly in the area of
                  discretionary funds and whether they have the adequate
               16
               17 review and decision mechanism that even meets  the  minimal
                  standards set by RMPS for the use of  discretionary  funds.
               18
                              MR. TOOMEY: Let me comment on  that  a  moment,
               19
                  because there was difference of opinion as to  its  xeadiness
               20
               21 to assume the responsibility for a triennial  status.  And  I
                  guess what we did was to compromise the situation  which  was
               23 to say, triennial status but review at the end of  the  year.
                              DR. SCHMIDT:  Sister, were you,going to comment?
               24
  ce- Federal Reporters,  Inc. SISTER ANN JOSEPHINE: Yes, I,would  just  like
               25



   eak 9                                                                     80


               I Mr. Toomey, has this program done anything to provide services

               2 in Cairo, Illinois?  I know this was requested.

               3             DR. SCHMIDT:  The answer  is no.

               4             John?

               5             DR. KRALEWSKI:  Just a couple of  questions and

               6 comment here that might go along some of the  lines you were just

               7 outlining but on the budgets it wasn't clear  to me whether we

               8 were giving them money to add staff.  You  were  recommending

               9 $750,000.  They were running 517 or something such as that, the

               10 way it looks.  Could you,clarify that for me quickly, what will

               11 they be able to do with the 750?  Along with that are you
               121recommending developmental component?
               13:           MR. TOOMEY:  We were recommending full-time people

               141rather than part-time people as associate coordinators to
               151 replace the part-time coordinators that were at Southern-Illinoi.,

               16, and at the other universities.

               1'7@          Rather than having them as linkages to the

               18 universities, having them in the area of rural  health,  urban

               19 health and taking a segment of the responsibility for the
               20' structure, itself, we were recommending in addition  to  that

               21 only,the deputy coordinator.
               22            DR. KRALEWSKI: Do you recall how  many  FTEs  that

               23 would add?

               24            MR. TOOMEY:  Four.

    Federal  Reporters,  Inc.
               25            DR. KRALEWSKI: Four?  And  were  you  recommending





                                                                                8 1



    eak 10
                  developmental component?

               2              MR. TOOMEY:  No, no    I, guess it is semantics  but

               3  it is called discretionary  funds.

               4              MR. KRALEWSKI: One other comment  I  don't  know  if

               5  I am reading this data, you know, from our book here

               6  right or not.  But it seems to me that last year in terms

               7  of the award that we gave them which  essentially  was  supposed

               8  to be used for, you know, for the, to carry on their

               9  program, develop some other projects then d  evelop a three-year

              10 'program for us.  It appears that they implemented some 22 pro-

              11  jects with it at very low level funding and now  we  are  coming
              121 back this year and asking to increase that low level funding
              13  for all but two of the 22, up to, you know, much more substantial

              14  funding.  And I ra ise the question over whether,you know, that

              15  indicates any real, you know, ability to really handle

              16  the question over what projects should we implement and how

  @6          17  should we best handle some funds.

              18


              19


              20


              21




              23


              24

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                                                                               82
      #7

        arl     I             MS. HOWSEAL:  This region had its budget stated

                2 for three months in order to phase into  our  three-cycle  review

                3 process, and they operated with the funds   to discontinue some

                4 of their old process and initiate some of   the new ones  with

                5 this last three months funding, and they did it only with the

                6 three months period knowing the projects could be turned off

                7 if the reviewers felt they didn't have merit, but it's not

                8 any -- they aren't projects started a year ago,  they  are  brand

                9 new projects being started the last three months of this presen:

                IC) year, and it is because of our need to bring the  region  into  a

                11 different review cycle that that this was done,,  not  because
                12 @l of the --
                13            DR. KRALEWSKI:  22 projects?

                14            MS. HOWSEAL:  Not only 22.  Some of those were

                15 held  over  from the last year.

                16            DR. KRALEWSKI:  They don't show that un ess

                17 well, I  may  be reading this wrong.
                18            MS. HOWSEAL:  The printout probably doesn't   show
                19 when these projects were initiated. If  they  were  initiated
                20 during the last three months, the printout would  probably  show
                21 they started at the beginning of the year, when in reality

                  they would onl,, -c4-- -@,-,nd4ng starting October.

                23            DR. SCHMIDT:  Dr. Luginbuhl?
                24            DR. LUGINBUHL:  I would like to ak a question,
  ,ce - Federat Reporters,  Inc. point of information. I am lcoking at the budget in the actual
                25





                                                                        8 3
         ar2

               I  grant. I note that the budget in the actual grant  lists  a

               2  number of associate coordinators, but they are  categorical.

               3  They are not the kind Of associate coordinator that you  are

               4  recommending.

               5             If this award is made under the terms that  have
               6  been outlined, what assurance do we have that they will hire
               7  the kind of associate coordinator that we are  recommending

               8  as opposed to going ahead with the budget?
               9             I am trying to get some feeling for what authority

                  this recommendation has, and I am asking this  particularly

                  because I got the impression that this program had been given

              12  some guidance in the previous year about the need for re-
              13  structuring the organization, and apparently did not follow it.
              14             MR. TOOMEY:  I don't know that it had the instruc-
              15  tions of the previous year, and I really can't answer honestly
              16  the fact that they will do what we say.
              17             I would assume if you tell them that this  is.the
                  basis on which the funding has been made that they will
              18
                  consider it directly enough. I don't think they  have  much
              19
              20  alternative.
              21             DR. SCHMIDT:  Seems to me at this point to
                  enlarge a little bit on your question, that what has been
              23  recommended as one-year funding level was site visit, and so
                  in theory, staff, et cetera, would carry back to the  region
              24

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                  the strong concerns of the committee and the assurance  that
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                                                                                  84
        ar3

                   the committee would be looking at  what  they  have  done,  during

               2   the coming year.  And the  stick       that one has is the

               3   funding level or  the second and third  years  of  the  triennium,

               4   if you wanted to  use a bigger stick, what the committee
               5   could do would be to recommend withholding the triennial

               6   status and give them one more year, and have them revi@e
               7   the trienn@al application and come in  in  one  year  with  the
               8   triennial request.  That would be a bigger stick yet.

                               Let me just ask a very  simple  question  that  hasn't
               9

                   been asked for a vear or 5o around th3s table, but -IS  thl-l@,
               .ol
               11  a viable region?
               121             MR. TOOMEY:  Yes.
               13              Tha-L".,s a s-Lmpie answer. But you have got  interest
               14  in the community, you have got interest  on  the  part  of  the
               15  medical profession, you have got a  great  thrust  coming  out  of
               16  southern Illinois, as I see it, in the future.  You have,
               17  you really have. A personality of  the  man.  He  is  a  good  man

                   running that RMP.  You have got capable, qualified staff.
               18
               19  You have got an  interests  education.  You  have  --  you  really
               20  have the backing of those three universities.
               21              One of our concerns had been that the university
               22  was exercising too great influence.  In actual fact what
               23  they were doing was  evidencing  great  interest.  Now  at  the
               24  time that it was categorical, I am sure there was great
  ce- Federal Reporters,  Inc. influence coming from the university in terms of their
               25





                                                                            85
      ;4r4

               I  projects.  Right now what you have is great interest on the

               2  part of the university in extending its own services and its

               3  own concerns through RMP.

                             So I think there is no question, as I look at the
               4
               5 total picture that this is a very viable organization.  This
               6  was one of the reasons why despite our discussion as to
               7  triennial status that we felt with all of these pluses,
               8  despite the fact that you can focus on the minuses very
               9  easily, in. light of all of the intangibles, that this  has

                  pol-en@,
              10       .-J-al&ly a great 'Luture.
              11             DR. SCHMIDT:  Do you feel that the turf problem

                  with Illinois is a minor one or moderately serious  one  or
              12

                  very serious one?
              13
              14             MR.' TOOMEY:  Well, I don't know how to evaluate it.
              15  We talked to Dr. Snoke who was out of the governor's office.
              16  He is not ready to make the decision himself.
                             DR. SCHMIDT:  Dr. Snoke is totally confused by the
              17
                  whole thing.  You wouldn't be able to get anything but confu-
              18
              19  sion out of Dr. Snoke.
              20             MR. TOOMEY: Certainly  the  recommendation  that
              21  the-two groups get together and there is some indication

                  that can declare areas of urimarv con
              22                                        c(-rn wbi,c-b would be
                  southern Illinois for the bi-state RMP, and perhaps what we
              23
                  might call a DMZ in the Springfield area in which there would
              24
  :e-Federal Repoitets, Inc. be some concern on the part of both Illinois and bi-state.
              25





                                                                            86

   ar5

                              But, you see, southern.Illinois is up in the

                2  Springfield area and relates to bi-state as far as its school

                   is concerned so that there are  some problems, and this perhaps
                3

                4  would be one of those areas in  which there is an acceptable

                5  overlap.

                6             DR. SCHMIDT:  Dr. Thurman?
                7             DR. THURMAN:  I would just agree with Mr. Toomey's
                8  analysis.  I think in answer to your question, it is a
                9  viable region.
              io              My sc.--.nd question there, is tl-lere a motion on the

              I I  floor?
              12              DR. SCHMIDT:  Yes, there is a motion on the floor
              13   made by the principal reviewer.  I am not sure it was seconded.

                   I will ask at this time if the motion which was to-wit,
              14
                   "approval of the triennial status without approval of the
              15
              16   developmental component, but with discretionary funds to the
              17   tune of 1.15, year one; 1.230, year 2; 1.316, year thre  e"

                   is that the motion?
              18
              19              MR. TOOMEY:  With review at the end of the first

              20   year.
              21              DR. SCHMIDT:  That's correct, with review, with
                   a site visit?  In one vear -Drior to the maki-ng of t--be- -,ec-.ond
              2/--
              23   year award.
              24              Is the motion seconded?
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                                                                             87
        ar6


              I              Dr. Thurman?


              2              DR. THURMAN: I would like to'offer  a  substitute

              3   motion going along wit@ the funding, but withholding triennial

              4   status with preparation of a triennial application for  next

              5   year.

              6              DR. SCHMIDT:  All right, is there a second?

              7              DR. LUGINBUHL:  I will second.

              8              DR. SCHMIDT:  Substitute motion is seconded.

              9              Let me ask someone whether or not this would  cause

             I 0  some breakage or to what extent would this be Li'@iouLjlit

             11   detrimental?

             12              MR. TOOMEY:  I think I'd defer this to somebody

             13   who knows the area better than me.

             14              MS. HOWSEAL:  Well, there are two sides of the

             15   story.  One is the tougher problem and how this will be

             16   settled in the next year. That obviously is  a  consideration.

             17              The second is that this region last year came  in

             18   with a triennial application and staff said that at that time,
             19   is that correct, that they weren't ready foi triennial  status

             20   at that time, and held them off an additional year?

             21              Their program plan seems pretty well 3n order.

             221  But it is the organ3zational pro lems that need to  e wor e  on

             23   1 think it

                             DR. SCHMIDT:, The question is, breakage  damage
             24
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                                                                          88
        ar7


                             DR. LUGINBUHL: I have heard  discussed  several


              2 times in the last day and a half this  question  of  breakage,

              3   or injury to a program-by the use of too  severe  measures

              4   to try to bring about remedial action.  It appears to me the

              5   two measures that are available are., one, some form of budget

              6   reduction; and, two, 'Withholding triennial status.  I would

              7   gather that both of these have been employed on a number  of

                  occasions in the past. It would be very helpful to  me  in
              8

              9   voting on this kind of a question to get some indication  of

                  what kinds of damage have actually been observed from  these

                  classes of action in the past.

              12             In other words, has this really resulted in
              13  S"Lgn--!-rj'-cai-.lL injury to some programs, or is this a concern that
              14  possibly has been weighed too heavily?  If that is the case,
              15  it would obviously indicate to me that we should use these
              16  measures more freely rather than less freely.
              17             I just don't have any feeling for what  effects

                  these actions have been on programs and just how real a throat
              18
              19  it is.
              20             DR. SCHMIDT:  I will try to answer that.  I think
              21  that as you hinted at yesterday, the committee during  the
              22  five or six years that I have watched it, has  chosen  the
                  route of not stressing region, if there was a question of too
              23
              24  much breakage, it opted not to stress the region  in  that

  :e- Federal Reporters,  Inc.
              25  way. Usually other routes for effective action  have  been





                                                                            89
    ar8


                  taken.  Either the chairman of the site-visit committee,

              2   such as Sister Ann, or the director of the program, or

                  somebody went out and got to the people who had to listen
              3

              4   who were in a position to do something.

              5              Then either the coordinator was removed or the RAG
              6   chairman was removed or the RAG structure was  altered.  But
              7   I don't think that a club has been used with enough force

              8   in the past, to answer your question.
              9              The committee, if it's erred, has erred on the side

                  of be4-.,- --on--c--vat,
                                    -I."C,.,Uslng these other routes to get Li-le.
              10'
              11  messages back. And I -- actually the committee  has  talked,
              121 and staff knows the talk about stopping funding  completely
              13  of a region, for example, withdrawing regional status,  let
              14  alone, you know, something else.
              15             And these methods have not been used for  really,
              16  if you look back'the regions, Indiana will be coming.up,
              17  which has more or less a cataclysmic  year that was achieved
              Ig  really through two site visits in a row, and we will be talking

                  about that.
              19
                             So that I ask the question quite deliberately from
              20
              21  my experience, that sometimes you will run the danger of
                  the RAG or some of the critical Deonle iust throwing iip their
              22
              23  hands and saying the hell with it, and going away.  And  we
              24  haven't taken that risk deliberately in the past.
  ;e-Federal Reporters,  Inc. Mrs. Flood?
              25





                                                                          9 0
    ar9


                             MRS. FLOOD: I would like to  comment.  My  point

              2   of view as to the potential breakage, I think the member

              3   universities of the consortium expressed to the site visitors

              4   a concern to fulfill their participation in the guidance of

              5   the regional medical program in the new light of RMP de-

              6   emphasizing the medical school-oriented projects and

              7   emphasizing more trends toward a programmatic approach.

              8   Seemed to be no qualms on Dr. Postals part.

              9              I think that this is true, Dr. Schmidt's  point,

                  that -erhapz the problem of withholding triennium status

                  to this particular region, which I think is viable and  has

              12  potential, would in a way give these consortium people

              13  that feeling to heck with the whole thing, we have tried, but

              14  may be going the wrong way, and now we are getting no backing,
              15  and because of the tougher problems, not giving them potential

              16  with some secure funding for the future of these years, I

              17  would put in a word for the triennium.
              18             DR. SCHYIDT: The issue should be clear  for  the
              19  committee then.  The substitute motion would withhold the
              20  triennial status, but do everything else that the  original
              21  motion did so that you will be voting really in effect on the

                  triennial status with the substitute motion.  Are vo-Q ready

              23  for the question?
              24             All right, all in favor -- do you understand that

  ,e- Federal Reporters, Inc.
              25  if you vote yes, you will be voting to withhold triennial.






                                                                             91
      arlo



                  status?


              2              All in favor of the substitute motion, please  say

              3   aye.

              4              Opposed, no?

              5              The motion is defeated. The original  motion  then

              6   is for triennial status, et cetera, et cetera, as I recited it

              7   before.  Are you ready for that question?

              8              DR. SCHLERIS:  Like to have a little discussion

              9   about the discretionary funds which sound like a developmental

             ](J' component to me.

             11              DR. SCHMIDT:  I will try to speed this up by comment-
             12i  ing.  I think probably the reason they want them is to be
             13   able to compete with the Illinois regional medical program

             14   that does have these funds it can sprinkle around and stimulate

             15   this in their back yard, and they have got to heable to

             16   stimulate this in their back yard in order to be able to

             17   develop the sorts of things that will change their  direction

             IS   that we are telling them they have got to do, and we have
             191  discussed before that sometimes the regions that deserve  the

             20   developmental component least need the funds the most in order

             21   to have flexibility, et cetera, and I would assume that  this

                  I  @l-C S4@uation thcrb.  Is thaj- accura@@.@
             41.  @3 @AA

             23              MR. TOOMEY:  That's accurate.

             24              MR. HILTON:. Are we endorsing the concept of

  e -Federal Reporters,  Inc.
             25   discretionary funds for other regions? As -- seems to  me  we





                                                                         92
       arll


                  had some discussion about the developmental component versus

              2   discretionary funds at some earlier region some months back,

              3   this came up then, too.'--

              4              Are we saying that this is a viable option for

              5   folks who don't qualify for the developmental  component?
              6             DR. SCHMIDT:. I think that each region almost has
              7   to be looked at individually.  Obviously the answer to your

              8   question is yes.  But we aren't making any general pronounce-

              9   ments or Anything el se.
              lo,            DR. PAHL: Dr. Maraulies indicated  to.me  that
              11  he will be presenting this general topic of discretionary
              12  funding and developmental components and other names by which

                  these Lutids go before the forthcoming October council, not
              13
              14  trying to make a policy at that time, but to clarify the issues
              15  and perhaps come out with a definitive statement, because we
              16  do not have a general pronouncement and obviously we  are
              17  getting into this area.
                             At the moment you are free to act as you choose
              18

                  on individual case-by-case basis.
              19
              20             ER SCHMIDT:  I think we will kind of restrict this
              21  to a couple more comments.

                             Dr. Luginbuhl?
              221
              23             DR. LUGINBUHL:  Two quick questions.  If we are
              24  indeed giving the developmental component, why don't we
  ce- Federal Reportets,  Inc. call it that?  Why do we use some other name?
              25




      arl2                                                                                                                                         93



                               I                          And  number  two,  is  the  letter  that  goes  to  this

                               2    program,  or  is  the  advice  that  goes  to  this  program  going
                               3    to  include  some  expression  of  concern  about  having  a  part-

                               4    time  director  with  a  --  with  another  outside  activity?

                               5                          DR.  SCHMIDT:    The  answer  is  yes.

                               6                          All  right,  I  am  going  to  call  the  question,  unless

                               7    there  is  some  --  something  new.    Because  we  are  just  simply

                               8    not  going  to  get  through  our  day's  work  unless  we  shorten  this

                               9    UP.

                            10                            DR.  JAMES:    The  questions  comes  then  to  M-,7  mind,

                            11      in  this  kind  of  situation,  if,  in  fact,  there  needs  to  be

                            12      some  restructuring  of  organization  and  which  eventually

                            13      results  in  restructuring  of  programt  then  monies  that  are

                            14      already  allocated,  if  in  fact  they  could  not  be  redirected,

                            15      I  am  at  a  loss  to  understand  why  there  should  be  --  why

                            16      that  the  RMP  should  be  awarded  additional  funds  for  --

                            17      whether  it  is  called  developmental  or  discretionary,  when  in

                            18      fact  it  would  appear  that  the  base,monies  that  are  available

                            19      need  restructuring  and  when  that  is  done,  and  used  to

                            20      restructure,  organize  restructure  program,  then  it,  to  me,

                            21      would  show  that  the  whole  program  then  can  very  well  use  new

                            22      funds  for  development,  once  it  gets  its  base  straightened  out.

                            23                            DR.  SCHMIDT:    I  think  the  way  I  will  answer  that

                            24      is  to  say  that  the  committee  just  voted  not  to  deny  triennial

    re -Federal Reporteis,  Inc.
                            25      status.    That  means  that  in  the  committee's  opinion,  the  region






      arl3

              I   has the ability to make the necessary decisions to expend the

              2   funds they have wisely.  one category of which is loose and

              3   not earmarked for projedts now, but is, quote, discretionary,

              4   unquote.
              5              All right, I will put the question.  All in

              6   favor of the motion, please say aye.

                             And opposed, no.
              7
              8              There are "nos," but the "ayes" have it, and the

              9  motion is carried.

                             I think that we will at this noint take a no more
              lo,

                  than 15-minute break and start again promptly in 15 minutes.

              12             (Recess.)

              13'

              14


              15


              1 6


              17


              18


              19


              20


              21


              22


              23


              24

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              25





     mea-1                                                               95
     CR 7149
     #8

                               DR. SCHMIDT:  We are going out to the great state

              2
                    of New Mexico-,which has the largest regional advisory  group

              3
                    in the history of the program.

              4
                               During your comments I hope you will  discuss  why
              5     they have a regional advisory group that seems to include the
              6     whole population of the State of New Mexico.
              71
                               MR. HILTON:  For the record I can't be heard.  For

              8
                    the record, okay.
              9                Just a few preliminary comments and I will make

                    them very brief in view of the pressure of time.

                               My talk deals with specific sources, very  general
              121   items,, before we go into specifics to kind of sensitize  you
              13    to some special problems of the New Mexico area.
              14               I should mention that since the submission of the

              15
                    printed documentation on New Mexico we have received much

              16
                    new data, as recently as the day before yesterday a phone
              17    call iving us additional information which I  will  bring  up
                         9
              18    at the appropriate points throughout the report.
              19               We were under, during our site visit, some time
              20    pressures.  The New Mexico Program staff had taken the

              2 1;
                    liberty of preparing quite a fairly well stated -- using

                    overheads, other kinds of materials which pretty much blocked
              23    in our time.  lie were forced to subdivide ourselves and
              24    fractionate their well-organized plan in order to get  a  lot
  e- Federal Reporters,  Inc.
              25    of ground covered we wanted to cover.





     mea- 2                                                               9 6



                               Some points pertinent to the consideration  of  this
              2
                    region: The state is large  geographically  with  a  population
              3
                    of slightly over a million. The  geographical  expansion  of
              4                                               i
                    the state creates special problems that the region has

              5
                    attempted to address itself to.
              6                The state is multicultural,,emphatically  solwith

              7
                    the major cultures being Mexican-Americant Anglo  and  Indian
              8     and the feeling generally being that efforts to improve
              9
                    health care have to take that fact into account and  try  to
                    work with the facts rather than try to change it  and  smooth
                    everything out and work with some kind of easy glossy  kind  of
              12    program.
              13
                               The state is poor, I have been  told.  I  haven't

              14
                    been able to verify this. The military  installations  are  a

              15
                    major source of employment in the  state.  Continued  support
              16
                    therefore for any of the projects being conducted by the
              17    program staff has been exceedingly difficult and if you look
              18
                    at some of the projects listed there, RMP has a largely

              19
                   .young staff, CHP agencies not awfully prominent in  the  state.
              20               Then RMP in the absence of very forceful

              21
   0                representation on the part of these other kinds of health
                    concerns in the state has really become very prominent.
              23    That prominence has been greatly helped by the large RAG,
              24
  e-Federal Reporteis,  Inc. that  is  a relatively  new  development  there.
              25               But we  had  some  concern,  still  speaking




     mea-3                                                                 9 7


              I     generally, that R14P has become the center for so many things
              2     in New Mexico that we may in fact be supporting activities

              3     that in other states would be supported by other resources.

              4               Going item by item, at a fair clip, too, through
              5     our evaluations, our site visit report, I should mention
              6     that the primary purpose of the visit was -to review their

              7,
                    173-175 application, triennial application, and to assess
              8     their progress since June, 1971 site visit.

              9               In conducting that meeting for that purpose, we
             ,I^ I
                    observed the following things:  That the goals of RMP as
                    stated in materials certainly seem to be in keeping with the
             121    RMPs' mission, the increase in availability,  improving
             13     quality care, moderating the costs of care, et  cetera.
             14               We had some problem with the goals and objectives

             15     in that there seemed to be an absence of measurable short-

             16     term objectives in the context of what the program  was

             17     attempting to do.
             18                General priorities have been identified  and

             19     there is a listed rank order which aids the program  in

             20     making decisions about what we found that if resources are

             21     reduced, et cetera.

             22                Ui-idet -Li-le area o.L' accoi-tiplisi-Liiients ai-iu'

             23     implementations, program staff has stimulated several
             24     worthwhile activities throughout the state.    They do of
  e -Federal Reporters, Inc.
             25     course now have a pretty substantial EMS activity going on:





                                                                          .9 8
     mea-4


               I    Registries, involvement in the hatch area of New Mexico.,
               2    programs internally to aid staff, things involving processing
               3    centers, and a computer budget monitoring system so they
               4    can determine on a moment's notice how much they have got to
               5    spend in each item, a cultural training laboratory which has
               6    already done some things and plans other things that will
               7    help with that multicultural nature of the state I referred

               8    to earlier.
               9,             They are developing a statewide system for

               IC         de hospitals -o                , A
               Ii   staLew-L       L. j.  L.  centrally purcl-asd     "-,he ho-,e 2.s
               11   they will be able to reduce costs of certain aspects at least
               121             other health agencies within the New  Mexico
               13   region, as I pointed out earlier, do rely pretty  heavi ly
               14   upon the NRMP.  They have become the primary agency for

               15   data analysis in the state.
               16              Physicians do look upon the program for
               17   professional and technical assistance, consultation,

               18   information, et cetera.
               19              Under the area of continued support because of the
               20   problem of the general impoverishment of the state, they have
               21   not been able to do as well as we would have liked to have

                                                             pl,ishments.  We
                    seen them do,  There have been some accom
               23   have encouraged other kinds of things be done to get

               24   additional help.

  :e-Federal Repoiters,  Inc.
               25              Dr. Stone of the medical school in his




     mea- 5
                                                                             9 9


                    discussion of his grantees,  stressed  I  think  very  clearly
               2    that the medical school is unable to  pick  up  many  of  these
                    kinds of efforts that--they would like to.'  He  was  kind  of
               3
               4    emphatic about that.
               5                On the matter of minority interests, the majority
               6    of the state's population percentagewise is one minority
               7    or another.  Representation on the program staff of
               8    particularly the Spanish-speaking  group  was  in  my  opinion
                    quite poor; not my   opin ion, the team agrees  on  this,  that
               9
                    representation was ffuite poor.  Very few professionals, very

                    few clerical.

                                Now, it should be pointed out one   of  the  new
              121
                    developments that I referred to earlier that we did receive
              13
                    in our phone call information that the RAG for RMP has
              14
              15    met as of September 16 and that at that meeting they
              16    declared their intention  to  initiate  an  affirmative  action
              17    plan which would remedy-some of our concerns in this     .area.
                    Even since our meeting with the    NMRMP staff there were

                    improvements in that  additional  persons  were  hired  between
              19
              20    the time of our site visit and the time of the September 16
                    meeting. So there  was  visible  evidence  of  intention  to
              21
              2'@)  improve an affirmative plan and it seems to suggest there wilt
              23    be greater pickup in this area.
              24                I had the opportunity to get into the New Mexico
  LI-Fedeial Reporters,  Inc. area a few hours earlier than I had  expected  I  would  so
              25




     mea-6                                                               100


                I    during that period Dr. Gay, the coordinator there,  arranged
                2    that one of his staff would show me around.  I did  get   a
                3    chance to visit a cou @le of the clinics and some of the local
                4    reservations to get a kind of firsthand feel for what the
                5    staff's relations were on the community level.
                6               The staff, especially in  the  community  health
                7    service section of the NRMP staff, is pretty community-
                8    minded, generally young, have not been as aggressive, at leas:
                     not as yet, as I would have liked to have seen but potential
                9
              I^v    4-s still- there. Talking to a number of staff, even in the
              11     setting of the clinics, and talking to the  people  in  the
              12     clinics, we were very well received.
              13                The manager of one of the clinics  1  talked  to
              14     had great hopes for a continuing relationship  and  a
              15     developed relationship.
              16                We did something in this particular area in this
                     region that I don't know how frequently it is  done;  it  has
              17
                     not been done on anything that I have  had  yet.  We  invited
              18
              19     from the general audience comments,  criticisms  really,  any
              20     kind of thing anybody wanted to say about RMP,  pro  or  con4
              21     We did that somewhat expecting that we  would  be  blasted,
              0)1)   especially from the Spanish-speaking section of the audience
              t- t-    -
              23     but found that on the contrary, while there were things that
              24     people had to say and they felt very strongly about them,
  ,e -Federal Reporters, Inc. there was a consensus even among those who  were  opposed  or
              25





                                                                       10 1
     mea-7



                    seemed to be opposed to NRMP activities that it was doing

               2
                    better than before and doing well.

