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                                                      P zi.           A                               t,,)         r) 1 v     --3

                                                                         n

                                                                                 @AlzAH  J.  S'                                                                         n c- r Fit
                                                                                                                                                                                       o n,,@  a r,

                                                      Development',  DPMP,

                                                                                                                           c, c,, u   :i.            c   r      z7s @r-

                                                                                                                                                 i.aho.

                                         19

                                                                                                T,.'@.   FLO-ID,           I:',    Paso                   Tcxa@.,

                                                                                                   C)      @,T'A@'r,LTYJ"N                                      01-

                                                                                                                                                           Y-@  c7   n

                                         @)3
                                                                                 D l@'             P C E   1'7                     I j,,' I:Z     I,',,    h                      n. c.

                                                                                 D P,,     P A  U L  A          I T      7 -'f:                                   1).   C


                                                                                    2

                       PRESENT (continued):

                                         I!JA@         TI(TNt3, New York, ilei%T York
                                   DR. Pr    MI@,! l@7. 14)%

                                   C. POPFr.,t        Iqpokane, Washington.

                  4                D-r, ANTI'LONY I,. KO@1A.ROFP, Boston, Massachutetts.
                     f
                  15                   l-@ICIT7',.r,,D JA@IrT@7AY, T,7i-nston-Salcm, North Carolina.',

                  6                Vi-6:@ :)TTA R. GORDON, Creat Rend, Yansas.

                  7                EDWT?@T C. HTROTO,'Los Angeles, Califotn3'.a.

                  8                MARIEL S. MORGAN, Albuci,uercfue, New Mexido.

                                   And Others.

                 17

                 18

                 20  !I

                 21

                     j;

                 24


                                                                                3

                                        p P, 0 C 1,      N

                                DR. l)2.@IIL: @,7ill r-11-acting pleas,@- come to order?
                  2
                     T-7    none all plu 'ged in, UT) at    head table, and  I  think
                     ..e are
                  3
                                    with this           of the I.'Iational -Advisory
                  4     .-an proceed

                  5
                                l,lost of you were here yesterday for the meeting  of
                  6
                     the ad hoc @IP Review Committee,   but I do wish to  welcome  to
                  7
                     the table '4rs. Gordon, and Dr. Ilaber, and @,ir. IIilli}@,on. @,le
                  8                                                                   1
                     are very pleased that you can  re-arrange  your  summer  schedules
                  9
                  10 and be here with us.
                                As you know, this will be, or is expected  to  bet  the
                  11
                     final meeting of the National  Advisory  Committee,  called  to
                  12
                     disoerse the remaining fiscal 73 funds, which have been relc-aqn(
                  13
                     as a result of the court order. All of the 197A  fiscal  furid--'i

                     were obligated prior to the close of the   fiscal year,  June  30t 'Ili
                  15
                                And as of this state, @.;c- have approximately 23 to  i
                  16
                  17 30 million dollars for making our awards following this AugLis
                  18 Council meeting. Now, we will be  discussing  more  of  that  in
                       few minutes, because we had a  rather  lengthy  open  session
                  19
                     yesterday. And many of the  topics  were  discussed  with  both
                  20
                     the Council members sitting as observers, and the review com-
                  21

                  22
                                I liesitat3 to go over all of the material again, and@
                  23
                     perhaps it miglit.be better as we gojinto the closed session tol
                  24
                     take up some specific Poiftts. If there are questions that bear@
                  25
                     oh the points we discussed yesterday, but I thin),: 1 should mak@,


                      one of two g@-n--ral comments.

                                 STiocificall,,r for -the benefit of the  three

                  3   not be with us yesterday, lc-cause I ti-i-Lnl-, it is

                  4   the da   s proceedings .   I,'irst of al 1, l@Ir. P,-Libel diO -a':e a
                             y

                  5   presentation and go over -Llie current status of the

                  6   and vie did provide, T bc-li eve, a hand-out, did we r4c"@-,

                  7   yesterday?

                  8              ZIR. B,@UM,: Yes.

                  9              DR. WAIIMOCK: @lo.

                  10             DR. P@.T.IL: !fell, it was intended to give  a

                  11  out.    Can we make sure that we get those now, toda@!.

                                 @l-IR. BAUPI: All right.
                  12

                  13             DR. PAIIL: 1,Thich summarizes the basic 6leren"-S O,:

                  14  the I.Touse bill that has been reported out by the fu.7L 1- c C

                  15  I  won't  go into all of that now.  Because, really, I "I

                  16  that we still haverany steps to qo before we have

                  17  and by giving you our sum,-.iary  statement,  I  believe,

                  18  understand what  the  main  features  are  very  quickly.

                  19             It is a long bill, some one hundred pages.  It does

                      certainly  make provisions for a transition period, and
                  20

                      anticipate  that  the  local  regional  medical  oroqrams
                  21

                      with these CIIP age cies and experimental healti'l   ser%,,i   (f a!
                  2                       n

                      systems,  and Ilill-Burton organizations ,,iill be   given t-he
                  23

                      opportunity to become incorporated into the Proposed or@a-iza-
                  24

                  25  tions.


                                         is @prc,,T could is n t c--tainly  y  @@7,-IY
                                                         0

                    to perpetuate the      ,-Irourari as @,ic I.Iiow it.        youi
                2
                3   vlho have been following the lc- islation closely       certainI
                                                   9

                    appreciate that.
                4
                5              I,.hen we have copies of.the floor bill we  will  tryi
                6   to get them out to you, because I do believe that  it  will  be
                    faily close to what may be passed.  And  of  course,  the  time i
                7
                    table for enactment of legislation is unknown for good and

                    sufficient   reasons.
                9
                10             But it may well be passed later this fall.
                               MR. BARROWS: You have just given me a note  saying the
                11
                12  summary of the bill is attached to the Council agenda.

                               MR. BA.Ul-,I. It's the  item stapled.
                13

                               DR. PAIIL: Oh, I thought it was a sepetate hand-out.
                14
                15  I see it.  It's the next to the last item.  There is a Nation   1
                16  Council for Health Policy established v,,ithin DIIEW.  'i,7e do not!,
                17  know at this time what relationship such council will have
                18  with this council, or to the other legislatively mandated

                    councils,- of the constituent programs.
                19

                                          T.10
                               MR.  OCDEN   tld it be appropriate for Tnb to  speak
                20
                   1-to this  legislation at this point?
                21
                22             DR. PAIIL-. Yes, I believe it would be a  good  tire.
                               @IR4 OGDETI: In reviewing Mr. rubells summary yesterday
                23
                24  and in thinking about the matter overnight, while  I  have  not
                    Yet.had an opportunity to read tl-ie summary ul y it  is  here.
                25


                                                                               6
                              I am greatly concern d that fil@ 16204, as @@7e h(-,ared it
                    d,-scri!Dc-d sc@ems to ignore the role that PI.IP has played in the
                2
                    health care environment in recent years.    I would like to
                3
                    read to this council and to those present at this session, the!
                4
                    open session a letter from Senator PIagnusen who is chairman
                5
                    of the.F>ubcommittee on Labor, lic;alth, T@,ducation and Welfare,
                6
                    addressed to Senator 't,,c-nnedy.
                7
                              And I am quoting.   Dear Senator Kennedy.  it has
                8
                    been reported to me that the  proposed le islative revision  of
                    t7ne Public Health Service Act  in effect eliminates the Region
                10
                    Medidal Programs.  And would divert the  appropriation  that has
                11
                    been used for rl,!P purposes  to local planning agencies, as
                12
                    I understand the present proposal.
                13
                              Planning agencies would  then be expected to develop
                14
                    services in the same manner that  PLIP has been doincT in recent
                15
                    years.   I am somewhat concerned whether  planning agencies are  i
                16
                    4--h-- appropriate bodies to be engaged in the development of
                17
                18  services.
                               From my experience with the Washington-Alaska R,--giona'
                19
                    @'Ic-dical Program it seams to me that the development of servide
                20
                    in this complicated undertaking demanding the skills of @,erson;3
                21
                    experienced in the delivery of dare, and cohttadt planninc,- eLn--@
                22
                    pends almost entirely oft the determination of health care
                23
                    needs
                24
                               By an agency and staff which can attempt to mdtc.,l
                25


                      the local demand for  c;,@rvices  ac@ainst  resources,  and  ho,oefu2,1'-,,'
                   2  (-'@vcl.op a co7,-,T,)unit,,, Consensus as -t.-.o how to the z-eeds.
                                 It seems  that few if any planning agencies '@,,ave

                      a broad spectrum of   nersons i-@itl-i the knowledge  and  e:@.@,Derience
                   4
                      necessary for the actual creations new services.          ::cr does
                   5i
                      it seem practical for the planning agencies to do so, since
                   6
                      it  would  create   an   unnecessarily   large   and   cumbersum   crganiza-
                   7

                      tion.
                   8
                                 I  would  think  that  a   planning   board   should ta@abla
                   9
                      Of  expressing  the  communities  will  and  the   board   of   a   devel@,-
                   10
                      T-.ent  agency  should  be  canable  of  making   sound   technical   judg-
                      ments about the best way to develop services at        the    ent

                      level  to  meet  the  needs  outlined  by   the   Plannina   agen--v.
                   14            These are tvio distinct activities @@.,hich r-'-.-@,iire  -,"he
                      involvement of boards and staff i@,,ith their efforts an@- different
                   15
                      skills.  This  is  the  way  the  successful  PI@IP   such   as IkiA
                   16
                   17     are now Working.    I am concerned that if we attempt to      t r c t@@
                      both activities into the same  structure,  one  of  thln  a@ i ,   '-s
                   18                                                             t  viti-
                      will suffer, and it may very  well  be  the  quality  of  the services
                   19

                      developed in the function.
                   20
                                 The medical school. faculty,, the medical  sl:)6--iali--,ts
                   211
                      the medical idministrators  and  oti@iers  who  are  basic  llY  int@.
                   22
                    Tested in the way  care is delivered at the patient  e-,rel ma,,,
                   Z3
                      withdraw or not be  well utilized if both functions are ass
                   24
                      to a planning agency.
                   25


                                  It is these @-,ct@-sons, who with     I.ea@tershj,,), can

                   2   expands %--he present health Cate system in pr,.@@oaration for a
                   3@l natioi-i   caltli insurance.    The regional medical I-Iro@      to
                                                                                    ram

                   4   date h,    nvolved the talents   of most of  those  most  cap,-ible--@,

                   5     m sorry  -- of those most able to develop services.

                   6              Their:record  for  gaining  the  cooperation  of  all  parts

                   7   of the  delivery  system  and-improving  the  quality  and.accessibi'i-

                   8   of care  is  unequaled  among  the  public  health  service  Act  pro-@

                   9   grams. It does not  seem  reasonable  to  assume  that  the  capabil'i-

                  10   ities P-NIP organizations are developing are tran8ferrable to         I

                  11   other orgahitations, especially,@@@here the new organizations

                  12   have few of the talent orientations of the pred--C,.,Ssors.

                                  Certainly I recognize that all rYip organizations
                  13

                       like planning agencies and other health programs      have   not   been

                  15   uniformly  successful throughout the nation.  But-     any lack Of

                  16   success  is  more  attributable  to  lack  of   consistent   leadership

                  17 .1 direction at the federal level than it  is  t'r,,  fault  of  the  P?i

                  18   approach.

                  19              And undoubtedly are we going to need to make some

                       effort sometime in the development of health care reso
                                                                                   urces.

                  21   Hop6fully this task  can  be  assigned  to  agencies  whose  dypbrt-isd

                       -and experience can iiial@e the optirriim contribution. iu@.I.P organiz@--
                  22

                                                 -ianaed and,strengthenod
                       tions might need to be cl                            in some  -arts   1
                  23
                  24   of the nation.
                  25              8ut in my opinion they probably represent the best


                                                              sibility
                 I  means of i,,-, sing the quality and acces          of care for@

                 2  tire average .it4-zan'.

                 3
                              In 8urrary, I am ho,)eful that the new  legislation

                 4  Will be able to reco,7i-iize both thr-, consumer and @rovLder

                 511 relationships needed to make the health system @,orj', -0
                                                                         p- perl,,

                 6  There should be some way the new legislation can  insure  the

                 7  continuation of healti services, development agencies si4-.,ii-ar
                 8  to     in str cturb   d experience, thereby not dissipat  thei
                                 u      an                                   e

                 9  national resources that we have developed.
                 10           It might well be advantageous if  the n---,,.7 le@islat-',_c:i

                 11 Were to establish a forr-lal mechanism to assure that t.-ie

                    Of
                 12    the planning agencies and tli@@. P-1@IP -ir,,@co6rdinated, i.6-.f

                 13 tli at m@l-ip Is are in fact developing deliverv systems

                    th-.health needs identified bv the planning auenci6s, and  such@
                 14i
                 15 mechanisms could certainly behe established without scrapping

                 16     present ptoc[rams.

                 17           Creating entirely new bureaucratic
                                                                  structures in

                 18 future, and in the process, using what would  remain .,:e have

                 19 achieved for existing I?J.!P systems, such as the I.,Iashinqtbr.-

                 20 Alaska program have been highly successful..  Thark -v6,l for

                       r consideration.
                 21 You

                              SI
                               @i,@car--ly, '@,larren G. nusen .
                 22i
                 23                I would like to  suggest that it is the  sense
                 24 of this Council that TIP 1,,-)204 as we have heard it cic-s6ri
                 25 lis inadequate as it is now drafted.  In that it faiis'to teccg-


                                                                             all-
                                                          le of adequate he    -4i serve c---,@
                     nize sufficiently the ii-@por@@ @,L ro

                           prient ef.C
                 3              @d e,4forts which simply cannot be li-ited to t,.--
                 4   localited  geographic areas @%71thin a stcite would seer. to !De
                 5   encompassed in @@'re concept of the local healtl- service area
                 6   within a stAte which the governor would designate under t"iis

                 7   bill.
                 8              And further, that this proposed 75,000 a year t,,."o
                 9   year limit for a project is grossly inadequate in our ex,Der-
                 10  ience since it simply will not attract meaningful or useful
                 11  applications.  Therefore I would like to propose  a r-solul.-,Ion.

                 12  along these-lines.
                                t6- it resolved  that the Congress in aa-optirc
                 13
                     or similar 1--aislation give each stat(-@ the statutor@,,  a.-Li@
                                                                                      n, an C

                 15  a! support to maintain a senarate  ealth sv8tems 6evelobi-,c-n'r_
                 1 61agency on a statd-wide basis or inde endent  oinriss on
                 1 7 in a  publicly  accountable  way  and  devoted  exclusively  to Such
                 18  work, and be it further resolved that     the    dorrent8,nrece Ing
                 19  this resolution, and the resolution itself be transmit ed to
                 20  the members of the House Intekstate a d For ic          i-.merce
                                                                       ,Tn  o
                 21  mittee, and the Senate Labor and Public Welfare Com,:rittee pc)-

                     'th 'r co sideration.
                 22     ei    n
                                DR. PAIIL.- Thank you .@ir. Ogden.  I,, r@,o' Ion n-a-@ been
                 23
                     made, to have t-he dbuncil ddop  t
                 24


                                MRS. PIORGA14: I second it.

                  2             DR. P7,JIL: Seconded.  Is there discussi.orA?

                  3             DR.           @Ir. Ogden, would you read  that  resblut.'

                  4  again, please.

                  51            ?,I ROC-@DEIT: Be it resolved tlicit the Congress in

                  6  adopting IIR 16204 or similar legislation give each state    the

                  7  statutory and financial sui,)port to maintain  a  separate  hbalthi,

                  8  systems development agency on a state-wide basis or independent

                  9  commission appointed  in  a  ublicly  accountable  way  and  devoted
                                                 p

                  10 exclusively to such work.

                  11            And be it further  resolved that the  omme

                  12 ceedina this resolution, and the resolution itself be traii,(3

                  13 mitted to the members of the Ilouse Interstate and  Foreic-Tn  com@,

                  i4 mic$rce Committe6, and the Senate Labor and  Public:l,-7elfare

                  15 Committee for their consideration.

                  16            DR. PAHL.-  Discussion?  Dr.  Sdhreiher?

                  17            DP,. SCHREINER: Yes. I  just  wanted  to ask 6  questionI

                  18 You would  favor the dissolution  of  the  redional prodess?

                                                                                      f
                  19            MR. OGDTN: Yesi I am*  Because  I  think this Pi6de o

                  20 i6aislation is directed toward the state-@vide activity,  I

                  21 rP-cbcrnize that many of our regional and medical nrogra     flow

                  22 over state boundaries but if we are to have an in6apsulated
                     program which is state  boundary  oriented,  it  seems  to  me  that!
                  23

                     that we can accoinodate to that through our existing MIP'S.
                  24

                                DR. WAIIMOCK: Your point was a specific statement of
                  25


                     I  operated plan?
                                         OGDE'I: Yes    (it this   particular   piece   of   16qi8
                     2

                     3  tion.
                     4              DR.  WAIUIOCX,.  This   particular   piece   of   legislation

                                                                                                e
                        because the RIIP as we have been looking at them do6sn't 6v r

                        flow into other states and so forth.
                     6

                                    MR. OGDEN: Tliat',i correct.
                     7
                                    DR. I-IP@l-@21OCK: Pegio-is, a.-, I understand it     I   was
                     8
                        told    them could be' no larger than this room, or they couldibe,
                     9
                        the    whole United States.      That's what called a regionAl area.i
                     10
                        So  we   are seeing some of these things, this is some          of the

                        thin  s  that  I  was  putting  to  my  mind  all  day   yesterday,   and
                     12      9
                     13  III earlier this morning.
                                    I didn't   get tp and write it      on a s'Al@,et of p@i:?er.
                     14  ii
                                    MR. OGDEN: Of co rse, we have some states, for
                                                        u
                     15
                     16 ekdmple,,  California,      where we have one TUIP for the whole      s tate;.

                      i For  the  state  of  j%low  York, we have at least four.
                     '17

                                    DR. WP2,11-IOCK: Four  @-hat's tight.
                     18
                     19             MR. OGDEN: And Under this hew piece          of !6gis atibni

                        these four Pi@IP's would become one.
                     20

                                    DR.  WPM40CI"":   Yes.
                     21

                                    ',IR.
                     2
                     23 suggested   to this Council     previously.
                                    DR. WAt4MOCK: Well, yoi:Llve been on it longer than I
                     24
                        have.
                     25


                               DR. PAII@@: Is tliere fiirtli.,-,r Discussion. Dr.   ro

                               OR. KO."IROFF: Yes. I find
                  2                                               i n synpat--Ily
                  'I    Ogd---n's ?rc,-,)osal. I ,qondc..r tliiouqli, if could d,!-nfer a
                  3
                  4 vote on it until some of us have had a chance to read the
                    su i-,ary of the Bill, which I, at least, ha,,7--nlt had a chanc=
                  5

                    to do yet.
                  6
                  7            To take action on.it, because the basic apprehension
                    that a T)lanning agency is not typically  a  body  constituted
                  8
                    to represent the providers or to implement service activities.,@
                  9
                    I think it is a very real concern, but I share
                  10
                               DP. PAIIL: I am sure others perhaps have  not had the
                  11
                   'Opportunity also to read this,   and thus, with  Council's  sense
                  12
                    ae wi'Ll- defer voting on this motion until later when we have
                  13
                   ihad an c portunity perba-)s follo@,7incT at least the m
                            p                                             orning cor ee
                  14

                    break.

                               I believe I v7ould like to take the unusual Step of
                  16
                    aski--.g whether any members of the public, because I know  that
                  17

                    several people are here from PMP   s and also Dr.  Sparkmah,  who
                  18

        7
                    is the Chairman of the Steering Committee of the National

                    C06r6inatotgi might wish'to add a comment  at  this  oiht  in
                  20
                  21 Ithe proceedings, and if not, there will be another opportunity
                                                                           7

                   iduring       or     ub ic session
                           the f  mal p  l'            for any comments.  on  this
                  22

                  23
                               Dr. Sparkman,, @,7ould you care to make some comments at
                  .4
                    this point?    On the topic under consideration>
                  25


                                                             speal@ing for tll     m tion, or
                                   DR. SPArl'!,tU@'-I: You iii,2an                  0

                   2   j
                            .-n general.
                   3                               s thinking of commenting 0  the r@lotioni
                                   DZ. P't'I IL: "I wa                             n

                   4   if vou will.  'Lhe  to,3ic  of  substance  of  l@Ir.  Ogden's comments.

                   5               DR. SPAI@N!Ali: Well, than],-. you.   I  appreciate   the

                   6   chance of   appearing before you again.  And representing the

                   7                                                     re           Ogden.
                       Coordinators, and I support the motion as           ad by Dlr.
                   8   I think the two important factors in the bill as I understand
                   9   it -- I, too, have not seen the entire bill, although I have

                   40
                       seen the stmmarV that has     been distributed to you.

                                   7L-id I have looked with some care on 13995 which is

                   12  it's predecessor, which I think hAs not been mo6ifidd very much

                   13  but  I  thin]<  there  are  two  important   fattots,
                   14              or,,-- is  the  subdivision  of  existing state"wl6e   or
                   15  regional PL@,IPIS into smaller atea-wide Regional t@ledical Program$.

                   16  I  think  the  subdivision  into   multiple   smaller   areas is appropri-

                   lL7 ate for planning, as has been demonstrated by the action of

                   18  those CIIPB or area-                   which can iddhtifv h
                                             wide agencies                             ealth

                   19  problems in their areas and deal with them.

                   20              But this is,     think, a totally     inappropriate   way

                   21  fro  Pecrional !,.,Iedical Programs        function since On A stat6-
                   22  wide basis we can       acquire  s-',.-@. and    have caliber an  a bread@.

                       of different kinds of- disciplin@@-@@
                                                               and    deal with p          w
                   23                                                                      hichi
                   24, we do on'a state-wide basis with the medical associdt on,. the
                   2,5 Voluntary health association,, health departments, and 0  enqise,


                      deal with health as stat@--@,@,ide   t

                   2             I think it   oulel,      virtually tcrm,'na-e an

                      PJIP in t@@le areas which i    familiar with.  And as    a mat'-.n-r

                   4  of        in the blue slit--et ,.iYiich is one of the re-ports on
                   5  1-7as'li@E-, .,,jton I-lealth matters, @..,Iiich I am sure some of you are
                   6  familiar  with  last  week  reported  that  the  bill  as  written

                   7  would be the last rites for PJ@IP.
                   8             I think this in effect i-S true, that any health
                      resource development activit  kind of things           is   doing,
                   9                                 y
                   10 look to me to  be  added  as  an  afterthought  and,ii  a  totally
                   11 inadequate manner.  I would like to mention just a couple c-@
                   12 other things, fie@o, if I might.

                                 DR. PAIIL: Please.
                   13

                                 DR. SP2-1,i@K!-IP'-,@T: Relative to the orientation
                   14
                   15 to regional medical program I I-,now that some of you have
                   16 served on regional advisory groups, or other committees          or
                   17 in otheiways have been involved with '--he  regional  r@.e,A.ica@L

                   18 programs      redcgnize that some of the other        f
                                                                         s 0  you  hd  enot,

                   19 some are new.
                                 Some of your Dredecessors have had the 6T)08rtunit%, of
                   20
                   2   aving  o  site v'                      dical               id theme

                     'I have talked to have indicated that this was a ve y he
                   22
                      experience in thddkstandin  what P--'.,Il"ls do.  I recognize  t 1
                   23
                   2  you all carefully read the written m,@t@.rial we submit to       %'ou
                   4

                      the Appiicat ons  or programs or pro]ec s.
                   25


                                  Ile are grateful to you for the time          takes to

                                                                        oesn't  (@l,uit-- tell
                   2   all of these, @,ut I          that t"@@- -a-,-.)er &
                   3   the story that I tl-hin',@ iou ,%,ould have an o,,Dportunitv  to  ander-'!
                   4   stand     %70U were actually had had an     on-site  visit,   or   had

                       a li't",  more contact @.,,ith a coordinator.
                   5
                                  I know you have an orientation       session for Dr.   Pahl
                   6
                       and his staff  the  details  of  @7!ii-ch  I  don't  know.  But  since
                   7
                       T  hav-  thought  about  this  I  belatedly  recoaftized  that  as,  a   I
                   8
                   9   grou,@:), the coordinators of @.!Pls lia@,-,-- done a poor job in
                   10  expressing to what they feel the @,a@, @@,P's function.
                   11             Itnd I have written to Dr. Pahl asking v,h,--t -mr ti-iere

                       are strengths that would  prevent  us  frori  co-,Imun-icat  ncT  frcell/'
                   12
                       with you,  and I have not had an op,,Dortuvii+,-v to have a      response
                   13
                       to him on  this , but 1 i-nt.6-n,," to 7c! lo%i un on it, unless  you
                   14
                       want to speak to it at the momc..I,)t.
                   15                                                                           1
                                  DR. PA.TIL: I believe not,    right  at this time, but we
                   16

                                                                          ers individually      I
                   17i will be discussing th    s ,@7ith sc)iil= other matt
                   18  and with th-- Steering Committee.

                                  DR. SPARKI-.UU-i: As  an  example,  I  don't  know  whether
                   19
                       all membe_rs of  the  National  Advisor-,,r  Council  rd6eivedthis  w'nich
                   20
                       is, a resort of a program accounta',--i'Lii--.v re-pbrt that was submit@c-
                   21
                       that was released about a month aco.               is  this  a   familiar;
                   22

                       document to you?
                   23
                                  I-IR. BAUM: It's been riailed.
                   24
                                  DR. SPAYWW.,T: Tlo%@; many of @u had a  chance  to  see  it?  i
                   25


                   I             DR. PAIIL: It @,icis rrailed

                   2                  3.r'ull: It was mailed out as soon as vTe CTO.

                   3             L,R. PATII,: @@lell at the time of our phone- call it

                   4  should ha.-,  -@en received by you.

                                     OGI)T@'.@'@l-. I did not receive i
                   5                                              t.

                   6             DR. SPARKIIAN: Iiot verv many.

                   7             DR. PAI-IL: We shall mal-le other copies available  to

                   8  you.

                   9             DR. SPAPi"\I@ll@ll:   this is of no  value  in  r.6-asu  nc
                   10iindividual Tu-lPls. But it is a measure,., of the aclqt6qat6  -ir,,Dact

                   11 Of PJ-!P' in helping to train health n@@   @@ssionals and a6t,-,all@@
                      servin    eo-ole.  I,,-nd in iT-,,,@.) 1me n tc i n @f i tv a c t i VI ti e
                   12       9  p

                   3                0
                      and while I  w uldn't expect you  o read    every word of      4"

                      is reasonably well done.

                                 And it is the  kind of thing that I wou       ope  VOU
                   15

                   16 had  had  achance to look at.  in order to    better    understand

                   1,17 what we are trying  to  do.  I  would  like  to,  then,  after  I  have

                   8  had a Chance to talk to Dr4 Pahl, @4ollow-up ,,it,n  ways  in

                   19 which we may communicate with you.

                                 T
                   20            I'lithout burdening you.  I know that you all qa

                       ore   than bn6uOh to read.  The second it6  1 w6u!
                                                                  m             k- to

                      mention briefly is the goai of @tli-c @,lational  dvisorv coanc4 I

                      and I am T)lbat6d that in the -notion that llr. Ogden  th a t ',,,,a s
                   23
                   24 seconded  that you all looking at the policies of Pi@ip     at you

                      all,'I think, then beginning to take steps to provide the
                   25


                                     t
                   I  leadership tha        .1tional Advisory Council  has  ",,-ovidecl  forl

                   2  RYP in the past.
                   3             I recognize that in your last two              in the
                   4  previous year things have been pretty well i@        ,first    at
                   5  a result of the phase out directed by the adi.z,,Iistratibii),  and
                   6  then the rather abrupt release of impounded funds so you were
                   7  kind of overwhelmed with applications.
                   8             But I would like  to remind you that you ate A very
                   9  respected  group,, on  the  health  care  !scene.  You  represent    i
                   10 a  group  of distinguished and dedicated people and that Your
                      word  relative  to  egional  medical  programs  part  in  health  dde!
                   11                   r
                   12    im ortant an             -liat you should tak  time t  d  iv r
                      is   p          d I  think 4L.                           0 C-1 c
                   13 to consider health   colic from  the  stand  point  of  the  NationAli
                                           J.D  y
                                                                                           i

                      Advisory Council.
                   14
                   15            And I hope that you i@ii-11 have time to do this. At      1
                   16 your last meeting  as an example two resolutions c me to
                   17 you from@the I-lational ReviCN4 ConLmittbe, and one of them  r,-mcom-l
                   18 mended that CHP' turn  to  IU@IP's  when  appropriator  or  technical!
                   19 and professional assistance regarding health care changes
                   20            And the second one encouraged PJIP's and CIIP,8 at        I
                   21 the state  and local levels t.  Aork together c
                      ways in which better programs would be carried on kdqardless
                   22
                      of the exact language that    is in the.legislation.@ thes6, 1
                   23
                      thought'. iqete both good ideas
                   "4
                                 Mr. Rubel spoke against    both, and af e  wh t   I  thou h
                                                                         t                 9


                                                                discussion   by   y
                     1, was very brief consideration and                          ou, both   of
                     2  them v;cre rejected.     On Ji:tne -00, immediately  after  the   i-,eetl-C@
                     3           to l,ir. "iibc-1   d  said  I  was  disappointed  in  his   dis-
                     .11 I wrote                 an
                     4  al?pr@--\7al of t'@   and it seems to rrp@ '-.his is   inconsistent   @qit-@
                        his previous sr     em--nt relative to on-going      positi've     relations
                     5

                     6  between PDIP and CIIP.
                                    IIhich I  wholeheartedly  support.  -I\.iid  I  -.;aid  that   i
                     7
                        I  hope  that  there  will  be  some  tangible   evidence   from   him
                     8
                     9  on  action  relative  to  this  positive   relationship.   !Tle   hasn'*-
                     10 responded  to  met  nor  have  I  seen  any  evidence  Of   this   action

                     11 on his part.
                                    To  suni-)ort  what  he  said  at  the  Meeting  last  time.
                     12
                        T@et me add an   anecdote regarding     this.  At the 'i,',a.-,hington-
                     13
                        Alas]-la area we  have t.,70  particular  grant.-,  @,7h-r-    la vo t C, s'-
                     14
                        forces looking    at  these  kinds  of  alternative   arrancTei,-iants
                     16 @between PJIP and C'.IIP with the best people     we can f i cl in 1D bth
                     17 r@IP:and CHP  a  d  other  health  care  activities  in  '@)oth  .gtates.

                                    l.@26tinq  and  trvinq  to  shed   thei    sted  iht-r-   ts
                                                                          r   ve            -S

                     19 as  much   as possible, to tee    what kind   of  pro ram sh6u   cl emergei
                                                                               9

                     20 and lastly, that in Alaska,       out coordinator,     @vho is no@,,,, a very;,
                     21iable vouhq lady announced -.to me last wee],, tha  -,h4n I      @,,,a-@ about

                        to get Carried to the  dirtctc-)r  of  the  Anchorage  Clip  acral@IC%7.
                     .2
                                      said  I  was  all  for  this  kind  of  O-XT3  oration  but
                     23
                       lit seemed   to me this ,,7as carrying it  a  little     to    r.
                     24

                                    Thank you,, very much.
                     25


                  I            DR. PAIIL: Tilanl@ you very much, Dr. ST) ai-, a n .

                  2  v7ill have a formal open session a little later,  and  others

                  3  rrs8ent should feel free to comment upon  the  matters  that

                  4  were discussed and Dr. Sparkman, should you wish to make

                  5  additional comments.
                  6            But we shall table the motion until the Council has:@

                  7  had the opportunity to review the summary.

                  8            DR. JANEIIAY: At some time in the agenda,  I  would

                  9  like to respond to Dr. Spat},,man's comments about the dalil)er-:

                  10 ations of the Council relative to the resolutions.

                               DRi PPJIL: Perhaps this might be an appropriate ti,,.

                  12 then, Dr. Janeway.    Our agenda is flexible this rnorn--ncT

                  13 and perhaps this would be a good time.

                  14           DR. JAI;EWAY.   I would like Dr. Spari-Iman,

                  15 not -like the impression to go unanswered, that  the  Council

                  16@ did not deliberate appropriately upon the  substance  of  the

                  17 resolution brought by the  Technical  Review  Committee.  In
                     particularly that the wording of it is such  that  it  implies

                  19 a necessary conflict between CIIP and RPIP.

                  20           The concern of the  Council, or  at least the  sense

                                                             a ssome con ern
                  71 of it as I recall it, was that there

                     the planning in control function being amal  atdted  into  the
                  22                                              9
                     same agency. The implication is there, we felt;  and  I  think
                  23

                     quite correctly that      a                                o 'Id.
                  '.)4                     the  dvi.sor,,r council for P@   i t @17 U.L

                  25 Ibla inadvisable for this Council to be making   d' t t    1
                                                                       ic a  oria


                                              ry 1.)o!-,ition 'rc.,-lativ-3 to the
                 1   statement from an adversa                                '-@cns

                                                 -iavi-@@@ no (-,@ontrol.
                 2   of  an @i@,enc,!  1 h@l'-che

                                                        ui-a you that there
                 3             @nd I %,@ould    to
                 4   adequate discussion, at least i@     minds of the peb-@-;le

                      e
                 5   ar  around this table.
                 6             DR. Pz'@IL: Thank you.  is there further discus@i-c-.

                 7   on this point?
                 8             If not, 1 would like to.return to  my brief rdport
                 9   to you.  There Are several points and items  of business 7.1"e
                 10  should consider this morning.  First, I would like to,
                 11  the indulgence of the Council members who were here
                 12  to repeat very briefly for the be@iefit of those who were --o--
                 131 here yesterday, our current status with respect to t@@,@o    c:@--
                 14  tions that the Council had considered last
                 15            Let me take this opportunity t6 do this, bec@.,-,s--- .,.e
                 16  have representatives from both of those regions here this

                                        'll be speaking  ith us, ver  s o t@,
                 17  ribrning, and they wi               VI             h t
                 18  And in order to provide the Prover background and utdetstar,,din
                 19  1 believe it is necessary for me to repeat these remar s 04:

                     yesterday.
                 20
                               As you will recall,  at our last Council meet ng,
                     'two of the recommendations made with regard to sp6cif 0
                     tions -- the applications from I-laryl@ind and I,-'@assau-Suf--Oi,-:
                 23
                     were of the following ftatLird:  that is, that funds should tc,@:
                 24
                     be a,.-.,iardtd for those particular applications and also that the


                                                                                                          2 2

                            t,@io programs    in (ju,@:-,t4-on should be terminated in an ord@rly

                        11  fashion.
                        2

                                          The   rccoi   r,,C.,id,-itions   were   accepted   by   the   director

                            and i@      re on our     T,@,,iy to                           in aood faith
                        4                                                         these

                            when       @@,7as called  to our attention that again.,           @ii.   a   result,

                            I am afraid, of a dismal ignorance of the law, that we were
                        6                                                                                        t

                                 abler   as   a   matter   of   fadt,   to   implement   what   had   been    the@
                        7   not

                              tnoil recommendation.
                            co           And   the   second   Part    of    that,    the    ord6r!v    terminator,
                        9

                            of the two oroqrams, that          isi we had only the opp           rtunitv      to
                        10                                                                     0
                            implement the first Dart of the recommendations and that                      is
                        11

                            not to provide funds for those            s     ecific      anplicitions that     were
                                                                        p
                        12

                            reviewed at that tire.
                        13

                                         In   fact   that   was   the   case.   14o   awards   were   made    at
                        14
                            the  June   Council   to   either   the   Na8sau-Suffolk   or    t    e    @-laryla@di

                        16  programs.   However, we were in error in believing th t your
                        17  recommendation    could    be    implemented    and    when    w       e
                            of   this   error   by   out   office   of   cefteral    counsel       Tiiinediat6l"i

                        19                                  9              p  n e   ou                         a

                            bn
                        20    --n An error, on our parti  and that v7hat we                        to do was

                            inf orT'@l c- r-I        ey   I     ave a rio         an       e
                        21

                                       tiliat right, t   rc--FtibTnit a-o      c     0       r  h   r   L
                        22
                            by the  review CO.@rlittoe -v@estetda@r,  and bv th @q
                        23

                                        m'he reason that that         action ii                      at   the
                        2,4                                                      as taken    @,7 s
                         lauplications in ques ion,              e app ic                 la
                        25


                                                              li-atic)ns   under   considerate
                                 the June  Council  and  aE)E,)                              @.c)n

                           This Cc)uncil                 are  slinT.).Icr.,,ents to
                   3                Tac bud@,,@,t pe,@ri-od for all ro-@io,-ial medical proqra@,@,--
                                         bruary 1, 1974     tIl.-C)uq"I Junr@, 30, 1975  arid
                   4    extends from Fe
                   5 !I those a-o,,Dlications reviewed at t,ie last Council meeting, as
                   6    well as the ones before you today technically are supplements

                   7    to existing awards.
                                    Therefore  it  is  not  aDor@riate  for   the   Council   to
                   9    make a recommendation beyond funding        for the  specific applid-,-
                   10   tions in question.       Ilaving  gotten   over   that   psychological
                        hurdle and shocked everyone we as a headquarters staff,

                        i,76th the staffs of the two regions     in question try to      worl@,
                   12
                   13   effectively within the time constraints that were on           all o.L

                        us.
                   14
                   15               And we  extended  the  deadline  from  July  1  to  JUIN,7 9

                   16    0    0
                   1'7  amplify those applications.  And our staff met with the staffs
                   18      the  two  regions  and  6u   may   i    ne that there were both

                        several trips involved, and many telephone calls,          an   as   a
                   19
                   20   result of this we believe that the regions in question under-
                   21   stand fully the concerns that the review committe             nd   the
                        Council had and hai.@sl,:)ol-.eii to those concerns   in the  oplicati-I'@.
                   22
                                    Also, we have made two, made know to th @-e         r&qioiis
                   23
                   @24  the fact that during the open session both the revieq coiilrllltt@s
                        and the council the-re was the opportunity to s,,?e          on   behalf


                                                                                      2

                       of these matters.