               3
  is                          Concern seemed to center Around its not doing
               4
                    enough or what it is doing isn't fast enough to please.  The

               5
                    general feeling was even from the opposition that the program

               6
                    is having an impact.

               7
                              Again I relate this to a large  degree to the fact

               8
                    of expanded RAG which was expanded by the way to intensify

               9
                    representation from throughout,the state.  So our
             10     recommendation with regard to the minority area is that
             I 1
                    there should in fact be increased representation.  More
             12     needs to be done certainly

             13
                              Dr. Gay has provided, who is the coordinator,
             14     James Gay, has provided pretty strong leadership in the
             15     NMRNM. It should be pointed out it is another one of those
              '16   programs which has undergone some pretty cataclysmic change
             17     in the past 12 months or so.  In fact, there is evidence
             18     of how change was, had been undergone and was still
             19     undergoing at the very time we were meeting with the NMRNM
             20     staff; the changes being some of the literature we have had

             21
                    up to the moment of our going there to review and discuss was
             t-2    updated in the process of their presenting their visuals.

             23
                              one area for example, prominent instance of this
             24     was the complete change in management operations right in
  e -Federal RepoiL-ts,  Inc.
             25
                    the middle of our visit, you iniglit say, moving from a




     mean
                                                                       10 2




                   matrix kind of setup in which staff operated on a task force
               2   kind of basis,.issue-oriented basis back to a more

               3
                   conventional organizational staff.
               4              We kind of got the feeling when this was cast on
               5   the screen that it was not only new to us but probably to
               6   much of the staff, as an indication of how this is

               7
                   developing.

               8
                              Throughout that, however,  Dr. Gay-I.thihk
               9   impressed us all with his ready  willingness to learn, his
              10   enthusiastic willingness to learn.  He seemed to be
              11   listening and took notes throughout the session of the things
              12   that were in fact being said.
              13              We began to feel a change both in the site visit
              14   and of course with these recent phone calls.  We.have.seen

              15
                   things happen since the site visit that go well I think
              16   generally.
              17              Dr. Gay has established excellent relationships
              18   with health providers and health-related agencies'in New
              19   Mexico and I guess that is best testified to by the fact
              20   that a great deal of them, if not all of them are on the RAG

              21
                   in addition to considerable consumer representation.

                              With regard to program or core staff, the

              23
                   decision to decategorize the program staff structure,
              24   moving away from the traditional emphases appears to have
  e-Fedeial Reporters,  Inc.
              25
                   been sound and effective and carried out, though you will




     mea-9
                                                                    10 3


               I    notice in the projects themselves that there is still a kind
               2    of mix of traditional emphases, plus-some of the newer things

              .3    that are coming out.
               4              Now, traditional programs, or I  should  say  the
               5    projects, old projects listed in your printouts  have  been
               6    supplemented by a variety of what they  call  developmental
               7    projects, which we can go into some discussion on a little
               8    later on, but these developmental projects then are  to  be

               9    run directly by the project staff.

              10               And tliure more than in the old projects we  see
              11    a real emphasis on new directions.  The community health
              121   services section of the NPZIP staff represents the truest
              13    form of what I would call a thrust, onelof,-the truest  forms
              14    that I have seen in NRMP.  In fact, if you look at the
              15    projects, one gets the feeling as mentioned in another
              16    program, it said it was being a program, it is  a  collection
              17    of projects. However, in their reorganization  and  in  going
              18    back to more traditional organization of staff,  they  have

              19    gotten at least some of the idea of thrust.
              20               Community health services represents a compilation
              21    of kinds of projects in an area that relates to working with
              sell  cl4r.4cs, .,,,o--ki-n" 4- Tn d4.-.-. health rehab4-'-itat4-o.-., w,-,--k4r,-
              IL  IL  - -          -, -..-                                 -  li
              23    consumers; that thrust also has become what they  call  their

              24    community response system.

  e -Federal Reporters,  Inc.
              25               It is attempting to organize itself on a





     mea-10                                                            104


              I     statewide basis and the exact dimensions of how that  shall
              2     be accomplished,-by the way, I.am not entirely clear, from thE
              3     site visit and not satisfied from the material received
              4     subsequently that it is really all worked out yet, but their
              5     hope is that through a number of mechanisms available to them
              6     the community health services component will be felt through-
                    out the state and will be the primary source, nerve center,
              7
              8     for receiving suggestions for things RMP should do in  that

                    region.
              9
             10               They have got a number of approaches,  number  of
             11     ways they can go about doing this.  They have attempted I
             12     think unsuccessfully to use their RAG as a basis for picking
             1 3    UP 6uli9e-stioi-is o@' pct>jecls aiid LI-ieir RAG :-s qu-,-,'t@.e exteris'l- 'i@@ 4=
             14     covering the entire state.
             15               The problem there is that when they try  to  hold
             16     RAG meetings in Northern New Mexico to cut down the  travel
             17     they get the Northern New Mexico side of the RAG.  If  they
                    go to Southern New Mexico, they get the Southern New Mexico
             18
             19     side of the RAG so if they hold two meetings in the course of
             20     a year they really get only one side of the state covered in
             21     each meeting.
             22                So we suggested to them there might be other
                    methods they use; they might go to the community health
             23
             24     education services which have already devided the state into
  ;e-Fedetal Reporters,  Inc. four quarters, and to use RAGs or local advisory groups, one
             25




     mea-11
                                                                       105


               I    for each of the four; that might be another way in which  the
               2    community health services group might be able to pick up in ar
               3    orderly fashion real grass roots kinds of input.
               4               There is an interest there in any event in  really
               5    relating more closely to consumerism as it was pointed out
               6    in part their success or failure would depend on bringing  in
               7    minority staff because as matters stand now there are only
               8    three Spanish-speaking staff on the NRMP and this does  create
               9    difficulties in relating language and culturalwise the  people

              I C)  they ar-@ attempting %to reacL--L.
              11               It is very confusing to look at now on graphs  and
              121   charts but has additional problems beyond that in that it  is
              13    a response system first and foremost.
              14               Many of the accomplishments of the region have
              15    really been in response to inquiries from people outside of
              16    NRMP who say,-"You know, we need this, that or the  other,"and
              17    then of course the staff has been geared up to just take  that
              18    suggestion and run with it as a response.
              19               We did have some criticism that there ought to  be
              20    more initiation on the part of RMP but we think in that
              21    regard that people know about the RMP, certainly not the
                    ra'se of many reaions; so thev do feel free to come to it
              2 /@-                I
              23    despite the fact that it is not itself initiating to the
              24    degree we would like.to see it.
  e-Federal Reporters, Inc.    The RAG seems almost too large but as I say, it
              25




     mea-12                                                                  10 6


                    does reflect combining of a broad representation  and  I  think
               2    more importantly, reflects a combining of two kinds of life

               3    of the program.
               4               When Dr. Gay took over, he inherited some of that
               5    and felt in his judgment rather than trying to erace  what  had
                    come before, to integrate it in a newer  and  bigger  scheme.
               6
               7               We had less problems with the RAG than the internal
               8    organization,numbers of committees, task force kinds of
               9    committee structures using RAG and staff personnel to carry

                    out the programme objectives.
                               Again new information in response to  our  criticism
              ]2i   of the number of committees of which there were  some  14  in
              13    number,the September 16 meeting had at least, there was some
              14    indication in the 8eptember..16 meeting that these  would  be
              15    reduced to nine.
              16               Consumers are more than adequately  represented,  by
              17    the way, on the present RAG and I think this is certainly
                    necessary in view of the fact of the limited impact of  CHP
              18
              19    in the area.
              20               One of last year's concerns, in response to  the
              21    Executive Board, as authorized it increased from eight to 11

                    members.
              23               We also have some concern relating again bac  to
              24    the coordinator that the structures that had been
  ;e-Federal Repoiters,  Inc. developed did not allow enough coverage of central
              25





    mea-13
                                                       107

               administration; I guess, to put it another way, if Dr. Gay
           2   got sick that the whole thing seemed it would fall apart.
           3   He didn't have enough--direct help at the top.
           4           They responded to that too. The nine-sixteen
           5   meeting did endorse the recommendation that there be two
           6   deputies, one for support services and one for operation in
           7   the programs that would assist Dr. Gay and in that way
           8   further units or bring together the organization.
           9           The grantee agency, you know, of New Mexico has
               provided excellent administrative support to the RMP. The

               medical school no longer has as it once did excessive
  07149   12   dependency upon RMP,and grantee and RAG relationships are
       #8      qui-'L@.e good.
          13


          14


          15


          16


          17


          18


          19


          20


          21


          24)


          23


          24

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   CR 7149                  One evidence of the relationship between grantee
    9          2  and staff, we were able to determine what'appeared to be in-

       1       3  credulous, but delightful situation where  the  grantees  is
  piw
               4  apparently providing virutally rent-free  facilities  for  the

               5  N@IP as they move into additional space. I say virtually becausE

               6  1 don't know if that ever was  investigated  to  everybody's

               7  satisfaction but it looks that it might in fact  be  the  case.,

               8            On the matter of participation, key health interests,

               9  institutions and groups are participating in the program, this

                  accounts again for the size of the RAG. We did hear from the

                  Red Cross representative, the president of  the  New  Mexico
                              I

              12  Nurses, the CHB representative, the 14edical  Association,  Dean

              13  of the Pharmacv School, even testimony from a dissenting

              14  student from the medical school locally, on some of the activi-

              15  ties, but at least everyone was there and  the  general  feeling

              16  was that the problems remained with problems of the rate

              17  of change.

              18            We did have two recommendations under  the  area  of

              19  local planning, site visitors were made aware of some problems

              20  arisen in regard to providing P14P proposal to CHP in advance

              21  and for CIIP comment and there was feeling that this  should  be

              22  done so that CHP would hav--     opportunity to respoi-id -w-c--'L'L

              23  in advance of a proposal going to us.

              24            The site vitors recommend that the Chest projects,

  D - Fedefal Reportefs,  Inc.
              25  community health education sbrVices projects  should  in  fact





                                                                            109


           9  1  create four local advisory groups in the next year to provide as
  Reba 2       2  they are willing to undertake the appropriate responsibilities

               3  and resources, their share.  We   did have concern about the

               4  actual representation on such a   broad scale of the state and

               5 we think if  representations  focussed  locally,  as  was  proposed

               6  through the use of the community health education services,

               7 that they will have  more  meaningful  participation  on  the  part

               8  of each representative.

                            Feeling was that no one in the Norhteastern New

              io
                  MCN4----- I-,,oul4- "-c     'La be concerned about-. Sout@.I'Iwes-@ern

                  New Mexico and to look really carefully into that but if the

              12  northeastern end of it has its  own  LAG,  Local  Advisory  Group,

                  relating to the Drogram that you would get a lot more particip-

              14  ation and there would be a.focal  concern  with  the  local  needs

              15  there, other matters of assessment  of  needs  and  resources  you
              16  may have seen some of the very nice little brochures, the

              17  informational services office of this outfit is great. .

              18            Publications that  they  made  available,  some  studies

              19  they have done on various aspects  of  NRMP  activities,  maybe  a

              20  set of these booklets, some 14 or 15   in number on the table

              21  over there. The orograrq has done a good job of compiling

              22  conmunitv health  nrofiles but aaain, I thi.nk that is the

              23  last program we reviewed, there is a problem in utilizing this

              24 information in carrying out the projects and programs. They havc

  e- Federal Reporters,  Inc.
              25 done a good research job on  this,  at  least  the  material  looks





                                                                          110


         #9    1  good, it is well written material, easily readable and I  have
  Reba 3       2  got about 20 pounds of it in the mail in advance of the site

               3 visit.

               4           The program does need to include assessment of need

               5  and resources as criteria for review for determining program

               6 staff activities; programs should make better use of  the  data

               7 base for the fund priorities.  Under the area of management the

               8 site team was impressed with the innovative management  pro-

               9 cedures and rated this as quite excellent, included among those

              10 a process4Lng pool, means by which speed'Lc-i: ai-Ld i-ieater pro-

                 duction of information materials could be produced and  also

              12 their monitoring, computer monitoring system.

              13           Budget:  Other matters of evaluation,@the full-time

              14 evaluation director complements the agency and works well  with
              15 RAGS evaluation committee.  Members of the evaluation committee

              16 staff and RAG Participate in the programs activities where  new

              17 programs are developed and technical review committee  sessions
              18 where the proposed programs are technically reviewed.

              19           The team endorsed review Quarterly progress reports
              20 by the evaluations committee and these are required  by  all
              21 project directors. Other matters of program proposals  NP14P

                                                            onsidered as line
              22 describes developmental nrolects as those c

              23 items under nrogram staff.
              24           This matter of terminology was brought up. We  had

  -e-Federal Repofters, Inc.
              25 a sketch in which it was the effort of the coordinator,  the






     #9        1  entire staff to characterize M4P's and to define within that

  Reba 4       2  broad characterization exactly where NWIP'came to rest.
               3             Three models described to us were    the   traditional
               4  RT,-IP, the transitional Pd4P and the developmental WIP. NIU@IP
               .5 classified itself as the  last  type  that  had  the  flexibility
               6  within program staff to function  quite  well  in  a  variety  of
               7  areas and to really  bring  about  change  without  depending  on
               8  branch.occies, some  really  6bject  to  that.  Some  aspects  of
               9  their overall program in fact do look transitional.
               I u           I already commented or, the character of -L-lie pro2jec;L@s
               11 they  wished to support.  They ranged from the old categorical
               12, through the AHEC right now to their developmental programs, the@
               13 described what seemed to be pretty relevant kinds of thrusts.
               14 They want developmental component funds which will be used
               15 to study feasibility of identified program opportunities.

                             The establishment procedures for reviewing new
               16
               17 program proposals will be utilized for developmental domponen
               18 requests.  Under  dissemination  of  information  a  program  has
               19 efficiently disseminated information to key groups, other healt'
               20 related institutions. The  team  did  suggest  that  the  program
               21 could more advantageously  utilize  one  of  the  most  important
                  health resource  s that thev aDDarentlv are not usina. the Lovelade

                  Foundation for Medical Education and Research located in New
               23
               24 @lexico.
  :e-Fedeist Reporters,  Inc. I think we should be strong on this, we would want
               25





                                                                           112



           9  1  it to be collected in the advice letter to this region.

  Re)-)a 5     2 Utilization of manpower and facilities, the site team was

               3 interested in and enthusiastically supported most of the new

               4 directions, the new types of manpower that were described.

               5           However, they were somewhat frustrated by the

               6 fact that they still are basically intentions and are  not  well

               7 developed programs of activity.  This relates somewhat to

               8 the response concept, responding but not  initiating.  Again,

               9 in talking with some of the staff in certainly the  areas,  they

              iO have very good ideas there among this young staff.

              11           There seemed to be some uncertainty,  however,  and
              12 II had here the opportunity to speak very personally with a numbe@
              13 of the staff, seemed to be uncertainty as to whether  or  not

              14 these good ideas could in fact be implemented. There was some

              15 uneasiness and I am not certain whether the uneasiness  is  what

              16 it was or whether it was when the administration of the local

              17 PMP would endorse them, perhaps both, I think the site visit

              18 in that regard would have been helpful.

              19           I think the leadership, we were liberal, encouraging,

              20 patted on the back where appropriate and withhold support where


                          te. Ther
              21 appropria        e are some technical legalities on  some  of

                 tho pro-4ccL-.s. f,e-,rara 'L o 'L 'L-. I'leTc, @Li-i L'acL appear to be designed

              23 to assist established health professions, training  programs  of

              24 one kind or another, specifically dental assistants, medical

  e -Federal Reporters,  Inc.
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                                                                      113



         #9    1           This is a matter to be looked at very closely. The
  P.eba 6      2 T)rograms intentions to emphasize new kinds of paramedical
               3 manpower are laudatory but plans in this area are not yet well
               4 defined z)erhaps because of the uncertainties that I have
               5 identified.  Through a variety of their programs they have
               6 in fact contributed significantly to the improvement of health

               7 care in the area.
               8           There are four New Mexico communities who  applied
               9 for a national health service core assistance with the  help
                 of     NIU@.R staff an'" --here arc several other pro4ecl@s, at the
               v                                                  i
             11  Tierra Maria Community Clinics where there have been some
             12, marked good apparently. Short term pay-off, reasonable to
             13  expect, the operational activity is proposed will increase
             14  the availability and the accessability to service groups and
             15  enhance the quality of care in the next two or three years, it
             16  was the general judgment of the site visit team.
             17            We did at the time of our site visit on this matter
             18  of regionalization encounter some discomfort on this  matter
             19  of where shall the control lie. Dr. Gay had inherited real
             20  problems because of the apparent emphasis on decentralization
             21  of NMRP resources prior to his assuming that role.

                           In resnonse to that condition which was verv
               A.
                 limited, created a lot of problems for him, he moved rapidly
             23
             24  toward centralizing, putting everything pretty much under the
  ,e - Federal Reporters, Inc. central Albuquerque office control and there appeared to  be
             25
                Iin the language and the -- the language of the application and









                                                                             I I A


           #9      the thinking of  the  staff  some  uncertainty  as  to  this  issue

  Reba 7         2  of, decentralization versus centralization of effort.

                 3            I think as  we  talked  about  the  need  for  represent-

                 4 tation, the plan of using    the local Chest LAGS, et cetera,

                 5 that there began to be a  feeling  on  the  part  of  the  staff  and

                 6 part of  the  coordinator,  that  there  is  a  middle  road'between

                 7 these two extremes.

                 8            It remains to be  seen  whether  or  not  this  will  in

                 9 fact come  out in the wash.  But I have a strong feeling it

               10  %il-i,i 'oecause we approached the  topic  trom  several  different

               11  directions from the point of view of projects and point of view
               12 lof  local  representation,  point  of  view  of  staff  recruitment,
               13  even.

               14             Not for examole  be  able  to  recruit  people  from  one

               15  community that is --  to  which  they  are  indigenous  to  one  end
               16  pf the state to travel to the other.  You are necessarily
               17  talking about some kind of decentralization in that area as well.

               18             DR. SCHP4IDT:  Bill, I will ask if you can try to

               19  wrap it up in about five more minutes at the most.
               20             MR. HILTON: I think  I  can  do  it  in  two.  The  region
               21  has provided  evidence  that  they  are  trving  to  attract  other

                   support. The-,r have not L-een                        @@uce    -ther
               22               1                                      -C--     -
               23  support really has not been available in many respects       but   we
               24  urged them to try it but  on  that  and  they  said  they  would  but
  e- Federal Reporters, Inc. you reallv don't know what the direction is going to be.
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                                                                             115


         9                   The state apparently is poor  and  local  industry  is
  Reba 8        2 limited, too, in what it can contribute.  All  in  all  this  is
                3 a general I guess kind of summary of  this  before  we  go  into
                4 matters of budget, it was the site  visits'  feeling  that  on  the

                5 basis of what has happened since  Dr.  Bay  assumed  office  that
                6 this is basically a strong program in need of some guidance and

                7 counsel.
                8            They are willing to learn. It is not a program which wa
                9 are going to be having to tape  record  the  same  message  each
                  year,.at 'Least we did not leave w'Lth the feeling it was.  It  'LS
                  ripe for counsel on some of its  directions  and  goals  and  so
              12 Iforth. And it is basically  a  pretty  strong  program.  I  think
              13 with that I would normally  defer  now  to  our  second  reviewer

              14 who happens to be Sister Ann  Josephine.  Since  she  had  to  leave

              15  she did leave me some notes, summarizing any questions or

              16 comments she had.

              17             I have not had the chance to look  over  the  notes  but
              18  I could do that you know, or while %,7c,- are awaiting questions.
              19             DR. SCHMIDT: If these  notes  are  legible  why  don't

              20  you pass them down to the end of the,tabl-e and let staff-
              21  look'at them, and we will ask him  to  summarize  what  she  has
                  to gay very bri.c-fl  and wbv don't yoii ao  ahead  with  recommen-
              22

              23  dations?
              24             MR. HILTON: All right.  Site visit team recommended

  ;e - Federal Reporters, Inc.
              25  that '.Il,!P@IP be approved for triennial status for 05, 06 and 07





                                                                            116


         f9   I years and that developmental Component be approved  with  the

  Reab 9      2 condition that a mini-site visit be made within the next year

              3 to review the region's progress.

              4            On the matter of budget, briefly, the request  was

              5  in the area of program staff, $1 million 319,000.  Site visit

              6  recommendation was $830,000 on that figure. Developmental

              7  component request was for $138,000. Our recommendation was

              8  $120,000. operational projects request was for $223,000,  we

              9  recommended $350,000 which does in fact include $118,000 for

              10 the ti:tmor registry     -n the nast was           in   thcr

              11 program staff, moving into their operational projects.

              12           DR. SCHMIDT:  This is the first year or for all three

              13 years--

              14           MR. HILTON:  First year and carryover, I think carry-

              15 over, -- let's see.  Yes, for all three years.

              16           DR. SCHMIDT:  Level funding for three years?

              17           MR. HILTON:  Right.
              18           DR. SCHMIDT:  Frank,, have you had time to glance

              19 through Sister Ann's comments?  Could you cover anything there
              20 that might be in addition to what Mr. Hilton has covered?
              21           MR. SCHNIOIISKI:  Basically, Sister Ann has six

              22 statements here, I will rapidly mention these.  One,  Sister
              23 Ann comments that support from other resources must be developed
              24 and this is, further supports the site visits team recommendation

  'e- Federal Reporters, Inc.
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                                                                             117

          9        1  comment deals with her concern that maybe the developmental
  Reba 10          2  component should be reduced.
                   3        There is no questionmark   or there is no exclamation
                   4point so I don't know how to interpret this.  I am surprised.
                   5The third comment deals with the question of whether RMPS should
                   6-orovide consultation and this deals with the statement, if the
                   7program is interested and seriously intends to facilitate state
                   8IR-10 planning, it should bring people with appropriate experience
                   9in managerial and financial aspects of MO planning.
                             1-ic         -2Li:c)li this out before the site visit
                   11 report was written. This is one point that was not clarified
                   12 and was asked to be included in this. The fourth point deals
                   13 with underutilization of information due to lack of knowledge
                   14 of the resourc es availability. .Again, Sister asked for guidance
                    y P@"IP staff to insure adequate use of available data in plannin(.
                   15
                   16        The fifth deals with evaluation process. And suggests
                   17  hat evaluation process needs to be implemented. Then the
                   18 final noint, final point concerns the tumor registry pfo]ect
                   19 ich is -- it is a question what plans are there to Phase this
                   20 t between the local Cancer Society.
                   21         These are the major concerns.
                              DR. SCMAIDT:  Is there an answer to that last
                   23         MR. HILTON:Ile spoke with the tumor registry people
                   24 oncerning this. We were impressed with the importance of the
   Ace-Fedetal Reportefs,  Inc. ctivity, apparently beyond those who are directly involved with
                   25




                                                                               118


           #9 1 it. There is also  a  feeling  of  its  worth.  But  again  apparently

  Reba 11       2  they have run into something of a brick wall in terms of

                3 attempting to get support for it. The  feeling  seemed  to  be

                4 that the resources simply  were  not  there.  Everyone  agreed

                5  it was a good thing to have.
                6           Of course those who were closest  to  the  project  felt
                7 more strongly about it. We did suggest that more aggressive
                8 efforts should be made to seek continued  support  for  the  effort.
                9           They assured us they would continue  to  try  but  there
              io ,-.,as this fccl,-.-.g ---4 a real frustration, that 4"-h@- effort real'Ly
              11  wouldn't pay off so why bother in the first place kind of
              12  thing. That in fact efforts in the  past  despite  the  amount  of
              13  work that had been put into this by one of the physicians
              14 closely involved with it  in  attempts  to  recruit  assistance
              15  have been so futile that there did not seem to  be  any  teal  drivc
              16  on the part of the neople who  were  supporting  the  tumor'registry
              17  to go out and as one guy said you know spend days, weeks and
              18  months at trying to do something that simply was not there.
              19            DR. SCIUIIDT:  We do have a motion on the floor.
              20  Is there a second for the motion?
              21            DR. ELLIS:  Second.
              22            DR. SCIU@IID@-'  All right., it is seconded., so we are
                  ready for discussion. I believe first, well, let's see, John,
              23
              24  you have got the microphone. When  you  are  through  you  can
  :e-Fedeial Reporters,  Inc. hand it to Dr. Schleris.
              25

  end 141- 9




    CR7149                                                                  119

        #10-ter-1
                I             DR. KRALEWSKI: A couple of  questions  and  comment.

                2 One, I am in a@reement that the state is a poor state and pro-

                3 bably has some Limited ability to share in the  funding  of  RMP

                4 Programs.

                5             On the other hand there is a lot of Federal money

                6 going   into that state,,OEO Programs in the state, HMO, a

                7 couple   HMO planning grants, I believe there is a National

                '.8 Center Health Services Demonstration Grant, and I was wondering

                9 how much effort is being devoted by the RMP Group-to,.:you',know,

                10 intermix their programs with these programs,  and  make,  you

                11 know, these funds useful to some of their activities.
                121           Number two, one of the questions in the past was
                i3 just how much of this budget is going to  support  that  medical

                14 school, I wonder if you would comment to that to see  if  they--
                15 are really breaking away from it, and number three, the comment!.
                16 on the question of whether they should add staff with HMO
                17 capabilities.

                18            I am not so sure they should, perhaps,  if  these

                19 other agencies of HMO Grants, like the  Loveless  Clinic,  et
                0 cetera.  If they are developing that kind of talent, maybe,-RM-P  I
                31 should stay out of it.
                22            MR. HI:LT-V'L4. Ta'rl.'Lrig your questions backwards, I
                23 agree   with you, our feeling was, our general feeling  was,  and
                24 we  do  have a minority report on that by the way,  that  they
                I
  ce-   Federal    Reporters, Inc.
                25 probably should, in fact , use the resources that are existent




    ter-2                                                               120


               I  in their HMO planning.

               2             Medical school support, one of the things that was

               3  shocking to us or surprising, where we could not see they were

               4 getting that much out of it. They were  giving  away  grant.

               5  There was involved staff -- staff involvement, more specifically

               6  on that.  The Dean, at the time we talked to him was on his

               7  way to, I believe it was Harvard for a course in fiscal

               8  management, and when we questioned him about this, he said,

              .9  perhaps that is why they have, in fact not benefited or

                            the -@4.@@ua@-ion as much as they probably could, and,

                  in fact, may, in years to  come.

                             But on the matter  of other Federal help, perhaps,
              12

                  Frank can give us something on that.
              13
              14             MR. SCHNIOWSKI:  In terms of coordinating with the

                  two HMO Grants in Albuquerque. Dr. Gay is on the  board  of
              15
              16  one of the HMO planning groups and he is actively  involved
              17  with the other one. I had rather not comment on  why  there is
              18  two grants in one area.

                             DR. SCHMIDT:  Miss Kerr?
              19
                             MISS KERR:  Speaking of other Federal funds available,
              20
                  I, too, was concerned when Bill was talking about the educational
              21
              2@& programs and as a point of information, the week 6f October 8th
              23  to 13th, there will be 75 hand-picked people, 25 each from the
                  regional medical program, the New Mexico Medical Society and
              24
  .e-Fedeial Reporters,  Inc. from the Department of Education, and they are bringing in two
              35




    ter-.j
                                                                          121



                  consultants; one of them is myself, to talk about health

               2  care education programs, and what might be available in the

               3  State of New Mexico, maybe this is one reason they are turning

              @.4  to this kind of conference, I hope.

               5            DR. SCHMIDT:  Dr. Scherlis?

               6            DR.  SCHERLIS:  Do I read the application correctly,

               7  that they are asking for 35 new staff positions, is that

               8  correct?