                                  And          get to t.'iL, oocn session,  this  morni@n
                  2
                  ,3   we will have staterr@ents from rer,@reserititivc@,s of  both  regions.
                  4  ii     apart from that i,:.,,atter I ,,7ill indicate to the  Coundil
                     !'I you will recall at the June  meeting  @-oi,i  approved  88  million
                  5

                       dollars recommended for approval.
                  6
                                  88 millions of   dollars.  we  actually  made   awards   of
                  7  i
                  8    84 millions of  dollars,  and  the  reason  we  did  not  implement
                       fully your recommendations was because it was felt to be better
                  9

                       management  to  reserve  the  different,  four  million   dollars,
                  10

                       so that we would have  a  total  of  28  millions  of  dollars  for
                  11

                       su,,Dobrt of the recommendations at this meeting, because iqe had
                  12
                       anticipated at that time to ha@@le aDpro@limciteiy 43 million
                  13

                       dollars  in reques
                  14

                                                                                 der    0
                  15              An d @,76 felt we needed the 28 million in or       t
                       provide appropriate iT-.T)lementatibn of the reconind dati       f
                  16                                                          n      on  ro

                     I   is Counci       s a resu    0     e ac ions 3us     a e      a
                  17

                       recited with P-lar land, and Ndssau-Suffolk, those'two ap      lica-
                                        y                                             p

                       ti6ns have increased the requested fiqure so that       the  eviet@;
                  @19

                       committee vdsterdav had'in the    53  applications   e   re   it
                  ,20

                       a total request of 46 million dollars.

                                  Our total dollars tl,r-@t are available for  sup  ort  O.'L
                  22
                     i Rcaional Medical  Programs  included  not  only  th6  28  mii  16n
                  23
                     1 dollars, but some unexdendbd b lances of anpt6,xin@at iv one and

                       6 half to no more than two             dollars,  from   prior   budget
                  25


                        periods.

                                    So that the total    monies that    we  have,  and  we  will

                        knovi exactly cis @@ic re-ceivc--, the re,.-L)ort and expenditures  forms

                        this         the  total  amount  that  we  will  have   following   this

                   5    Couftcil  meeting  for  support  of  regional  ?@ledical  Programs  @,7illt

                   6    be  approximately  29.5  million   dollars,   to   30   million   dollars.

                   7                The  committee  acted  yesterday  in  our  closed   ses8ion.,@@

                   8    So  we   will be going over the specific recommendations. We

                   9    have  a  point,  however,   which   does   require   your   consideration.

                   10   And as I  discuss  what  the  point  is,  I  would  lil,,e  to  pass  this

                   11   statement but to you.

                   'tL2             And indicate to you    what our problem, i
                                                                                 S,  under   the  I
                        dburt Order whidh was signed      and  thus  the   litigation   is   bndedl
                   13

                                    Lbns  of  dollars  wai7e  given  to  the  defendants,  if  you
                          Ve Tq
                                .iJJ4

                   15   Will,  for  purposes  other  than  the  direct   support   of   rdqi6nal

                   16   medical programs.                                                         i

                                    Th's wa  the negoti

                   is   -.-@ttlem--nti and those purposes were     described very    completely

                        by 1-@ir. Rubel.  Now,  the  condition  in  the-  court  order  it  that

                   20   if  l@Ir.  Rubel  and  staff  are  unable  to  obligate  th  f   rli,   ibn

                        dollars v7itl-lin  90  days,  90  da  s  from  the  signin  Of  the  final
                   21                                     y

                      !-court order  the remain  g

                        reverts    to the  support  of   the   regional   medical   prog Ms.

                                    Thus,     May be faced in    late October with     the 06ssi@ll

                        ity of distributing a very small or       medium s'ze, or ait-h6uo
                   25
                        unlij-.ely a large size sum to the regional       medical programs.


                                                                                       2 C,
                       u:) to five riillio,,,l doliz-,.rs.      h,@li-eve 'L--hat there will
                                few dollars                        obviou@;l, theta is  a
                    2  be very
                       great interest on   @@-hc; ;)art of the administration  to   utilize
                    3
                       those funds, effectively for the pu     rposes they were used diirina
                    4
                    5  the negotiations.
                                  But we  do not wish to call this Council back @-hould'
                    6
                       it be required for us to distribute the small quTn.  Thus,
                    7
                       i@i-- have drafted a statement which perhaps I can explain to you
                    9  rather than  6 over the formalities, which would, I think,
                                    9

                    10 accomodate the situation very viell.
                                  mind  hot  require  your  further  attention  on  matters
                    12 which I believe are riot OIL sufficient importance to ]-,air  r--)I,Aot e:

                       meeting
                               .  T,,Ihat we will propose to do with the close to 30
                    13

                    1   i  i n  o  ars
                    15 first  pay  up  to  100  potcdnt  of  your  recommendatl6  s;  f6  each

                       of the Ppill's.
                    16
                                  Should  there  still  be   funds   available   us    fter   i
                    17
                    18 vi6 have awarded 100 percent levels of your recommendations
                       t day, we would  then  return  to  your  recommended  leve  s  f  11  w

                                                 ti            se I j
                    0  at the June council mee  ng.  Becau            ust   indicated@to   vou

                                                                       or    ro ra
                     I that although you recommended that we sul)P  t             Ms  t   a
                                                                             p
                    21
                    2 'total level Of 88 million, we     reduced that to    84 million,  so
                    .2
                       we would then take anv t6maiftiftg funds and pay      appropriate
                    23
                       amounts      to the
                                 UP         June council recommended leve S.

                                  In the event, and t"            a lot of if's  bu       this1


                    is    ,,7ay this program trust   things. Sh,,)uld t',, st' 1
                                                                           -I'
                                                                     avai"  :)I e
                    2

                                                                  ctober,
                    3to us  or ,,ihat ma.,l bcco'@iLc, available to us in 0zt s a
                    4ilrestlt Of the situation I have just indicated to vou with tle-m
                                                                      ke a di.->tr4--
                    5ifive million dollarst we would then proposed to ma
                    6             la, and the formula is  iven at the bottom
                    bution by formu                       9
                    7of this page, and it would Tqe,rely state that @,,,e would take
                                            made  from this August council meetings
                    8the actual award that we    r
                    9  a,-id the actual award made following the June council i-.eeting,
                                              of those two awards ate of tile total
                    10 land find out what percent
                    I
                                         hd and A        u oil 7,eeting*
                    lawards made at the Ju       ugust co n
                                                    age to whatever remaining funds
                    I         And apply that percent
                    12

                                                                   clion.
                    !I'..,e have. And distributc- those funds to eOc"I re

                                                                              at
                                    Uitable Dnd in keeping with your recom-end  Ions
                    14i-IL-.hat this is C-Cl
                                                           anci
                    15 of the June and August council meetings/have been unusual, in
                    i6                 basically have been revi=-,,.ied, simultanecusl,,
                    Ithat all pro5tAmst

                    17 ';rather than at quarterly petiods of the year.
                    18        Secondlyt the competition, t e alp Ita  @yis
                    @19 lin un er a competitive syst6m, whereas during the earlier part:
                    20 of 1974 we were mal,,in'g. disttibutib  on a  ormu a  as
                    21 perpetuated tank standings of regibns for 10,72.  So v,,bdt we
                    22 Ilfeel is at th last two council meetings, this one  ande
                    icouncil- meeting, are bur b-tt indication of the latest 6onsido@--
                    23
                    24 latioi of merit of each region.
                                   fore the formula that we  ave@  @-vise  e b c 1 j.
                              There


                     1    to be fair.
                     2               That is                 0 . I        I        -lade it clear,
                     3    and I would Tilde to    !,IEivc- either a (tiscc,@S-@io.-4 or endorsement
                     4    or, if you would,           to consider it later,        Discussion      or
                          endorsement of either      this ,)rcrosal or a Modification because              i
                     5
                          n    this council meeting ends         we still r-.a-%T be f aced w       a
                     6    o ce

                     7    distribution of funds.
                                      And I do not     have that authority       unless   @@e    reconvene!.
                     9    At  some  future  date,  so  I  would  like  to  o@-en  it  no,,.,  for   cancra,l
                     10   discussion  or   clarification   if   I   have   not   nade   it   clear.
                     11               DR. Tv@7A!,',-PIOCI":  That's  only  a  minor  sum  of  onbyi you    i
                     12   say about four million dollars.           @jr a            and   a   half dbllar5-,
                     I    is that correct?  First you will take the sum                  alloca  ed   @4or@!
                     14   eighty eighty million dollars,
                     15                                                     rst  I   will   S6   th   -icun-
                                     DP,. PAIIL- ilell, let me try, :L                              e    as
                     16   that were available to us to pay 1-,p to                -o r e    o       a

                     17   we reco      n    0

                     19                DR.  PAHL: The funds remaining                  then return
                                                                                     t

                          of those recommendations. If funds still                        either %.,,hat   i@
                     21
                          we have currently avail@i'lle, to us tiis 8u  er, or an, L@-lat
                     23   may become available to        us in October, I ,,-Culd t On emT)Iby
                          4-
                           he f ormula that I have       give-,,i %@Iiii.ch @,@iould fenrese t    ercente"g
                     24
                             t&rmi  d      r each region based oft the        viLn6 and      6ust t6unciil
                     25


                              ictual a,,,,,ar s to that rc@gion,   @@,lill ;Dc at I'@e
                  311 100 -P-rcc-nt Jun.@ and @LUgkist Council recori@-@-c-nded levels and a:D@'--Z@

                  4l@ that to ,.;ha@---ver bala,-icc-- rciTtains.
                  ,7)         DR.          I N-,,ould life to move that that be t-=n-
                  6Idorsed,  or approved that
                  7           161R. OCDE"il,,T: Can I ask a (Itiestion?

                              DR. PAHL: Yes
                              I.j'.R. OGDEN: Iam unclear as to what this five million
                  10 !!would be used for andthe manner in which that will be
                  11          DR. PAHL: I can speak mote fully to the second

                   ',then to ,-he' first point.
                              ,IR. OGDEN: I think it is the first i:.)oiit that 1 an

                    i,@-or  interested in.
                  15          DR. PAHL: I can get you material for  the first
                  16 !LeL'. me speak to the second point, however, @,ir. Og 61n.  t@16

                  17 negotiations on the se  enen  o     is
                  18 @'conducted primarily on behalf- of the defendants by Of 66uisef
                  19 ,our office of caneral counsel and the person of     121"a"e
                              And to t e purposes, nee s,                  liat

                  2@ibe r6nresented by having 142'.V6 millions of doll  sa
                  22@ :,to -the administration thus have been our most -n(I under his
                     ir6ct Per onal consider tio
                  23
                                                yr--sterd        e
                              II,-- handed to us,      ay, a rath t len4th  state en,-

                    ,,hich frankly I had not seen until yesterday because  t is a
                  25


                          te ac-Ei.v'ty @,7-i ,'-in bill
                     @.,t a r a
                                   :L

                    do is        vou        F-, a Tnc,.!   1@'i t I I"L a vtI i'l. -c0
                2

                    'to get I'@r.        st)-@,a@- t-,o @-@orc      L,@-cause we
                3

                                                                              d
                4

                5

                               L I  the riannz.!r in ich th@,- money will be sne-nt
                6
                7   I understand is fully through contract process. And the   purpose
                    generally designed to lool@. to,,,.,ard the new legislation a-nd to
                8
                    have organized, defined, cleared, and publish  those kinds

                    of   studies which are concerned with health planning method-
                10
                    oligies, evaluation studies, and to development of manuals

                    and procedures which will be of assistance to the organizations
                12
                    which we expect to be developing and supporting as a result
                13
                    of t@. proposed legisl-c,.ticn.

                                am not sure that that says much more or even as
                15
                    well as what he said yesterday, but I cannot anii@lif@),
                16

                               DR.            It's kind of anticipatory,   -as I
                17

                      t it .
                18

                               DR. PAIIL: It's kind of anticipatory   let's go off
                19

                    the record for a moment please.
                20

                               (Discussion off the record.)
                21
                               DP. P@-T@l-'L- I-'- c-c-iri go b,ck on -the record again.
                2-
                    I-)@c haT.DLD Y i f 1, 'Jr. Bell today, to try an.,,I. get 1-i3m t@c)
                23
                   l@ coTpe and speak to thi-s point. I'L@ i@c. of imporant, but it
                24
                    hz,,s been quite rcri-p.@.1--ral to my -ictivi-.-t,ic@s. Unless tl-ierc is
                25

                            I i                                                     I
                                                                                    I
                   i
                   i


                                                              @-I oil         t

                          tiink i.t      ti-@c,                          1 -i  o f t'@i E.,  co c

                                                         for  I'@li',IP    Hand      tlii.:71      is       file

                        t'd   1              Ti,(,,i-i@,y. 2'incft  I   tjllini@ wc-,   iri,71-).E-ove  the        Manne

                          and               of    I-Itib(-,ls                 the.   P,,onc-,y  mav  ,iot
                       6

                          be  apl)ronriatelv  snent.
                       7

                                                                               ear       on        how        tho        money1
                                       DR.   PAIIL:   Yes,   well.  that      b

                               )ent.    It        is        the        re-sn6nsibil.ity        of        this        Coun        il        tc)         approve
                       9  is  s,                                                        c

                          all  grant  funds.
                    10

                                       '-@4R.   OGDEN:   Unless   say  to  I,.tr.   Pubel's  resolution

                          that  you  leave  the  authority  to  ex,-.)encl  that  mc)n,-y  and
                    12

                          to  rol-i  tie  right  to  spend  it  in  the           in          vou            s,,7@nd.@
                    13

                                                                                                          ns-
                          it, ho,,, ,r)u clioo!7,c to siDena it, and                      0
                    14
                          is spending  it  under  authority.
                    15

                                                      Isn       It       this       the       result       of       the        count        cr-@er,
                                       i.17@.   HII@IT06

                    17    Bob,   rE,,t-11@l--r  than

                    18                      PAIIL:  It's  the  result  of   the  court  order  but
                    19    I  am  in  a verv  poor   position  to  take  issue  with  lir.   Oc,,e@n.

                                       @IP,. TIII"OTO: Okay.
                    20

                                       DE.  PAT)IL:     T'@7hat     I     @%Tould      say,      is      that      it      -ir.      m,,, c-  r  -
                    21

                        I .-                    ,   -,n                  -t-          -,t  col-..I-@- @           Ford,
                        . 5,tanding,that    --n     c@,nr,     of gran- funds mtir@.             C.L
                    22
                          and be rc-coi-dr.-encir@-d for @ipprovrLI. by t@-iis council.,  but  cort--ac,""
                    2.3

                                                                              it is cu,,:,,tom or @,C-

                                                                                                C@ i4--
                          f ra @-i 1 ybut cer@-i-ij-nlv. to            of        Try     T    no


                                                                                                   C,:l  -
                              f

                                                                                                              ti
                                                             -to
                              d t   u@!7, a r c-    i

                        3     c o -i-ii

                        4

                              five
                                                                                                              t e ch n c
                                                                     @,i r 6.,D din  con-trE,.c

                                                                              I je V,@
                                                                                                              c   o r
                        6     it  must         co     -    o re      u-t   I
                        7     you  to  have  a               undc-rstaiiding.
                        8                   PIP,.            i,7as   it  dosignat,c.@lin  the   court  or,,m-r

                        9     as   coi-i-@-ract  fune,@-?
                       10                   DR.            T     turn      to      r@,,,y quasi-la@,,,,7c-rs.
                       11                                            ],)oth          a little     infori7@a4@ion.
                       12     think   one,of the ti,-LngF, the court                      did          to
                       13     impotindr-,O   'L u-ri  Lis an  c)      kii    @ti-i i-i 2 r      o c; a         us.

                                                                                                        4
                                                    C)                         t@,,cs a@,,,7a,,,
                       14     the   a@              t
                                                                -d   funds to us,                      it a@,7F 4Z-ib I(.
                       15     of   tied      released                                   andina)  es
                       iG     to   nine, ten con@-.rac,tF@ 4@-l-,at ill,,P           that's @,.,Iiat             it is.

                           @l
                       17  11 So,  then,         have  five i7L-'Ill.ioii   l@E@,s,  to   alloca,tc-   to   our

                                                         T
                       18                    LNIR.   OGDI@l@'i: If tlj,.at is        case   and  it  goes   ii-i  ti-iat@

                       19     route  then my question is out of order.

                                                                YOS
                       20
                       21                    DR.             Is it ac,tuallN,7 spelled out as contract.
                                             MR.   GARD!-7LL:   T@iqt's   right.   I.P'icy  Cio,.'Ilt  !lave   to  I,-)e
                       22
                              nade as contracts.             Tl-,@y arc- not ria6e availal)2.e to us to            a    0

                       24     to our

                                             'LIR. OluDEI@l: Oka,,,,7.


                                              D'-

                                                              LI,, 4
                                        -TI

                                                              CLI1,C@ oi. ti,
                        r c   c, a   a s-         0

                                                        -to h,.iv,-@ a coun            --For t at@
                     li 2- c- zz ,,:k)uld br@
                                   T don't reall@T                    for  sl,? -endin@i a-i"7 ti r,,-c

                   6    on

                                   I move the motion.
                                   DR. PAIIL: All in favor of the proposed resolutioil,?

                                                   for distributing
                   9    Relative to the   formula
                   10                    l@LEI@l:   didn't get c). second.
                   11                    @,,OPGA-@ : Yes we did.  I secc)nCi@a
                   12              DR. PAIIL: Ill'i sorry,  -L, ha,,3 be-en riov,@ci and seconded.

                   13   All in favor, plei--c- say lye.

                                   VOICES: i%ye.

                   15              DR. P7--i.TIL: Ori-oosed.

                   16              (No resT)cnse)

                                   DR. P,,%Il@LT                     d.
                   17                              .@@@otion is carric
                   13   i          MR. OGDEIT: As a matter of editorial consent, shoul

                   19   the bottom line read        J'une?
                                        GA:ID7-71.L: The words will be datc%-d in
                   20
                        will     effective Scrtc-.r,!)clr 1. You're being terribly @n@zhn

                                   DR. T@T.TL: ,'@ll r3.g)it. @'o@.7   we have @.,ottc..@:n that,

                                                   ver to the arthritis, btit 1 sc-@-I     '-t
                        I next wanted       -,ov-c o
                        both Dr. Gramlich and @ir.                 left tl,@, rooni. So, first
                   2,5  ;I @@c)UlCi -J'U.-.t like to have the minutes of the la t meeting con-
                        I
                        I
                        II
                        ii
                        II
                        if


                                 T         t'i@@v arc att,-ict-iA  z@i.ij. f u  i a  n,@

                          ai-i

                 4    @).cti.or, on

                                     OCD'@c"'T: Tlilcse I-,aven't mLLil.,-,d out.T

                                                                  -ic
                 6    no  reason not  to suggest a iic)tion t,@i@it tl -y a@.)
                                                                           provec@.

                 7                            Second the notion.

                                 P                                IIlk
                                     P',!L: The motion has bec@-,n    to -accept the

                 9    minutes   as submitted.  Anv discussions

                 10              (Iqo response.)

                                 DR. PI@LIL: All in favor of tlis. @@otio,-i?

                                 VOICES: Aye.

                                     PAIIL: OD;Doscd?

                    lit
                                 DP. PAIII,: The motion is c@ii-i-icd.

                                              As a ,niattcr of fa,--t, it @,!ould b@,

                 ii   and  still is part of the minutes.

                                 DR. P'IIL: We walk a tight @--ope here..

                      in just  a -Iioment, having a report from '-Ir. '.,Ilatt @,,Dear to ]Drinq

                      @?OU, ULD to date on the status of the. arthritis procra-,n. Pis

                                                                                c- ia v
                 21   ,,ou will         at the last council meeting,   ..'att,

                            just -ibout g-attircTt,)vc)u at this r.)oint.

                                     Q'Dl p@@P:

                                 DP. Pz'-IiIIL: if that --,.s su@I'L@.ci@-_Iiit. you recall at
                 2,1
                 25 1 the last Cot,-ncil m,2ei--ing, you did     to a I?i-ss--ntation by
    I*              i, 6
                    ii
                    11                                -
                    ii
                    ii


                                                 r    C,  Z?, 0, 1c

                              2

                                                                                                                            d
                                                                                                      d c-@@ r a t
                                                                       a                     C,' c

                                                                                                                   v   c-,          j. t t C-
                              4       r@co-117.endat,4.c)n,,;   of   th         a(3   hoc                                   c 0 ITLM@

                                                                                                                                        o u
                              5       czli'-'@@7F-Tu@nt  to  that                    %@7@::'   liav,,@ r:@ad               and

                                                                           s n i7 j.-t t o
                                  4                                                        cl.@@ci-i,  -   the   ct,,@rent        status       O@
                              6       li'@le   to   call   on   ',-,Ir.           r

                                                                                ti Critics   Piece   the   last   Council
                              7       the   program,   and  our             ac

                              8       meeting.

                              9

                              10

                              1  2

                              1 7

                              2!Qj

                              2,i

                              25


                                                                                                                                              j.     t

                                                                                                                       on
                                                t  r   r-,   c

                                                                                                                        f                                            ear,-
                                                                               7 4                r

                                                                                                                                                                    0 f  p
                                                                                                          0
                                     4      Tried  4  and  a               h,-i 1 f                                     f C.)

                                           r)i-lol-  @2Lrthr4-tit-, ccnt@.-e
                                     5

                                                                i-Ilh.@n   the                           for
                                     6
                                           ar)pl..icatioxis  from  43  r,@gi.ons                           to-t@.illing          almost          16          -i',-lion
                                     7
                                     8     dollars.             So        it        @ias        a        highly        col@,@retitive         situation  In  the  re-
                                     9     Vic-@7 .       Polic,2'.c-s                 establ.isi-ir@@d       @@,,]-iich       took       out        of  t-I.E-.  @unnizi(-,
                                           those     kinds     o-r     activi.t-i.@as     @-,-hicii     did     not      C,@li-@l-n      t(-"      "Dc@  C.@      ructI.-,i

                                           CLi.d  riot  seem          to  directly  Is:)--ar               on  patient                                         t    e

                                     12    d                        -)f  th,@:-,cTs  j"or                               nC.            c-,,,.,,tensic        c-     c  a  r

                                           to  pztieiits.

                                                                                                                                                  y
                                                                           c-  o u't-- c 0        t   I  1 -I         r e c o i      i
                                                                                                                                                                    @d
                                     j,4
                                     15    art.-irl        tis  rl-vie-@v-7                           a-.,id          Council         at         it                 s c-  S   c,@,
                                     16    32.   of     t-lic@  Y@-74i:l        aTDr)lic,-,-Lions        for         ilot
                                     17    a p -,2. r    d        ',n c,                                                               '@ed       f

                                     ig ismall  amount.
                                     19                         I        shouldn't        say        small         ainotint,         tIA-1@it's         editorial.         Bv
                                     20    an           amount  of       almost       a       )ialf       a       million                                    t:le  apr)ro-
                                     21 ii val  of  the  Council                          --un(',cd,        or        approved,        ten@,e@,,        to         @,-Dprovc@

                                                                                            U
                                     1-1111.,,'i--h,&,  allocation  o@-   -lack               ne,  to  all  of  the  r:@rc,,,,-ra                 7,  i--ha-L-      7,,l  f @.1 @l..
                                         ,%,.,itlain  tl-ie  -carrar'@@ed               amounts  avail.al:)l-@-  to                  thc-  --,)rograr:@,.
                                                                         that  is  27  of                                                                     ind         the
                                     24
                                           renaming  'Lour  @.,,ho  were                                            but  for                      thc-,re  @."--re  n(-)i--


                                                         e

                                                                                                                             1-i@  ci i-n,-) i,,. n t
                                                             a@,c2  in

                              3                                             y
                                          o c. r

                                                                                                          c-@ff,@ct t):,.@at a rc7,,r,,;.cin

                              5       iF, or is not approved for                                           funds  o:c-  Ls  or               not

                                                   C,  for  the  utiliz,.-A-t@.ion  of                                        fundc. 1!7as issue-'
                                      Fi.     0 v  e

                              7       on     June       29    The  lettcr  also                                 that  each  of  4,-,he  regions

                                                                                       lot ar-t"iriti@3 activi-tv respo,-C, in
                                      receiving approvals for                      I

                                      writing    as     to     its     a--ceptari(,-e     of     the     award,     @,@hc-'re     an     al,,7ard     is

                              10  !I  involved,  and or in all cases the conditions of tlic- a@.7ard,

                                      which  was  the  sl;-_@;%Ltement  embodied  in  the  ap,,@,rovals  as  to  t                                  0

                                      kinds  of  -@ctivi-@ies  that  ,..@,liould bc@  undertaken.

                                                         And  the  limits  of  the  fi),nds  that                                  be      exp-enc4@ecl-

                                      .for  those        a c t i v        s .    To@,iay                    acce-pt@@iiicc-s 21.                t'losc-

                                      IV4P's  and        we      are      waiting      for      an      additional      ten.      To      round       it

                              I la    up.      Ei<4-ht     of     those     have     bc-@r@ii@l     contacted     as     of     @@c.,ster,-Iay,     irLd

                              i7      theory!  ar.@@                  cis  rap-,-di.                                     get  their  accept-
                                                                                       y    as  tlic@\,,        n  to

                              13      ,nce@s  in.

                              19                         As  vou  can        imagine,  going  from  a  request  of  sixteen

                              2,,)    million  to  something                 in            order  of  less  tlai-i             five             millions

                                                     -tic  cuts  were  iiiEicle,  and  some  restructuring  of
                                   1  S Or[10  CA Z @,.i c

                                                   -the                       'I-as           n-cc@,n-,s,3ary,  an('t
                                      i@iithi..i,,        ap,,:)rov,@ls                                                    L,  once cli, ,nac-@s arc;

                                      )Deing     negotiated.

                                                         It  anrc-:ars  at  this                            that    cnI.v    on,@@    or    t,@.,o    of

                              Z5      the  31.  approved  regions  may  tarn  down  the  funds.                                     On(-;


                                                                                                           Ovcrh-@-,i@i

                                                               C@ V.1 - C'I
                                                       t                                aTid

                                                                                                                          C
                                                                                                          rc,,copir,,enCi
                                           c@ r act'; c,,ris  both at  t,.ic,.

                                                                               (D                              ion c;
                                                                                 ,,i - u from tile
                         5      -the re  I-De  some   centralized  fO@@

                                                                                            part , of tha'        I ti :1
                                              !I-dicc

                                                                                               at there be        a met
                         7      -he r,iost    important       aspect -is a dc--,si-r-c@  tli                              hod
                                and an approach to            coordinating liko:.         kin6is     of     programs      that

                                nevertheless  are c'@.-Lspersed the  31  Rl,f(P's.

                         10                     W6   are   also   in   the   advice   letter   of    June    29    z@,,,s)-led

                         11 i,!! tile  l@.1p,  sto give  it some thought,  and to give  us  the
                                of their r@x,-@er4.-.nc-a and thoughts.                IT(D@,@eve-r,  tl-i,@y   did   not   have';

                                the  full                        nac;,3c@i  by then to         @.vc-   z.,   proper
                                                                                             9

                                i-n our estimation.

                         15                     7@-nd    we    a@-e    presently    preparing    a    letter     to
                         I      that un and give them more  concrete                                        @,uch .i@3  %,?iio   1

                         17     arc,. trip, I-)all                       got                       -@,nC,  fc4,1- @That !-.j-nds

                         18     of purposes and          what are  the nature of the  @@)rc)g@'tams that

                         19     have boon approved. for fun@ti.ng.

                                                                                                                     t  m c-@    ii
                         20                     And just in  conclusion,  to these remarks

                                read vou             draft part of the  letter that pi)rpO'--tS  to
                             ij
                             ij
                                -the api-)r-nv(--d prograicis.        Tl,,@@, eml?has.Ls of tile  approved pilot

                                        ains    is    the    extension    of    1)resci-it    I-,nowleclae    in     arthritis
                                pL-,@gr

                                                  treatment and care to coordinated services

                                (3,c,inons-'"-rated    imv)roved    patient    acess    to    care,     and     extension     ci:;


                                                                                V 4
                                                                          scr  C(

                                                                                                                                                                s

                                                                            r             c'@ @i. n,i. c s

                                                                                                                                      cc@i!i I'@u      y      @3 a!
                                       4                                                                                       -r           i  ni.t          -i
                                                                                                                           n   hc!7,,@,).i,tals anCi          th---c,--,@
                                              f                                ucoL.-Lc.,-,.c7l T)rof-ira
                                                       1 j- t     s       I'd

                                                 4                     lt4
                                       C,     v                                                                          @,,i'l increase  tl,io                                 4
                                              1-iancilin(.j  capabilities                          of                4.- a s    and ,)rival@-.e           rhys@@.cla-.s
                                       7
                                       a      and  @,yill  e(7,ui@n  larger                   i,. u ml),c r  s  o.@.7 i-,,@Ci-Lcal       and  health  perscnne3,
                                       9      as support services ill ,Hospital.                                     c 'I- in -Lcs  @.i-id            increase--'
                                                 a     c.       cars  @.,7i!l  be  incrp-asc-(3  t,@irouc,,:-i  the                                                     o-

                                                         I'l t  t ra i i@@ I @n g  a c@@     vi -L.'l C-,::o
                                       12i                                                                                               conductc--,('A  F,4@-  -.an-.-

                                                            f or     4 rt-,-
                                                                            ro-,,ed u.@-i.li.,,iation                     c @"D            -,I  r (@, s 0 u r c7 @@- s--c--
                                       13

                                                            @is          s@r'
                                                                                                           -I ci
                                                                                                                                         @juiclanc@-;
                                       15        Ic@,nc@.       Exi@ti.n,-, h:zalth                                                               and
                                                                                                                                                                C :L -
                                                 r-i n cl@ c- a 1 th  c,, r o,,i  s      s -Li               !I E.,                         r., F-. s  p@ s s c,

                                       'i.7
                                                                                                           and
                                       13        prograi-.s  ar@  coo,---rating  and  (f,@,,-,,.onstrations    of  a:,?prov@n-@-
                                       19        ark@-',-iritis  health  car@  Celiveries.     Sevn-ral  modest                                               studies

                                                  o                     c.@ri@tr2ria  fc,.-@
                                                                                                     aualitiative  care  through                              l) r,7,,,, i- c'e

                                                          @rmance@                                                     -on@,uct,,@(1,   and
                                       2@

                                                                               @,,,n                        c-".          .)lovcr           educational.

                                                 be  C,,cvclop@6  in
                                                                                               rt        -@ith                                        occuDaL.-

                                                                                          n o',
                                                                                                  icr  rc-gD..o.i


                                                                                                        r @i
                                                                              r t          n t
                                  of 5aiar

                           2      a c t i. 4L t

                                                                 of                        @for-uf@inci on the p-

                           4      of    o-,7 income      c,.rol,r-,,S,  -urz 1                     others  are        i:," c 11 .13 -i ngi
                           5      on  t'@-ic  develotiiilci-it of     care Czaliverics  in economic dirocivantag,!",.,

                           6      inne    r                               'tatric arthritis  s
                                          -city rc-sid.,2n s.         P                                 cervices will           be     I
                           7      developed    in     a     variety     of     settings,     and     one     program     is     derron-I
                                  strati,.-jg ir. 2:@oveei services  to the  geriatric population.
                                                    p
                           9                       Localities which Pres@ntly have  little or no                            rhp-tma@-
                                                   resources are being supported by the  initiation  or

                               i  the      expansion      of      medical,      now       medical       institution       teaching

                                                   Across  the  coz,.ntry,  chap,-c-rs  of t'@i-z  art,,-,ritis

                                            4                                                            on  t o
                                             -i,c,-n are ',,?
                                  f  ou,."-                 rovidi.nq      program coordinate

                          15      and    increased numbers of              volunteer           workers        in        supportive
                                  services.   And increased                agent                       to local  ser%yj_ccl@.3

                          17    and resources.

                          13   i                   That    coimT)letes     my     report,     Dr.     Pahl,     unless     t-eicre

                          19      are qu--stiofts.
                                                   DR.   P2ilIL:  Thank you very much,  !Iatt.                 Dr.  Ilaber?            i
                          20
                          21                       DR.Ilt',jl@EP@:  @-,3hat  is!,,  where  is  that procrtim

                                  get I at ric     services?
                          22
                                                   IIR.  SPE-AP-,:  In lichigan.  @'7j@,,ivcrsity of

                                                                 Thank you,                    Dr.  Grcirilich?
                          24
                                                   D.'Z.  C-,7,,A@ILICII':  l@L'@7  I  i-j,-clicated to you,  I
                          2@5

                                                                                                                          t 1. C  'D
                                  t@o Y,-)U  for not havina becii  a.blc  to clet @%7i-'L-.l  YOII a  l@"@


                     this mornina due to -Li-ie road construction        eelavp-d T,,.,!

                           'I

                                I wona-(-@red,         if voia have a statement to

                                             4
                     make 9!-=nerally  or   @'i @ ri k to add cii-,@ci the information
                 4

                     I did pass  to  ,iou 1 thought I would like to make an
                 5

                     and statement  to  council, rather than a formal resolution.
                 6

                     But perhaps you would like   to make some comments, as a result.
                 7

                                I would have,a great deal, Dr. Pahl, except to say
                 8

                     that this is a great example of the flexibility of
                 9
                10   process, in the administrative organization that ic;           to

                                                                           and
                11   accept the task, early on, accomplish i4L-. rapidly,

                     bring it to reasonably successful solution.
                12

                                l@latt's report is superb  and  I  have  nothing  I.-O  add
                13

                     to it.
                14

                                DR. PAIIL: "L'hanl,, you. L-- t me just take  one  or  two
                15
                16   minutes, and indicate to you.        are  attempting, should

                17   there be further funding co,-ling to us this year than anything

                     we have spoken about to date, or will there be special arthritis!
                18

                     funds made available to this program we would atterot to engage
                19

                     in those activities which the committee recommended     to   you,
                20

                   i and you endorse  that is to Provide centralized audiovisual
                2!