              @9            MR. HILTON: You are a-little  under.  They  are,  in

                                    let us see, A-.o, t'LLey were asking for 2'j new
                  fact, a s k
               v

              11  positions.

              12            DR. SCHERLIS:  I added it  up and got 35, I guess
              l@3 from the pages 59 up to 62, or three, but they are asking  for

              14  something within that range?

                            MR. HILTON:  Yes.
              15
              16            DR. SCHERLIS: Looks like it is  closer  to  30.  The
              i                                                                  1
              17  other question I have is in terms of page 30 of your site-visit

              18  report.
                            Do I gather that you all looked at their individual
              19
              20  projects, and suggested a level of funding for each development
              21  of'their developmental programs?
                            MR. HILTON: What we specifically did,  was  to  look
              23  at their developmental programs.  We did this in a couple of
                  sub-group meetings.  There was such a lump of some involved
              24
  ce - Fedetal Reporters,  Inc. there, in that area that we thought we better look and see what
              25





    ter-4                                                                       122



                I it really was going  into,  so  we  did  invite  discussion  from

                2  those closely involved with the projects to get a clear under-

                3  standing in our own minds, rally, what they had in mind; what

                4  they were planning to do.


                5              Yes?

                6              DR. SCHERLIS: I don't  mean  to  suggest  that  this

                7  was not the way to do it, but you assumed they had good

                8  judgment and evaluation  mechanism,  and  priority  system  that

                'g they are able to set up their own developmental program.
                I-                                                                     I
                10             'ilhat you have done is X out most of it, then turn     i

                11 around and  give them a developmental  component  and  says  "Do
                121 with it what you like."
                13             I know the hour is late but this is a rather

                14  interesting approach.
                15             MR. HILTON:  If I can recall again, Frank, I will

                16 ask your assistance on this, too.  There were clues which
                17 preceded our taking this action with regard to the new programs
                i8 And, by the way, the team visit  was  chaired  by  Dr.  Tamiroffl(?)!
                19 of a hospital in New York who was on vacation, so he was not

                20 present at this particular meeting.
                21             As I recall, one of  our  reasons  for  taking  this

                   Darticular  approarh wn.-, somp. indication we     -f----M
                2d)-
                @3 testimony that some  of  the  program,  referring,  particularly
                24 about the health education  for  public,  there  had  been  some
  ce -Federal Reporters, Inc. intervention in the program thing, on the part of the
                25






    ter-5

                                                                      J-


               I  Assistant or Lieutenant Governor of the state, which had

               2 bloated that figure from something closer to $50  thousand  to

               3  $250 thousand.

               4             That may have prompted us to look closely at  some

               5  of the other new projects.  There is no plan for that expansion

               6  between what we recommend and what they ask for in health

               7  education but that was not entirely a staff decision, either.

              18  That was, in a large measure, a result of -- I am not sure,

              19  is the Lieutenant Governor a member of the RAG?

                             Yes.  That was larg6ly@
              10                                    the result of the represent-

              11  ation on the RAG.  And, I guess what we found ourselves doing
              121 then, was sort of going through these projects with the staff
              13  to kind of weed out or give them an excuse for weeding out
              14  some things that had developed, problems they had inherited  with

              15  their RAG.
              @i6            DR. SCHERLIS: Point of information --  the  AHECS,
              4                                                                   I
              'f7 was that a one-year shot of funds?

                             Wds that planning or what?
              18
              19             MR. SCHNIOWSKI: There is four,  National  Advisory
                  Council recommended approval for four geographically dispersed
              20
                  community health education systems throughout the state.  These

                  are four separate pro-j'ecl--s, twenty, twenty-two thousand dollars
              22


                  apiece.
              23
                             DR. SCHERLIS: Was that just one year?  What  is  goinc
              24
  ce-Fedetal Repofteis, Inc. to happen after that year?
              25





                                                                         124
    ter-6

               I            MR. SCHNIOWSKI:  That is right.

               2            DR. SCHMIDT:  This is one year planning.

               .3           DR. SCHERLIS'.;  Was that just planning?
               "@4          DR. SCHMIDT:  Planning, yes.  Other comments,

               5 other issues to raise?
               6            MR. SCHNIOWSKI:  I would like to mention one factor.
               7 I am not disagreeing with Mr. Hilton when he stated in concern

               - of the area of minorities but I think it is good to point out
               ;8
               9 that the Program,s-Reqional-,AdVisory Group contains 44 minority
               If% group representatives,
               v

                            This has tremendously increased under Dr. Gay'

                 from previous years. The executive committee  has  increased
               12
                 from eight-. to eleven members.  Five of the eleven members are
               13
                 minority group representatives.  At the time of the site-visit,
               14
                 the Program staff had three minority group  representatives,
               15

                 just on the program staff.
               16
                            After we left and made our recommendations, our
               17
               18 suggestions, I might say, to the total site-visit, Dr. Gay has
                 increased this from three to six program-staff members.  All    I
               19
                 minority members on his RAG are actively involved in all  of
               ?o
                 the committees and the one weekness@we did point out was  we
               21
                 certainly recommended an increase, we thought he was maybe doin-
               @A-
               23 not as good a job as he could, in terms of hiring program staff.
               24 And, this is the main weakness in terms of minority members.

  -e-Fedeial Reporters,  Inc.
               25           I don't want to --




    ter-7                                                                 12 5



                1             DR. SCHERLIS:  How large is RAG?

                2             MR. SCHNIOWSKI:  One hundred sixteen members.

                3             DR. SCHERLIS: That can be representative  of  a  lot

               -,4  of the population.

                5             DR. KRALEWSKI:  The whole population.  May I make

                6 a comment?

                7             DR. SCHMIDT:  Right.

                8             DR. KRALEWSKI: This budget again,  if  I  understand

                9 this correctly, we are recommending more money than they are

               -0 asll,14-ng @'-@r on operai--'Lona'L projects--

                              MR. HILTON:  Only because of the tumor

               12             DR. SCHMIDT:  There is a switch of"funds  from up

               13 on top to down in there, actually.
               14             MR. HILTON: Yes, what we have done is taken  out  thel@
                  tumor registry which was listed  in their request,  their  initiali
               15

               16 request for program staff.  The  distinction that has to be kept

                  in mind here, is what they have'donethey have got two sets,
               17
               18@ of.-projects.

                              One, under program staff; and one  operational  pro-
               19
               20 ject which is separated out. And we  simply  removed  from  program
               I                                                                    I
                  staff their tumor registry project, and reduced that whole
               21
                2 figure substantially in i--F-rrn.s of the other      -,nder +-hat.
               23             DR. SCHMIDT:  Other questions?
               24             Or issues?
  ce - Federaf Reporters,  Inc. DR. LUGINBUHL: I would like to question  the  tumor
               25






                                                                        126
      ter-8


                I registry. Seems to me that a very good test of  the  work  of  a

                2  program is the ability to find other funding and the fact that

                3 this program has not been able to find  other  funding  suggests

                4 to me that possibly it is not quite as valuable as it might

                5 appear at first look.

                6            And I may be speaking from a  general  bias,  because

                7 I have not been impressed with the value  of  tumor  registries,

                8 generally, and I have yet to see any very hard data that sugges   s

                9 that these-have had a major impact on even the  care  of  cancer

              10  patients, or advancement of our knowledge in this area.

              11             So, just as a general principle, I would favor funding
              121 these programs from local resources, and if  these  are  not
              13' forthcoming, I think this may be a measure of their true   worth.

              14             DR. SCHMIDT:  Well, the question has been   answered,
              15  so I will limit your answer to what your estimation  is  that  they:
              16  will seriously attempt to find funding for that  on  the  local.

              17             MR. HILTON:  If rather emphatic advice is made to

              18  them in an advice letter to them, I think  that  might  help

              19  to spur them to try again, harder this  time.  I  would  not

              20  make it strong enough though to make a contingency.

              21             DR. PERRY:  I have the same question, Sister, and

              22  asked about the amount of the developmental             hc.-e.

              23  This is one of the largest ones that is being earmarked of
              24  all the programs.  I would like a little fruther justification,

  ,e - Federal Reporters,  Inc.
              25  you know, that they are really capable.





      ter-9                                                                 127



                 I              The questions that have been raised on some of the

                 2..problems that have been developed, I  would  like  you  know,  a

                 3 little further comment on just that    one part.

                 4             MR. HILTON:  With regard   to that developmental com-

                 5  ponent, as I recall, in our deliberations, we really did not

                 6 give that particular matter a great deal of thought.  We

                 7 certainly did not feel they should get as much as they requested

                 8 on it.

                 9             The question raised earlier, concerning the develop-

                 10 itiental progz@dm has been kind of turning round in my head

                 11 since he raised it, because I canisee the direction he is
                 121 heading,-on that.  Yes, we are all in agreement that under Dr.
                 13 Gay's leadership, it all seems  to  promise  real  well  for  the
                 14 future, but the reason the developmental programs that are
                 15 listed on page 30 of the site-visit report went -- went the kind.
                 I16of sky thing that we gave them, was because of the -- some of

                   the builtin problems apparently in terms of what kind of input
                 17

                   would be made to the program despite Dr. Gay's influence, et
                 18
                 19 cetera, and you know, I would have to, in view of that fact,

                   and in the contention in which it was raised and I would also
                 20
                   have to look myself, again, at the component as it now stands.
                 21
   0             22            T would; at this poi-.-+-- then, perhaps, Frank,  can
                 23 recall some things I am  forgetting  now,  with  regard  to  what
                 24 your deliberations were on the developmental component.
  ce- Federal Reporters, Inc.  MR. SCHNIOWSKI:   I think Dr. Scherlis is concerned
                 25




     ter-10                                                          128


                I  with the developmental component.. Again, we have to kind of

                2  repeat the statement that the region indicated to us, that they

                3  were going to control these through program staff, and use

                4  them as a line, item budget.

                5            Our recommendations to treat these as  individual

                6 project activities, not as a line-item-budget within program

                7 staff, reviewed by the RAG, monitored by their systems,  and

                8 reviewed by CHP.

                9            Thus $222 thousand, which we recommend for  these

              10  acL-.iv-'Lt--Les in essence, is taking this amount of money and

              11  moving it down into the operational project area, not keeping
              121 it up at the program staff level.
              13             DR. SCHMIDT:  I would like to move the group along
              14  to making any specific modifications of the  recommendation,

                  or whatever.
              15

              16             Mrs. Flood?

                             MRS. FLOOD:  I don't mean to delay the continuance
              17

                  of our schedule, but I do feel that there is some aspects of
              18

                  the economic picture of the State of Nbw Mexico, that although
              19

                  it has been covered in some measure, should be expressed  at
              20

                  this time.
              21

                             I think: if voiA take into consideration, the sparse 11
              23  populated areas of the state, with the only large urban
              24  impact area being in the City of Albuquerque, with the ttemen-
  ce-Federal RePOTters,  Inc. dous population of minority groups with underdeveloped educatio
              25




    ter-li                                                             129


                I  opportunities, the economy of the state is only dependent,

                2  truly, on the military and the many diversified aspects of

                3  military input there, Los Alamos, et   cetera.

                4             That, to put the pressure   on discontinuance  of  pro-

                5  grams, even the tumor registry, although I am not in a position

                6  to state whether it is a value project at  the  moment,  but  to

                7  put the burden of pay or maintenance  of,this  type  of  project

                8  on the people of the State of New Mexico, at this time, is just

                9  not feasible, it is not a realistic approach.

                              There is not that forthcoming econon.4-^- -@n-o-e to
               10

               11  support programs at home, so I would be reticent to offer     any-
               121 thing other than a recommendation to not cut program based on
               13  the fact that they have not been able to find other methods

               14  of support locally.
                              DR. MARGULIES:  I wonder if I might comment, becausei
               15

               16  I think the comment just raised is  terribly  important  in  our

                   deliberations.
               17
               18             This is the most painful  type  of  consideration  we
                   have to go through. If an activity, over  a  period  of  time,  is
               19
               20  not able to find other means of support, it either suggests

               21  that it does not merit other support, or there are no resources.
               22  Now, if there are no other resources available,  that  is  a  kind
               23  of deficiency of a systemic kind which we are not in the
               24  position to resolve.
  :e-Federal  Reporters,  Inc. Whether it is the problem of  the  economic  status  of
               25




     ter-12
                                                                         130



                I  New Mexico, or as is much more common, the unavailability of

                2  third party funds to pay for a service  which  is  generated  out

                3  of a demonstration activity, et cetera.

                4             If RMP funds, or any other program like ours, which

                5  is developmental, remain in support of some project or activity

                6  because there are no alternatives, rather than becaus6"it

                @7 belongs there.  It very rapidly exhausts our resources, and

                8  really cannot move.  In the case of the tumor registry, it

                9  miaht be even more difficult to justify, because there are

                I^v so many do@abts about the effectiveness of that as a program,

                11 but this is valid even when you  are  supplying  a  demonstration
                121 activity in a service, and it  is  especially  troublesome,  when
                13 what you are doing, is really worth doing; but  if  we  begin  to

                14 supplement Medicaid, or other types of activities with RMP

                15 funds, we are lost.

  -10/s-ll      16

                17

                )8
                i                                                                     I
                19


                20


                21


                2-A)


                ?3

                24

  ce -Federal Reporters,  Inc.
                25





  'R 7149
                                                                               131

  'lake 11
                                DR. SCHLERIS: I know you  are  anxious  to  move  us
  tor 1
                2   along but my dilemma is I still haven't reached in my mind

                3   how I would react to this and I think that is the position

                4   of your review committee.

                5              Looking at some of the projects for which they are

                6   requesting support for the 05  year,  some  one,  two,  three,

                7   four, five of them began in the 01 year  and  if  we  give  them

                8   funds now to set up new projects, we are going to be faced

                9   next time with these being in the 06  and  07  year,  as  well

                    as the new ones that have corne aboard that they can't L-"4,&ase

                    out because of lack of support.

               12              My concern is that  if  everything  that  is  started

               13   in New Mexico has to be continued indefinitely because

               14   there are no alternative methods for support, we better

               15   avoid starting new programs  unless  we  know  with  assurance

               16   that they can be continued or unless we have the feeling

               17   that our beuget will be rising proportionately over the

               18   years to take care of this.
               19              Also, I reflect the concern of the site visit
               20   group which was impressed with the fact that many projects
               21   go on through core, which means  they  really  don't  get  the

                    evaluation they should get under other types of surveillance.
               22
               23   one way is to move them out of core,  the  other  is  to  insist
               24   that all core projects have the same type of review.
  e -Federal Reporters,  Inc.  I am in a dilemma as far as the $120,000 for
               25






   dor 2

               I  developmental since there are ways of cutting projects out

               2  that have been continued now to the fifty year.

               3             Will you respond to that?

               4             MR. HILTON:  Well, I think what you have succeeded

               5  in doing is pulling me into the dilemma with you a little

                  bit, however, I did recall some discussion with Dr.  Gay,
               6
               7  that he has an intense interest in having available the

               8  capability and this again harks back to something said

               9  either today or yesterday in one of the other programs.
             10              He has an intense interest in havina the capability

             11   to be flexible in programing.
             12              I think this is where the whole discussion  of
             13   developrenta'L component came i,-@p j..-i the first peace.  -fn
             14   fact, we discussed at some point his desire to@,be able to

                  rechannel funds in areas in which he felt there was great
             15

             16   need.

                             There may, in fact, and I am uncertain of  the
             17
             18   details on the other program, there may, in fact, here be a
             191  need for that kind of flexibility in order for NMRMP to become

             -    a better program.
             20
             21              I have, and again, I think I am speaking for the
             221  team, considerable confidence in Dr. Gay's ability to  do
             23   this in such a way that NMRMP does, in fact, become an
                  asset, whether or not it be done through discretionary funds
             24
  e- Federal Reporters,  Inc. which he did not question or developmentally, I think that
             25






                                                                       133
   dor 3


                  flexibility ought to be there.

               2             I am confident under his leaderwhip it will be

               3  used to the benefit of the program.

               4             Would you second, or any comment with regard to

               5  that, Frank?

               6             MR. SCHNIOWSKI:  Not to beat it to death, but the

               7  Tumor Registry Project has drawn outside support from the
               8  National Cancer Institute.  They rate this as one of the
               9  three best registries in the nation, that is their judgment.

                             The pro4l--,--t d4---ect--.-, Dr. Key, has approached
             "I,
             I v
             11   the area of continued support in the wrong manner.  He has
             12   been advised by one of the -- Dr. Tucker, who talked to  him

                  aside, and indicated it would be much more efficient  to
             13
             14   approach continued support th rough the medical stafft of
             15   the individual hospitals as well as with the hospital
             16   administrators which he had been working with in the past.
             17              By the end of 173, they will have only  three
             18   remaining projects which they originally were  funding.  One
             19   of these is the tumor registry project. The other,  we  have

                  recommended the EMS project that has been going on for  four
             20
             21   years to be locked with the new EMS activity, which  was
  0          2'-) recently funded from RMPS.

                             The third projdct is their leukemia  lymphoma
             23
             24   project which was started in their third year.
  e - Fedefat Reportets,  Inc. DR. SCHMIDT: Bill?
             25





                                                                            134
  aor 4


                              DR. THURMAN:  I just want to add a minority report

                   to what Dr. Margulies has said.
                2

                3             A well-run tumor thing is a real asset.  Remember

                4  during the Civil War we didn't think stethoscopes were

                5  any good.
                6             DR. MARGULIES: They  are  now?

                7             DR. THURMAN:  Depends on the doctor, Harold.
                8             DR. SCHMIDT:  I presume that resolved everything

                9  for us.
              10              DR. SCHLERIS:  I will listen to     on registries
              11   but hardly on stethoscope.

              12              DR. SCHMIDT:  All right.
              13              Does anybody want to do anything in regard to
              14   developmental component, then?

                              I will ask for any amendments and we will test
              15
              16   out the developmental component first.

                              Does anyone wish to propose an amendment to the
              17
              18   main motion concerning the developmental component?

                              DR. SCHLERIS: I was  going  to suggest two things.
              19
                              One thinq,I think we would  do this region a favor
              20
              21   if we reduced their total grant because it will make them

                   get rid of some of the projects thev have had onaoina for a
              X.   A.

                   long period of time.
              23
              24              If we want to give the coordinator of the New

  ,e- Federal  Reporters,  Inc.
                   Mexico program some potential mobility, we wouldn't give it
              25




                                                                        135


   dor 5

                  to him if we give him money for projects which EMS  might

               2  want to phase out.

               3             I guess I also suggest reducing the developmental

               4  component.  I was thinking in terms of droping that 1.3
               5  down to 1.15, the second year, 1.2, the third year, 1.250, but
               6  even that is being generous, but I think developmental

               7  component should be significantly cut.

               8             DR. SCHMIDT:  Would you make --
               9             DR. SCHLERIS:  Drop it down to 80 thousand, 80

                  thousand for each of the       years, developmental component

             11   and the first year, the 05@'-y6ar: 1.15; second, 1.20; third,
             121  1.25.
             13              DR. SCHMIDT: Do you make that in the  form  of

             14   a substitute motion?
             15              DR6 SCHLERIS:  Yes, sir.
             16              DR. SCHMIDT:  This includes.approval of the

                  triennial status obviously.
             17
             18              Is there a second?
             19              It is seconded.
             20              Discussion then will revolve around the substitute
             21   motion and we will limit discussion to the impact of this
                  level of funds and their ability to do what thev want to do.
             22
             23              Are there any comments?
             24              MR. HILTON:.  Is there an assumption here  that
  e -Federal Reporters, Inc. there is an inordinate number of programs that will be running
             25




  ior 6         11                                                      1 36

                   beyond the 05 years?

                2             DR. SCHLERIS:  Both the number and quality of them.

                   They are going i
                3                  nto th@ 05 year now, and if  we  are  going

                4  to talk about a triennial status for a region that is

                5  attempting to, as you say, get mobility, I don't think you

                6  have mobility if you continue these projects  and  I  think

                7  this puts on them the onus of deciding what they are going to

                8  continue.

                9             Also, you have looked at their developmental

                   programs, it was anparent you thought many -of thcm werc

                   markedly overfunded as far as what they were requesting.  I

              12   think this gives them the opportunity of sharpening up what

                   they are looking at and I think $120,000  is  an  excessive
              13
              14   amount, particularly since they are involved now with helping

                   implement the Emergency Services Medical Program, which will
              15
              16   absorb a great deal of staff and time because they are
              17   funded for two years on that, aren't they?
              18              And this is going to absort more than they
              19   recognize, as far as being involved, even though they may
              20   not be  the contractual agency.
              21              MR. HILTON:  At this point I am inclined to
              22   agree  with you on developmental component,  which  I  might
              23   move as a motion after we defeat this one.
              24              But on the matter of continued  programs,  as  I
  e-Fedetal Reporteis,  Inc. understand it, there are only three projects that will be
              25


  lor 7                                                                    13 7

                 1  continued beyond the 05 years, one of them being the tumor

                 2  registry.

                 3              MR. SCHNIOWSKI:  I don't see any tremendous

                 4  hangover of dead weight in that regard.

                 5              DR. SCHLERIS: They are  requo.!tiftg,@for  the  05

                 6  year, the continuation, besides the tumor registry, of

                 7  five projects. Now  what  we  will  be  saying  is  beyond  the
                 8  05, but we are talking specifically about 06, 06, 07, isn't

                 9  that right, five  projects  which  add  up  to  something  like

               in   $170:000 is being requested@' into the 05           -sn"--  that
               IV

               11   correct?

               12               DR. SCHMIDT:  Dr. Ellis, do you have a comment?

                                DR. ELLIS:  Yes, I do, Mr. Chairman.
               13

                                I just wanted to point  out  that  this  is  such  a
               14
               15   poor area and it seems to me that perhaps the developmental
               16   component moght  give  them  the  opportunity  to  work  toward
               17   methods of health delivery that would really mean something
               18   in the lives of some of  these  pepole,  and  I  w-@as  thinking
               19   about the opportunity to develop nurse midwives and
                    pediatric assistants and assistants for the elderly and work
               20
               21   within that frame.

                                But I was thinking that technical assistance
               23   it seems to me, might  be  helpful  in  getting  them  to  make
               24   the  right  choices  in  t.erms  of  program  without  necessarily

  e-Federal Repoiters,  Inc.
               25   penalizing them.





                                                                        138
  [or 8


               I              DR. SCHERLIS:  I just want to make one comment.

               2   I am aware of their needs, and I would agree with you.  There

               3   are  certain programs they might move into but I  don't  see

               4   any assurance that we have been given that this is the

               5   direction that they will take, as far as the expenditure

               6   of their funds'and the continuation of projects  they  have

               7   had, do not seem to be in that direction.

               8              This is the other reason for my statement, not a

               9   failure to recognize their needs.

                              DR. ELLIS:  Would you think that technical

                   assistance might provide this way so we wouldn't have so

              12   much lag between the time that these problems appear?

                              Some of these are very long-range problems.
              13
              14              DR. SCHERLIS: Right, but we  are  talking  about
              15   developmental component and triennial status, it seems
              16   beyond a little bit in time as far as telling them  they  need
              17   a little bit of technical assistance, this is  my  concern.
              18              DR. SCHMIDT:  We are assuming that staff is
              19   listening to this and thato technical  assistance  will  be

                   offered and provided and so on.
              20
              21              John?

                              DR. KRALEWSKI: I think technical  assistance  will-


                   be useful, I think this budget as being proposed here,
              23
              24   however, under the new recommendation will give them  room  to
  e-Fedefat Reporters,  Inc. run and develop that new thrust, and if this is a  new  order,
              25




   dor 9                                                                 139

               1  I move we curtail debate, is that an order or is that --

               2             DR. SCHMIDT:  Yes, it is.  I will call the

               3  question on the substitute motion unless there is a violent

               4  objection from the committee members.

               5             All right, then, we will vote on the  substitute

               6  motion, which is triennial at a level of 80 for developmental

               7  component and 1.15, 1.2 and 1.25 for the three years.

               8             All in favor please say aye.

                             (Chorus of ayes.)
               9

              101            Opposed, no?
              11             The ayes have it so the substitution motion

              12  carries.

                             Ai-.td --, believe tl,,at -Llie necessary assistance w'l i
              13
              14  be arranged for by staff following this discussion.

                             I would like to move on to Northern New  England
              15
              16  before we break for lunch.

                             Some of the committee members sneak some pie  or
              17
              18  soup or something like this. So the record will  show  that
              19  Northern New England left the room, Bill Luginbuhl.
              20             Dr. Thurman?
              21             DR. THURMAN:  This will be surprisingly short,
              22  mainly because the conclusion of our total visit was that
              23  this whole RMP is just like starting a first year.
              24             I would point out that we had representation from
  ;e-Federal Reporters,  Inc. the Advisory Council and Mrs. Wycoff, Tom Nicholas and
              25





                                                                           i- 14 v


   dor 10

               I  and Roger Warner from operating RMPS, both of whom were

               2  valuable to a new RMP in that sense of the word.

               3             Particularly-a word of the staff, in that I

               4  think that C. C. Conrad and Spencer Crobin, as well  as  the

               5  others with us were quite helpful to this group  of  people.
               6             I might give you one quick work of history
               7  about this about this group because that is where  the  real

               8  problem has arisen in the past with Northern New Eng an

               9  RMP.
              10             It became operational, had a planning grant in
              11  166, with its first operational year at 169.  At  that  point
              12  in time a committee from the University of  Vermont  Medical

              13  School- actual@ly ran the program.
              14             The man who -,is presently coordinator arrived  in

                  the fall of 1969, but throughout all this period of time,
              15
              16  their primary emphasis was on developing a data base.

                             Some of the questions that arose went high enough
              17
              18  to get to the administrator of HSMHA, for some type of
              19  resolution and that RMP and CHP tried to arrive at a merger type
              20  situation, too, so that there would not be an overlap of
              21  any-kind.
              22             This was partly at the request of  the  governing
                  bodies of the state itself, to further complicate it because
              23
              24  the state was small and because of this experience  with  RMP
  ;e -Federal Reporters,  Inc. in the past, had been largely in the data  base  development
              25





                                                                         14 1
   dor 11


               I  experiment in health service delivery money, they  requested

               2  one dollar and received $932,000 for supplementary health  --

               3  mental health services delivery, so obviously they were  not

               4  ready to use it.

                             This created even more of a conflict bet ween  the
               5

               '6 RMP and CHP merger.

                             What happened was that they began to listen  more
               7

               8  and more to the signals from this committee and others,  and

               9  RMP actually began to change to a true RMP, roughly in

                  'Taniiary of this     1972, w,-4--'.,. the appointment of I" "Lr.

                  Danielson as coordinarort reinstitution of RAG, as we  know

             12   a RAG, with removal of a lot of situations that had gone

                  on betore, I would hot leave you with the feeling that  there
             13
             14   aren't still problems, because of the fact that some of  the

                  boards still overlap betw eeh RMP and CHP, the divorcing  of
             15
             16   the whole business of the health services delivery syst  em
             17   contract is still not a complete divorce, even though  they
             18   changed the name a little bit.

                             In this change it did make it possible for RMP
             19
             20   to get rid of some of the people who have been moved to  the
             21   other corporations to help continue the data base in  related

                  areas but in this reorganization, thev have been -- it  has

             23   been necessary for them to bring about some of their  staff
             24   and PMP losing their job.
  e -Federal Reporters, Inc. All of this has been accomplished reasonably  well
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                                                                          142
   dor 12

               1  by the people on board, and I think, in essence, represents

               2  now, since January of 1972, a nine month, eight month period

               3  of time when we were there, of reogranizat ion,  along

               4  traditional RMP lines.