                     .-ssource-@, the O@, v,2 c-) @):n on L-- of certain training films, vic4ao-

                     tapes and so forth.
                23

                                But this requires a reasonable i.nvestrr,,,ant,  -nd  %,:e
                24

                     do not have the dollars   at the moment.  1,7e do intend as   -r.
                25


                                                                                      the e>,.4 St-
                                         -icate@r,@ to        to !:)ul.l t
                             Sp@ar ina

                             activities       in4-
                                               LIO a cohesive 13ro--r@-im through the qood
                       2

                       3     of ",r.  SF,.-;ear.
                                            7,-nd heyond -,i:iiinal funds                for some
                                etings,     and  so J'or@' ,  I believe           c@an accomplish
                       5     m c@
                       6     So  .,7c  do  hcp-@ -L-o h-2 able to report       back to you at so--@2 Luture
                             time    that    the program    is    not    an    assemblage    of     disjointed
                       7
                       8     ,orojects but     does represent a total national program.
                       9                    Tio@,i,   facing   us   yesterday   and   today   there   are    a
                       10  i limited  nuirl@or   of   arthritis   applications   in   the   Juli-,.,   I-   @',"p
                       11  1 applications.   I believe five             regions    saw    fit    to    include
                           l@
                       12    arthritis requests in the current applications.                                    to
                             sa,; t,@-la-k"- most reg-@-c-L-is clearly understood that the
                       13

                                               )@r                --ad to
                             ar@hri L.1  s  inr,  -am was @-,ala            the fiscal 74                    act
                       14
                             the   activities of the specially established ad hoc a--'-.r4t4:,:
                       15
                       16    review   committee   which   met   for   one   time   and   was    r--is'--ancl.--d.
                       7                    Thus, -,.N7e havc a situation in i,7hichI ac7jr,:L-i4@stra@@ivel-:

                             and indicate to those regions that basically their
                       '19   have    been    submitted    inappropriately,    although    I     thi-n-@     in
                       20    SOY-@-3 cases there have been honest misunderstandings,  so that
                       21    perhaps this news would not be taken lightly.
                           11
                                            I 'Leel that, '4@,,o%.!ever,     L. is important to rn-cpc-n

                                     ,c)u  very  briefly   tl-i-_   fact   that   we   believe   the   -@-Ilot
                       4,
                             arthritis center TDrc(7z,,3r,, -@...,,as established and is no icnc,-er

                             Olson .   That   is,   regions   should    not    be    ncrmitted    to    siDend


                     curr,-!r@itiv avi-.il.lal)lc-. funds or @@,,iiatever furi(is col-o tc)

                                      @hc (Ii.f-,tr.-L!Dutionc, 'iF
                                                             tijn '-.)L,,en d4
                 2   in     Y,,@a,-,
                 3   this -nornina to su,-j@-)ort additional activities.
                                  are trying to !)uil-@lz a national coliesi,,.c
                 4
                 5   and as a result of that I have prepared a statement
                     I would like to read to you, and if you feel ,,-ou need to  stua,.
                 6
                 7i  it we can distribute it.  The timing is perfect, !',en, thank

                 8   you.
                 9              But I believe it would provide you with the sense
                10   of what I  believe is necessary in order to be fair to all
                11   regional medical programs and to try to  build  a  cohesive  Pro-i
                     gram . from, those activities that were reviewed and aDT.)roved
                12
                     by the Technical  Board of Exneri--.s.
                13
                                The statement that  I would lik-c@ therefore,    you
                14
                15   to read to you and ask for Nrour  endorsement is the follo-@@.,ing,,
                16   the underlying authority for the 1974 initiative  in  arthr---tis-
                     %@ias pilot in tcbi)e and intent. found  heterogeneous  activities
                17
                18   beyond this level would not be appropriate employ,-ant of

                19   current grant funds.
                20              The full development and delivery of services for
                     arthritis is an enormous undertaking, and requires a continuing
                21
                     i@ell organized a+--tack such as could be initi..,a -d un--"--r pr
                 2                                                   tc
                     pending legislation.
                2z')
                24                    while Council is fully aware of the uraent
                     needs in the arthritis field, it does not consider @,x-,)3rditurc-,!
                25


                             ritirr ot@-hc-r than fox'
                         a r,-h
                                             I m-etinri to be             in ti-i@,
                  2  mac.,@@ at the jtanl,, cou!-ic:L.
                     present environment-,..
                  3
                                and the allocation or expenditure by individual
                  4
                     regional medical programs of funds for arthritis   in additi
                  5
                     to approvals provided at the June 13-14  1974 Council meeting';
                  6
                     are not approved.  The Council will entertain approval of
                  7
                     additio                   hritis in the event of ap
                  8         nal thrusts in art                           propriate
                     authority and new urant or other funds become available to
                  9
                  10 the RIIP   S.

                                Dr. Gramlich?
                  11
                                DR. GRM4LICII: I heard i.-.,-,erefore in-th-- p@-riodizatioii
                  12
                  13 process at @-he June meeting there were four applications
                     that wore approved by not funded. Those were outside the
                  14
                     scoi-3a- of this
                  15
                                DR.PAIIL: Those four are outside and they have been
                  16
                     given specific permission follo,..,,inct, that Council discussion
                  17
                  18 to utilize their funds to supi,)ort, Becatse those aDnlidations,
                  19 went to and through the review process by the art]-Lrj,.'tis  review

                     committee.
                  20
                  21            This pertains only to those activities that were

                   ,.not re
                           viewed by that special  arthritis review cfroui.).
                  22
                  23            DR. GRAT-ILICT-1t:okay.
                                                               permitted t  rebudget,@,
                  24            DT-Z. PAIIL: Because regions are          0
                     and Finybody can rebucl(,f into ,III-tliritis in.tlie doming year.
                  25


                                                          a
                       (2,oi-i It l@nov7 hovi @,le cc-',,'

                  2   b,-isicallv leave it c),,-)cn c-, n, d c-, d
                  3              The applications in arthritis that have come be@4ore
                                                                  rthritis panel, and
                  4   you today  have not been reviewed by the a
                                                                           r)ossibilit@,
                  5   cannot be  because @@e have no possibility,  have no
                  6   o4 calling them together again.
                                 Flat i-7e are saving, therefore, is that your June
                  7
                      actions, including the form whic';-l @.ie did not have funds to
                      pay,  but were given permission by   that closes the arthritis     1
                  9
                  10  program effort unless  special  arthritis  funds  were  made  avail-
                  11  allc- to us, or unless additional       funds, and then  it  @qculdi

                      come back to this Council in ful@ measure.
                  12
                                 That is the statement, the intent of th,@  stateT,-en+..@
                  13
                                 DR. GP..M@ILICII: It seems reasonable And Perfectly
                  14
                      clean to me.  I move  that it is adopted.. Unless Council
                  15

                  16  wishes
                  17             DP. 1-@Al@.L@.IOCT',: Second i@..
                  18             DR. PAHL: It's been moved and seconded.  Is there

                  19  a discussion?
                  20             DR. JAI-TEI-7AY-. Isn't Lee intent of that also to exclu@@--
                      those grants which on technical grounds were di,@ap,,?rovc-d?
                  21

                                 1)@. PLT.-IL: Yes.
                  22
                                               I think this @,7ill be clear in the sc-tns-@.
                  2,3
                  24  of it.
                                 DR. PAHL: This then %.7ill be incorporated.  This       i
                  2


                                                                     4-n t-@e Junc,
                                     .)@)r(,voct a
                     says

                                     corn         I-"P f un@'@; Ok i E@, aF ca. v  s
                         of ic-, c@ n cr

                                                              ot
                  II!' can-,,)Il- utilize th,--ni, any activities (,Eliln

                                                                       04-
                                          or e,--c@)ected to 1.)e availo.t@l?
                 4   currently ava4-la@l,:)la

                 5   actions we have taken to date, this mornina.

                 6              DP,. L@OTIAPOFF: Do you know off hand those ve regi ors

                 7   that we can consider that 'in making funding-?
                 8              DR. PAIIL: The specific four regions?  ".r. Spear?
                 9              IIR. SPEAP,: Florida,        T,,Iississippi, and Tri-

                 10  State.

                 11             DR. FLOOD: Tri-lcdtate brought up

                                                                              seconded
                 12             DR. PPIIL: -here is a ri64-ion on the "Ic.,cr anr-
                                          J.

                 13  All in favor of the motion, please say aye.

                 14             VOICES: Aye.

                 15             DR. PALIL-. All opposed?

                 16             (!40 response.)

                 17
                                DR. PAIIL: notion carried. That congeries th@ formal

                 18  business,  except for, I think the ver  important pi-,bl c
                                                           y
                 19  Session, and I would like to ask Council whether you %,.,ould

                 20                                                    ck
                     like a br,-ef break and then bring some coffee ba    t-0 the
                 211 table and have your open meeting with the reT)reF,@-riL@-a4@-ives,
                 22        t           iild lilrc, to continiic- on, and  have a
                     or the .,c-r you wo

                 23  break?

                 24             DR. t-IILLIKMI: Coffee now.
                 25             DR. PATIL: All right. I think that is fair to our


                      visitors too.

                                                                        oh, tc-n or
                                   y     It             reconv@-n(-@ in

                                                                                 'inuts
                      minutes, as soon          can i,i."  soi-,,,  coffee or Ooug'

                      back to -the table.   And then      fill  be refreshed for hearin
                   4                                                                      9

                   5  from our guests.

                   6              (',-.@reupon, a short recess was taken.)

                   7              DR. PAIIL: I-lay we -come to(xder please?   Now that we
                   8 have had  a  chance  to  get  some  refreshment,  I  would  think  we

                   9  are in better position to consider the remarks of our guests.

                 lo   I would like to welcome both Mr. Bacon and Mr. Sargeant from           1

                 11   the I,,Iaryland I'li-!P.

                 12               Mrs. i.icCarthy, Dr. (.3cherl,     Prasad, from 14assau-

                 13   Suffolk PDIP,  and  of  course,  Dr.  Sparkman  has  already  spoken
                    iidith us this morning.
                 14

                 15               If there are other  guests,  I  do  not  have  their  names!

                 16   here.  We   would certainly  invite  you  to  participate  in  the  open

                 17   session.    I have  been  asked  because  of  other  commitments  to

                 18   if we could call on  Mr.  Sargeant,  from  the  14aryland  @,IP  first,!

                 19   and   would do so now.

                 20               And I would  ask.to  have  you  identify  yourself,   if

                     !you will.,  for the record.  And  give  us  vour  statement,  or  sub-@@
                 21

                       it a statement, and then following anv      discussion   will   you
                   2

                    ,ipl---ase -- we'll h,,-,-ar also from Mr. Bacon. if you care to  spea.l,.
                 23 i!
                 2@S  and then if that-is satisfactory, we will come to Dr. Sdherl,

                      and others from the Nassau-Suffolk RI,IP.
                 2.1)


                                                                                ap@;oint
                                  SAPGF,@ITIT: Than;, you. :r do        12

                    '@,@ent in Balti@@or3, a,-iO, that is @,7h,-,t ,;,ou
                                                               .7c,t wi-,,,n voLi trlr
                 2

                    'chedul  things so -"4qht.
                 3

                                                                 OM ittCa of t'le TI@egjol@,7
                 4                              -IL-he Exectitiv@o C  m
                              I am a member o
                    Advisory Group and the Maryland !:,cgibnc-il ,,"Iedical Program. i,il,,e
                 5
                    you I am a volunteer and give My time for --  to%,,,ards  hopefully
                 6
                    110
                 7  perating an@ efficient and.,@@ffective regional  medical  proc,,ram.1
                              I do have a statement  which  has  been  distributed  to
                 9  liyou, but in the interest of your time, I am  going  to  summarize
                    iit if I can.  1,Pac-n we@received the news referr@-d to earlier
                 10
                    !this morning in IL,-Iaryland  we did discuss it at sc)Tn.,@ length
                 12 i,and felt it important that perhaps people comma from all    ov-@,a r1
                    'the country are not aE;cogn4zant of the City of               E;Lnd
                 13
                    '@the state of iiar-,71and, as tlic-v  might  1)@,  and  wo-  felt  it  would
                    The important that you understand our case,   and   our    philosophies!,
                 15
                 16 land therefore  that  is  part  of  the  reason  that  I  am   here   tor-I.ay.
                 17           The gentleman from VA is proba'Dly close to @lar@;, an
                 18 so understands the geographic situation perha-.ps I)ct-L-sr than
                 19 most  of  vou  and  I  am  sure  Dr.  Schreiner   does,   from   T@7ashington.
                     aryland  has  a  fairly   large   population   but   our   Regional   ,Medicaid
                 20

                                                                            0
                                                                              T,)ulation
                     ovulation only serves about three million of t@i,3@4L

                    4
                    @@,.Iaat is -@,ade up of 2.7 million, in 1%117,rvland.

                              L7'-%nd 300,000 in Yorl,-, Pennsylvania.I  thi.nl@ it @,.,a@,

                                                         t!
                      f -c-rrc-d to          s iio.-ni.n(!, i.@ re (.7  i-,ic-dical -)rogr,@.,@
                 24 1
                    I                                                          all    ofi
                    @rl.o cross state boundaries and ours indeed does.     As
   0             25 1
                                                                                        I
                    i                                                                   I
                    I
                    I


                                                       have been
                         IL-.he Regional Programs we                     1%@(,d in changing     prior",
                    2    itic-s, and @a change in tile effectiver@ess O--r                 and so     i

                    3    forth.
                    4                 clo we have been somewhat per-,-'Ilc-xed at            and      i
                         somewhat harried at tim                        get   in   our   a,-olica@ions!
                    5                                es in orC-,er to
                    6    for money.    i@ad I ar,. sure that you have e>:-.)erienced the same

                    7    situation @-hat we ha
                                                  ve.
                    8                 'I@0%,7, of the three million people that we serve in
                    9    the !."Laryland Pegio.-ial ZLeOical Program approxir"atel,-,7 two
                         million  of  that   total   is   included   in   the   Metropolitan   Baltimo3 -e
                    Al." arm-a.  That comprises the five standing counties =.s well as
                         Bal,-,imore  city itself  which is a      separate and distinct politic

                    13   subdivision, not part of a county.

                                      7,nl in western II,-iryland   tl,,.3re are
                    15   300,000.     These fi               on th- statement which was
                                               gtires  are
                    16   given to you, I am rounding it o'Lf; on tne Eastern shore of
                    i7   1.1@aryland,  which  I  guess  is  referred  to  as  Chesapea'@.--  coun  ryti
                    18   there are approximately 250,000, and in t';ae southern part

                    19   of Maryland is 115,000.
                                      Then we have an additional 300,000            in Ybr1r," Penns@l
                    20
                    21   vania.   Interestingly enough, of the population, and that is
                            0 Million in the Baltimore a--ea, '75.()       percent of tlat po-,.)-
                    22
                                 are
                         ulation/in the low income area, in fact, 2-D.6 percent of the
                    2",
                         peo le   in metropolitan Baltircre citN.7 alone are 'k,@edicaie,
                    24

                         recipients.
                    25


                                  In fact, 114 u@-i-cent of all the people in ,--he

                       of LI-,La.ryland, the c-@nt,-rc -,:)ot,)ulation of i-laryland ,,7'.Io z.,r,,a r7.,edL-

                       caid recipients reside in     altirtiorc citv.  li'@nce, T t'ii-n'-
                                                    i3                I

                 4  il what I am trying  to point out to voti is that many of our

                 5  II obligations have  been centered on  Baltimore city,         has

                 6     been onathe  cr4tiCiSMS that we have had.

                                 And we have tried to expand our    services in areas
                 7

                    ii outside Baltimore, but primarily the greater -Dart of our effor

                 9     and concentration has been toward improving     methods of the

                       people in Baltimore city to receive medical    care.  AnO-.so,
                 10

                 11    while it mav seem out of proportion to the men-)ers of the

                       group  and the members of the technical advi.sor-,, arcuLi indeed
                 12

                       it hasn't when you look uDon the  geographic  and  the  --coromici
                 13

                       distribution that exists in the state of
                 14

                                 Now, we have adopted  many  approaches  in  our  efforts

                 16    to submit grant applications. i,le have     amongst  thoseinclude@

                       support of planning, for llaalth Maintenance Orqanizations
                 17

                 18    we have been a great deal of patient education    in hvner-t--nsic-

                 19    for the low-income black families, particularly in Baltimore     i

                 20    city.

                                 T@,le have pioneered in the areas of ho7a hn-all.-"" care
                 21

                       services  to neiqliborhood corporations and      have also IFL@sisi--iF
                 22
                       in the training of pediatric  nurse practitioners @,.,ho --odav
                 23 ii
                              land  are serving not  only Baltimore city, bul- they
                       in marv
                 24

                 2',
                       are serving in the rural rov(-,r-,%--v areas as well.