               5             Dr. Luginbuhl was present for much  of  the
               6  situation because of significant questions in the past,
               7  in reference to the RMP to the medical school.  I think
               8  they have well understood the strong staff support  and  our

               9  review committee and council comments about what  was  wrong
              10  with their RMP in reference to collection of a data base

              11  rather than anything else.
              12             At this point in time, I think they have well
              13  understood that our feedback session was particularly good.
              14  Their request for specific staff assistance, C.C. and
              15  others, was very significant and meaningful, I think.
              16             And it represented, for me, at  least,  the
              17  opportunity to say very stronbly that this is an  RMP  that
              18  is still back in 1966 and that is hard to accept,  but  that
              19 'that, the 1966 constitution of this group in  1972,  leaves
              20  little question in my mind whether they will succeed.
              21             The present chairman of the RAG is a  little  bit
              22  still out of step and out of consonance with  the  new
              23  direction of RMP but he is a very educable  individual  and
              24  they have not developed goals and objectives in the feedback,
  e -Federal Reporters,  Inc. they actually asked us in a way how much time they had to do
              25





                                                                          14 3
   dor 13


               1   it and we left them with a figure of 90 to 120 days, which camc

               2   off the tops of the heads of the site team rather than

               3   having any other direct-ion.

               4              I think the whole question  of  minority  interest

               5   in Vermont was raised and we were not able to  speak  to  that

               6   very well because of the particular structure of Vermont.

               7              The only way a minority group could be constituted

               8   would be to have somebody who was born out of  the  state  and

               9   then moved into it, because there are no other minorities

              10   in that sense of the word.

              11              The poor are not the minority in Vermont.  If

              12   we are going to get on another New Mexico, it is here.

              13              But I think that in general, 'Ln speaking  to  all

              14   of the other segments-we normally speak to  in  review  o  an
              15   application, I could say they presented to us a very  good
              16   approach of taking the best of what they have had in  the
              17   past, not related to developments. of a technic al data  base,
              18   have coordinated it now with an approach to  the  future  that
              19   looks to be well structured and well organized  and  that  we
              20   are now in the transition period.
              21              This transition period is entirely different
              22   from the one that is usually bandied around here about going
              23   from categorical to noncategorical, and instead, the
              24   transition from data collecting group to a  true  health  care
  e -Federal Reporters, Inc. delivery group.
              25






                                                                       14 4


                             If we are going to ever be able to evaluate  any
              2   RMP, we ought to be able to evaluate this one because they have
              3   got the best d@ta base-you have ever seen to see now what
              4   is going to happen in the future in all of their areas.
              5              I think this will be meaningful, not only to us,
              6   but alto to other branches of HSHMA and HEW, because they do
              7   have a truly significant data base and if you look at the
              8   end of the site visit report, you will get a feel, and this
              9   does not represent all of the things they published.
                             You get a feel for what the they have done since
             .0
             11   1966 in collecting information, so we should be able to
             12   Very, quickly evaluate almost any program that is brought
                  about in the deli--iery of health care in th'Ls area.
             13
             14              I think that as we look at the process of  their
             15   organization, the coordinators very firmly moving to take
                  total command of the situation with strong assistance  from
             16
                  the RAG, he is the one who.has been responsible on going
             17
                  face to face with every single person and saying, "You  are
             18
                  not really contributing, why don't you resign," or "We really
             19
                  need you badly,, you are the kind of guy who we hope can
             20
                  help us make the change in the future."
             21
             22              Although the l@G is very small at the moment,
                  it is open-ended in reference to their by-laws, and I believe
             23
                  the additions we have brought about will be significant.
             24
  e -Federal Reporters,  Inc. The RAG chairman clearly is a university man,
             25





                                                                      145

   dor 15

                  but he is a university man who has pioneered community health

               2  programs throughout Vermont, which is a reasonably tight

               3  structured state.

               4             So I have no concern about him carrying  too  much

               .5 of the idea of the university.
               6             In speaking to the university and its relationship,

               7  one of our fellow committee members has led the charge to
               8  get the offices of RMP off the grounds of the  university  to

               9  cut down a tremendously spectacular overhead rate, and he
              -is 0has now si-icceeded in th4--- they are mo4,4-ng and they  w4@'Lli-
              11  now have an off-grounds place, although the  university  will

              12  still be the grantee.
              13             We have no concern in any way about the management
              14  or effectiveness of funds because they are moving very
              15  comfortably in their structure to make sure that all of their
              16  so-called advisory committees, which is their mechanism of
              17  action, have a very firm,bu get.
              18             T hey have a definite plan, with each budget
              19  there will be a timetable and if  that timetable is not  met,

                  that the money will no longer be  there.
              20

   end 11     2 1

              22


              23


              24

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                                                                         14 6

   #12

      arl                    Going back to our earlier discussions, money is

               2  one of the clubs that we have, and they are using it well in

               3  their approach to programs.  I think that the program  staff

               4  is presently being realigned, as I indicated, they are  phasing

               5  out a total of 11 jobs, actually more than that, but 11  are

               6  being phased out, some going to other opportunities and some

               7  just being phased out. They have brought on a  young  physician

               8  to work in the area community development.  And his

               9  enthusiasm and capability]3Dth are significant, and I think

              10  on tj'L-AaL@- 'A-aasis we don't have ariy :real concern that they will

              11  begin to derive programs from throughout the state that

              12  have a strong community base and meet the need for delivery  of

              13  health care in an entirely different way.

              14             This is his cup of tea. If they can keep  him  in

              15  the program, it will be great.  I have some concern that they

              16  may lose him because his type of talent is in bad need all

              17  over the country today and so he may go.  The RAG understands

              18  the way to go.

              19             I think that they have,-- will make future

              20  appointments on the basis of knowing exactly what should  be
              21  done before they get into it.  They have pulled again, as

                  I indicated, not only at RAG: biit committee management, thet,
              22
              23  have pulled their best people from the best and have let

              24  most of the dead wood go.

  ,e -Federal Reportets,  Inc.
                             They have done this very, very well which is a  real
              25





                                                                              14 7
    ar2

                   tribute to the coordinator in that I think  his  experience

               2   in the program for over two years before he became
               3   coordinator made it possible for him to get an honest

               4   evaluation of what is going on.
               5              I think our only concern is the site team, about
               6   his role, was that in'the area of continuing education and
               7   manpower development, if he has a blind spot, this  is  it,
               8   and we tried to emphasize that pretty much in our  site  visit.
               9              I think staff is well aware of it as  a  reasonable
                   blind spot. It 4-c- --M-hasized enough in the feedback session
                                        r

                   to make everybody else well aware of it, and I believe that

                   will probably answer the most significant problem that
              12,  exists at the present time in their entirely  new  development.
              13
              14              I believe I would stop now in this discussion because
              15   there really is nothing else that I can firmly put a  hand  on
              16   at this point in time to say about this program  because  I
              ,7   think we should look at it as a program that  really  developed
              18   a coordinator, no coordinators in January of this yeari
              19              The RAG is working well, though small,  to  make
              20   itself meaningful.  And they really have nothing e se to
              21   present except a truly significant data  basis  accomplishment
                   and now with the opportunity to turn around and move on.
              23              Rather than recommend, we might listen  to  what
              24   the secondary reviewer has to say first.
  ce-Federal Reportefs, Inc.  DR. SCHMIDT:  The secondary reviewer is  Dr.  Lewis.
              25




                                                                          14 8


    ar3

                I  who is not here. So, Spence, do you have any comments on  --

                2  let's move on then to your recommendation.
                3            DR. THURMAN: Spence, you don't  have  anything  to
                4  add, let me add, do you agree with what I have said?  No,
                5  C.C., I don't know whether you heard about what I said of
                6  the possible blind spot of the coordinator being in man-
                7  power coordination And education, and we leaned very
                8  heavily on that with the hope that we would do away with his

                9  blind spot.
              lo,                           @@les, I th4-n]-, onc 4%--'A-.ing the rc-@,4-cw
              11   committee might be interested in.  The Kellogg Foundation
              12,  has made a grant to the University of Vermont Medical  School
              13   for the introduction of the problem of oriented medical
              14   record in medical practice in Vermont.  This offers an
              15   opportunity for the northern New England RMP and the medical
              16   school through the department of continuing education to join
              17   forces in a way in which they have not been able to join

              ,8   forces before.
              19              I think this offers a mechanism and  advisability
              20   as to how the continuing education resources can be addressed
              21   in a meaningful way that is a very real promise, I think
              22   in terms of case history, maybe of interest to know that
              23   one of the graduate students of the University of Vermont
              24   did a master's dissertation on the case history of the
  ce -Federal Reporters,  Inc. northern New England RMP. This person is now on the  staff.
              25





                                                                             14 9
        ar4

                I  So if you need a good case history, there is a 100-page

                2  dissertation.

                3              DR. SCHMIDT:'- Recommendations, then?

                4              DR. THURMAN:  The recommendation of the site

                5  team was that triennial status not be granted at this time.

                6  This was quite honestly discussed with the entire group, but

                7  that it receive two year approval so they understand, or we

                8  understand they understand we understand they have turned

                9  the corner and are ready to develop a good  RMP  at  this  period

               io  of time. but with this two year approval at the 1-c-v,al of

                   $850,000 each year that we also grant them developmental

               12  component or discretionary funds, and our recommendation for
               - I the f-.rsq@- year there would be 10 percent of the present  fund;
               1 3

               14  for the second year, continuing 10 percent of whatever the
               15  funding is for the first year.

                              DR. SCHMIDT:  We will have to label that discretionary
               16
               17  and that amount is within the 850,000 obviously.
               18             Is there a second to that motion?
               19             DR. ELLIS:  Seconded.
               20             DR. SCHMIDT:  It is seconded by Dr. Ellis.  Comments?
               21             DR. JAMES: I would like to  have  one  to  explain  to
               22  me the relationship of the research  and  development  of  health
               23  systems incorporated which is the recipient of HSMHA's

                   experimental systems contract.
               24
  e- Federal  Reporters,  Inc. I see where they were awarded $900,000 to develop
               25





                                                                            150



     ar  5
                1 experimental delivery system there.  It occurs to me that

                2 with the geographic and demographic information we have as

                3 far as Vermont is concerned, that there will  possibly  result
                4 some kind of conflict -- well, can't say conflict, but I
                5 wonder just how much overlapping of effort in such a small

                6 state, that Vermont represents.
                7             It seems to me that there might be some turf
                8 Interference, and I get the feeling that one is going  to  take
                9 precedent over the other in view of the fact that  the  popula-

                   !on IS small.

                              DR. THURMAN:  I might respond to that by saying
              12 1 this is the one dollar they requested for which they  received
              13  932,000. And it is very clear in everyone s  minds  that  there
              14  will continue to be some degree of difficulty in understanding
              15  the role of each of these because of the fact that RMP in
              16  Vermont has had an image of a data system and it is this
              17  divorcing of the data system from RMP as we think of  RMP  now
              18  that the new program actually represents.
              19              The overlapping of boards, who will do what,  all
              20  of that is  still a bad situation. I think this will  not  be
              21  clarified over the next several years because of the fact
   0          22  that RMP actually helped with the development of all  of  the
              23  Plans for what is now the experimental system to the  tune  of
              24  roughly $150,000. Isn't that right, Spence,  over  the  years?
  ce-Federat Reporters,  Inc. Okay, 350,000, missed by 200,000. It is a piddling  amount.
              25




                                                                         151

      ar6

               I  So I think there will continue to be some real  problems  with

               2  this.  The medical society is well aware of this,Dr. James,

               3  and their concern, the board, they have actually  changed

               4  the name of this now to call it a Vermont, it now has VHSI

               5  to get around some of their problems and their board  is  made

               6  up of providers, politicians, public and the payers.  This'is

               7  part of the thing they are going through.

               8             I think Dr. Danielson as coordinator and

               9  the early development of the present RAG, nine to  12  people,

              10  are so burdened by 4@- ' .-. is whole situation that j@ would no@L. be

              11  concerned about RMP being hurt.  I am more concerned, not
              12  truly that concerned about it, about HSI being an ineffective

              13  program because of the emergence of a strong HCP.
              14             I think staff will have to continue to look  at  it
              15  and I am sure the northern New England RMP will be coming back
              16  to staff and saying why can't you do something with those other
              17  guys in Washington, because that is the way they feel about it
              18  right now.  Point out that one person whols been not so
              19  burdened, but very concerned about the situation, is  Dr.
                  Luginbuhl because he and others wonder what they are going
              20
              21  to do with this @32,000.
   0          2--)           DR. SCHMIDT: I will comment  iust  brieflv.  I
              23  don't think that blame, with the word "blame" in  quotes,
              24  for the situation can be laid at the door of RMP at  all.
  ce-Federat Reporters, Inc. RMP is a victim of essentially HEW muddling and  meddling
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                                                                                                                       152
            ar7

                               in the  state of Vermont,  and  if  somebody's got red eais over

                         2     this,  it  is  the  Secretary of HEW.   And  this  is  an  incredible

                         3     blunder by HEW,           and  in"'effect a manipulation of  a  state
    is
                         4     Plan.

                         5                      I  thinkthat the RMP and people  in Vermont are going

                         6     to have  to      kind of recover  from a reeling blow that was

                         7     dealt to  them by feds coming up there and manipulating the

                         8     state,  and  I  think the RMP will be  in great part,  part of

                         9     the  solution of this problem.

                                                Mv words  are quotes  from HEW peo-ic who have been
                       10,

                       11      investigating what went on  in Vermont and how a request  for
                       12 1    one dollar got turned  into a  forced upon the  state  1 million
                       13      @ly HEW.    It is an incredible  story.

                       14                      Are there other comments or questions  then?

                       15                      DR.  ELLIS:   We don't understand the  $1  request.

                               Could you tell us?
                       16

                       17                      DR.  THURMAN:    They were  told  that with this

                       18      tremendous      data base  in hand,  where else could you --  could
                       1 9     really you      document what you were                doing with experimental
                       20      health  services delivery and other approaches,  and  so  they
                       2       said don't you want  some of our money?
                       2                       And  in essence,  the  answer back was we are really
                       23      not ready  for  it,  which is  an honest  statement,  so  they said
                       24      at least put your hand             Iin the pot,  and they put  their hand
    -Federal Reporters, Inc.   in the pot  for a dollar,  and were  showered with greenbacks.
                       25







         ar8

                  I              DR. KRALEWSKI:  Aside  from  who  would  apply  for  a

                  2  dollar, I am hesitant to vote, I like your funding

                  3  recommendations, but I'-*am hesitant to  vote  that  two  year  kind

                  4  of thing since generally we deal with     a triennium, or say
                  5  look, here's another year, you can try to work out an applica-
                  6  tion.  Would you comment on this?  Do you think we have to
                  7  go give them a two-year kind of period?
                  8              DR. THURMAN:  We discussed this at some length

                  9  and Spence can comment when I finish.

                                 Our feelina was  that  the  reallv  had  made  a  marked
                10                                          y
                11   change in  their approach.  They  had  the  people  now  who  under-
                12   stood what the story is all about.  And therefore that if we

                                          4 b - Z
                13'  would seriously 4Ln.LL.L L part'Lct',Lar'Ly the development of their
                14   community-related program  under  Dr.  Robins  and  he  would  not
                15   be able to add additional people, he could only talk to them
                16   on the basis of one  year,  and  that  then  triennial  status  if
                17   everything continued to go well.
                18               There's been so much problem and so many people
                19   like our  chairman's  referring  to,  so  many  HEW  investigating
                20   groups that have passed through the state that the crown
                21   sits on uneasy with so much money.
                22               We felt strongly that if we just went for one
                23   year with this group that he would have real troubles continuing
                24   to develop what he wants.
  kce- Federal Reporters,  Inc.  DR. SCHMIDT:   This would not,  you  know,  by  the  two
                25





                                                                      154

       ar9

               I  years -- are you saying that under no circumstances next

               2  year could they come in with a triennial

               3             DR. THURMAN:  This was discussed at the feedback

               4  session, nothing prevented them from coming in for
               5  triennial status next year, but we wanted to give them  the

               6  feel for two years for continuing development.

               7             Spence?
               8             MR. COBURN:  It is built into the recommendations
               9             DR. SCHMIDT: It is part of  the  recommendation.

                             DR. THUM14AN:  Yes, 4LL-. is.

                             MR. COBURN:  They are not going to be able to write

              12  you a triennial application after the site visit.  This will
              13  be then applied in the second year as you are suggesting here.
              14  If we go in with the recommendation that here is a base
              15  for a couple years, and although we'd like to have you move as
              16  rapidly as possible in formulating a program thrust and

                  developing a three-year program, and sending that program
              17
              18  in here for approval, I'd be agreeable to it.

                             DR. THURMAN: I think to finish it off,  we  said
              19
              20  there would be a site visit next year.  This they understand,
              21  and if they wanted to before that site visit actually prepare
                  a triennial application, fine. but if it looked li.-ki- th(--y
              2
              23  need another year to actually go on as they were, that  was
              24  one of the reasons for. the recommendation of level funding,
  ce - Fedefal Reportefs,  Inc. that they would then know that they had to talk to that group
              25





                                                                          155
            arlo

                 I  or some group again next year about an increase in funding-

                 2              But we felt that the security of this program with

                 3  its past problems and the actual  divorce  now  of  HSI  with  a

                 4  whole change from RMPS staff that they may or may not be

                 5  ready to try triennial application this year in order to meet

                 6  site visit next August again.
                 7              DR. HESS: I would  like  to  think  that  with  this
                 8  recommendation we are coming very close to a leveling off
                 9  of funding for this  particular RMP.  So it happens with your

                    recommendation they wi.11 be funded at about @2 per  ca-,,-+---,

                    which is the highest, as far as I can recall, the highest

               12   funded RMP, on a per capita basis of anywhere in the country.
               13               True, they do  have  scattered  population,  but  no
               14   more so than Arizona, New Mexico or the mountain statesi
               15   Low income, yes, but no more so than Mississippi.
               16               I would think there ought to be a point where
               17   certain RMPs begin to level off while others are coming up.
               18   Particularly when so much  other  federal  money  is  coming  in
               19   which is addressing itself to  health  care  systems,  so  I  am
               20   just concerned that we don't  get  into  a  situation  more  and
               21   more simply because they got in and got something going.
               '-)2 Seems to me that we have just about reached a plateau.
               23               DR. SCHMIDT: Other  comments  prior  to  a  vote  on
               24   the motion then?
  ,le -Federal Reporters,  Inc. If not, I will call for a vote.
               25





                                                                    156
       arll


               I             The motion is understood.  All in favor, please

               2  say aye.

               3             Opposed, no?

                             And I hear no dissent.
               4

               5             It is 1:15.  Cafeteria is out of soup, but there

               6  are a few other things left.

               7             We will reconvene at 2:00 o'clock sharp.

               8             (Whereupon, at 1:20 p.m., the hearing was recessed,

               9  to recon vene at 2:00 p.m., this same date.)

  :12         10



              12


              13


              14


              15


              16


              17


              18


              19


              20


              21




              23


              24

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   CR 7149                                                                      157
      13
   eak 1
                                          AFTERNOON SESSION

                 2                                                        (2  p.m.)
                 3              DR. SCHMIDT:  It is   two O'clock.  I have been asked
                 @4 to remind the Review Committee members to be filling out

                   your rating  sheets.  All  of  the  regions  that  are  under  review

                   should be rated  by  Review  Committee  members.  So  be  sure  you
                 6

                   fill these out.  We  have  three  left  to  do,  Texas,  Indiana
                 7
                 8 and Memphis.  We w  ill begin with Texas and Miss Kerr.
  xxxxx          9              MISS  KERR:  Thank  you,  Mr.  Chairman.  I  think  we
                 II^.went the records to sho@ty  Mrs.  Flood  has  excused  herscl@4.  She
                 v
                 I was an important part  of  this  visit,  so.  The  visit  to  Texas
                 12, was made in August of this year.  The State of Texas makes
                   -up the region and it consists of 254 counties with a population
                 13
                 14 of 11,200,000 people.  I feel somewhat pressed for time here and

                   I think this is unfortunate, not because it is so big but because

                    t has accomplished so much  and  has  so  much  potential  that  I
                 16

                   would like to share it more  in  detail  than  I  will  be  able  to.
                 17
                                The grantee institution is the University of
                 18
                 19 Texas at Austin. It  is  made  up  of  17  institutions  of  higher
                 20 education,  three  of  which  have  medical  schools.  Dr.  Charles
                   LeMaistre  is  Chancellor  of  the  system.  Physical  agent  is
                 21

                   the  same  institution.  The  coordinator  is  Dr.  McCall,   central

                   office  is  in  Austin  with  projected  ten  subregional  offices.
                 23
                 T 1
                 24             At the  moment six  exist,  at  El  Paso,  Houston,
  :e-Fedetal Reporte,s, "c' Tyler, Abilene, Laredo and Lubbock. They expect to add to this
                 25




      eak 2                                                                158


                 list San Antonio; Dallas will then leave two to develop.  In

               2 Texas there are 21 CHP  "B" agencies, 19 of which have councils
               3 and have been funded from between .$10,000 to $20,000  per  agency
               4 by state funds.  The last site visit was made in
               5 July of 171. Dr. George Miller is  Chairmanlof  that  group.  Also
               6 on that site visit team was Alfred Pompa.  And I say this becaus@
               7 these two gentlemen were on the visiting team one year later.
               8 The region appreciated this continuity. As Chairman  of  the  team
               9 I appreciated this continuity.
              101            In the meantime between the last site visit and the
              11 one in August, there were four interim staff visits to  the  Texas
                -region,  on an introductory visit from Buddy Says here on
              12
                 my r4Laht, onc relative to health services
              13      1
                 activities, one relative to health services activities.
              14
              15             Also the members on the team in addition to Dr.
              16 George Miller and Dr. Al PompA were Mrs. Muriel Morgan of the
                 council, and Dr. John Low, director of the South Dakota
              17
              18 regional medical program.     Regional medical program staff  were
                 Mike Posta who is present in the room, Joe dela Puente and
              19
              20 Dr. Roberts who is here.  And I am hopeful that they will feel
                 froe,to contribute after I am through with the initial report.
              21
              22             In addition to this group, we  had David Eubanks
                 from the HEW region 6 as program representative.  The purpose
              23
                 of the site visit was to assess program progress, processes
              24
  ce - Fedetal  Reportets,  Inc. and the proposed triennial application.
              25




   eak 3



                1             Now, following the last site visit a year ago in
                2 August of 1971, there was an advice letter sent out  following
                3 council meeting which contained five major concerns for this area

                4 relative to this area.  I will visit those in a moment.

                5             However, I would make it clear that we had a  team

                6visit the night before at which time the team decided
                7that while we were focusing and basing our observations on all tie

                8criteria for review, we would focus primarily on these five area:@)

                9to be sure that we were probing deeply enough to  have  answers

                 for this review committee and council when we returned.

                              The five concerns and there is somewhat overlapping,:

              12 at the time of a year ago, it was identified that  this  region
              13ineeded to establish priorities under its new program direction
              14 The subregional staff members, it was felt, needed more assistance
              15 and support from the central office and RAG members in the develop.
              16 ment of specific program activities.  It was felt that there
              17 needed to be more and better representation from allied health,
              18.one more, additional representation from minority  groups,  the
              19 fifth one, some of the reviewers felt the process seemed to be
              20 more of a central office academic review rather than peripheral

              21 involvement in input.
              22              In developing into these more deepl,y, I think
              23 they will come out as I progress along through the report,
              24-             did find these five  concernIs being based and attended
                  ust how we


  ,-e-Fedefal Reporters,  Inc.
              25 to.  From the time of the last site visit until December, it is




    eak 4                                                                    160



                 unbelievable what this region had  done  with  the  development

               2 of goals,objectives and priorities,. riot only  the  amount  of  work

               3  done but the process in which it was  done.

               4  It involved not-only the coordinator  and staff, but many meetings

               5 of the regional medical program, representatives  from the

               6 subregions, the  executive committee, and  it  was  a  well-organized

               7 process coming out with seven priorities well understated

               8 by pertinent goals.

               9              There was  only one question about  this  whole  area

              10 of goals, objectives   and priorities and this was

              11 Dr.  Low who felt that  perhaps the objectives  could  be  stated
              12 Isomewhat more in measurable terms.  Didn't seem to be a glaring
              13 omission but this was  a  suggestion  for  improvement.  The  RAG

              14 was divided into seven  major  committees,  each  one  responsible

              15 for one of the priorities and they worked individually in

              16 task forces coming back at  intervals,  to  compare  notes  and

              17 finally came up with the seven priorities accepted by the

              18 total group.

              19              The objectives by testimony  during  the  site  visit

              20 are understood by all of those participating and they are supported

              21 by all those  participating.  Chief  of  program  development  evalu-

              44 al-iioris to ue erLip'Loye(i aiid iiture @,xpert consultation will be

              23 sought in strengthening  the  evaluation  committee.  They  did have

              24 a man on staff full-time on evaluation  but  in  the  process  of

  :e-Fedefal Reporters,  Inc.
              25 further developing the subregions and  giving  them  the  kind  of




                                                                          16 1



    eak 5      1  assistance they felt necessary to come from central office,

               2  this agent who is a very capable person was put in a position

               3  to coordinate and assist with the activities of the subregion

               4 programs and, as a result, it vacated the position of one

               5 full-time evaluator but this is in  their  plans  to  replace  this

               6  person very shortly.                                    1

               7               It is very clear that the  subregional  offices  are  nov

               8  providing more input into the system and this was verbally

               9  supported by every one-of the.siibregional representatives

               'iO that was there including Mrs. Flood.  The  all were very   vocal,
                                                             y

               11 very supportive and very appreciative of the kinds of

               12 assistance that they were,getting.  The issue    of advisability

               13 which was done by the council and sent  back  to  the  advice  letter,

               14 the issue of advisability @"of developing  local  advisory  groups

               15 was discussed and the concensus was that  the  CHP  "B"  consumer-

               16 oriented planning councils are  being  developed  and  that  potential

               17 activities of local RMP advisory bodies would constitute

               18 duplication of effort.

               19              It seems it would also be  detrimental  to  community

               20 efforts in Texas because not all potentially effective,

               21 articulate and well informed consumers have been introduced


                  into the s-,,st--M. 7%
                                        ef-4or@, -.o 1--raj4-n consumers 'Ln paiLicipation,

               23 however, is presently being supported by RMPS.

               24              In addition, five contracts for developing an enviro---

  ce - Federal Reporters,  Inc.
               25 ment for Chicano health  consumer  participation  is  being  supported





    eak 6                                                                 162

                 by RMPS in Texas, California, Colorado.  These priorities

               2 when appropriate have been followed in the funding

               3 of operational activities.  They are addressed to regional needs

               4 and reflect the possibility and instrumentality for continuous

               5 development and improvement. :As far as implementation, there

               6 is much evidence of continued accomplishments by  RAG  committees

               7 and staff.

               8             For example, support of planning effort toward

               9 comprehensive proposal with reference to renal disease has

                 resul@.c,"4 in promising activity.  If success'Lu'L'Ly funded, it will
              IV

                 bring to Texas one of the first efforts addressed  to  compre-

              12 hensive care of a particular group by regional basis.  Without
              13 a doubt, in my experience of project proposals, whether it be

              14 RMPS or any other, this proposal for the kidney program was
              15 probably as well thought out, planned through a committee,
              16 advisory committee, bringing everybody across the state of Texas
              17 aboard that could have any input to its implementation and it
              18 was exciting really to hear about this. It has  been  so  well

              19 done.