                                                       to         out cor,-tc- of the ver,:,

                                                                                            4-
                                   of -L-he                                   i.,-, th  hc.
                                                         d r) n  (,-4
                                               T-1

                                  S 4                                                   ur        t
                         i-i-i the  late   of                i   a I--i,-iore      can    c     c-t
                    3

                                          -issoc.ici
                         those of    vo,l L             @@,ith  medical   schools   in   the   city.
                    4

                         There is    always  great  ri-valrv   i)-@t@.,-een   th@   medical   schools,
                    5
                    6    who is going to be the first with what.
                    7                 In   Baltimore   when   we   developed   our    mechanism    for
                    a    let  me   cret   the   correct   title   here.   I@',idnc-y   Transplantation
                    9    Program.   We   were   funding   part   of   this   several    years    ago.
                         We were able -@o bring together the state'.@ t,@@.,o medical schoolE,
                    10
                    11   the   state   health   Department,   a   kidney    foundation,    and    two

                         or         of the communi-@@,- hospitals which '-=-d their own  pro-
                    12
                    13   gramso- to bring them together.
                    14                So  no%,  we  have  one  unit   working   in   a   coope   ative
                         manner to    accomplish the objectives that"Lour or five units
                    15
                    16   were  working  to@-7ards  before.  1-@le  think   that   this   is   a   very

                         positive   acconnlishmcnt   that   has   been   made   -n   the   city    of
                    17                                                          -L

                    18   Baltimore, particularly when as I said earlier, there have al-I

                         ways been rivalrv.
                    19
                    20                7-\nd Isee some smiles on some Doctors faces here.
                    21       also   back   -n 19'@)9 a@ske:d for and received a grant of 5115,OOE

                         -ou,.i(7ed  off  fora                c.@-,FjeO, chest  c-a_rdic-pulmonark,,
                    eL% 2
                         rssucci;--ation @-raining program.        @@nd this has been taken over
                    23
                         since that time '-)v    the  ITeart Association of       'aryland who has
                    24
                         trained some 13,000 individuals in the life             savincT technique.
                    25


                                                              is          then in  coiiri@cticii  @,,7it"i
                       i   i-ratarials into Dutch.       fair

                     2     it.,; patient education ,')roc-framT, ii,,  rL,.roT@--.

                                                                                      very       important
    0                3                  lo, again,        tli.L   tliFtt this is a
                     A   il i@or us.         t'@iese         thinc,,s  that   I   ha-ve   just   mentioned
                     5     to you.    we feel thev demonstrate the vital role that the
                     6     @laryland  Regional .1@ledi-cal Program has played in          the   develoDr,.enL--
                           of   new   and   effective   methods    of    Providing    critically    needed
                     7

                           services where few if any         previo             sted.
                     8                                               usly     exi
                     9                  You have before      you    today,     or you will have before!
                     10    you   today   two   projects   which    applied    for in our  Jul@,  applicati@c.-,:
                     11    two  of  them   applied   directly   to   the   Western   part   of   llarylan@..
                     12    Where   three   hundred   thousand   of    our    population    reside.    They

                     i3    are iDart of the second application T)rogtam.
                     14                 They involve health education in            one    case,    health
                     15    education    for    teachers     and     professionals in school system
                     16    a   joint   effort   to   educate   the   teachers   so that we can corinunic      a
                     17    this   information   to   the   students,    and    the school s@,stem in

                     18    Western Maryland, which is part of the App@l,tlachia Poverty

                     19    Region. area.
                     20                 Over  on  the   Eastern   shore   we   have,   which   is   250,OC)o

                         i population,  -,,ic- are funding a clinical cancer program                  a
                     21

                                                                                                    4. 4
                           ho,--@.)itcil  discharge  planning  p7oc  ram  and  continuing  e(.-@,ucci@-Lonal

                           program  in  generali  in  Tiv!-nrt   Coui-ity.   All   three   of   these   ar--
                     23  ii
                           now   being   continued   under   private   enterprises   and    private    fundi@'i
                     24
                                        York,   Pennsvlvania which we serve, with a population
                     25


                                                     ro-,cimately we ,,ia%l@" c,-von
                    ,@,ith a population of 300,0,,@0, ap,@)
                2   continuous attention to this area.
                              '.le have an acute intermediate and I.or.,7- term scope
                4   care program negun in 1969 with a grant of $561,000.   -@h4Ls

                  i established a sp-
                5                   z=cie.1 hospital tLnit for the total care and
                6   rehab of stroke T),:itients. 7@nd since the termination of i--"ie
                7   funding for that program, in 1972, the entire program has beer-
                    continued, and today is serving an areas with a population
                8
                9   of 300,000.
                10            We are very proud of these accomplishments. T.@@ich
                    @.ie tlink are uositive things which perhaps in the -ush of all7
                    the other applications and information coming to irou rray be
                12
                13  overlooked.
                              I would just like to make one last           to
                14
                    point out that each of the eight projects that @,:e have pro-
                15
                16  posed for funding which will be before you today, at least,
                17  we anticipate is aimed at achieving a specific objective speller
                18  out'in the latest, I said latest interpretation because as I

                                @-ed earlier,
                19  have indica4             there have been continuous c@-anges
                                            and that is cl             r a-"
                  i of Federal guidelines,               evelop6d doop    @lve
                20
                    relationships in the improvement of  care in unde@-sn-rved areas.
                               Develo-.)l,-ig Innovative approaches to medical cart.
                2
                    ,Hill of these projects received full review by t,,-- Tn-chn@---al
                2-3

                                  t e
                                    e of our Rectic)nal Dic@dical program
                        iew Com
                24
                    reQional  advisory group and by the "'@aryland Cor,-Prehensive
                25


                    IT-al@h Plan agency.

                                       7        much for -%,,our time. I h c-i v c,n
                                       c,,u

                                              (-Io ha.ve c     details on @.2
                3  ii as brief as I could-. T, T@      omplete

                                  has already been distributed. I am glad to answe--
                4   material that

                5  III your questions.

                6             DR. PAliL: Thank you very much, Mr. Satgeant.     Dr.

                7   Gramlich?

                8             DR. GP@-,',LICTI: !@ir. Sargeant, I am sure @%7e all ve---v

                9   much appreciate your lucid comprehensive  remarks.  Play  I  ask

                10  your occupation?

                11                           I happen to be the Executive Director

                12  of the State l@l-C-dical Societv.

                13            DR. GRP-.1-ILICII: ror the state of I,Itar,,land?

                14 i              S.71,@.G@.,@-'@-iT: Yc-s.

                15            DR. PAJIL: Dr. Wararoclc?

                16            DR. 1-7AI@IOCK: ,-7hat did you say about the medical

                17  schools competing together.  I,,Ihat?

                18            'lR. SAP.GFA' rn : T,,l e did get them into a kidney transDla-@@-
                19 lprogram.  It has been vorv effective and xie have  very  active

                20  recruitment for lcid,-iev transplantation that are

                21            DR.           P@ut that is the only program thev  get

                   !!'together on.

                                  Si@P,(,7A@JT: They have gotten together in -anv

                    others.  The university medical service program is wor@-,@-ng
                24 i
                   Iv,--ry closely -@,7ith them, as is the Medical Society.  have
                25

                    a close relationship that able try to bring them together.  @rv


                                                                         T@l"a tl-ii-nk cor.-
                       to
                              11      see each other's vie,,%, Points -
                             t, em to

                                                                  il: that is e7.@@rel"
                                          io,7aver, we caon't t
                  2    )etition is good.                       @@'i a. I

                  3    'Dad.
                                        T:              y other discussion or co!-,-r,,.ents.
                  4                  P,'@H-1 -Ls there ai-i
                  5    -L,hank you very much, @@'Ir. Sar@ieent. 1-7e hope you make @,-our
                  6    appointment in Baltimore without breaking the speed limits.
                  7              @Ir. Bacon, do you have anything to add?
                  8              PIP,. BAC014: @10, in view of the time pressures, Dr.
                       Pahl, it has been a pleasure to be invited.  And if there
                  9
                       are questions I would stay around.  But I also want to get
                  11   .'-Ir. Sargeant back to his meeting.  So I won't interfere  witi-i@,

                  12   that.
                  13             DR. PAIIL: Yes, Dr. Janeway.
                                      J7-,IIET.-,IAY: Could T ask one (-,uestion c)-F-
                                 DR.                                          ;-'r. S-@rcie-a,li
                  14
                  15   even you say you got them together,  does that mean in the
                  16   kidney transplantation and dialysis.  are being done in on     J',7

                  17   one of the universities?
                  18             !@-ITZ. SARGE7,,'L,;T: @,le have in Maryland,, perhaps, a unique
                  19   situation.  Two years ago the state legislature -Dassed a
                  20   statute which set uD a Maryland Kidney Commission.  That
                       Maryland Kidnev CorL-mission has jurisdiction worki-na @,,ith the
                  21 I!
                       CI'BA to designate onlv certain areas for ki-dnev transplants
                  22

                       and dialysis.
                  23
                  24              In answer directlv to your question, no. r.hat does
                       not me                                    it
                  25         an that there is only one univers  y in Balt4-or-a doing


                                                                    some interchano,@-
                                                             t 0
                                       ly there wouid liav
                   I    that.  OlDv4 011-@

                   2    back a@@ld for@,:,i.
                                                                              I think
                                                                         But
                                                 y dialysis, centers
                                             man
                   3
                                                                                        lanta
                                        ndiiig there are onlv,t@@io
                   4    to my ui-id@-rsta                          units, two transp

                        t-;on u 'ts in the City.
                   5          ni
                   6              DR. PAIIL: TIAIani-I you verv much.  He  certainly  under-@
                                                                              rhaps we may
                        stand as vou dash off to another     appointment,    pe
                   7
                        now turn our   attention   to   I  believe  Dr.   Larry Scherr,     i
                   8
                   s,   from                                       d Dr. Scherr  if    you
                             ilassau-Suffolk  has   astatement, an
                   10   will identify yourself --For the record we will be pleased to

                   11   hear from you.
                   12              DR. SCIIEPP,: Dr. Pal-il, members of the Council, I.'m
                   13   Dr. Lawrence Scherr, Charrian of the llassau-Suf-folk regional
                    11  advisory group.  I'@-nd I am a member of the area's medical
                   14 :i

                 @15    community.
                                     I appreciate the fact that I can appear iefore

                   16
                        you.
                   17              The Purpose of my visit here is     to express the
                   18   stron          t of the regional advisory group for our program
                              g suppor
                   19   and to ansvier  any questions that pu may have.       V4'e recognize
                   20   very well the   critiqucc   of  this  Council  and  the  organization

                   21   Cf.  our  RAG  group.
                                    2%nd actually to that end I visited the division
                   22
                   r3 ti of -.he regional -i=-clical ,-)rocT,.-am with another member of Pj',,C,
                                               ,taff, c .,.rorl,, out means to put into effect
                   24   to speak with @-ie c
                   25   what  v7as   necessarily   to present this grant before you.


                   1  Yesterday I unfortu,nat(-@Iv could not be here, but rFiny oF
                   2  you did hear our coordinator,     .1lr. PrasaO,. go over the contents

                   3  of our P--oqram.
                   4              You also have a prepared   statement   from me  and  I

                   5  will not go over that again.  The content of       the program and
                   6  any questions referrable to that I will explain -- they are

                   7  explained in that statement.
                   8              I just would like   to clarify one or two points,
                   9  that are  not  in  that  statement  itself.  To  begin  with,  our
                   10 region, Long Island,  the  two  counties  as  in  Maryland  has  a   1:
                   11 comparable Population of 2.1@.  7,.iilllon  people.  The  distribution
                   12 of the population is in a                    geneous fashion.
                   13             lialf being  in  an  established  suburban  community,

                   14 the other in.  a rural conmunit@, fast becoming a suburban

                   15 community.  Secotdlv, there is a rather -anique geographic

                   16 position of our region.  It is pcnninsular in origin, and

                   17 finds itself admirably to rc-gionalization.

                   18             And it is that end that we have    developed our pro-    i

                   19   ram.   It is a community based regional medical  program  @,7hic'-"i
                      9

                   20 has been in actual operation for the past four '. years  and
                   21 has been recognized by  the  community  as  an  appropriate  acjc-ncv!
                   22   o  the implementation of certain health Programs.
                                  Dole, earlier this year,    the i@egional Advisorv @'rouT@
                   23
                      th@-ough@it's committee had established the goals and priorities
                   24
                   25   of ar@-Lbulatl-ory care. The  actual  development  of  delivery  ser@


                                                                              and this
                                      ostic Services   Of preventive  care
                            and diaun

                  2                                       @-as, the goals and
                                    conforr, d to our ar
                  3                                                 aiin@-ng Council  and
                       o-@ ",,issau-Sui@.L@olk Coriprc-ii,@nsive liiaalth Pi
                                                   good effective cooperation bet@,.,een
                  4    was ac4--ual!Ni the start of

                  5    tic- two agencies.

                                       t
                  6                     he grant before you is really a  revitalized

                                                          regional medical Program.
                  7    ani3roach for our Nassau-Suffolk
                  8    '-.T@- are proud of the stated objective and the m6thcCts of ach'

                  9    ing these objectives.
                  10                                      does have fourteen directing
                                  To go into  d@-tails it
                  11   arlbulatozycare projects.  It   has two emergency services    pro4j---,
                  12   which are  in c-ss-.3nce ambulatory care projects.  And it has
                  13          al  programs which have aft@'Dulatory care components to
                       t@..,o ren

                  14   the -,i
                  15              Thereby Meeting our goals and -priorities. Now,, some
                  16 1 of the nrogra-ms, despite the current limitation on @--@"@Ps future
                  17   course do require two years for realistic como etldni         Our
                  18 1 grant contains provision for this as well as      the  means   for

                  19 1 continuing staff support.
                  20              That             ly for the monitoring those particular
                                       -s, not on
                  2 1  programs that are   carried forwards  but  for  monitoring,  what
                       ',',as gone on !Defor--,  '-i@it is going on this vear in the T)rocTr a.-,
                  22
                       that have been starting', in previous years.     7@iid v.16 believe
                  23
                       that is a rather vital and important role.
                  24
                  25                Just three other   very brief items.  One is the


                                                    p b-al-cver, that our newel rnc-7,,ni,.
                      P-@,@IP staff. The advisory grou

                                                                                     and
                  2   s k--a f funder the dir@cction of @?@Ir. !)rasad has the
                      the wisdom and the   leaC@@crshi.p to holn us carry this )rogr,,
                  3

                                  it IS F
                                        ,UCCC@,f;fUl Cor
                  4   Through o                              on.
                  5              The grant before you          I think, not only refl-cl-:z,
                  6   their dedication, but I think it reflects their expertise in        i
                  7   their field, and I -oint out again, that their technical
                  8   competence and their   cooperation @,ith regard to our  area-,.,7idei
                  9   comprehensive health   Dlanning council.
                 10              Secondly the PAG itself has    corrected so.7,--, of its
                 11  most of its  prior oraanizational difficulties.  That is,
                 12   the separation of tl,-je,functions of' the grantee organizations    i
                 13   from the regional advisory group itself.  The ':)y-lai.,7s havn
                 14   been revised and ccmple@Lelv contor,-,n, now, to RI!@T.1 directives.
                 15              Pnd I think they have   sustained a continuing interest
                 16   by the way, in it's-objectives by this representative communitllr
                 17   grouo.  Pmd we believe that it is a major and a viabie organize
                 18   tion to serve the health needs, on Long Island.
                 19              Secondly, a word abou-6:the grantee organizations.       i

                                                                                         f
                 20   oUr grantee organlztion  is independently incorporated sDeci ic
                 21   ly to deal with PIIP -functions.    I ,,7ould just likes' to ,')oint
                      out that in a recent fiscal,           covering t.-iree to five
                 22
                      months on a rather intensive basis,, really     on a daily basis,

                      the grantee orcanization was commended for      its' expert handli--Ic
                 2,1

                      of the fiscal matters.


                                  This, I understand is uiius-,uzAl to have- a commendit.@.ci-,,
                       (-';n an    c,--n'Ler--ncc Final l-,, i n    @3 i n (7,      .@U@
                   2
                   3   li',,,c to reaf firm   sLipoort of our program in the sunDort or

                   4   the regional a--'.visor,,/ group.
                   5              r@,7e believe that the nrogram is well designed and
                   6   it  is well coordinated @-o meet    the needs of the, people of
                       Long Island.  @,@le have asked  for an amount which exceeds slign@--7
                   7
                       two million dollars for this next period.  @,,7e do ask and do
                   8
                       request and do request that vou favorable consider this, and
                   9

                   o   thank you verv much.

                                  Di@.PAIIL: Thank you very  much,  Doctor.  I  arm  sure  vou

                  12   would be very responsive to any questions that ma,%i Come up.
                       Is there a discussion    question?  l,'Ir. @lilliken?
                  L3

                                                                                      n re aci
                  14                               lith regard to past bu@,gets,
                  15   to the projects that you     are Proposing, or recommending, within
                  16   this, what has been built     in to see that these projects are
                             -relaL@-ed with other sources                       ,:ha4-  s
                  17   inter                                 of funding.  And
                  18   tlie'potential for their continuation  in  case  the  P.;'iP  money  is
                  -19  not available after this grant      period.
                  20              DR. SCIIERR: That  of    course  has al%@,,ays been a ma  or
                                         L                                      spite the
                  21   consideration o' the .2,egional advisory Group.  Da

                                                                                    %,7
                     !-Sunl)osed last @,car of funding, and that is to see. a av          0
                  @'2
                       stimulate the   Droject to j3z@iin-         t%nd encourage the-

                       office or o4,--ller provider organizations to iDicl-. U,,:) the -.orc-ram
                  24
                       provided it is demonstrated its worthiness.
                  25
                                        I tii.-ik that therein is the    strencTL-h of our


                                                                    have been picked ur-,,
                                Those programs that have started
                      program

                                                        tion,,; ci,-iarc-Tcric,
                      in some asi3ect by other orcianiza                 services  bi
                 2
                   11 county  health  departments, renal programs, by some institu-,io-,;-,,
                 3
                 4    and by community m,-@dicine, and by hopefully the institution
                      by which that is developed, and so on.
                                 It is our intention  from the very beginning to
                 6
                      use the regional program as a stimulus to start developing
                 7

                 8                                 0
                      each  programs,  ultimately  t be picked up on a more permanent

                 9    basis by other means.
                                 DR. PAHL: Thank you. Is there further discussion
                 10
                      of questions  of  Dr.  Scherr?
                 11

                                 (-.,To response.)
                 12
                 13              DR.PAIIL:-',Ir. Prasad, would you have anything to

                      add?
                 14
                                 l,4R. PPASAD: No. I spoke yesterday.
                 15

                                                  17OU Use
                 16              DR. PAI-T@L: liould       the microphone, please, if
                 17   you care  to make a  coriment?
                 18              I-IR. PPP!,SAD: 'Alto. I spoke  yesterday  before  the  Revie%@
                 19   Committee, and most of the   Council members who were present,
                 20   and T have no comments to make.  Unless you have some questions

                      to ask.
                 21
                                 DP.PAIIL: Thank you.   @,iss I.,,TcCartliy?
                 22
                                 @@IISS @ICCAPTIIY- @lo. Than],, you.
                 23
                                 DR. PAHL: 1,7ell, then, if there is no further dis-      i
                 24
                 25   cussion   on ilassau-Suffolk, I  want  to  thank  you  for  returnin@,


                                  to av, and L,-ubriittii-icy y@),,ir               through    Mr.     Prasad

                                   d -a,,7

                                         Ar.--@ there any             of  the  pi:,.)Dlic  who  wish   to

                                  a statement to cor,",nant upon the proceedings so zLar?

                                                                                                  -iscuss
                                         T@',@,es the Council have anything further to a

                           in the open session.   Dr. S,.@,arkman?
                                                               JL

                     '7
                                         DR. SPAPJ'@@N: Can I make        one more point, Herb?

                                         DR. PTJIL; Yes.

                                         DR. SPAPK@%IN-4:  I  th-,'-nk  you  are   all   familiar   iqith

                           the National Association          PIIP, which instituted the !-a,-@-,,suit

                           which released the impounded funds.  1,7hen this was se
                                                                                                   t   up

                           it was our view that this would t,4erve not Only this                 lawsuit
                           purpose, but      also   some    organization    like    the    rmerican    Public i
                              a'                                                  staff  educak@.,-l-on   and
                               ith Association and others to provice

                           training.
                                         And in fact we do have such a           meeting planned in

                     -:7
                           I,,--zriver for September 3rd, and 441--h, I                        i,7hi@h  I
                           think a very good program has been developed.                           so far

                           has been oversubscribed by the various P,@.lPs.

                                         end which will deal with the variol-spatts of !UIP

                           p2--oc4r:a-Pis:  pro3c-ct  e,@svelopment.  Management,  and  -L   @,7rt   sure
                           iqill.  be  of  considerable  part,  zrkid  we   see   that   as   tli-3   logical

                                                                     iation.
                           e.-.tension of the Nati(-;nal       'ssoc
                                         T,,cl@ually, all of    you  are   invited   to   a+--tend,   and

                         @i
                         'I we Hill   see that information i.s given to you about it.
                         ij
                         @l
                         @i
                         i

                         11
                         @l


                                                                            6 4

                               DR. PAI-TL: Than]-, vou.  Dr. Cramli,ch?

                 2             DR. GRPIILT%@'ll:  Would it @-c, appropriate to ask Dr.

                 ,3 -Sparkman to cTive us a one-minute explanation of  what  the

                 4   NPJ,!A is?

                 5             DR. SP).\-RKDIP.N:  v-es. I had hoped that  Dr.  Jack

                 6   Enale  from the Lakes Area PMP was going to be here, since

                 7   he is the president of the  board.

                 8             This is an organization, Dr.  Gramlich,  set  up

                 9   aside from the steering committee in the regular coordinating

                 10  with the coordinators committee, funded  bv  personal  and

                 11  private sources quite aside from anv grant funds and initiated

                 12  originally around O-eptember of last year when  it  became

                     apparent that without the release of  impounded  funds  the
                .13

                     @P@14P future looked prettv bad.

                 15            But it has continued with meetings of the board,      i

                 16
                     the hoard being made up of some representatives of the

                 17  coordinators, some have come from the steering committee.

                 18  age think there is a real need for the kind of staff training

                 19  that such an organization can provide.

                               We hope that this is going to  he  the  ultimate

                 21i future.  obviously we should he out of the legislative

                     I mean, the leqal  problem. As Dr. Pahl- has said  and  as vou
                 2 i
                     know, this, I believe, has been handled and, as 1 hope    done
                 23

                     with shortly.
                 24
                               There  has been question as to whether  PIIP grant
                 25


  @2                  func-,',; 7ould he used for this T)urr)os(,-. So far they have not

                 2    been used.  @.nd I have spoken vigorously to this point.       I

                 3             that lectallv it may be. appropriate to use   grant
                      am told

                 4    funds.

                 5               rut I think until i,7e are l@evond the legal problem,

                 6    until we have clearly established that this is an educational

                 7    activities, that these should not he used.  qo far they have

                 8    not been used.

                                                          up of a @.?ide  varietv  of
                 9               The- membership is made
                      people     P:--!P staff, advisor@r group people, other individuals,

                      with i,7horr, we have worke6.  There are some institutional

                      memberships,  people  like  medical   assocations,   hospitals,

                 13   volunteer  organizations @,7ho @,,,ish to join in that fashion.

                                 DR. PAIIL:  Dr. Haber?

                                 Thank vou  Dr. Sparkman.

                 16              DR. IIABER: Dr. Srarkman, I  hope  vou  1,yill  indulge

                 17   me  to  the extent that I will probably   ask  you  about  matters

                      that   have concerned me deeply for a long -period of time.

                 -19  But it strikes me that with the imminent emergence of a

                                                                  a
                 20   national  health  insurance  strategy,  dert  iniv  the  organiza-

                 21   tional and substantive efforts demonstrate by RDIP have a

                      role to play, particularly in the transitional vears.
                 22

                                 ?,!,v Question goes to this point4  If indeed,    as

                 2@.1 this booklet indicates,    there are  some  21  million  people
                 25   Who'can  begin to  be  beneficiaries  of  a  -national  medical


  i-i3                program, that has been done to brinq home to the reonle

                      the clients, if
                                       70U    1 1   the  benefits  accruing  to  the

                 3    program?
                 4               It strikes me that I am unfamiliar       much of the

                                                               terms of p     a
                      effort has  gone into the providers in              opul rizing
                 6    or informing.  1-7hat has been done or  what could be done to
                 7    bring this home to the people that are the potential natural

                 8    beneficiaries?
                 9               DR. SPARKI@ll:  I think not enough has been el-one,

                           aber.  If  I understand  the  intent  of  your  question,
                 @O   Dr. P

                 11   one of the iroblems that I see as a  coordinator  of  an  P@IP
                 12   is that in  order to function most effectively you do some
                 13   very 16i.7-key way to bring people toaether and rake as

                      relatively little evidence of your    existence.
                 14
                 J!t             And I find that this is the way you    can get dif-
                 16   ferent groups toaether.  And sometimes they hardly recognize
                      that  the  regional  redical  program  is  accomplishin  this.
                 17                                                        9
                      But'in order to demonstrate to Congress, the public and
                 18
                 -19  others that you are accomplishing something, this     is not a
                      very effective order of operation.
                 20

                 21              And so we find ourselves   caught between these two

                      I think that in general reaional medical proarams have  one
                 22
                      a  poor job of Demonstrating to beneficiaries that they have,
                 23
                      in  fact, served a useful purpose.  I find continually as I
                 24
                 25   move around our ti-7o-State  region, T@7ashingtob and  Alaska,


                                                                                 C 7

  n4              I   that there are unexpected and  surprising  numl-ers  of  people

                      who have been touched in some way I)v our   regional   medical

                                                        hat their  appreciation   and
                  3         m who volunteer the fact   t
                      procrra

                  4   their hope that something like   this will  be  continued  because

                                                          kind of assistance to
                  5   they have been unable to find any
                  6   bring together activities  to  accomplish  needs,  to  respond

                      to needs that they have.
                  7
                  8             DR. FABF@R: I would  hazard  a  guess  that  probably
                      90 to 95 P-er cent of the beneficiaries,  while  they  mav  be
                  9
                      aware of the local clinic  or  school  operation  or  outreach
                  10
                  11  operation, are not aware of the fact that  this  is  served  @,v
                      the regional medical -oroaramin terms  of  coordinating,  idlan-
                  12
                      ning and executing of it.
                  13

                                And that is a critical step,  it  seems  --  to  bring

                  15  that realization home.

                  16            DR. SPAPKMA@,l:  I would agree.  And I would welcome

                  17  any,-thoughts here any of the members of the @Tational  Advisor,,,

                  18  Council have about this. I think  we  have  done  a  poor  job

                  19  in this respect.

                  20            DR. PAHI,:  I  think in view of the time  I  will  close
                  21  this open portion of the meeting  and  again  thank  our  Visitors

                      and ouests for appearing and  speaking  with  the  Council  and

                      being available for discussion, and  ask  at  this  tire  that all
                  24  individuals in the room other than those v,,ho are part of
                      our Council or Federal employees  please  leave  at  this  tine.
                  25


                                                                                  6 8

                                                                 h, and then vie   will
   n5               I            Let's tal@-e a tN,7o-minut(,- stretc

                  2   enter our  review of at-.)r)licatioii,;.

                                 (A short-.rccess was tal,,en.)

                  4              T)R. PAIL:  l@lay vye come to order again, please?

                  5   Will council. come to order, please.    I would  like  to  recon-

                  6   vene the Council for now the closed session and the review

                  7   of individual applications and,  just  as  is  our  custom,  call

                  8   to your attention the  statement  on  conflict  of  interest  and

                  9 1 confidentiality of  meetings  which  you  will  find  immediately

                  o
                      behind your aaenda.

                                 And I would like now to turn the meeting over to

                                               uide us th
                  12  Mrs. Silsbee who will c
                                              .T          rouah the apnlications.

                  13  Most of ),ou  were here  yesterday  and heard   the discussion.

                      We hone  that  that  was a mutually rewarding   and   satisfying
                  14

                  15
                      experience.

                  6
                                 I have heard some favorable comments from the

                  .7  Review Committee members.  And I certainly hope that you found

                  18  it of interest. Let me state @-.for the  record  that  this  was@

                  19  an unusual proceeding and that it was through     a domedv,   a

                      sot of highly unusual circumstances, but that     the  members  of
                  20
                  21  the Council were sitting   as official visitors   and not  in  any

                    @'-way  as   particinants.

                                 And  so  your discussion,  review  and   recommendations

                      today are  now as Council. members and riav be  in  support  of
                  '4 ii
                      or  quite  divergent  from  whatever  discussion,  recommendations


                                                                            6 9

  n6             I  were made vesterdav.

                              Pnd with  those few comments, Jud@i, @.,,ould.. @),ou

                    please lead us throuah?

                 4             @RS. SILSERE:  there are a couple of background

                 5
                    items that I think are important here.  The committee did

                 6  express after the meeting yesterday some concern about the
                    speed with which they had-to move, but they never  had  a
                 7

                    choice.
                 8
                              They had the Council meeting today.  And it may
                 9il
                  1.
                10  hot have been apparent'to all, but at the get-toaether in
                ii  July the individual reviewers did talk with one  another and,  !I

                    in most cases, where thev were n6t able to, thev tried to
                12

                13  communicate by phone.   So there was a good deal more back-

                14  ground  in terms of their deliberations than appeared  in
   0

                    public  in the record.
                15

                16            The other thing is that we put  on your desks this

                17 11 morning -- I mean, in front of you   this is supposed to
                18  be pink.  And this is the Staff's -- yesterday as  the Commit-!

                19  tee was deliberating we were trying to  write these up so

                20  that you would have something in front  of vou.

                2"L           This is the gist of the recommendations of the

                    Committee, and they are  alphabetically  arranged.  Also, just

                  j; now we have -- I feel like, yes, Virginia, there is a way of

                    doing this -- we did. get the transcript for yesterday

                    morning  s session hack in time.
                25


                                                                           7 0
  n'7                         This is the first    we have been askinq for this
                2   for some time, but it finally came about.  That is only
                    those regions that-'i,;ere reviewed in the morning.  The after-
                3
                    noon session is still beincT typed.  So we have asked the
                    Staff to take apart the  transcripts and give you the
                511
                    verbatim transcript of those regions that we now have  the
                6

                    transcript available on.-
                7
                              With that background, I think this morning we will

                    try to go alphabetically.
                9

                              Dr. Schreiner?
                10
                              DR. SC11REINER:  Before you do that, I would f nd
                    it helpful in perspective to kno%f if vou added up all these,i

                    what did it come to?
                13
                JA            IIRS. SILSTFE:  A very good point.
                              DR. PAHL:  Well, I have the fiqure.

                              MRS. MORGAN:  It was on the board.
                17            IIRS. SILSBEE:  I erased it from the board this
                    morning because it didn't seem to be a thing to  be  public
                18

                    knowledge.
                1
                              DR. PAHL: The figure  is  $26,557,154,  which  is,
                20
                    from a management point of view, a verv nice level.  But you
                2 1
                    should not he bound to it in either an upward  or  downward
                    direction, particularly in view of the action you took this
                23
                    morning@which gives us that kind of flexibility  to  manage
                Z04
                    our.affairs
                2,5


   ng                           DR. SCITREII@IER: That gives us a feel for where @.7e

                     are.

                  3             @IRS.              am as)-,inct @,lrs. Leventhal to dis-

                  4@i.1 tribute  the  kind  of  running  summary i@:e keen that puts toge-

                  5  ther as much information as you have at this point.  This is

                  6ii the sui=.ary data on the recommendations yesterday.

                  7             DR. JANETIAY:  Mrs. Silsbee, can   I make a    gratuitous,

                  811 comment?

                  9             MRS. SILSBEE:  Yes,, sir.

                  10            DR. JANEIIAY:  1 think it   is an extraordinary

                  11 it accomplishment to be able to get the transcripts on the     tabl6'

                  12
                                          must
                     this morning.  You         have had people chained to the @.?all.s

                  13 all   night.  I don t know how  that was done.

                  4             MRS. SILSBEE:    lqell, this Gentleman to mv right

                  15
                     and  his peers are  the  ones  that  are responsible for that.

                  16 But  also, a push,  I  think,  from  the Director's   office   helped.

                  17
                                DR. PAHL:  We found that once the rumor that I

                  18 relayed yesterday  didn't  materialize  there  was  a  free  evenina@

                     for everyone.

                  0

                  2 1

                  23

                  24

                  25


                                               ALABAI,!A
  n9
                               I-.IRS. SILSBEE: O.K. Could v7e start with  Alabama?

                 3   I think the best wAv to proceed today is to  ask  the  primary

                     reviei-7e                                       0
                 4          r to make whatever comments and  make  rec  Emendations
                     and then if the secondary reviewer has  anything  different  I
                 5
                                                      ot be necessary at this
                 6   will ask for that.  But it may n

                 7   point.

                               Alabama.  Mrs. Gordon?

                               MRS. GORDON:  I was pleasantly sur rised this
                 9                                                p
                 10  morning when I read the various and sundry  things  we  have   I
                     received, since I wasn't here vesterdav.   I  agree  primarily
                 12  with the comments made yesterday.  The  onlv  addition  that
                 13  I would have is that A2,abaTra does have  couple of their
                     projects that nearly all of the monev  is for equipment.
                 14
                 15  And that I do question.

                 16            That is 126 and 125.
                 17            MRS. SILSBEE:  Mr. Ogden, you were present yester-

                     day.  Do you have anything to add?

                               MR. OGDEN:  No.  I would  agree with  the comments
                 19
                     that were made yesterday, particularly those which ap
                                                                            'pear

                     in the transcript from Dr. Vaun.  Project  number  134  does
                 21
                     indeed Appear to he  the  sane Project that appeared here in
                 22 ii
                     the previous  application  and was rejected.
                 .3
                               And it  is  unlikely -- Ifelt in reading the materia'L

                     that was sent to we     that it could be completed in a
                 25


                                                                             7 3

  nlO                reasonable period of time.  And some of their other projects

                  2                                   e withi.n.the periodof one
                     perhaps are not terribly feasihl

                  3
                     year.
                  4             The matter of the eaui.pmerit doesn't bother me that

                  5
                     much.  And I would agree with  the allocation made by the

                  6
                     Review Committee yesterday.
                  7                                            her feeling on
                                Mrs. Gordon, do'you have anv ot

                  8
                     that?
                  I                                                                 1
                  9             MRS. GORDON:  No.  I would agree with the alloca-

                  10
                     tion.
                                MRS. SII.SBEE:  Could I have a motion, n ease
                  12            MR. OGDEN:  if Mrs. Gordon will move it, I will

                  13 second   it.

                  14            MRS. GORDON:  All, right.
                  15            MRS. SILSBEE:  The motion has been made and
                  16 seconded that the Review Committee recommendationof a
                  17 funding level for the Alabama application for $680,000 be

                  18
                     approved.

                  19            Discussion?

                  20            (No response

                  21,           MRS.  SILSBEE: All in favor?

                                VOICES:  INye.
                  2
                  23            MRS.  SILSBEE: Opposed?
                  24            (No response.)
                  25            MRS.  SILSBEE: The motion is carried.


                                                                                7  4

                                                  ,ALBANY
   nll
                                tIRS. SILSBEE:  The next  region is Albanv.  Dr.

                      Watkins is the primarv reviewer.
                 4              DR. @'Y'ATKIIIS: Albany has a history as a  superior
                      region.  In the May  funding which Council recommended in
                 5
                      June it almost got  100 ner cent  of  the  request.  in  other
                 6
                      words, it was 1 million  66.hundre-d  thousand  and  thev  got
                 7

                      1 million 12 thousand.
                                They are asking this time for 541,437.  Mr. Barrowsi
                 9
                   1  recommended 487,000.  Based on Albany's superiority and
                 10
                 11   community involvement, T,make a motion that they get 487,000,1
                   li which was  recommended  -yesterday,by  the  Review  Committee.
                 12

                                I-IRS. SILSBEE:  Dr. Haber?
                 13
                                DR. HABER: I have nothing  to  add,  except  that  I
                 14
                      would ask Dr. Watkins if we could ameftd his  motion  to  make
                 15
                 16 ;III it $500,OOOJI $13,000 More than he has suggested.
                 171            MP.. MILLII<EN:  For what reason?                      I
                 18             DR. HABER:  I think that these   projects  are  well
                 19   conceived.  I think that the one I am particularly interested
                      in is the one commented on in terms of evaluation of the
                 20
                      Medicaid screening iDroqraTn. I think  that  there  seemed  to
                 21
                      be some dispa2ity between some of  the  reviewers  about  what
                 @2
                      the level of funding should be.