                             While many traditional projects have  been  supported
              20

                 in previous years, these are now being terminated.  A new
              2 1

                 generation of projects as was presentpd to the            team
              2'd)
              I5 promised to deliver  improved  accessability.  Representatives
              2

               ' of various multi-discipline professional  organization  testified
              24
  'e-Fedefal Reporters, Inc. favorably on behalf of RMP. I bring this out primarily  because
              25





                                                                               16 3
    eak 7


                  historically this has not been true.  The relationships,

               2  the acceptance of RMP by the medical association has
               3 improved.  I would go a step further and say that the executive
               4 director of the Texas Medical Association was the one who was

               5 there to speak with us.  And what is probably a little more

               6 reserved in his openness and acceptance of RMPS than I
               7 understand about 90 percent of the physicians in that state are

               8 so this was encouraging.  But the other thing about the change
               9 in the predominance of physicians can be told, I think, relative

                                                                  4
               IV to -.he adivsory committee.   The advisory comrt-t@j,--tee aL- one
               11 was almost entirely MDs.  At this point in time, numbering
               12 51, there are 29 physicians on it.  And it was recognized
               13 that the region serving an effective role toward the delivery of
               14 health services because it, for one thing, it is serving
               15 as a bridge between what we call on the site
                  visit among ourselves in family, town and government.
               16
               17              In other words, it is bringing together the practicing
  e 13            Specialists  and general practitioners.

               19

               26


               21




               2i


               24

  ce --Federal Reporters,  tnc.
               25





                                                                             16 4




  Cr 7149                   As far as continued support is concerned, in

                2
    14            response to questions by the visitors, the regional representa-
     a 1        3 tives reviewed the continuing  status  of-the  activities  fund
                4 trhough 1970 to 1972.  Of 22 projects supported, only two will

                5 continue after the close of the current period.

                6           Eight will be supported by  self,  or  other  support

                7 that has already been  arranged.  Seven  will  be  discontinued.
                8 Either because they have been completed or because through

                  evaluation they have proven to be  not  worthy  of  continuance.

              10            And there is a question about the continuance of

              11  three others. Relative to minority interests and you will recall
              12 ithat this was one of the concerns of the last advisory group,
              13 and we went armed for bear to find  some  answers  to  this,  and

              14 I would have to say, that as we looked at the advisory committee

              15   constituenc.y there was some concern and a little more than

              16  concern, that not as much has been done in this area as wehad

              17  hoped would be in the  entire  interim  period.

              18            However, there has  over  the  period of the last five

              19  years been an increase in  minority  groups  to the number of 11,

              20  which seemed not too bad in view  of  the  fact that  they  only

              21  had a quarterly turnover with replacements. And we can't

              22  exiiecL air unusually rapid increase in this number through

              23  but there are also some other reasons.

              24            I think we all acted like generals  for  two  days  in
  ;e-Federal Reporters, Inc.
              25  this area and I think Dr. George Iii.ller's hat was the hardest an





                                                                                 J.V.i




      9 14         the biggest. Having been there before, being the one that made
  Reba 2         2  the recommendation for increased involvement of minority

                 3  groups, he really peppered away at this.

                 4             We even checked this out'with Dr.      LeMader relative to

                 5  their civil rights compliance and so forth       and so on. They had

                 6 as  I  say  improved  the  minority  representation  on  the  RAG,  not

                 7 as much as we would have liked but there is a strong commitment


                 8 to do this.

                 9             And words  can  be  words,@but  it  is  in  print.  Their

               10  procedure   for employment of peop'Le with a fo@us oi-i  eiftployii-ig

               11  those who   are  of  the  minority  groups.  I  think  at  this  point

               12  I will say that Dr. I.-IcCall   as  forthright  as  he  is,  we  could

               13  not back him  into  the  corner  on  this  because  he  was  so  honest

               14  about it and'said, "I am looking for these people, I have been

               15  looking  for  these  people.  I  will  continue  to  look  for  these

               16  people and bring  them  to  the  board  as  soon  as  possible  but  I

               17  will not commit myself to bringing aboard a black face or

               18  Chicano  or  a  white  person  unless  they  have  the  competency  and

               19  capability that  we  can  build  on  to  make  them  an  active  con-

               20  tributing part of our staff and RAG."

               21              The  minority  groups  are  extremely  well  and   consumer

                               the subregions. P-luch of the nroaram i.s arr,)na,--cl aroiin(4
               22  groups in                                   -  I              I
               23  the  inputs  from  these  people.  There  are  a  significant   rumber
               24  of minority personnel    on  project  staffs.  I  would  want  to  tell

  e -Federal Reporters, Inc.
                   Vou tllis:Dr- Sid Geroa,  who  sat  there,  and  he  is  not  a  very
               25





                                                                               166


        #14     1  vocal person, but he rose to his feet after much probing

  Reba 3        2 in this area, and this was the second day, he rose to his feet

                3 and in a soft kindly wa@, a Chicano,   made it very clear to us

                4 that the RAG, the Executive Committee and indeed the grantee

                5 institutions as they moved ahead in their pgoram planning and

                6 implementation, he felt and it was like a sermon, he felt that

                7 they had the well being of everybody in that state in mind

                8 regardless of race   color, creed, age or anything else.

                9           And it was beautiful to hear. If he had been more

              10  vocal before I don't think it i@7culd have been.quite so litipres-

              11  Sive. Relative to process, Dr. @IcCall, the coordinator, has

              12  undoubtedly T)rovided some of the strongest leadership with able

                            r-.on -Lr-,. his three year tenure that one could expect.
                     LlliS@L.Ca' 4


              14            There is a very viable regional advisory group and he

              15  has utilized them, diversified talents of its membership, in

              16  establishing the plan as presented in the triennial application.

              17  Dr. L@IcCall has excellent rapport with members of the RAG and

              18  rianv other health representatives throughout the state.  Agencie3

              19  and associations, indi viduals, and so forth. As an aside, at

              20  this particular time Dr. McCall was being interviewed for a

                  Coroner's position in mv own state and as a member of the collea@
              21

              22  and faculty there I was aware of this, somewhat involved in
              23  this I think he and I treated it with verv low profile, inten-
              24  tionally.
  -Federal  Reporters,   Inc. The review committee i,7a-,3 aware of this. The possibilit
              25





                                                                              16 7



           #14  1  of changes, I would say, despite the fact we knew change was

  Peba 4        2 possible, we felt that Dr. McCall had developed a staff, had

                3  allocated  responsibilities  or  delegated  responsibilities

                4 and given it the  authority  to  carry  out  these  responsibilities,

                5 and if he had, we felt that I,lr. Ferguson,  his  deputy  could  very

                6 well move in and move ahead with the program they were planning.

                7            I hasten to add before you get excited he has

                8 decided to stay in Texas. I think Texas is fortunate and I

                9 think we would have been fortunate to  get  him  but  we  will  carry

                0 on.            to program staff, the staff consists  of  1:'7

              11  professionals, all but two of them serving 100 percent of the tine,
              12 @There has been almost no turnover  in  the  last  two  years.
              13             I think this speaks well both for staff and for the

              14  coordinator, and six additional professional staff members are
              15  requested during the next year and include a director of edu-
              16  cational programs,  chief  of  public  development  and  evaluations,
              17  nursing education  and  three  subregional  representatives..
              18             The site visitors believe that these positions as
              19  budgeted are justified. The program staff reflects a high
              20  quality of broad branch of Professional discipline, particularly
              21  impressive was the quality of subregioiial representatives

                  to demons
                            trated  thorouah  knowledge  about  their  resnonsibilities
              22

                  with resoect to ccoqraohical assigned areas.
              23           1       -1  -1  @@
              24             The 51 member RAG group was very active from the
  e-Fedeial Reporters,  Inc. time of the last site visit through December and continues to
              25





                                                                         16 8


         #14   1  be but were particularly active at -that time with attendance
  Peba 5
               2 never going below 70 percent, and with people coming from all
               3 over that state of Texas  to work on RAG meetings, that attendance
               4 of 70 percent seemed to us to be very good.
               5           Geogranhic distribution of its membership was con-
               6 sidered to be satisfactory. However, as  with  many  regional
               7 medical programs Physicial representation proportionately was
               8 high while consumer interests remain relatively low.  I alluded

                 to that earlier but I need to go a step further I  think  and
              ]Oli-ndicatc again -L.A'4ere ate still 29 of the 51 who are physicians.

                           This question was raised as to why. And the chairman
              12 of the PAG, S. T. Bradshaw, not Bradshaw, Dr. Eastwood, who is

              ' I,- Ph.D. an - -.
              13 CE        a director of the medical center at Houston, quite
              14 apersonality, highly respected by the group who relates well

              15 with the RAG group, and in staff and the rapport seemed excellent.

              16          But anyway Dr. Eastwood explained that with the four

              17 -- with the three medical institutions within the system, and with

              I 8Baylor and one other medical school in the state,

              19          @IR. SAYS:   University of.11ouston is the medical

              20 3chool.

              21          MS. KEPR:  Getting underway. If they were to have

              22 epresentation from aeneral practitioners and so forti'L so on

              23 --hey could see that this could not be cut too much more if they

              247ere to keen the good faith of the physicians that  had  taken
  e- Federal Reporters, Inc.
              25 ;o long to get it built up and he convinced us that this  was


                 .rue.




                11                                                             169
        #14     1           And after our visit I think we felt that  this  too

  'Peba 6       2 was T)roper, too.
                3           The executive committee meets more often  than  the
                4 RAG committee and provided arqple guidance for the  coordinator

                5 and staff. Effective in providing leadership in  the  process
                6 and in utilizing regional advisory groups, 51  committees  and
                7 task forces. These were not left in limbo, they were well organ"-
                8 izbd and coorindated task forces and committees.
                9           Development committee assumed an active role by
              10, 6stab!4-sh4-ng sh----t tc--m -b4cct4-vcs. The Cha J4- -m, an o f e act,
              11  program committee is a RAG member and serves on  the  executive
              12 Icornmittee. General program activities for each  of  the  seven
              13  priority statements and funding  allocations  projected  for  use
              14  of growth funds in the second and third  year  of  the  proposed
              15  triennial event application. All this is to go to say that therc
              16  has been much planning, thinking,  brainstorming,  and  so  forth
                  prior to the submission of their level of request for funding.
              17
              18  I have talked about the grantee organization.
              19            There was some feeling at one time that perhaps there
              20  was a little bit too much control from the grantee organization.
              21  !,Te came away from their having probed rather deeply  on  this

                  too to find that the coordinator, the PAG  feel  lierv  free  to
                2
                  move ahead with decision making with absolutely no interference
              23
              24  or control from there, from the grantee institution.
  e -Federal Reporters, Inc. And they feel very comfortable with the physical
              25






                                                                              170



          #14 1  arrangements,  as  far  as  participation  is  concerned.  Many

  Reba 7        2  health interest groups are actively.participating in the region

                3 as evidenced by the number of persons who attended this two

                4 dav visit.


                5           14o major groun has  captured  a  controlling  interest.

                6 In preparing the budget request for that of last year there

                7 was a complete turn around with respect to funding the major uni-

                8 versities and institutions.  This  accomplishment  has  made  more

                9 funds available for the community. But -- as a result it has

              JO  i-Lc)t      about less cooperation from major health institution.

                  The political-economic power of the regions involved in the
              12,regional program, the CAP agencies  and  local  --  not  only  this
              13 but there is CHP  representation  on  the  RAG,  representation

              14 from MIP other P14P on the CIIP Council.  CHP  and  B  agencies

              15 are involved in the process.

              16            I have already talked about  the  CHP'S,  and  their

              17  situation.  During the last IU4PT the review cycle there was

              18  ample evidence that the  @IP's  minimum  review  requirements  and

              19  standards for local review have been carried  out  in  a  very

              20  satisfactory manner and this continues to exist.

                I           As far as the assessments and resources there was

              O)-) anl-l-r-- evidence the r--g'-on is conscientiously accumulating a

              23  great deal of data as evidence by inaudible -- the data is

              24  utilized in identifying specific and measurable needs of the

  e-Federal Repoftefs,  Inc.
              25  region.






                                                              171

        414  1         Management, the capability of the region continues
  P,.eba 8   2 to be excellent. Program staff.,and project activities are
             3 well coordinated including monitoring by RAG members and sel-
             4 ected ad hoc members. Progress and financial reports are requirei
             5 on a quarterly and monthly basis respectively. Relative to
             6evaluation as I indicated earlier at the present time there is
             7no full time evaluations director in the program.
             8         1 have talked about the termination of funding on
             9some projects that come about by evaluation and the limited
           10 funding being put on others as a process of evaluation and
           11 their need and expectation to fill this position shortly. As
           121far as program proposal the action plan is comprehensive,
           13 priorities have been thoroughly prepared with much review
           14 and are clearly congruent with national goals and objectives.
           15 Phe proposed activities relate to stated priorities and objectives
           164.ven to the needs of the region. @"4ethods of reporting accomplish--
           17i,ients and accessing results are proposed but address individual
           ]Bictivities really more than they do program achievement but
           lg)eriod review and updating of priorities are planned.

    end  14 20

  15 fls   21


           22


           23


           24

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           25




    mea-1
     CR 7149
                                                                      1 7 -9


                               As far as dissemination of knowledge is concerned,

               2    most programs have focused on appropriate groups and

               3    institutions that will benefit.  Knowledge, skills and

               4    techniques to be disseminated everybody identified to

               5    varying degrees among the projects.

               6               There is a notable degree of involvement of

               7    health education and medical institutions.  Better care to

               8    more people is a goal to which projects are  directe  .  Some

               9    solid measurement of result remains to be seen.  However,

               lu   they are also addressing themselves to moderation of costs

               11   of care.

               12              Utilization of manpower, the regions utilize

               13   community health facilities and it is apparent in the

               14   projects that are proposed

               15              Allied health personnel utilization has improved.

               16   Although new types of health manpower is a  sensitive  issue,

               17   further attention lis being given to this and this  statement

               18   revolves around the fact that the medical profession  in  the

               19   State of Texas is not yet ready to accept the position of

               20   assistance.  Maybe this will change but this was why this

               21   particular statement was put in there.

               2               Irice-rove,-,,en@k- of care, access '@O health care, -Ls
               23   their first priority and projects are being addressed to this

               24   issue.

   Federal  Reportefs,  Inc.
               25              Primary care will probably be  strengthened  since




     mea-/.                                                          173



               I    this is an important element in several of the projects.

               2    Less attention is given to health maintenance and disease

               3    prevention in the pro-osed activities.
                                        p

               4               As far as short-term payQoff the proposal is

               5    directed more toward the ability of access to services than

               6    simply gathering more information about health problems.
               7               The need for feedback: is projected.  Support.'Of

               8    projects not planned beyond three years.  Plans for
               9    transition to other sources of support are included in their
             in     proposals so tba.t three years is the limit of funding,
             11                As far as regionalization, we have talked about
             12,    the different regions.  It is a major goal of the program.
             i3     Tney do snare existing resources when possible and new

             14     linkages among providers ate indicated in the three-year
             151    plan.
             16                There is ample evidence that the,region has and
             17     will attract funds from sources other than RMPT. Thougli not
             18     discussed in detail the region account provided the staff
             19     with a document which indicates non-RMPT funding, to  e
             20     new and continuing projects and terminating projects

             2 1    $.150,380.
             22                It was the feeling of visiting team that Texas
             23     has much going. That it is well on its way to doing some very
             24     exciting things based on sound priorities and objectives

  ;e-Federal Reporters,  Inc.
             25     which have been developed cooperatively with a great deal of






                                                                        174

  ,R 7149
                1  consideration by all people involved.  They have been accepted
  @ake 15
  -ontd.
                2  by all people involved and it seems as though they are

      MEA       3  collectively ready to move out and do something  with  these

  lor 1         4  things.

                5             We also felt that the region is  under  excellent

                6  leadership from the coordinator, who uses well  his  central

                7  staff of people who do bring to the central staff competencies.

                8             We have before us the funding level requests and I

                9  think we can all read that the site visitors  did  recommend

              1.0  that they be approved as requested.

              11              Now, I would draw your attention to the fact

              12   that these do include the kidney project and that there are

              13   questions about that.

              14              Dr. Roberts pursued that more in depth, but it

              15   was the unanimous opinion of the visitors that they be

              16   approved at the level requested.
              17              It was also the unanimous feeling of the visitors

              18   that Texas kept its A rating.
              19              DR. SCHMIDT:  All right, John.

                              Dr. Kralewski:    Just a couple of comments.
              20
              21              I didn't visit Texas on the site visit.  As a
              22   matter of fact, I have never visited Texas RMP, so I really
              23   don't know the program.
              24              I am reacting to the application; I am reacting to

  ,e - Fede ra I Repot te rs,  In  c.
                   the site visit report.
              25





  dor 2                                                                    175


                               Unfortunately, the reports are striking me a

              .2   little differently than they apparently struck the group

                3  that visited Texas, but-let me just give you my impression:-i-,-.

                4  then we can go from there.

                5              First of all, it looks to me  as  though.that  RAG

                6  is still dominated by producers of  services  even  after  the,

                7  you know, team previously had been very concerned  over  i4,-

                8  and wanted to make changes.

                9              Changes have been minimal, and  the  addition  of

              10   women to the Regional Advisory Group, and then putting

              11   minorities on there, to me, is a  cop-out  and,  secondly,  it

              12   is a cop-out, I think, to say we don't  want  to  take  someone

                   b"-,--ause he is a minority group, we have got to wait  until

              14   we get that fantastically qualified guy.

              15               I have had about three programs tell  me  that  and

              16   it is a strict cop-out, because  they  don't  look.  There  is

              17   plenty of good guys out there if they  search  for  them,  so

              18   I think they are not doing the job in that regard.

              19               Secondly, when I look at the  projects,  I  think

              20   this shows up because, of course, in  their  screening  of  the

              21   projects, this is the group that sits down and sets the
   0          22   priorities and determine what should be  in  and  what  should

              23   be out.

              24               If you look at these projects, a good many of them

  e- Federal  Reporters,  Inc.
              25   are self-serving to the group that is on the Regional





                                                                         176


                I  Advisory Group, self-serving to producers of services.

                2             I know this is a conservative@state and they

                3  will have to chip away a while before they can do things.

                4             I find, on the one project, they are going to help

                5  someone develop an HMO, and I was looking that over to see

                6  who it was going to be, and sure enough, it is the Medical

                7  Society.

                8             So, now we will have another foundation developed

                9  at our expense  or the Medical Society more than likely.

              101             Well, you know, these are leaving me some real

              11   questions.

              12              Also, I note in here that it appears that a fait

              13   amount oL' projects are carry-over projects, they are not

              14   being phased out.  It may be that this again is an indication
              15   of some excess money that was given to them in the middle
              16   of the year and it just- doesn't reflect that in this
              17   application.
              18              Well, on the basis, on that basis, of my feelings,
              19   as I read through this and the feeling that I get, you know,
              20   for what they are doing, I can't really recommend that level
              21   of funding, nor an A rating.
              221             On the other hand, as I said, I have never visited

                   the program.  I am acting on the basis of information that
              23
              24   might be limited.
  e- Federal Reporters,  Inc. I respect the site team's wishes, obviously they
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                                                                          177

   dor 4

                1 spent a lot of time with it, therefore, I am in a bit of

                2 a dilemma.

                3             DR. SCHMIDT   Let's see.  Let me see.  Would you

                4 second the  motion that was made?

                5             DR. KRALEWSKI:  For that funding level?

                6             I couldn't second that, no.
                7             DR. SCHMIDT:  All right, there is a motion on the

                8 floor for approval at the level requested.

                9             Is there a second to that motion?

              iol             MR. HILTON:  Second.
              11              DR. SCHMIDT:  All right, it is seconded.
              12              All right.  Further discussion?

     15                       Dr. T-Ugj
  -.ake 16    14              DR. LUGINBUHL:  I was interested to check the

              15  population  of the area.
              16              I think it is 11 million people, and I don't
              17  really feel that coming up with per capita figures should
                  be t he way in which we determine allocations.  I do think,
              18
              19  on the other hand, that we have to give some consideration
              20  to the size of the aiea and the numbers of people that are
              21  being served.
              22              I think that the amount of money proposed works
              23  out to something like 22 cents per person.
              24              I know in one of the other programs, we have given
  ce- Federal Reporters,  Inc. probabl@. five times as much on a per capita basis.
              25





                                                                          17 8
   dor 5

               1             My question is, if it is an A rated program,  why

               2  Isn't it a bigger program in view of the size of the  state,

               3  the diversity of income levels, the magnitude of the problems,

               4  why aren't they able to utilize more funds and meet some  of

               5  these needs that are there?
               6             DR. MARGULIES:  I think that is an interesting
               7  kind of a question to raise.  It is more a matter of history
               8  of program development than it is geography or population.
               9             It is a problem that we have wrestled with at

                             e  -
                  varic)us ti--rn s i n RMPS.

                             This particular program was one with a  misera  e
              121 record up until the time of the last sit e visit, when George
              13' Miller was down, sort of astonished at the change about  it.

                             On the other hand, if you are asking the
              14
              15  question, why, if this program is as strong as it is and
              16  has that many people it is not able to identify more
                  activities of value to those people, that is a perfectly
              17
              18  valid question.
              19             I just don't want to mix the two issues in  the

                  discussion,
              20
              21             DR. LUGINBUHL:  Well, my major question really dealt
                  with the last issue.  I can't help but wonder, in view of

                  the population, why isn't it a larger program, and to lead
              23
                  me to question the wisdom of having a single program cover
              24
  ;e - Fedeial Repoitefs, Inc. such a very large geographic area and such a very large
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               I  population.

               2              I am not familiar with the California program

               3  because we have not reviewed it at this time,  and  I  gathered

               4  they have dealt with their large population by some sort

               5  of great division and I know that New York, which  may  not  be

               6  the best example of how to run a  region,  has  divided  that

               7  state into several different regional  medical  programs.

                              The question I am really raising, is this  too  big
               8

               9  an area to  manage through a single program?

              10              Is there enough emphasis being placed on  the  sub-

              11  regions or  on dividing iip the problem so that it can be
              121 addressed?
              13              MISS KERR: There was consideration  given  to

              14  having three -- Texas make up three  regions  originally,

              15  and it was decided to go with one.
              16              The other thing is the regions are comparatively
              17  new, with their representatives just  getting  out  there.and

              18  getting involved,, and I think that to use Mrs. Flood  as  an
              19  example in the El Paso area, where there are many Chicanos,
              20  she knows their problems, they relate well and there is a
              21  Sister Strohmeyer down in the lower valley who is equally
              22  as -- and I assumed, all of them were, from the way they knew
              23  their subregions as they discussed them with  us,  they  were

                  identifying problems.
              24

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              25              I am not sure at this point in time, though I





   dor 7                                                                  180
               I   am sure that they, too, will want more funding eventually, but
               2   I am not sure at this point in time but what  the  coordinator
  0            3   and the RAG feel that at this particular time perhaps that
               4  "We better take this much money and do well with it and then
               5   90 the next step."
               6              DR. MARGULIES,:' I would like to pick up  something
               7   John commented on, he used the same words in my mind  when  he
               8   said "cop-out".
                              I react, I guess, with some suppressed violence
               9
                   to this business of, "oh, yes, we are interested in

                   minorities and women but they must be of the:)best kind and
              12   of the finest kind of qualifications."
                I
                              Well, I I-,avc a      ob-c-tions to that.  t'ne
              14   is that it can easily be used as a facade for inaction.
              15              Secondly, if there was absolute equality as
              16   equality is usually measured, then there wouldn't be any
              17   minority problem in the first place, that is really what
              18   we are talking about, and
              19              The tlird is I doubt very much that a program
              20   which has to deal with issues of the kind that they have in
              21   Texas, particularly with the issues of Mexican Americans,
              22   migrants, and so forth, can do so from the kind of experience
              23   that they get from people who have never had anything  in  the
              24   world to do with those problems.
  :e-Federal Reporters, Inc.  I think it is a programmatic weakness but what I am
              25






   dor 8

               I  real ly wondering about is, if you believe in,general in

               2  these concepts, at what point does this become an issue of

               3  priority in determining what grant levels should be?

               4             Now, we have identified on several occasions in our

               5  review that there are deficiencies but there are signs of

                  progress, and so on.
               6

               7             This is one of the criteria.  The weight one

               8  gives to it, I supposek can be put down in some kind of

               9  arithmetic form, but I think there is more to it than  that.

                             And 1 think it is onl,, fair to say to you     our

                  own kind of judgment is going to be very strongly influenced
              12 1by just how much evidence there is of commitment to the issues
              13  o-A":-:ta:Lr play with minorities, with women.  This is so

              14  inseparable from the concept of an effective Regional

              15  Medical Program that 1 find it impossible not to be
              16  influenced greatly when we come to the question of grant

              17  award.
              18             Obviously, if there is a marked disparity- in  my
              19  view.. and that of the review committee, we will yield to the

                  position of the review committee and council, but I do  hope
              20
              21  that question is being given as much consideration as it

              21) should.
              23             DR. SCHERLIS:  I just wanted to take up some more
              24  questions about the recommendation of the site visit  group,
  e -Federal Reporters,  Inc. since a parently it, in giving all the funds that were
              25         P-





                                                                      182
   dor 9


               I  requested, apparently decided all the funds were to be

               2  wisely expended.  Looking over some individual projects,
               3  they are of interests -I question, though, how much impact

               4  they will have on health care delivery systems.

               5             The health project Number 69, Health  Evaluation

               6  Access and Resources Development, Ector County Medical

               7  Foundation, as I read it, it is a computerized effort to

               8  aid in diagnosis and seems rather expensive, it is

               9  $118,000 for each of the years, 166k at some six thousand
              I101 people.  If I read this correctly, haveta@,ttandatdiz6d

              I.I medical history questionnaire in English or Spanish, and if

              12  anyone has tried to set up computerized methods for getting

                                                          -agl-i area.
                  h-'-tor,-cc; t- -o '-cy@d that, "-h-s is a to

              14             Perform basic physical workup, which consists of

              15  urinalysis, blood pressure, visiaal test and hearing test.

                  These are the only ones that are listed.
              16

              17             You will then have electronic data processing,
              18  printout, a physician will look at the printout, and decide

              19  whether any medical care is necessary.

                             Then from that point, I sort of lost track
              20
              21  because they say diagnostic and treatment services will be
              22  obtained from public volunteer and private sources without
              23  charge when possible, and health delivery is dependent on
              24  that vehicle of access, if it is, it is really a very thorny
  e -Federal Reporters,  Inc. type of project to look at.
              25






                                                                       18 3


                              Yet, it is one hundred eighteen for each of

                2  two years.  It is fairly routine.

                3             I was wondering if you could tell me what GRO--
                       or  GRO are, since it'is taking place in five places.
                4  3:s,,

                5             MISS KERR:  Grass roots.

                6             MR. SAYS:  This essentially is seven to twelve

                7  in each group that get together.  The whole idea is a

                8  sharing of services.  Thus far, about the extent of the

                9  actifity has been sharing in service training, but we

              lo   believe that it will go far beyond that.  They are now looking

              I I  at this.

              12              It certainly is an activity that is popular

                1, among the consumers as well as the providers.
              1 3

                             DR. SCHERLIS:  The other program is an electrical
              14

              15   safety service, one which seems similar to many of the others,

              16   except here they are paying $50,000 for manuals, I guess to
              17   be put out.  Then to have it self-supporting, I question
              18   if at this period of time, knowing what we do about safety
              19   hazards, since all this is so well documented and available
              20   through many agencies and otherwise, I just question if this
              21   should be part of what RMP should support.

              22             MR. SAYS:  Well, this is a pickup on an activity
              23   supported by program staff for about a year.
              24             DR. SCHERLIS:  But they plan to support that again,
  e -Federal Repoiters, Inc. don't they?
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                             MR. SAYS:  No, it is a little different.

               2             The core staff activity, they-demonstrated the

               3  feasibility of this in-six hospitals and the Texas Hospital

               4  Association, whiieh is very progressive, very cooperative

               5  with the RMP, as well as other prior organizations, has seen

               6  fit to take this activity, asking for support for one year

               7  only, after which it:.will be continued through fees.

               8             It goes far beyond putting a manual for hospitals,

               9  but offering them assistance, actually going in and taking

              .0  a look at the way thev go about checking out 1-hci- equipment,

              11  and so forth, and possibly, even in some of the smaller

              12  hospitals, sharing electrical engineers, where the single

              13  hospital may not now be able to do so.

              14             DR. SCHERLIS:  Well, the lutline doesn't go that

              15  far.

              16             MR. SAYS:  If you look at the full-blown

              17  application, it does.

              18             DR. SCHERLIS:  I guess you had the raw project.

                  I question if this is the way to do it, since there are other
              19
              20  ways of approaching it.  This was the question that I had.

              21             DR. SCHMIDT:  Mr. Toomey?

                             MR. TOOMEY:  I couldn't find any mention of an
              22
              23  HMO proposal, but I would like to comment that if there is

                  such a proposal, and if it does concern itself with a
              24
  D -Federal Reporters,  Inc. medical care foundation, then I would recommend that it be
              25





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                I  supported.
                2             I am concerned about the medical care foundations
                3  that are established on-A as a defense mechanism against more
                4  and different and, if you will, innovative kinds of pro-
                5  visions of medical care, and to use the foundation for
                6  medical care as a mechanism to defeat something which is new
                7  and different,turns me off, but to fund a project which has
                8  as its base and concept great numbers of people or
                9  representatives of hospitals, public health  agencies,  CHP
                   aqencies, RMP people,, physicians, medical schools, and  so
                   on, it would be very refreshing and as a matter of fact, it
              12   might just possibly come up with something which would
              13      Ve!@y V"Urtliwlii'L@ @L.,.- te@--ias of aii HMO foundcti;ioi-@,. f@,
              14   care kind of proposal and would be different.
              15              I would like to see it.
              16              MISS KERR:  I am not sure but what there is some
              17   misunderstanding about this because the HMO activity has
              18   been as a result of RMP involved staff assistance,  but  it
              19   is being funded by HSMHA, county medical society,  but  the
              20   region itself is not involved in any funding of the HMO.
              21              DR. KRALEWSKI:  My comment to HMO was along the
              22   lines that this is the way they devoted some of their
              23   discretionary funds, I believe, and core staff effort, and
              24   it may be appropriate.  It only occurred to me that I suppose
  -e
   -Federal Reporters,  Inc. there was a lot of different areas that could have used that
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                                                                       186


   dor 13       1  kind of help, and as I was reading through  it,  where  they

                2  talked about the fact they were giving help to groups to
                3  reogranize the health system, lo and behold, it
  0
                4  happened to work out that way, and it may be good.
                5             I don't wish to speak against it, but I think that,
                6  you know, this is a big region, they have got a lot of people
                7  they are trying to subregionalize, and I hope  that  that  will

                8  help a  bit.
                9             The site team obviously thought  that  they  have

                   some strength and will be able to qrow and so I auess,

                   really, though, that my reflections on this is that I feel

                   it,.-would really be giving them a bit too much of a pat  on
              12
              -    Lli- ii  to go one hundred percent of what they have asked,
              13.
                   both in light of the accomplishments that they have achieved
              14

                   and in terms of what has been made on these projects.
              15
              16              Therefore, I guess what I would really  like  to  do
              -17  is offer a substitute motion, of funding at levels of 1.9,
                   21.1, and 2.3, with developmental funds in the  range  of  80
              18
              19   first year, one hundred and one hundred for the second and
              20   third  year.
              21              I think this will give them an  increase  in  funds,
              22   and As.-has been pointed out, this is a large population
                   group and probable that budget is not out of line.
              23
                              Y et, I think it will indicate to  them  that  we
              24
  ;e -Federal Reporters, Inc. still have some questions about exactly what is  going  on  and
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                                                                            187

   dor 14
                1  where that money is going.

                2              DR. SCHERLIS:  I second that.@
                3              DR. SCHMIDT.@- All right, there is a second, then,

                4  to the substitute  motion.

  nd 16         5              Their level last year?

                               DR. KRALEWSKI:  1.58.
  ,ake 17       6
                7              DR. SCHMIDT: 1.58, so this would  be  up  to  1.9.
                8              MR. SAYS: Doctor, I know  there  is  a  motion,  but
                9  I think there are some things perhaps  you  are  not  aware  of,

                   Dr. Kralewski., in this whole situation.

                               Dr. McCall is an extremely capable coordinator

              12   and he understands that to pull off a successful program
              13'  takes the commitment of the people to whom it is to be

                   delivered, and also those who-are  involved  in  the  process.
              14
              15               If you look at the application  very  closely,  it
              16   took him from July, when the last site visit was made, up
              17   until December of 1971, through a  very  long  hassle  with  his
              18   RAG and his development committee.  The priorities were
              19   developed once and rejected by the  RAG.  They  went  back  to
              20   the drawing board.
              21               They had only two months to bring in some kind of
   0          22   projects for this application, hence, the reason for his
              23   growth funding in the second and third year.
                               I happen to know that  since  this  application  got
              241
  D -Federal Reporters, Inc. into the hopper, in January, they could  use  easily  a  half  a
              25





                                                                     188
   dor 15


                I  million dollars more tow.

                2             For an example, in Houston, they are now

                3  operating, or talking with a group, this program has almost

                4  developed, it would take $150,000.  It involves two barrios,

                                                                  -. health advocates
                5  where they would like to employ six half-time.'-

                6  3-n each barrio,, under the supervision of  Chicanos.  This

                   dove-tails in with a program by Baylor,  the  Department  of
                7

                8  Community Medicine, which is also involved  in  a  hospital

                9  district that has the direction of seven  clinics  from  that

                                        i-,ry
              ,o   citv that deal with v     poor neighborhoods,  an  excellent

              11   opportunity perhaps to examine access  or  evaluate  access
              12   and quality performance on a patient  population  of  60,000.
              13              This is just, you know, a couple of programs t'nat
              14   have been examined and are in the hopper at this time.

                              This application started almost a year ago.
              15
              16              DR. KRALEWSKI:  Well, I appreciate that additional
              17   information and I feel that if you are  correct  that  this
              18   gentleman is a really good manager, that he  would  be  able

                   to take a million nine and probably reorganize  some  of  the
              19
              20   things that he is@doing and probably, as a  matter  of  fact,
              21   go through these projects and come out  of4there  with,  you
              22   know, ten or twelve or fifteen percent  savings,  at  least,
                   and then devot e that to these  very  worthwhile  activities
              23
                   that you are mentioning, and I suppose he  does  have  also
              24
  :e-Federat Repofters,  Inc. the opportunity to come back with an application a bit later
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                                                                    189
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               I-  for some additional activities as they develop.

               2             MR. SAYS:  One year hence.

               3             DR. LUGINBUHL:  I am certainly very much influenced

               4  by your evaluation of the leadership of the program, but I

               5  think the information about the timing problem is quite

               6  significant.

               7             What I would wonder about is this:  Would it be

               8  possible within our ability to make some cutback in terms

               9  of the project part of the money, but give that money to the

              In  program in a wav that thev could usp i.t- fl,pxibl.v r-)-,Ye--r the

                  coming year.
              12 1           If he is a really good man, he has come up with
              ' I      slew I.-hings, now that he has gotten priorities
              i3
              14  straightened around, I would like to give him the  flexibility
              15  because it already is a fairly limited sum of money for the

              .16 population and problems.
              1 7            I don't see the imaginative approach to  the,large,
              18  unserved segments of that population in this application,
              19  and maybe if we could preserve the dollars but give some  more

                  flexibility to the director, he could begih@,to address those
              20

              21  programs.
  0           22             Finally, I am somewhat concerned about the RAG  and
              23  the fact that it does appear to be heavily influenced by
              24  professionals.
  :e -Federal  Reporters,  Inc. I am wondering, as I have listened to these
              25





   dor 17                                                               19 0

                1  discussions, about the size of  these  groups.  This  one,  I

                2  think, is 50 or so people, and I wonder  how  well  they  are

                3  really able to meet an6'-set some of these priorities and

                4  particularly how do some of the underserved get their priorities

                5  into the application, if the group  is  dominated  by  priors.

                6             DR. SCHMIDT:  Well, I think one of the points that

                7  John was making was that if this is a  wise  manager,  he  can

                8  get discretionary funds out of the money he has just by

                9  simply not spending it for some of the  things  that  in  the

                   application he said he was go4ng  to  spend  t  for.  Y-u  are

                   saying can we force him by earmarking discretionary funds and

              12   the answer to that is, he can be advised  or  it  can  be

              13   recommended but we haven't been in the habit of so ear-

              14   marking funds.
              15              DR. LUGINBUHL: My  concern  is  a  little  bit

              16   different.
              17              If I am correct in my understanding of the process,
              18   whereby some of these projects get  into  an  application,  I
              19   think what happens at times is that people propose these
              20   projects and they are nominally within  line  with  the  goals
              21   and objectives and the group making the decision at the local
              22   level finds it very, very hard to say no, especially when therd
              23   is not some other proposal at that  point  in  time  competing
              24   for those dollars.
  e -Federal  Reporters,  Inc. Frankly, I suspect at  times  the  problem  of
              25





                                                                       19 1
   dor 18


                  setting priorities is getting passed on up to us.

               2             If you have the money or the potential for getting

               3  money and you are not forced to set priorities, frequently the

               4  easiest thing to do is just not set them.

               5             What I am suggesting is that by cutting back  on

               6  the project money, you are going to force them to set  some

               7  priorities and you are going to let them reallocate those

               8  dollars or force them to reallocate those dollars by

               9  increasing the discretionary funds and I would think that for

                  at least some coordinators, th---. wo,@,1-4@ be a -,rer-y welcome
             IV

             11   opportunity to set priorities and to, in fact, strengthen

             12   their hand in dealing with their regional advisory group

             13   ari'u dealing with some of the priorities that are making

             14   demands for project support.
             15              DR. HESS:  Just a question to further clarify

             16   this.

             17              It is my understanding that an RMP may shift

                  developmental components into projects but the reverse is
             18
             19   not true unless it is authorized,,is that correct?
             20              DR. SCHMIDT:  That is correct.

                             DR. HESS: So the implication of  your  statement
             21
             22   is, would be to approve the developmental component at  the
             23   requested level and take the cut in the project section  of
             24   the budget in order to.achieve your goal; if that is what we
  e- Federal Reporters,  Inc. are after, I think that ought to be specified.
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                                                                                 19 2


   dor 19
                                 DR. SCHMIDT:  All right, is this acceptable to
                  2  the mover as a piece of legislative history that will be

                  3  directive then?
                  4              In other words, developmental component is given
                  5  at the 10 percent level, the maximum allowable, but the cut,
                  6  the reduction down to 1.9 comes out of the project funds.

                  7  That we can do.
                  8              DR. KRALEWSKI:  Acceptable.
                  9              DR. SCHMI DT:  All right to the seconder, is

                  10 that acceptable.?
                  11             DR. SCHERLIS:  Yes.
                  12             MISS KERR:  I would like clarification as to what
                  13 'che motion o.L -Lhe moment is now?
                  14             DR. SCHMIDT:  It is for approval of the triennial
                  15 period at the levels, 1.9, 2.1, and 2.3 total funding levels.
                  16 The original substitute motion was for developmental
                  17 component of 80, but this has now been changed to a
                  18 developmental component that would be the maximum allowable
                  19 under the policy, or ten percent of the award, rea  y,
                  20 which would give them, what did they ask  or?
                  21             MISS KERR:  They-asked for first year $160,000,
                  22 second, two hundred thousand, and the third, two twentv-five
                  23 thousand.
                                  DR. SCHMIDT:  Well, that would still be permissible
                  24
   ce-Federal Reportefs,  Inc' then because it could go up to 10 percent of the award. So
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   dor 20
                                                                           193



                I  that gives them some amounts of flexible funds.

                2             All right.

                3             Other comments or questions then?

                4             If not, I will call for a vote on the substitute

                5  motion which we just reviewed.

                6             All in favor, please say "aye".

                7             Opposed'Ino?

                8             Dissent is recorded.

                9             Thank you very much.

                                @l,@        -1  @ U  C.! @ -1     l@
                              i  A,.nl,@    -LS L.ILAE L.Lrs@L. L..Lrite we ilave ever:

                   completed a discussion of T exag in 55 minutes, 65 minutes.-

              12              We can conclude a discussion of Indiana in 30

              13   minutes.
  xxxxx       14              DR. PERRY,@.'@  The word catalyst has been used
              15   so I will just say there has been a most dramatic transition

              16   here in Indiana in the past year.
              17              A site visit has not been held in Indiana, although
              18   an August site visit was set up, it was canceled by RMPS

              19   for the following valid reasons:
              20              Dr. Stonehill, the coordinator of Indiana resigned
              21   effective April 30, 1972.  The triennial application tha4t- was

                   submitted was submitted without reaJ.lv thp Asqiqi-Anop nf a

              23   coordinator, was reviewed by the staff here at RMPS, did not
              24   clearly present a three-year plan, thus the site visit was
  e- Federal Reporters,  Inc. cancelled.
              25






                                                                         19 4
       21,


               1             RMPS recommended the submission of a one-year

               2  anniversary application which would lead to a much stronger

               3  triennial req uest next year  and this has been done.

               4             Dr. Schmidt, the second reviewer and I have been

               5  on two separate site visits at Indiana.  Dr. Brennan and I

               6  in 1970, representing the council and the review committee,

               7  were there,  We were not welcomed back for the next site

               8  visit-

               9             Dr. Schmidt was in Indiana in 1971 and I am not sure

                       ii-2[s reaction about being welcomed back for a site visit

                  this time, but the purpose of the site visit and which was
              121 communicated at the site visit periods, I believe have led,--'
              13  to the most important decisions for change in this region.

              14             If there is anyone thing that I would say was

              15  probably the greatest strength of all is this attitude of

              16  desire to change that is recorded in this, not only in the

              17  application, but by other means.

              18             I am delighted that Bill is here at the table

              19  with us because members of the staff,,since we have not been

              20  there dur3ng this period of thime, there are members of the

              21  staff that have been in the Indiana region and it i@ some of

                  th Pir reflections and the;---        and cerL-.a'L.L-I'L--
              22                                                    Y

              23  recommendations of RMPS that will be a part of my recommenda-

              24  tions here today.
  e-Federal  Reporters,  Inc. To evaluate Indiana, let's look at some of the
              25




                                                                          19 5

  dor 2 2


                1  strengths and then some of the weaknesses for, indeed, even

                2  with the problems and dramatic changes-@-.that have taken

                3  place, there are strengths that can  be indicated here.

                4             With Dr. Stonehill's departure, which was

                5  requested two months earlier than his date of resignation by

                6  the RAG, I think this tells a little about the story there.

                7             I am putting this as a strength and it must be

                8  taken as a plus, as far back as the time of the, of this 1970

                9  site visit, in which I participated, there was a great deal of

              10   antagonism expressed between many Indiana Medical Assoc-L -.Lons,

              11   and by various groups, representatives of the Medical School

              12   at Indiana,Shave stated-.toBill-@ to others.that they have

                   beeiL rt-i's'iiformed on the status of !P,14P.


              14             And that the tight ship that had been identified

              15 and I guess these are words that both Al and our group used, that

              16 this man was running what was evidently heading for very

              17 rocky  shoals.

              18             With his departure, Dr.Behring, Associate Dean of

              ig the Medical School, has been appointed the interim or acting

              20 coordinator and a search committee has been set up for his

              2 1replacement.

              22             I recall Dr. Behring, he has served with this

              23 group and with the RAG for a considerable period of time,

              24 perhaps an indication, however, that this PAG was not that
  a-Fedetal  Reporteis,  Inc. active and not that involved.
              25





                                                                                196

   dor 23

                I              Already the relationship, and  I  would  put  this  as
                2 a strength,  already the relationship of the Medical Society
                3 and other  health  agencies  have  indicated  a'marked  improvement
                4 in the few months recorded since the resignation of the

                  coordinator.
                5
                6              Dr. Behring reports, as the interim coordinator,
                7 thatthere are  improved  relationships  wit  hthe  Indian  Hospital
                8 Association, many of the health associations that have been
                9 identified in relationship to this program, that they are,
              In  indeed, sharing with them their request for help in putting
                v
              11  this region into better shape.
              12           The RAG, with many of the problems,..'.I,.will list  under
              13' weaknesses.
              14               I feel, however, the  complete  review  that  is
              ,5  taking place with the RAG today is    absolutely   essential. It
              16  is still in the  process  of  major  revision.  Although  the
                  larger number are from Indiana University, and there have been
              17
              18  comments on this from the beginning,  Indianai,@  in  that  setting
              19  and in that state, certainly Indiana University deserves and
              20  should be in a major relationship to t is RMP.
              21               But in addition to this group,-  we  find  here  other
   0          22  institutions, other  groups,  their  relationship  with  CHP,
                  which I will speak to  further  her  e,  other  organizations
              23
              24  throughout Indiana are being represented in some of the

  I-Federal Reporters,  Inc.
                  planning that is going on.
              25


   dor 24                                                                     197
                I              There is no question about the  still  great  need
                2 for consumer input.  Representatives of some of the other
                3 health professions, the.-.health professions-are physicians
                                                                I
                  and nurses only. Dr.  Behring,  however,  again  has  expressed
                4
                5 his eagerness to the members of the  RMPS  here.  He  plans  to

                  answer the criticism that IRMP has received and that, indeed,
                6
                7 the Medical School will assume a different kind of relationship
                8 on the RAG and in relationship to the total program.
   end 17       9

               iol



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         A A


                             Perhaps the most exciting  strength  to  mention  is
  Peba 1       2  the regionalization that although begun several years ago
               3  has culminated in the past few months with some very strong

               4  effects. Nine area action  groups  have  been  formed  and  the

               5  formulation of active relationships with five existing CIIP agen-

               6  cies has been carried out.

               7             The formulation of two othdr CHP's are being planned

               8  with IP.14W now in a working assisting  relationship  with  them.

               9  On just a  nersonal level I,had  the  opportunity  of  speaking

              IV  at my nome town which is Richmond,  which  does  not  have  any

              11  I guess problem here in terms  of  interests  in  the  project.

              12             I was speaking to the Medical Society of Wayne County

              13  and it invited liberty County to this meeting. They did not

              14  know my relationsh ip to RMP in any way  and  in  the  business

              1 5 agenda of that meeting it was  pretty  exciting  to  hear  them

              16  putting together, having received  a  request  for  Indianapolis

              17  for the first time to get involved, to select the people to work

              18  with them.

              19             To be a part of action groups.  There  was  certainly

              20  to me as I look back and as I read this application, an indi-

              21  cation of the little small town out there  of  40,000  that  had

              22  hrr-n asked for ti-i--  4-- -- -mc to lar - 4c-Lpate i-n

              23  and this nroaram and  really  their  excitiement  that  Indian-

              24  anolis was lookina out to them for them they felt for the

  e- Federal Reporters,  Inc.
              25  first  time.






                                                                            19 9


             018             So this rcgionalization olan is a most important

   Peba 2         plus.  Develonment of effective comprehensive data base
                2

                3 which is one  of the majo'--r concerns of the 1970 site visit which

                4 deplored the  lack of any really major statistical basis for
                5 planning Priorities and needs, this has been accomplished al-

                  though there are oarts of it that need to be looked at out in
                6
                  these scoarate T)arts of the areas that are being put together.
                7
                8            The state-wide basis has been accomplished and listed
                9 in this. I am sure Dr. Brennan will be happy to see that since

                                                                     4-
                  this is one of his maior T)ijsbes at the-, io-7n ...

               11            23 now major data sources have been obtained.
               12 These have been obtained through contract sources and such
               13 tli@re ijri   s'La,te. And certainly there is a working set to
                  1.@lork with here in looking at the regional characterization.
               14
               15 Their set of objectives, broad objectives that have been put
               16 together certainly has to be better defined than they are at

                  the nresent time.
               17

                            But thev have this basis for the first time to look
               18
                  at it and really to work with it. The strengthening of the
               19
               20 program staff has been looked at as one of the major commitments
                  and needs of this program. And already there is a reassignment
               21
                  Df responsibilities of some of the people  on the -oroaram staff.
               22
                            This is a relatively small staff.tliose of you that
               23
                  are looking at any of the material and whether one considers
               24
  :e-FederaiReporters,lnc. hat the amount of money at an annualized level for the program
               25





                                                                              200


         #18  1  staff is around $379,000, this has been a small staff that

  Peba 3       2  the former coordinator wanted in relationship to running

               3  the program.

               4             In the projects area, particularly those of a categori-

               5  cal continuing educational nature, it is exciting to find

               6  that there has been a transfer of many of the larger funded

               7  projects to local funds. The coronary care project that they

               8  have carried for years,  their  stroke  project,  these  have  been

               9  taken over by the other levels and other kinds of funding.

              io             !.lore abott this also in the recommendations. A--

              11  I said you know and I will go back to that as another major

              12  strenth attitudinal desire now to change, it is very strong and

              13    I-La-t:lt:)en to L-eet that they do have tire ca,,r?acity to 'i-)ring til.'Ls

              14  about.

              15             What are the weaknesses? The major weaknesses,
              16  program staff, there must be additions -@o this. There are only
              17  two-vacancies, in the list of what has been requested. This
              18  must be done in certain areas particularly, planning, evaluation,
                   ssentially. They  have  an  educational  Dsychologist  there,  and
              19
              20  he needs additional staff help. lie needs a model, he needs
              21  some-help on how really  to  relate  their  projects  and  evaluate
              2 2 them toward program goals.
              23             @Ir. Smith who I had the privilege of knowing through
              24  this project and have had a working relationship in many other
  e -Federal Reportegs,  Inc. ways who was responsible for allied health and nursing has been
              25






                                                                      20 1


          #18 1  so succesful in that area and he really got quite a bit going

  P,eba 4     2 there, he is so successful he has been moved into another job

              3  there and he is going to be head of all the active planning

                 in the reaional narts of the program.
              4

              5            Plav Isay that leaves quite an opening, however, for

              6  allied health and nursing there, and they do need staffing

                 un in that area, particularly since they have begun to turn
              7

                 the neople on there in that area in relationship to this.  As
              8

              9  a weakness again from personal background, they have  no  one

                 Ivef from there               of --lli'-cd medical professiuii:5 which
              IV -

                 is in the medical school at Indiana which is recognized as one

                 of the most broadly developed programs because there is  only
              12 ,
                 .. ne i,-ted-Lcal center in that state, has respons'b'lity for all the
              13 0                                            1 1

                 community college programs throughout the state.
              14
              15          Still they have no voice in any way although some
              16 projects in the RAG or in any of the relationships there to the

                 program I do not know for this is an excellent program.  They
              17

                 have peonle of national stature in that setting, some of them
              18

                 serving with me on two IULA committees in relationship to allied
              19

                 health.
              20
              21          A weakness, the revitalization of this RAG, a spelling

                 out of responsibilities, certainly a leadership role, nlanning

              23 role, rather than just a reactor role to what has been bubbling

                 ur) or coming in is essential. ',lust be a major reassessment of
              24
  :e-FederaiReportefs,lnc. the regions review process. If on(-, looks and one has pointed tl-ii
              25





                                                                              202



            #181  out in the last two reviews there when we have,had site:'

  Reba 5       2  visits.

               3             Many members of the Executive Committee of the program

               4  have made  all of the major decisions  in  this.  They  have  a

               5  very poor  history of turning anything down.  The indications

               6  are that this review Process again being looked at and already

               7  in the v7orks, some of the planning and things that must be done.

               8!Minority representation in  the  total  program,  there  are  no

               9 minority professionals yet on the core staff.

                             Two professionals are working in some of -Lil@.L -L
              I u

              11  projects and three minority people are on the RAG.  It is an

              12 inadequate representation still but it is an improvement over

              13  two years ago.  They still have quite a ways to go. However,
              14 in the Project orientation,  the  programs  they  have  had  and
              15  I remember quite well visits with one of the black physicians
              16  who was heading up one of the community health projects, neigh-
              17  borhood health projects in  Indianapolis,  they  do  have  some

                   ood Projects going in this are
              18  cJ
              19             Of approximately 15  projects  implemented  in  this
              20  program only three old ones are requested for continuation.
              21  Of these the neighborhood health care center, nurse tractitioner3
              2't)- are two of these.  There are eiaht new ones they feel are
              23  ready to go. These are, some of  them  getting  away  from  the
              24  categorical.

  :e -Federal Reporteis, Inc.
              25             Thev have some health care emphasis and relationship







                                                                               20 3


                I  to their newer goals.  I  will  quickly  make  a  recommendation
  reha 6        2
                  to get this on the table then I certainly want Bill and
                3  particularly Al, who has been on site visit-and Bill who has
                4 been there recently to respond  to  this,  but  let's  get  the

                5 recommendation out in relationship to this.  They are currently

                6 funded in this reqion  at  $1  million  121,000.  They  have  re-
                7 quested a million  five  hundred  thousand  in  round  numbers.
                8            The staff having looked at this total plan have re-..

                9 commended  an increase of only  around  $80,000  to  a  million
              10  200,000. And the breakdown for this.  As  I  said,  they  are  in
              11  -- their major needs as I  see  their  projects  in  this  core

              12
                 1staff so I am recommending or approving actually the recommen-
              13  dation made by the RPII  review  staff  here  of  approximately

              14  $500,000 of this amount for staff.
              15             This will give them increases in salarv.  This will
              16  provide for the new director.  This  will  add  some  to  their
              17  evaluation staff. It will give them an opportunity to really

              18  staff up there where they are really going to need it in

              19  staff that has been  held  certainly  to  the  bare  bones.  In

              20  relationship to one of their  other  major  needs,  and  that  is
              21  to   cIontinue with the projects as they relate to the regionali-

              22  zation and into these areas,  they  I-lave  requested  $500,000

              23  for this.

              24             In  contractual  services.  The  recommendation   of

  e -.Federal Reporters,  Inc.
              25  the review staff here was  that  this  be  cut  to  approximately




                                                                            204



           #18  1  $300,000. With this they should indeed be able to go on further

   P,.eba 7     2  with their feasibility studies, their expansion of subregional

                3  Dlanning, and staffing in relationship to the regional program.

                4            They have made a request for approximately $600,000

                5  for continuation projects and for new projects.The recommendation

                6  is breaking this down to $200,000 each, $200,000 for contin-

                7  uation and $200,1000 for new projects. Adding this $500,$300

                8  two $200 ones, we come up with a total of $1 million 200,000.

                9  What this does give this program, an opportunity  to  do  with

                   c-,7e,-, '-his small increase of $8^v,'UOO, Nqliicli is recommended,
               IV

               11  is to    they have turned the corner  and  made  the  decision

               12  to change.

               13            They have 6 long way to go to  make  this  the  kind

               14 of T)rogram that we really can believe is ready for a triennial

               15  review and I believe with discussion with Bill that any recomm"

               16  endation that we make with the changes and things that they

               17  need to do, rather than insist or even  ask  for  a  trieenial

               18  review next year, that they be held at this level for two

               19  years, during this period of transition.

               20            They have turned the corner,  they  have  got  a  ot

               21  of plans going, things they have to do during this period

                   of time.  Gettina a new director althoi,ic
                                                            @Tli T -PTn, share the-,, ar-
               23  going to be moving right 'ahead with  this, with the Associate

                   Dean of the !/@ledical School that is working with them  but  I
               24
  :e- Federal Reporters,  Inc. think tl)ey need a period of time and we are not increasing the
               25

                   amount in the recommendation more than this $80,000.





                                                                               205



  CR 7149                     That is mv recommendation I put on the board.

  41.9          2             DR. SCHMIDT: Okay. I am the secondary reviewer

                3  and I will try to just  bring  out  the  issues  as  I  see  them.

                4  At the time of the site visit last year there was just a god

                5  awful program. They got F's straight across the board and it is

                6  a nrogram that i  f substantive changes had not occurred one would

                7  be considering whether to just stop all funding and just

                8  declare the thing defunct and tell them to start over gain.

                9             Problems with ineffective coordinator who had


               lu  a small staff they ran tightly and the staff really was not

                   doing the right sort  of  things.  They  had  the  worst  kind  of
               121possible  relationship  with  the  medical  school.   The   medical
               13 school comnletelv dom   inated it.  The majority of people on the

               14 executive committee than ran the program were from the medical


               15  school.


               16             The  principal  person  involved,   George   Lucameyer,

               17  P.ssociate Dean of the School, did not and does not understand

               18  regional medical programs. For reasons easy to understand

               19  the medical school is scared to death of the Indiana I,.Iedical

               20  Society because their legislative support comes from the Indiana

               21  @-ledical Society. Indiana  Iledical  Society  did  not  like  the
   0               @cord4lnator or reg-LoTa'L Tt-Leu'@Lca'L program.
               ,L  A.


               23             The medical school dictated exactly what @IP could

               24  and could  tot do.  The coordinator's primary allegiance was to tlio

  e- Federal Reporters, Inc.
               25  medical school.





                11                                                      206

      #19       1           Ile said if Push came to shove his  medical  school

  T-leba 2      2 appointment was far more'important  than  anything  having  to

                3 do with T4P.  The Executive Committee was not functioning well,'

                4 there was no data, no objectives, no  priorities,  there  was

                5 no programs, there was no plan, there was some projects. There

                6 was no subregional effort. And it was just terrible.

                7           The site visit two years ago told  them  this,  they

                8 got real mad, said it was an unfair site visit  and  they  just

                9 stayed mad for a whole year. And I  walked  into  the  biggest
              10  tran I have ever seen set by a teg4-on that @,,as -,,-,lling
              11  visitors up against everybody and the coordinator took   a
              12 Iday to realize that we had been set up.
              13'           And we left essentially escorted to  the  state  line
              14 by the highway patrol. And I doubled back to  one  ray  of  hope

                  who was a bright and new lady of the  regional  advisory  group
              15
              16  and we just did suggest that the  program  leadership  needed

                  to be changed, the medical school put off  at  arm's  length.
              17
              18            We had to get the people in the school  who  did  not
              19  know what PD,,IP was about out of the picture. And so on.  One
              20  member of my institution is for liaison purposes  a  member  of
              21  the Indiana regional advisory group. Done Casely.  And he would
              21) come back from Indiana RAG meetings just  cackling  with  qlee
              23  and hand me the minutes of the meeting which  took  apart  one
              24  by one the site visitors and challenged the  integrity  and  so
  .e- Federal Reporters,  Inc. on and so on.
              25






                                                                             20 7



           #19   I            But largely through I-laver  and  some  other  people,

  Peba 3         2 and through the supportive  staff  I  would  like  to  point  out

                 3 to the review  committee  the  importance  of  staff  support  and

                 4 consistency of staff support in taking to the regions the
                 5 recommendations of the review committee and sticking by them
                 6 and  really  accurately  reflecting  and  confirming  and   supporting

                 7 review committee in this.
                 8            They came in to  see  Harold,  they  probably  came  in  to

                 9 see Ilenrv Kissincrer, I don't know who all they came in to see

               IV  ljut t'L-ley got Lile same message uacii time and Llie:ce wds a revo-

                   lution. The coordinator  resigned  and  RAG  decided  he  did  not

               12  resign quick enough and threw him out.
               13             Baring, I think  it  is  a  cop  out.  Medical  school
               14  is suddenly saying we did not know. TIell, you know it was
                   mpossible that  they  couldn't  have  known  what  was  going  on
               15  '-
               16  because they were the nrogram.  They just were not payinq
               17  attention. And I really think that they did know but they are
                   having a change of heart and they are withdrawing.
               18
               19             The program is  doing  some  things  that  I  think  really
               20  are terribly important and if we are going to have a program
               21  there, merit the support of the JUIPS ---  they  do  have  a  data
                   basis. Thev have new leac3t-r-,hin t--hc-re r-oraani.7i.n@ thp  staff;

                   recruiting a new staff.
               23
               24             They have  a  different  relationship  to  the  school.
  @-Federat Repoiters, Inc. The@,r ha@re a very strong and excellent I--,,A(, chairman who seems
               25






                                                                          20 8


         #19   1  to have taken over.  They have the now goals, priorities,
  roba 4       2 and  plans.  There  is  an  excellent  exercise  in  subregionali-
               3 zation. They  have  phased  out  projects  and  they  are  phasing

               4  out projects.
               5            . They are restructuring their committee structure
               6  and they have for the first time a really pretty good relation-
               7  ship with the Indiana State 14edical Society. Their area, groups
               8  are very important, the@ are finally recognizing the fact
               9  that their CIIPB agencies are  around  and  they  are  beginning  to
               10 'ntcrnha-@ v7itl- -Oa-@ast,c amounts of  dollars  'hat  poure4  4n-o
               11 Indianapolis, millions   into OEO and @-IP just said man, we have
               ]2i to stay away from that  power and  that  influence  and  all  those
               13 dollars and so on, because the medical school said we have got
               14 to keep a low profile.
               15            They are beginning to interphase with the things
               16 that are going on in the real world about them. I think that
               17 I will support the idea of funding them at 1.2. I think      -they
               18 need this money to do the  things  that  they  are  doing.  I  don't
               19 know if they are falling into the trap of continuing the
               20 old activities.
               21            The ones they are continuing seem to be in the right
                  direction. I think there must be absolutely strona word from

                  here that what thev are to do with these funds is to build
               23
               24 their staff,  to  continue  the  subregionalization  efforts  and
  :e -Federal Reporters,  Inc. put money into that, to use  their  data  base  to  get  specific
               2 5





                                                                               2 09



           fl9  I  program  plan,  to  get  a  specific,action  plan  in   conjunction

   Peba 5        2 with  the  agencies  and  subregional  people  but  to  evolve  where

                 3  they are going.
   la
                 4             That is the third thing.  To continue the involvement

                 5 with  Indianapolis  OEO  and  all  of  the  other  multiplicity  of

                 6 programs that  are  active  in  the  State  of  Indiana  which  range

                 7 from a very rural thing in the south and so on up. Finally to

                 8 keep that damn medical school out of the R@4P headquarters

                 9 and let them be the fiscal agency but get this terribly op-

                 0- resc;ive school. oiit of tbp nictlire.  T @@Toul d seek the  recomten-

               11  datioa then,  feeling  that  if  they  do  get  a  good  coordinator,
               121 I think Baring %,;ill bring  this  program  along  and  he  has  gotten
               i 3 ti"le 1,7orcL.

               14              If they  will  get  a  coordinator  who  will  continue
               15  what he  is  doing.  Whether  they  can  come  up  with  a  triennial
               16  next year or not I  am  not  sure.  I  think  it  would  be  good  to
                   give tb.cm the business of  you  know  here  is  one  yeartS  support,.
               17
               18  you can  have  another  year's  support  without  a  triennial  if  you

               19  need it.
               20              We will look at vou on  a  mini  site  visit  in  a  year
                   or staff site visit in  a  year  to  see  how  you  are  doing  and
               21
               22  offer  staff  support  while  they  are  in  this  transition  phase.
               23  Di.sctssion?
               24              DR.  SCIILERTS:  Would  you  like  the  mostion  seconded
  e- Federal Reporters,  Inc. bv a member of the committee rather than by the chairmdn?
               25






                                                                                                  210



              @ig                     DR.  SCI-ItlIDT:   Let's see.  Yes,  somebody get me off

   T@eb,i 6          2  the liook.

                     3                DR.  SCIILERIS:       I second the motion.
   Is
                     4                DR.  SCIIMIDT:   All right, thank you.   John?

                     5                DR. KPALEWSKI:   We are moving this then for two

                     6  years instead of the one.

                     7                DR.  SCI-RIIDT:   That is right, at the level funding.

                     8  And. with, you know,  if they can come in  with a whiz bang

                     9  triennial next year, great, but if they can't,  let them have

                   IV   the feeling they got a little time.

                   11                 DR. KRALEWSKI:   Thank you.'

                   12                 DR.  SCII14IDT:   Other comments or questions?   It is

                   13   an example of a region that was turned around.  Florida was

                   14 another one I can think of and so on.  I think the main things

                   15 that have turned it around were the site visitors, who had the

                   16 strong support of staff who said yes,  they are right you know,

                   17 quit looking for an out.

                   18                 All right,  I will call the question then. All in

                   19   favor please say ave.   Opposed, no?

                   20                 Last but not least then it is ilemphis.   And the

                   21   prima ry reviewer is Dr. Ellis.


                                      DR. ETLTI:   "an'- yo-u, i-I.L. Chairman.  1 have been told
                                            @ @,j      @ I LFl


                   23   that I did not have to nanv minutes to do this by some of my

                   24   friends and I am goi-ng to try to I)c, brief so that the   won't
                                                                                                   y

   D -Federal Reporters, Inc.
                   25   be unha-,Y)v with me this time.





                                                                          211.


         #19   1            llemphis is a very interesting region and I  would

  P,eba 7      2  just like to mention before we go into the discussion of the

               3 visits something of the background and demographic information

               4 because this is a very large region and it is culturally diver-

               5 sified.

               6            The region actuallv consists of parts of five

               7 states, and it is made up really of  what  is  traditionally

               8 a trade area.  Also the area that is based on hospital care

               9 that is given to people in this 75 county  area.  21  of  the

              10 counties are in Tennessee. West Tennessee.  1-6 i-n Arkan.-,,n.,;,

              11 27 in Mississippi.  6 in PAissouri and five in Kentucky.  And yot:

              12 know that in this it is extremely difficult.
              1 3           There is a population o,- 1--wo and a IL-lai@il m4Lli4Lon,
              14 that is the 1970. It is interesting also  that  there  is  an
              15 essentially rural area, except for Memphis  which  has  about
              16 800,000 people, 600,000 people, and then  the  next  largest
              17 city in this whole area after that is Jackson, Tennessee, with

              18 50,000 T)eople.
              19            In terms of the racial coTanosition there are  31
              20 percent roughly a third, black.  A few Orientals an  t e res
              21 are white. @lany of these are poor. It is  also  interesting
   0          22 to note that in the Kentucky section there are  quite  a  few
              23 old people, the largest number of people over 65 in Kentucky.
              24            With reference to the racial matter while I am here
  e -Federal Reporters, Inc. I will say that this 31 percent does not reflect the situation
              25





                                                                      212



     #19       1  in some of the counties.  In Tunica County, Mississippi, there

  P,eba 8      2 are 73 T)ercent of the population is black.  While in the

               3 Ozark area you will have about the same kind of thing with

               4 reference to white people. And nine of the 27 counties in the

               5 Mississippi subregion having populations of more than  fifty

               6 percent are blac k.

               7          The infant mortality rate, I will mention this because

               8 it is very significant and will have a lot to do perhaps with

               9 the long range programs which can bring about  institutional

             10  --h--ngc.  7,in--4 -@@c have here an infant mortality -i a-L"- L,Liis

             11  is 28.9, comT,)ared for -- to this region and this is compared
             ]2ito the national average in 1970 which is 21.7, it is lower than
             13 1that now.

             14           The thing we want to point out, that in Mississippi,

             15  in the subregions in two counties the infant mortality  rate

             16  was more than twice the national average. When you see an

             17  Infant mortality rate of 28 and you recognize that there are
             18  counties with more than half, I mean twice as much the national
             19  average,, you really know you have a very, very serious problem

             20  and oftentimes this is overlooked.
             21           Noiq Memnhis region did not have a site visit. This
             22  time. The last, well, 1 miaht lust tell vou in passing  that

                 his region became operational in 1967,  I mean started its
             23  t

                 Dlanning in 1966 and 1967, became operation in 1969, and  in
             24
  e-Federal Reporters, Inc. 1971 had site visit in response to the triennial application.
             25







                                                                        213


         #19                I will just go briefly through what the site

                 visitors had to say.  The main      I will point out the  main
  j),eba 9      2

                3Problems.  And the main problems that they   found in the site

                4visit and that was really known before the   site visit was made

                5was that the RAG, the Advisory Group of a health council, and

                6that this advisory group consisted of about 156 people, and most

                7of these people 'V7ere in the priors class. And this,was  a

                8purely untenable thing to have the --  this  committee  and

                9council combined in this way so that the  coordinator  of  the

              10 program really was not in a position to carry out the program

              11 in the way that was in keeping with the  expectations  of  the

              12 regional medical program.

              13            Also the administrator, the coordinator  of  the

              14 nrogram, was thought by everybody to be greatly overextended.

              15 And he, Dr. Culverson, was the only medical person in the

              16 program. And he did not have a good manager under him to carry

              17 out the administration of it, the  administrative  aspects  of


              18 the program.

              19            So it was felt that because of the conditions

              20 existing in the regional advisory group and because of the

              21 lack'of proper supportive staff, that the -- a developmental

                                                +--he re s -- w               te
                                                               4-,,-h so--,c dc4-n-
              22 grant c!oi-il@ not be                                     4     4

              23 strengths noted at that time.

              24            These concerned the fact that the University of

  -e-Federal Reporters,  Inc.
              25 Tennessee  had given the program the authority.  While  the





                                                                                       214


             #191  regional medical program grew under the guardianship of the
  P.eba 10        2  university, it really changed, after the visit in 1969, and

                  3  made it possible for the PAG to develop on its own.
                  4             The excellent thing about the program seen in 1971
                  5 was the fact that five CIIP, five agencies and probably five

                  6 or Six B agencies worked very closely with the RMP program. It
                  7 was described as being a really excellent, because P14P provided
                  8 staff to help the B agencies with their work, and also worked
                  9 with them in planning and all kinds of outreach activities in

                    the corimlini-ttr.

                                The staff really developed well. And in the community
                12, they were described as excellent brokers for the Pd-4P program
                13 .. and also they were not just trying to sell programs but they
                14  were reallv architects, too, after they got over the operational
                    phase in the program. I said that the coordinator over extended
                15  ,
                    himself but the people, the site visitors felt that the
                16
                17  program had potential for being one of the best programs.
                18              And while they did not fund, I mean suggest a develop-
                19  mental component, they did grant triennial status as a resu t
                20  of the visit. Now with the suggestion that there be a complete
                21  overhauling of the RAG and the administrative structure and that
   0            22, some effort be made to correct certain things.

      end       23

   IT;,  19     24

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                                                                            215

   #,20

      arl        I             Now I have said before that this is a very

                 2 difficult region to describe with so many people who are

                 3 very poor.  Black and white.  But one of the things that was

                 4 pointed out was that there were  --  there  was  only  one  black

                 5 person, female, on the staff.  And also there was very little

                 6 input, opportunity for input  from  the  people  being  served.

                 7             Now I will go right on quickly  to  say  that  for  a

                 8 year after this visit, after  this  1971  visit  --  and  there's

                 9 nobody from the advisory committee  who  made  that  visit,  we

               I^v did li;Ave members of the council who were on that visit, these

               11  recommendations were made, and I would think, I said I didn't

               12  make it, but I would think from reading the records that Dr.

               13  Culverson made everyeffort to  begin  to  do  something  toward

               14  correcting the things that have been pointed out.

               15              The -- there was a site  visit  made  in  the  summer

               16  by staff to take a look at what the situation was at the

               17  present time.  And I would like to say that Mts.Kytt e

               18  knows this situation very well and can add to it after I

               19  have just said a few words.

               20              It seems now that the RAG has been reconstituted.
               21  I didn't tell you that that  156  member  group  has  executive
   0               committee of abol-it 45 members. Pnd it ...,as just  absolutely

               23  impossible to get  anything  done  that  they  didn't  themselves

               24  want because they met every month, while the RAG met only
  ce-Fedefal Reportefs, Inc. once a year, I guess. Twice. Once or twice a year.
               25






                                                                       216
      ar2


                I            Now the situation has changed quite  a  bit.  The

                2 RAG consists of 36 members. They are well  chosen  from  the

                3 geographic areas.  They are old and young, reflect the racial

                4 composition, and women. I think that there  are  nine  blacks

                5 and six women on this new RAG.  And it is a freestanding

                6 group, not encumbered by the old pattern.  Dr.  Culvetson  has

                7 moved immediately to see that guidelines have been developed,

                8 bylaws, that is, and also'that three committees,  policy  --

                9 the planning committee, and the policy and  review  committee

              10  and also reference committees.

              11             Now, these reference committees are made up

              12  primarily of the people who had to do with categorical programs

              13  There has been also a change in focus.  The  program  activity

              14  actually is looking at the underserved.  In  the  subregional

              15  areas where, like in the crowded areas of Memphis and  in  the

              16  rural areas there is an attempt to extend services to the

              17  people through cardiac  clinics.

              18             Also there is a  very important high risk  infant

              19  component which is  regional.  I think this is funded  jointly

              20  with the other agencies, too, isn't it?  Yes, it has just

              21  started.  Also family planning services.

                             I@    hard 4n this 'r'ef --me. '@o Le"' you everything
                2                        J. 4-.L L J.   iiLt- i- I- L.L
              23  that's been done here. I think it  is  extremely  significant
              24  that the regional program has applied staff to other agencies
  ce -Federal Reporters,  Inc. in order for them to get very much needed services in the
              2 5







     ar3

                I  family planning area and also to do something about getting

                2  ambulatory services to these greatly deprived areas that they

                3  are working to develop Lee County cooperative clinic in

                4  Arkansas and so on.

                5              I said before that the University of Tennessee
                6  has been supportive, has helped in making decisions, but has
                -7 not forced its own views. And  I  think  that  the  management
                8  aspects of the program have  not  been  reviewed  yet.  Right?

                9              MRS. KYTTLE:  That's correct.

                               DR. ELLIS:  But i-'-- is expected they will be . T
                0
                11 mention this because the visitors in  1971  talked  about  the
                12 kinds of positions which should be filled and talked
                13 specifically to the point of not having the staff expenditures
                14 be -- grow any larger until some of the operational aspects
                15 could be shored up.
                16             I believe there was a recommendation that, by the
                17 staff, though, that because of the fact  .that the coordinator is
                18 greatly overextended, that he be given an assistant administrator
                19 to look at the management affairs particularly.
                20             We have said there is no  problem  with  assessing
                21 resources and so on.  Now the evaluation component is not
                ),) strong because of the fact that, well,  they  can't  work  too
                23 well because one of the weaknesses that still exists in the
                24 programs, there is not .a clear statement of the objectives,
  ce-Fedeial Repotters,  Inc. goals and priorities. They have stated some broad goals,
                25




         ar4                                                              218

                 1  very broad, to make health care more accessible and to make it
                 2  more available, and to compare the  health  costs,  lower  the
                 3  health costs where pos sible in doing these two things.
                 4             But there are no clearly stated objectives as to
                 5  how broad goals can be accomplished;  consequently  it  is  hard
                 6  to evaluate the program because most  everything  can  fit  into
                 7  what has been stated as objectives.
                 8             I think the staff, knowing  the  whole  story,  and
                 9  unfortunately I have never beeninto this  section  at  all,  I
               -1I  4us+- know what people have told me about  certain  things,  I

                    feel that the direction in which this program is moving is very,
               12 1 very excellent indeed. And the  staff  feels  that  the  changes
               13   that had to be made as recommended by  the  site  visitors  in
               14   1971 have been made in the main.
               15              Mrs. Kyttle is here, and I would like her to
               16   add a few things because she has visited the area twice
                    rather recently, and has talked with  the  coordinator  and  the
               17
               18   other people.
               19              DR. SCHMIDT:  Okay, would you make any commen
               20   that you would?
               21              MRS. KYTTLE: Dr. Hess  has  to  leave  at  fourish,
   0              so perhaps he would like to make his comments now.
               23              DR. SCHMIDT:  Okay, Joe?
               24              DR. HESS:  One certainly is at a disadvantage in

  ce -Federal Reporte(s,  Inc.
               25   trying to evaluate the region from what appears on paper alone.





                                                                             219

          .ir5


                  I  And I must say when I first started going through this and

                  2  looking carefully at what was there, the first question  that

                  3  came to my mind is how with all these.problems with the
   0
                  4  RAG and what-not did this region ever achieve triennial status.

                  5  And, but, however, in talking with Mrs. Kyttle, I gather that

                  6  what is actually going on down there is probably much  better

                  7  than what was reflected in the paper and so that one has to

                  8  somewhat separate the activities that are being carried

                  9  out from the -- what you might call in a general way the

                10   organilza,Lioiial structures of the region.
                11                But I would like to point out a few things that
                12   are of some concern to me in looking at this total picture and
                13   trying to render a judgment concerning the funding request.
                14                One particular feature of this region we need to
                15   keep in mind is that it overlaps with three or four other
                16   RMPs in terms of geographical area and population, so t at
                17   there is the potential for funding coming into certain  areas

                18   from more than one source.
                19                The problems of coordination have been worked  out
                20   fairly well and a couple of these others remain to be
                21   resolved.

                                  Ti- i            to in the nresentat4--
                                       ,                                            PP.G  has
                22
                23   recently been    redefined from the original 150 some odd person
                24   group to 36 person group and the bylaws have been approved now.
  @e -Federal Reporters, Inc. But a lot of the further reorganization in terms of factories,
                25@




                                                                    220


       ar6


               I  so on, remains to be done, and so that at this point it is

               2  unknown to us exactly how that is going to shape up.

               3             The new bylaws do spell out certain subcommittees,

               4  but there is a broad category of -- appointive  committees

               5  which we have no information on what is going to happen there.

               6  So that the new RAG is one question mark.

               7             Another question that came to mind was the size

               8  of the staff and the way the staff is organized.  in the

               9  submitted.budget for this upcoming year, there is a  place

              10  for 59 core stuff situations, 54 of them full time, and

              11  there are 13 vacancies shown on the staff budget list.

              12  I haven't taken the time to go through and enumerate other

              13  core staffs, but this certainly seems to be close to a

              14  record for number of staff people in relationship to the size

              15  of the program and funding and so forth.  So that is another

              16  question.

              17             And in looking at what one can tell from the

              18  internal organization of staff, the data that is in the

              19  application, I have some questionlabout the tightness  and
              20  adequacy of internal organization of staff.  As mentioned,
              21  there am goals and some related objectives, but the priorities

                                      .1                               Z
              2,, are statements which  as one looks at them., may or man, not be
               Z-
              23  related to goals, exactly how they fit into their system of
              24  logic is not clear to me from the application.

  ,e-Fedetal Repoftets,  Inc.
                             In summary, I perhaps would have to say that  I
              25







       ar7

                I  am taking on faith what I have learned from Mrs. Kyttle's

                2  comments to me informally, that,they are doing many good

                3  things.  Some of these are enumerated in their progress report.

                4  But I do have somecpestions about it, what is happening in

                5  terms of the program management system, including the RAG

                6  and core staff.

                7            The new projects which are proposed, there are two

                8  of these which stand out in my mind as most consistent with

                9  some of the things stated in their goals and objectives.

                             One i--- prc4--l- 36, c:,tonsion o4 -cr,--ces, re-'g'bor-
                                                              li v -L


              11   hood health centers,and the other, 42

     0        12

              13


              14


              15


              16


              17


              18


              19


              20


              21


              22


              23


              24

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                               DR. SCHMIDT:  Let's continue on and get a data

               2 base, ask Mrs. Kyttle if there  is  anything  she  wants  to  say.

               3               MRS. KYTTLE:   The Committee work --

               4               DR. SCHMIDT:   Could you put the mike  right  in  front

               5  Of You-

               6               MRS. KYTTLE:   The Committee work and task force
               7  structure                   It was done so recently  that  it  could

               8  not get into this document.  The  staffing  pattern  is  a  proposed
               9  staffing pattern.  It  does  not  list  vacancies.  Those  vacancies

                                                                             Ml-
                  are ne@%T positions and that is what we, intend to have    @.kxc- re S

                  only one vacancy in existing positions and that is the     vacancy
               12 that Dr. McCall left quite a while ago  and  it  has  never  been
                  filled and it,'@   rate @@@@,needs to be filled but to say that
               13                  p
               14 there  are  56 positions in this regional medical program is not
               1,5 quite right.  There are 44.  one is vacant.
               16              I have attended the three meetings of the new RAG.
               17 It has kept me down there a lot but I thought if this is t e new
               18 blood here, then that is where the action will be.  It wasn't
                  a redefinition of the  regional  advisory  group.  It  was  creating
               19
               20 a new one and it did break off from its parent, which was the
               21 14-county CHP."B";To  the  MempIhis-Shelby  area,  MMCC@just  about
                  everything.  It was also regional medical programs.  And It
               23 was not easy to get away from that parent and still have good
               24 parental ties.  .And Drs. Culbertson and Cannon have done it, and
  ce -Federal Reporte's,  "c' in my view done it very well.
               25




                                                                           2 2 3
   eak 2



                              Dr. Johnson at UT was helpful in  getting  it  done.

               2 The old regional advisory group w  as representative of only those

               3 14 counties, and that is  what raised the legality of the regiona.

               4 advisory group and that was the single factor that disqualified

               5 them for developmental component funding when they were placed

               6 on triennial status.

               7              The biq funding issue or one of  the big funding issu@s,

               8 I believe, is the mc@(i@ contract  under  core.  And  when  staff

               9 met to try to identify issues, that was one that came up

                                  sentially
              ,O immediately.   Es          Memphis is pursuing  two  things,  its

              11 own concept of area health education centers which it calls
              121model learning centers which it thinks should'be in the hospital.
              13'and then development of the involvement  from  that  rather  than

              14 developing the consortium and including the hospital.

              15              They competed unsuccessfully for health services

              16 money last June.  Then the second large component of it is,

              17 Memphis submitted AEMS application for supplemental funding,

              18 received one year planning funds to sharpen a data base which if

              19 Memphis has anything it has a sharp data base.

              20              Coming from MMCC, it has received  as the collector

              21 of the data since 1966, so Memphis is writing   back saying by

              1)2 January 1, which is their next ,ear, v..@Tc w4-'-l havc -@harpened our

              23 data base and they are reapplying for the operational dollars thEy

              24 applied for before for emergency medical services and that

  ce-Federal Reporters,  Inc.
              25 ties into something I said before.  Their task forces have been






                                                                           22 4


     eak 3
                  established  and one of them is a task force for emergency medical

               2  services.  And at a metting of the regional advisory council las"-

                  week, I heard Dr. Cole who is the new RAG Chairman and Dr.
               3
               4  Culbertson feeling this group out on beginning to think now abou:
               5  priorities on funding levels that might not approach the

                  3.2 that they asked for.
               6
                               And where -- beginning to think  now  about  where  the
               7
               8  emphasis would be. And  I  heard  this  regional  advisory  council
                I say that if we have to make choices under that million dollar
               9
                  contract category,-then the choice wil.l. be emergency medical
               10
               11 services.
               12              The whole state of Tennessee, Dr. Turbshen and
               13 Dr. Culbertson have worked together  quite  sometime  on  the  state
                  of Tennessee's program.  Dr. Culbertson has all buy revived
               14
                  the Mississippi Emergency Medical Plan  that was almost in
               15
               16 disarray. No work yet  is  underway  with  the  Arkansas  Department
               17 of Transportation, hospital association, traditional lin     kages.
               18 But the State of Tennessee and State  of  Mississippi  --  a  scale
               19 of 1 to 5 are about 3 on emergency   .medical services and they are
               20 so deep into-it that I don't know, it would be difficult to turn@

                I back.
               21
                               DR. SCHLERIS:  A few questions.  A few questions
               23 first then perhaps a comment.  If  I  read  this  correctly,  their
               24 RAG met once last year, .is that correct?
  -.e -Federal Reporters,  Inc. MRS. KYTTLE: That is traditional  with  the  old  MMCC
               25






                                                                          225

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               I which was their RAG at  the  time  this  application  was  prepared.


               2 That is the old RAG.

               3               DR. SCHLERIS:  Right  and  emergency  health  services

               4  met accordingly at the time of the application, zero?

               5               MRS. KYTTLE:  That is the emergency medical group

               6  out of the old RAG.  That is MMCC.  You are right.

               7               DR. SCHMIDT:  Wait a minute.

               8               DR. SCHLERIS:  I am trying to get an indication

               9  of   activity.

               tu              DR. SCHMIDT:  Right but the RAG now, recently has

               11 met how many times, the new RAG.
               121             MRS. KYTTLE:  The new council is three months ol   d
               13 and it has met three times.

               14              DR. SCHMIDT:  Right, okay,, so that

               15              DR. SCHLERIS:  Well, this is important because
               16 I think in terms of  developmental  component  and  reaching  deci-

               17 sions according to priority, according'to what would be supporte,,,
               18 it is of interest to see what their past record is for the past

                  year and not just for the past three months.
               19
               20              DR. KYTTLE:  Dr. Schleris, it is   not the same group.
               21              DR. SCHMIDT:  Do you see they have constituted reall

                  for the first ti_me a rerTional adv4-sory group        months  ago.

                               DR. SCHLERIS:  Well, you see my dilemma.  I know
               23
               24 this.    I  try  to  count  the  number  too  of  RAG,  and  the  old  group,
  ce-Federal Repofters,  Inc. and  it  is  their  application  we  are  lookin    at. And what  you  are'
               25                                             9





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              I  doing is supplying us with additional and  very important new

              2 data.. I appreciate it but at the same time, it is difficult

              3 to get an objective judgment on this. In  other  words,  the  new

              4 group which is how many now, 36, but the program here was put

              5 together by the old group, isn't that right and the report we

              6  are looking at in the application is from the old group, is

              7  that correct?

              8              MRS. KYTTLE:  Dr. Schleris, you can appreciate that

              -9 a regional advisory group of 151 members that had R&D's

              ,O experimental contract, O"P and @IP, d4dn't give a  lot o' time

              11 and this  was quite a bit of the Memphis regional medical

              12 programs application but it nevertheless had to  go  through

              13 a regional advisory group that had EMS committee that never met.

              14             DR. SCHLERIS:  I am not trying to put a qualitative

              15 judgment on it. I am just trying to get  an  understanding  from

              16 this document. Looking at some of  the  specific  proposals,

              17 I will ask out of curiousity about the proposal  to  improve

              18 death statistics by teaching, individuals,  examinations,  post-

              19 mortem, where they don't have legal rights to do autopsy and so

              20 on. I wonder if you have any more information on  w  at  appears
              21 to be a,very intriguing and difficult proposal, how that cleared

                 RAG and what priorit'.  Did vou see that.  It is-orole-ct
              22                     y

              23 number 33.
              24             MRS. KYTTLE:  No, I am afraid -- I can tell you that

  ,e - Federal Reporters,  Inc.
                 it must have cleared RAG with a priority that was  at  least
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     eak                                                             2 27

              I  in the first five because it was one that Memphis chose

              2 to drag up from an approved but unfunded when they  were  extended

              3 and had money to activate, they activated that one but  the  tech-

              4 nical aspects of it I don't know.

              5              DR. SCHLERIS:  I don't know what communication

              6  you got as far as emergency medical services was concerned.

              7  They haveapplied for let's see, $1,100,000, were given

              8  $80,000 for the planning.  It goes to more than just

                 data base,.I assure you. I don't know the details  but,  perhaps

              10 Dr. Rose does.  This was one of the requests for larger amount
              11 of funding.  It was felt that they for many reasons weren't at

              12 that stage. It wasn't just getting numbers of  cases.  There  was
              13 11 a lot of homework that had to be done.  Can you comment on

              14 that, Dr. Rose?
              15             DR. ROSE: Yes, in fact a large part of  the  concern

                 of the reviewers related to how this Memphis or suburban,
              16
              17 if you will, EMS-type activity was going to relate to what  else
              18 was going on in Arkansas.and Mississippi and in the rest of  that
              19 particular state.  In speaking with Loraine subsequently on
              20 several occasions about that, I tend to believe that they  really
              21 did have considerable more information than was included in  the

                 application which, of course, the reviewers had to act on.
              ^z2
              23             DR. SCHMIDT:  Okay then.  John?

                             DR. KRALEWSKI:  I am not sure we have a motion on
              24

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                                                                              228

  Pak 7

                 1             DR. SCHMIDT:  No, we are going to return to Dr.

                 2  Ellis for proposal.

                 3             DR. KRALEWSKI:  Okay, I will hold up then.

                 4             DR. ELLIS:  The application which is before us

                 5requested roughly 3.267 for this year five.  The staff
                 6reviewing this made  the  recommendation  that  the  amount  to  be
                 7granted be 2.25, and that this would inlcude $162,700 for a
                 8developmental  component.  Also,  in  talking  about  the   supplements

                 9request that we have   been talking about, staff suggested that
                                                                                      . 'I
                  $237,r.100 be -ran,@-cd to support selected new activities,  'Liicludin

                  the expansion  of  component  number  36.  That  is  greatly  strength-
                 12jening the neighborhood centers and giving them something in order
                 13 to really build the program and extend it.  And then $225,000
                 14 to pursue selected activities under the contract request, this
                 15 being primarily to be  used  for  EMS.  I  would  move  that  this,

                  these recommendations be accepted.
                 -16

                               DR. SCHMIDT:  Is there a second?
                 17

                               DR. HILTON:  Second.
                 18

                               DR. SCHMIDT:  All right.  That is a second so
                 19

                  the motion  can be discussed.
                 20

                               John and then Joe.
                 21
                 21-)          DR. KRALEWSKI:  I am inclined to believe that in vieil
                 Iof the organizational, some of the organizational concerns
                 23
                 24 that have been  expressed  here  even  though  they  are  changing,
  ce - Federal Reporters,  Inc. there is a new direction  and  I  know  you  have  new  information
                 25






                                                                        229


    eak 8
               1  you really believe this organization is going to really do it.

               2  But we are giving them substantial.developmental component

               3  plus a fair amount of contract money and that is placing

               4  a fair amount of bucks in their organization without many

               5  restrictions on it and that makes me a little bit nervous.

               6              DR. HESS:  I would like to make a substitute

               7-motion.

               8              DR. SCHMIDT:  All right, before I accept that, I

               9 will let Dr. Ellis respond.

              IC)             DR. ELLIS:  i-L is my understanding that the

                 monies which they  have  now are very tightly budgeted and that
              11
              12 Ithere would be very  little room for growth and  expansion  in
              13 these  new  directions.  And so it seems that  a  developmental

              14 component of some magnitude might be very  desirable  in  this

              15 instance.  In order to give the new director, I mean he
              16 is not a new director but he  is almost like a new director becais(
              17 he does not have all of those 156 people and all. of the problems
              18 with no committees or anything to work with him.  That has been
              ig eliminated and I think he does need a chance to  show  how  he
  21          20 can expand the program.

              21


              2


              23


              24

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          #  22

          kar  11              MRS.  KYTTLE:  Dr.  Kralewski,  the  original  structure

                2  complication arose not so much because it    wasn't working, Memphis

                3  made it work.  And it very quietly went about a very good

                4 program. It was  the  legality  that  raised  the  issue  about  the
                5  CHPB, W@ICC, with a mandate to serve 14 counties being the decis-on

                6  making body that was serving 75.

                7              I would not want you to think  that  it  was  a  compli-

                8  cated, unworkable structure.  It was a complicated, of doubtful

                9  legality, structure.
                               DR. SCHLERIS:  lt only met once that year,    didn't it"

                               MRS. KYTTLE:  The full body traditionally met twice,
              121 that year   it met once.  The real decision making was in the
              13  board of trustees, 45 members, still"serving-14 counties.

              14               DR. SCHMIDT:  Let's see, do you have a comment

              15 in order here  we  have  someone  who  wants  to  make  a  substitute

              16  motion.  If you have a comment on what     is  being  discussed  now,

              17  please speak.
              18               DR. ELLIS:  I do.  I wouldn't think a    program, regari-
              19   less of legality, that only serves 14 communities when it is
              20   supposed to serve 75, is really functioning and functioning
              21   properly. And neither  will  I  think  that  the  guidelines,  which

              22   they were usir,.- in terms of develo ing  the  new  -rograms,  were
                                                        p-            r,
              23   appropriate to get services  to  the  underserved,  which  is  part
              24   of the thing we are talking about.

  e-Fedetat Repofters, Inc.
              25               But I do think that this legality thing, was a point





                11                                                     2 31

         kar 21 and I wanted to ask the question, did the regional  council  rule

               2  this out of order legally?  I know,it was requested that he

               3  give a ruling.

               4            MRS. KYTTLE:  We thought we might work with'the regicn

               5 in obviating that necessity and they got a new council and so

               6 we didn't have to seek an opinion.

               7            MISS KERR:  I would like to make a comment, but I

               8 would be willing to wait until after the substit ute motion and

               9 action is taken-on that.

              lo,           DR. SCHMIDT:  Joe, the floor is yours.

              11            DR. HESS:  Perhaps somebody might just make tome not s
              121 of this other paper there.  Iwould like to suggest for  program
              13 staff, eight hundred thousand.  For contract, two hundred thousand

              14 and I an, assuming here that some planning has gone on and that

              15 as far as this emergency medical service is concerned, I  gather

              16 that that owuld be their priority use.

              17            It is somehow, some proven heed in the community.

              18 That developmental component of a hundred thousand included, an6

              19 projects of nine hundred thousand.  To provide money to accomplish

              20 Project No. 36, which I gather is a key project in their strategy,

              21 and through re-examining some of their currently funded pro]ects,

              2  that they should b^- abl-- -lo -@4-nd money to 4'unu' the Ot'l-let projects
              23 or two in their new list, which is compatible with the new
              24 directions in which they say they are going.
  :e -Federal Reporters, Inc. That adds up to a round figure of two million  dollar
              25





                                                                     232



         kar  31            DR. SCHMIDT:  Is there a second for the substitute

               2 motion?


               3            MRS. FLOOD:  Second.

               4            DR. SCHMIDT:  All right' Mrs. Flood's second.  We

               5 are now discussing a two million dollar funding level.

               6            Miss Kerr?

               7            MISS KERR:  While it is late, it is not so late and

               8 I am not so tired, but I feel I have to speak my piece.  In view

               9 of decisions made earlier by comparison and in view of ingredients

              1 Ow oil- a -,riable Po#--ei-it.-La'Lly excitii@iy pro(jrant, I cannot, in al-i con-

                @8'iousness, support either one of these recommendations at this
                  c

              12 point.

                            DR. SCHMIDT:  You say either one?
              13

              14            MISS KERR:  No.

              15            DR. SCHMIDT:  Lorraine?
              16            MRS. KYTTLE:  Miss Kerr, this is an.anniversary withii
              17 a triennium and it comes to committee without any site visit
              18 report that would.give you the flavor of some of the exciting

              19 things that this region is doing.
              20            But it is a quietly efficient region.  It has some
              21 very,exciting things ongoing and even though it is late, I don't
                 know if you would have the time to hear about them,  Can I iust
              22

              23 tell you about one?
                            Memphis has two multi-pliase screening projects ongoinj
              24
  ce-Federal Reporters, Inc. and they just dida't happen. one is a mobile, white northeastern
              25





                                                                      2 3 3



         kar 41  Mississippi, two and a half years ago.

               2             MISS KERR:  Was this thrust of RMPS.>

               3             MRS. KYTTLE:  Two and a half years ago it was startec.

               4  It is just widening up.  The companion one with an intercity

               5  Memphis, predominantly black stationary multi-basic screening.

               6  In anticipation of this year, they will have completed the

               7  targeted screening.  The multi-phasing screening activities acrcss

               8  the country have gotten together and they met here in Washingtor

               9  to develop a protocol to evaluate what we have done and nine

              10  were se'AecL-e-ul, arLu' of Mei-tipl@iis I were.

              11             Memphis' multi-phasic screening have  screened  more

              12  people than all the others combined.  They are going to be a

              13  pivot for a contract to evaluate what we have  done.  And  they

              14  have just gone about it very quietly.

              15             Inter-mountain is in there, Ohio vallies is in there

              16  and so is Memphis'.  And I just -- if you would like to listen

              17  to some of the things that they have done like that,, there  is
              18  more excitement there, but this is not that kind of application.
              19  It is not a triennial.  It'doesn't have a site visit report and

              20  I think it is at a disadvantage here.

              21             DR. SCHMIDT:  Mrs. Flood?
              22                   L00b:  Well, aaain, recoani.zina the di.sadvantag--
                             MRS. F

              23 of trying to evaluate on paper, looking at  the  print-outs  for
              24 the components sort of descriptor devisions  that  are  provided

  -e-Fedetat Reporters,  Inc.
                  in the print-out for the staff and of regional  functions  done
              25







                                                                         234

        kar 5 1  under,the previous contractual fundings we have talked in the

               2  history of the region of the tremendous impact of the 21 and

               3 under, of the minority groups, yet if you  study  the  print-outs,

               4  which is not a very good way to evaluate, but there is no emphaEis

               5  utilized  from the central core staff activities to address
               6  these high priority needs of these particular types of populations

               7  and as Dr. Schleris pointed out, our point of reference  as to

               8  be the track record and, again, I will realize staff is at a

               9  disadvantage trying to present to us this changing flow.  But

              In  I am not sure that we are adequate in giving them  the  re-uested
              I V
              11  funding and perhaps even at the level that Dr. Hess has propose([.

              12             DR. SCHMIDT:  John?

              13'            DR. KRALEWSKI: Would you refresh my  memory  again  on
              14  the contracts, what do they hope to accomplish with that?
              15             MRS. KYTTLE:  Oft page 19 of the document, I have
              16  written out the five categories of the@mi.llion dollar  contract.
              17  And the three large portions 'of it, one half of.it is for
              18  emergency medical services and we have seen their application

              19  on that.
                             And, here is emphasis, Mrs. Flood.  Through  the  work
              20
                  of the staff, which surveyed emergency rooms, its'needs, their
              21
                  uses, the population that they serve, the State of  Tennessee  in
              22
              23  developing a statewide emergency plan zeroed in  on  the'regional
                  medical program as the lead role for the emergency, stemming
              24
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                                                                                 235



         kar 6  1              DR. KRALEWSKI:  Well, have they applied for emergenc)

               2   health service grant?

               3               MRS. KYTTLE:  Right.

               4               DR. KRALEWSKI:  And they have been partially funded?


               5               MRS. KYTTLE:  Right.

               6               DR. KRALEWSKI:  why.-is that showing up as five hundr(d

               7  thousand dollar contract?

               8               MRS. KYTTLE:  There is no mechanism for them to

               9  reapply for the operational dollars.

               .0              DR. KRALEWSKI    Have Lliey c(Napleted their  p4.anning?

               11              MRS. KYTTLE:   'The region felt they had completed
               121 their planning before we   told them to plan.  Very strongly.
               13              DR. SCHLERIS:  Is there anything to prevent their

               14  coming to  RMP for emergency medical  service  plan  in  the  future

               15  as part of their RMP program?
               16              MRS. KYTTLE:  That is what they are doing.
               17              DR. SCHLERIS: But  they  are  asking.for  a  contract  -

               18  here to do  it locally, isn't that right2

               19              MRS. KYTTLE:  Yes.
               20              DR. SCHLERIS:  Without   there being any documentation
               21  of what it  is they are actually planning to do.  At least a

                   part of their document is concerned.
               22
               23              MRS. KYTTLE: They  look  activate  the  same  plan  they
               24  presented to us back in iufte.
  @e- Federal Reporters, Inc.  DR. ISCHLERIS:  I want to make  one  point  cleAr;  that
               25




                1                                                          236

         kar 7 1  is, there is a great deal of. difference between putting something

                2 in writing and then verbal reports. This  disturbs  me  a  great

                3  deal.  I know you are familiar with the area, but going through

                4 volume one and two, I don't come out with a great deal of  'in-r

                5 formation about what it is that they are going to do with these

                6 funds and the Memphis application as it came  in  for  emergency
                7 medical service didn't reflect all the planning that you indicate
                8 took place, and this is troublesome even to be told that well,
                9 they had already done all the planni.ng..'@They thought every bit

              10  had been done.

              11             It wasn't reflective of what they  said.  I  do  have

              12  considerable concert about the level of funding.  I question

              13  whether emergency is the way to go as the first step.
              14             MRS. KYTTLE:  It is a part of civil steps.  That is

              15  RMP's role.  RMP's role in this state consortium is the emergency

              16  room.
              17             DR. SCHLERIS:  As I see it, if we -aprove4,these-.funds,
              18  we are saying  we think that contract is a great idea.  I, for
              19  one    if-you want-me to have faith, believe me, on a Friday
              20  afternoon after two days, my faith increases more  and  more  an
              21  more and I will become a believer if you like, but it takes an

                  Awful lot of conversation even-this late in the dav.
              22
              23             MRS. KYTTLE:  No. we didn't think it was worth five
              24  hundred thousand, that is why the staff recommended 225,000 for

  ,e-Federal Reporters,  Inc.
              25  all contract work and they are going to have to make their








                 kar  8  1     choice.    And  they  have  told'us  their  choice  is  still  EMS.

                             2                           DR.  SCHMIDT:    Okay.    Where  we'are  is  with  the


                             3    substitute            motion  at  the  two  million  dollar  level.


           E       22        4


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                                                                      2 38

    #23

       arl                   Are there other points to be brought up?  If  not,

              2   then I will call the question.

              3              On the $2 million level with the breakdown  of

              4   900, 100, 200 and 800, as you see on the board --

              5              DR. JAMES: I would like to make a  comment,  I


              6   believe.  I think I am still hung up on -- and will be as

              7   long as I possibly will remain on this committee, in regard

              8   to geographical locations of RMPS, especially as they are

              9   related to populations. Like Mississippi.  Like  New  Mexico.

              v   Like Memph-'Ls.

             11              And I think that we have heard that there -- in

             12   the Memphis area that th ere has been a restructuring of their

             13   administrative structure, which is too young yet, I think, to

             14   have a real impact in terms of what really are we going to do,

             15   because we just haven't had time, but I believe from  the

             16   statistics and information we have received in terms  of,

             17   again, going back to the neonatal infant mortality which is

             18   an indicator of the lack of health services in the area,  and

             19   I don't think that that needs any further elaboration,  I

             20   would feel that these are the areas that need the strongest

             21   support of staff continuing technical advice to the  RMP,
             22   to stay on ton nf i-hp RM-P to be surethat it is creating the kin'A

             23   of program that will benefit the people. And this is  what  I

             24   hear are services.

  @e- Federal Reporters, Inc.
             25              I am aware of some problems Memphis had not too





                                                                   239
      ar2

               I  long ago in another area.  I don't want to get anything

               2  confused, but I realize that this is an opportunity for  RMP

               3  to begin to shore up some of those ends that were not

               4  covered in some other areas that have to do with the same kind

               5  of circumstances.
               6             I realize that I don't have as much information as

                  even maybe some of the rest of you have, because you are familiar
               7
               8  with some of the programs that were going on prior.  But just
               9  in terms of the situation and the effort that is being put
              ,to forth and the direction, we may be at a disad@,,ant.-Ag-@ wl.,Lcn we
              11  heard Memphis yesterday morning to start out with, we may  be
              12  a little bit more, would have been a little bit more  under-
              13  stanaing of the problem that exists there.
              14             But I think that I can only say that if we can  go
              15  with Vermont and a 400,000 population, with the excess amounts

                  of money that have been poured into that community and  that
              16
              17  state, then we can go with Memphis and help them to  improve

                  their services.
              18

                             DR. SCHMIDT: There are some issues  raised  there,
              19
              20  Leonard.  Do you want to comment?
                             DR. SCHLERIS:  Be outrageous to try to answer that,
              21
                  but @erhaps I can try only in-one way. This is not  meant  at
              22
              23  all as a rebuttal because I share your concerns.  Our problem,
              24  though, is I think a little different than looking at an area
  ce- Federal Reporters,  Inc. that has needs. I think it is a question also of looking
              25





                                                                 240


         ar3
                I  at whether the funds requested really go at those needs and

                2  whether they would be handled effictively-.

                3             I think RMPS would fall flat on its face many

                4  more times than it already has if it were to say that because

                5  an area has desperate needs that therefore we should be
                6  uncritical in our judgment as far as these needs are concerned.
                7  My reason for referring to the fact that it is  late  in  the
                8  day is that I think the group is getting  more  lenient  late

                9  in the day and not harder late in the day.

                              My concern about these funds  relate  to  looking

                   at the projects as submitted and some of  these  are  frankly

                   experimental.  The one about more accurate death certificate,
              12   certification, I question many ffipects of it.  1 would like to
              13
              14   know more about it. It is  essentially  a  research  project.
              15   I am surprised it has cleared RAG.
              16              The problem with multiphasing screening is.of
              17   interest, too, because of certain RMPS  statements  on  this
              18   sort.  Included in this is a project on home care, which again
              19   many of these have been supported Iaround the country, there
              20   are certain statistics on this.
              21              One   can go  through  the  various  projects  and
                   come away with a feeling that RAG has not set its priorities.
              23   I am a little unhappy about the response  of  the  emergency
              24   medical services  and  h.ow they are going about this,  and  it
  ,e
    Federal Reporters,  Inc. would be better if we had the full  information,  but  again
              25





                                                                           24 1
          ar4

                    on faith the contract of  200,000  or  part  of  it,  even  though

                2   there is need and heaven  knows  there  is  need  all  around  the
   is           3   country for EMS, $200,000, I  don't  know  how  they  are  going  to
                4   use it.
                5               We are being told  we  should  depend  on  the  group,
                6   but if you  go about their decision-making capability reviews
                7   to what we  have been told, RAG met once, the county-. three
                8   times, the  EMS met zero, so I don't know what went into that
                9   formulation, so it isn't a question of feeling Memphis doesn't

                    havp need-,  It                 of my inhib4-tic.-. in te--M-@ -@f

                    whether or not they   are going about meeting these needs in the
               121  most effective way they  can.  I  am  just  trying  to  equate  it
                    on tL-iat zas.-'Ls and I tliink $2 million as advised here is  for
               13
               14   what we have seen, I think,  a  very  generous  way  of  meeting  it
               15   because they still have the developmental components.
               16               I. for one, will support the $2 million.  I may
               17   have come up with a lower sum.  If this fails, I might      Is-cill

                    offer that as a suggestion.
               18
                                DR. SCHMIDT:  I think unless there is something new
               19
               20   to put before the group, we should call the question.

                                John?
               21
                                DR. KRALEWSKI:  I  would  like  to  offer  an  amendment
               A.@
               23   to this alternate proposal here and that is that we strike
               24   the contract money, we  keep  that  project  money  at  the  900,000
  ce- Federal Reporters,  Inc. that's being su  ested,  and  we  aive  them  a  full  developmental
               25                   99




      ar5                                                               24 2


               I  component to the limit of what that would run wild be  about
               2  there, essentially what they are asking, 162, maybe a  little
               3  more than that as it would work out in the final budget,  but
               4  then out of the contract they can rethink their whole  plan
               5  of slipping into an emergency program here that might not
               6  have been outlined and still have some money under
               7  developmental for some discretionary kinds of activities.
               8             DR. SCHMIDT: Well, if I am with you,  you'd  give
               9  them the 800, program staff, and the 900 for projects,  and
                  ti, , 4- ic; 1 million 7. 'LO percent of that -Ls 'L70, and
              io

                  would come down then to l..87 million. That is an  amendment

                  to the substitutb.-motion to the main motion.
              1 2

                             Is there a second?
              13
              14             DR. SCHLERIS:  I will second it.
              15             DR. SCHMIDT: All right, it is seconded,  so  now
                  we are down to discussion of the amendment to the  substitute
              1 6
              17  motion.  Anything not germane to that is out of order.
              18             MRS. KYTTLE: I think some of the flavor  of  the
                  amendment came from comments by Dr. Schleris and we have  got
              19
              20  to do something about these printouts that led you to  think
              21  that this home health care is less than winding up.  It  was
                  something that was started two and a half vears aao.  The
               2
              23  multiphasic screening projects were started two and a half years
              24  ago, and if you are going to look at these printouts and  not
  ce-Federal Reporters,  Inc. equate proper time with them to realize that that is the part
              2 5




       ar6                                                               24 3

                1 of this program,that that is the part  of this program that is

                2 phasing out, then they are misleading.

                3             I have heard this group several times today get
                4 hung up on that.  That's the phasing out program.  The high
                5 risk infant.  The expansion of the home health center.
                6 The satellite clinics. That is the new part  of  this  program
                7 that is building up and the part that disturbed you is the

                8 part that was started two and a half years ago.
                9             DR. SCHMIDT:  The current level there is at 1.627.
              in IWhat is being recommended now is 1.87, which is  not-too  much
              eV
              11  of an increase.  I think we will test the sentiment then by
              12  vote onthe amendment to the substitute which is 1.87,  with  a
              13  170,000 developmental and no contract.
              14              All in favor of this, please say aye.
              15              And opposed, no.
              16              All right, the "noes" have it, and the amendment
                  is defeated. We are back to the 2 million level,  and  I  will
              17
              18  call the question on that.
              19              All in favor, please say aye.

                              Opposed, no.
              20
              21              I will have to ask for a show of hands.  Please
              22  raise your  hand.

                              I have four ayes.
              2-3-
              24              Noes?
  ce- Federal Reporters,  Inc. Four.
              25





                                                                             24 4
     ar7


                              The chairman will vote to break the tie.  And vote

               2   aye.  So that the substituted motion has it.

               3              Before we adjourn, I would like to ask the one

               4   question.  At the request of staff, we did prepare --

                              DR   JAMES: Excuse me, sir, I  didn't  quite  under-
               5
               6   stand that.  You said the substitute motion passes?  You

               7   voted aye for which motion?
               8              DR. SCHMIDT:  The substitute motion.
               9              DR. SCHLERIS:  $2 million.

                              DR. SCHMIDT: 2 million I-Pvel. wbi.(-h is 800i  200,
               10

               I I 100, goo.
               12             DR. JAMES:  Thank you.
               13'            DR..              @Alere a quest---Lon a-uout-- procedure

               14             DR. JAMES:  No.
               15             MRS. KYTTLE:  I am sorry, which one?  The 2 million?
               16  okay.
               17             DR. SCHMIDT:  It is approved at a 2 million level.
               18             DR. JAMES:  Yes.  Okay.
                              DR. SCHMIDT:  Staff has requested that I request
               19
               20  the committee recommendations remaining, if there are any
                   comments about this chapter four that I   asked you to look  at
               21
               22  last night.  it has to do with the functions of review
               23  committee and council and so on.  This will go to council.
               24  For their essential, essentially their approval.  I am asking
  ce- Federal Reporters,  Inc. if there are any substantive queries or comments on that at
               25






                                                                        @245




                  this time?


                             MR. HITTON:  I  would say only that I would have
               2

                  appreciated having that document  of that upon 3oining the
               3
               4  committee.  I have since  that time just about-figured it out,

                  but it was an awful loss  in productivity while I figured it.
               5
                  So I am very glad to see  that this will be available to the
               6
               7  future members who join the committee.
               8             DR. 8CHMIDT:  I will strongly urge that a letter
               9  be sent to review committed members asking for specific

                                          going to coun il.  I w2LllL express iTty
                                                       c
              io  comments pror  @o
                  personal appreciation to a most -- somebody turn off their

                  mike.  -- To a most hardworkinq and understanding committee,
              12
                  particularly for understanding and tolerance exhibited to

                  the chairman.  Thank you.
              14
                             Be sure to pull out your rating sheet and have that
              15
              16  available for staff pickup.  Thank you.
              17              (Whereupon, at 4:40 p.m., the hearing was
              18  adjourned.)

   e23
              19


              20


              21




              23


              24

  ce-Federal Reporteis,  Inc.
              2 5