                                Since both of them are a little bit below what
                 24
                      they asked- I think we can be slightly more generous and     giver
                 25
                                                                                       t


   12                then some more.

                               MRS. SILSBI@"--:  Does thatconstitute a second, Dr.

                  1  Faber?

                4              DR. l,ABER:  Yes, it does,, if Dr. 1,7atkins will

                5 i  accept  it.

                6              DR. I.,7ATKINS: I accept it.

                7              MRS. SILSBEE:  The motion has been made and seconded
                8    that the  Albany application be approved at a  $500,000  level.

                9    Additional comments?

                1 0            Dr. Milliken -- I mean, Mr. !-Iilliken?

                11             MR. MILLIKEN:    I am concerned about  the  precedent

                l'@' for the future applications.

                13             MRS. SILSBEE: Could  you  use  a  microphone  please,

                1 4  sir?

               @15             MR. MILLIKEN:  I am a little concerned about the

                16   precedent of this amendment  for consideration for  the  forth-
                17   coming applications.  I think  if v7e could use specifics the

                18   Dr. gave in terms of a specific project that the increase

                19   be allocated specifically to that for the reasons that he

                20   gave rather than leaving it to the judgment of heaven, thev

                     might spend it on projects that this Council and the
                2 1

                  ii. Committee feel were not worthy.
                  1
                22

                               And I notice a departure from our usual routine.
                -3
                     I am not  against it.  But I believe there ought to be more
                r,4

                     specific  instructions.
                25


                                                                               7 C

   nl3                         MRS. SILSBEE:  Mrs.  Plorgan?
                2              MPS. MORNAN:    Can we give  specific   instructions

                3    to the regions as  to how they are to  spend the money?

                4              MRS. SILSBEE:  T,,,Te can strongly recommend that the

                5    basis of the funding decision was based on that aspect.
                6              DR. PAHL:  We can give advice, but we do not    really@,
                7    earmark it for one specific project.  And in that sense,

                8    in adding additional funds we would just  have  to  rely  upon

                9    whether they chose to follow our advice or not.  So your

                10   reasons should be very well spelled out.

                11             But we can't guarantee the results.  We do our best

                12   to transmit that advice.

                13             DR. GRAMLICH:  Dr.  Pahl,  Mt.  Milliken's  remarks
                14   have crvstalized a oro@-ying concern that has wormed  its  way

                15   into my mind. This soundt a little bit  like  --  I  want  to

                16   apologize and make it very brief.

                17             The mechanism that is used is illustrated by this

                is   particular request, especially where yesterday you will
                19   recall that one reviewer said,   let's make it this  figure,,
                20   the second'-, reviewer said., let's make that, and they  said,

                21   well, let's just split it.

                               And I like the approach that Dr. Haber has suggested
                22
                     that they be more specific.   And this points up  to  me  the
                23
                24   urgency of the problem which   is only existitg in this parti-
                     cular session, -because if this is the last session it will      i
                25


                                                                                  77

   nl4            I   never be up again.
                  2             But here  is a situation in which the whole structure-
                  3   is a reverse pyramid. The  primary  reviewer,  who  is  the  only

                  4   one who has really had the time and  the  ability  to  go  over
                  5   the grant request in detail is the one who starts at the
                  6   bottom of the apex of the pyramid  on  which  the  total  funding

                  7   process is accomplished.
                  8             The secondary  reviewer.says,  well,  yes,  I  think
                  9   it is probably all right, or mavbe we  ought  to  do  this  or
                  10  that.   But then the Review  Committee  accepts  that,  and  if
                  11  we accept it, in  turn,  the  Review  Committee's  recommendation
                  12  !ex pro facto without any really terious consideration we
                      are just compounding that pyramid, on which some very
                  13
                  14  important decisions at the  regional  level  might  well  take

                      place.
                  15

                  16            So my plea is simply that I think yesterday's

                  17  review session, which wasinteresting,   very  interesting,   wa
                                                                                    s

                  18  probably unique in that  it  was  pressured  timewise,  an  may

                  19  have reached the right decision -- probably in most instances

                  201 it d3')d.

                  21            But I would agree.    I think the Council should

                      subject 'that to ample scrutiny  before accepting it.
                  22
                  23            MRS. SILSBEE:  The motion has been made and
                      seconded that the AlbAny  application  be  approved  at  $500,000
                  24
                  25  with advice to the region  about  the  one  pro36ct  involving


                                                                               7 8

  nl5            1   the   State.

                 2              is there further discussion?

                 3              (No--response.)

                 4              MRS. SILSBEE:  All in favor?
                 -  -                                                                1
                 5              VOICES:  Aye.

                 6              MRS. SILSBEE:  Opposed?

                 7              (No response.)

                 8              MRS. SILSBEE:  The motion is carried.

                 9              The next region to be teviewed is Aritona, and Mr.

                10   Hirbto is  the primary reviewer.

                11              MR. HIROTO:  May I ask if the afternoon transcripts

                12   from yesterday's session will be,available later?

                13              MRS. SILSBEE:  Yesi Mr. Hirotb, would you like to

                14   hold off?

                .15             MR. HIROTO:  Yes.

                16

                17

                18

                19

                20

                21

                22

                23

                24

                25


                                                 ARKANSAS

                  2             MRS. SII,SBEE:  We  will go to Arkansas.
                                I'm sorry, I can't remember which   ones came   u
                  3                                                             p
                  4   so if you all will point  this out it would  be most helpful.
                  5             Dr. Komaroff is the primary reviewer of the

                      Arkansas application.
                  6
                  7             DR. KOMAROFP:   The June Council rated this region
                      as average.  its'funding  level on the basis  Of  the  June
                  8
                  9   Council  recommendation  is currently 1.425 million.  They seekl

                  10  a supplement  of  $816,000.
                  11            The main concern  of  the  June  Council-centered
                  12  around the stability of the core staff and the uncertainty
                  13  about a new coordinator to replace Dr. Silverbladt.
                  14  According to Mr. Posta and the Staff of DRMP, that    problem isi

                  15  being resolved.
                  16            Virtually all the vacant  staff  positions  have  been
                  17  filled. And the current  acting  coordinator  Verv  likelv  will
                      become the permanent coordinator.  The  rojedt proposals in
                  18                                           p
                  19  this supplement are somewhat disappointing to me.  And I
                  20  think Dr. Carpenter's review  yesterday  summarizes  my  impres-

                      sions.
                  21
                                The ap lication ,consistt of a great variety of
                  22                  p
                      unrelated projects.  Many seem   designed. to further the  goals
                  23

                                                                                to
                      of a single institution within   the region rather than
                  2
                      accomplish regionalization.  I   agree with that.  There are
                  25


                                                                                    80

    nl7          1    two projects that I think the Council should be particularly       1

                 2    concerned about.
                 3               one is  a-'verv  large project,  the  Arkansas   digestive

                 4    disease  center,  which   requests $176,000.  It  is  actually   a

                 5    low  priority  project  from  the RAG.  The  thing  that   concernsI
                 6    me about  this  project  is  that they  state  their  primary  object
                 7    tive  is  to,  quote,  facilitate the  further  development   and
                 8    upgrading  of  the  gastroenterology  training  program  at  the

                 9    medical center.
                 10              And they  wish  to  utchase  S88,000  worth  of  eouip-
                                                    p
                 11   ment.  Additionally, they will hold     a  we6k!v  conference  to
                 12   which  practitioners  from  the  co=unity  would  be  invited,   s
                 13   1 imagine they currently  would  be,  And  hold  a  few  educational

                 14   sessions around the region.
                 '15             But it is clear,  and  I  think  they  state  frankly,

                 16   that the purpose of  this  grant  is  really  to  supplement  the

                 17   training  proaram  in  gastroenterology  at  the  medical  center.

                 18   And I think the  Council  ought  to  express  some  tangible  con-

                 19   cern about that.
                 20              The second Project  that  perplexed  me  is  a  project
                 21   to  establish  rape  crisis  center  control  program.  This  is
                      sponsored by the National Organization for 1-7omen,  NOT!-,-  and
                 22
                      the State of Arkansas, and i..,ould enhance  the  abilitv  of  a
                 23
                      woman who had been  raped  to  seek  imm6diate  guidance  as  to
                 24

                      what she should do medically and legally.
                 25


   nl8                         I think there are similar Prototvpe for-this  kind

                2    of a ra e crisis center around the countrv.that apparbntl-v
                            p
                3    are quite effective.  But the concern I have is whether R-MP
                4    funds under Section 900 -@'of the law really allow for this

                5    kind of a categorical activity to be supported.
                6              It is not honcategorical; it is categorical.  And   i
                7    it does not fall, in my estimation, within the language of

                8    the law.

                9              DR. PAHL:  It is also discriminatory.
                10             MR. KOMAROFF:  I suppose rape can be.  I would, to
                11  make these recommendations tangible, agree with the level of

                12   $400,000 the Review Committee recommended yesterday, but
                13   with two restrictions:  one, that there be no dollars exnende8
                14   for the rape project and, second, thatno more than S30,000

                15   be expended for the digestive disease proposal.

                16             DR. ITAMIIOCK:  Which would be for education?

                17             DR. KO@IAROFF:  Yes.

                18             DR. PAHL:  Dr. Komaroff, I think we would feel

                19   comfortable with that recommendation as a program.

                20             MRS. SILSBEE:  Dr. Janeway?
                21             DR. JANEIIAY:  Dr. Komaroff and I have discussed
                     this prior to the meeting.  I concur with the technical
                22
                     review and with Dr. Komaroff's comments, and second t e
                23
                24   proposal.
                               MRS. SILSBEE:  A motion has been made and seconded
                25


                                                                           8 2

   nl9              that the Arkansas application be approved at a $400,000

                2   level, with the follm-iing conditions:  that no dollars be
                    expended for the rape review Project and that no more than
                3

                4   $30,000 be expended. for the digestive diseases activity.
                5             DR. JANEWAY:  That is component 104.

                              MRS. SILSBEE:  Component 104.
                6
                7             Is there further-discussion?
                8             (No response.)
                9             MRS. SILSBEE:  All in favor?

               10             VOICES:  Aye.

                              MRS. SILSBEE:  OpTiosed?
               11

               12             (No response.)
               13             MRS. SILSBEE:  That motion is carried.

               14

               15

               16

               17

               18

               19

               20

               21

               22

               23

               24

               25


                                                                                         8 3

  n2O               I                                 BI-STATE

                    2               MRS.   SILSBEE:   The next   application to be reviewed

                    3   is Bi-State.  The    principal reviewer there is @Ir. @!illiken.

                    4               Mr.   Milliken,  Dr. @%7atkins was here yesterday and

                    5   you weren't.  I don't know whether that

                    6               MR. @IILI,IKEN:  I will defer to him.

                    7               MRS.   SILSBEE:  Dr. Watkins?
                    8               DR. Te7ATKINS:  Yes.  The Pi-State request was for           i

                    9.  $472,458,   and  the  recommended  funding  level  was   for   S275,000,.i

                    10  And  I  agree  with  the  Review  Committee.  I  think   that   this

                    11  Bi-State  critique,  the  projects   compared   to   May-June   were

                        sort of  ar  utd  the  same  level  --  in  other  words,  the  same
                    12.1            p
                    13  level  of  prioritization  and  so  forth  --  except   that   since
                    14  time  is  running  out  it  is  possible  that  they  might   have   Padded
                    15  a little to get the $472.
                    16              So what vie are  asking  is  that  this   be   reduced to a  I

                    17  more feasible figure for     them  at  @@275,000.  There   was   a

                    18  recommendation by two reviewers of 270 to 300 thousand.  And             i

                    -19 I  think  one  reviewer  even  suggested  335   thousand.   But   we

                    20  are suggesting that it be 275 thousand.

                    21              %IRS. SILSBEE:  Mr. Milliken?

                                    MR.  @@ILLIFEN:  I  would  like  to   in aenoral    agree
                    22
                        with that.  However,     in  looking  at  the   many projects    that
                    23
                    24  were  recommended  be  dropped,   there   was   one, number 59,
                        evaluation and placement of long-term care         patients.    I  don't'@
                    25


                                                                            84

  n2l            1  know the gualitv of this program.
                 2            iTowever  generally there are two great needs in
                 3  the country which would show  aneed for developing and
                 4  continuing such  projects.  One relates to cost containment
                 5  for health care, and the  other to get resources in place for

                 6  the impending national health insurance.
                 7            And based on this, and if this  is    I would have
                 8  to rely on Staff -- if this is a program  that can be a
                    quality program and make contributions to those two needs,
                 9
                    I woul-ld recommend that we add $30 000 specificall
                 10                                                   Y 'earmarkedi

                 11 for funding of number 59.
                 121          MRS. MORGAN: I  don't  see  where 59 was deleted,

                 13 anyway.

                 14I          MR. HIROTO:  It wasn't.
                 '15          MRS. MORGAN-. We've got 57, 58., then we go to

                 16           MR. MILLIKEN:  Oh, really?  The list I have

                 17 indidates;---
                 18           DR. WATKINS:  Let me see if  I can -- the regional

                 19 office made comments on 60, 57, 59 and 64, which were
                 20 favorable. And it would  he  an  additional $60,000.  The
                 21 question is:  Are we  in agreement with this?  If vou are

                    in agreement I will addthb $30,000.
                 22

                              MR.  MILLIKEN:  Right.
                 23
                              MRS. SILSBEE:  O.K.  Mrs. Flood?
                 24
                              MRS. FLOOD:   The Review Committee's comments that
                 25


  n22                are listed on the pink sheet says that brief mention  is made

                 2
                     of Dr. Felix's arrival as the new coordinator.  Vowever,
                 3   little discussion was giv(n to his new role in plans or  the  i
                 4   role he might play in the developmett of  this  application.
                 5             Being a little bit familiar with the past historv

                 6   of the Bi-State program, I think that the power  that a  man
                     of Dr. Felix's personality and capability might  have in
                 8   making the program develop into something stronger even   in
                 9   this last phase is something we shouldn't overlook.
                 16            Now, I would agree that at first.glande some of
                 11  these projects do not appear to be of the  most  outstanding
                 12  quality.  But I would think that Dr. Felix has the capability
                 13  of holding neutral ground in a particular area v7hek
                                                                         e  there

                 14  is quite A bit of University medical school discussion, and
                 15  there is impingement on Bi-State by the Illinois PM.P and

                 16  here has been itactivitv at times by the Missouri RM.P.

                 17            I would like to ask if the gentlemen might  consider!',
                 18  in light of the cut that was given at the June  Council,  an
                 '19 additional $100,000 to fund the Bi-State program at S375,000

                 20  rather than $275,000, with your specific  recommendation  of

                 21  that project being included, that 59, but  with  no  comment
                 22  @L- about the rest of this money     that is, $60,000 or

                 23  $70,000.
                 24            That might be of value to Dr. Felix to accomplish    i

                     something, coordination it another area.
                 25


                                                                             8 6

  n23                                                1 that he needs  addition
                               MR. MILLIKEN:  You fee                        al

                2   staff, do  you?
                3              MRS. FLOOD:  No,I don't think he needs necessarily
                4 ii additional staff.   I think he needs a little discretionary
                5   capability there, to be responsive to these  things in  the
                          so
                    region/that he doesn't have the stigma of being r'elated  to

                7   the universities in that area.
                8              I think he needs a little more discretion so  he
                9   can be more able than the previous coordinator  to  relate to

                10  needs-in that region.
                11             DR. WATKINS: llelli if we were to review and  we
                12  were to add, I would suggest that it he based on  what  we
                13  just mentioned, the regional office  comments.  And  those
                    comments were an additional 60, not 100. So  I  would  want
                14
                15  to have a reason for adding to the 275, and the reason would

                16  be @strongly in favor of the regional comments  which  were
                17  the Projects just mentioned 59, 64, 60 and  57.

                18             That was the group eliminated by the  reviewers.
                19  That is a group that is worth 60,000. so it  would  give  me
                20  a better feeling if I said 60 rather than 100.
                21             MRS. FLOOD:  Well, I would Accept the 60.
                               MR. MILLIKEN:  lqhat bothers me -- I am not against
                22
                    adding another 40@-000. We have the money. But  I  think  we
                23
                    need a more tangible, s ecifid Advice for so doing, in line
                                            p
                24
                25  with my earlier comment.


                                                                               87

                 i                                                     to add
   n24                         I think it puts us in a verv bad light

                 2   additional amounts without a verv specific cause

                 3             DR. WATKINS:  Can we have  Staff comment  on  this>

                 4             MRS. SILSBEF:  Mr. Posta?

                               IIR. POSTA:  I think the purpose of what Mrs. Flood

                 6   Picked up in the green sheet was primarily instigated by

                 7   Staff.  It was something that was  not said rather than what

                 8   was said.  Dr. Felix did come in  and talk to Dr.  Pahl  and

                 9   the  proper staff here at DPJ4P.
                 10            He did respond with a  three-page  letter  stating

                 11  some of his goals, what he would like to do during the text
                 12  year in the St. t6uis area.  As we know, he does have a

                 13  terrific reputation.  A     0              s been on  o
                                             nd t  date -- he ha          b   ard

                 14  since July lst -- has gotten together with experimental
                 15  health delivery service system there in St.  Louis  as  well

                 16  as with ARCH program and the CIIP agency.

                 17            And Ono of his primary goals is to utilize the

                 18  institutions already set up and yet at the same timct6
                 -19 pursue some of his goals in primary care  and  in  manpower.
                 20  Now, the other point that was mentioned in  the  pink  sheet
                 21  you have before you was  the role that Dr. Felix  has  played

                     in establishing and preparing  this  particular  application.
                 22

                 23            And when we asked him that, the  answer  was  com-
                 24  pletely negative:  He did hot  have a role in preparing this

                 25  particular application. So it is our  strategy  at  least  to


                                                                              88

   n25          1    present this to you with expectations that perhaps Dr.

                2    Felix would have more latitude in getting into those areas

                3    that he particular"has a special  talent  for.

                4              MRS. SILSBEE:  But for Councills consideration,,

                5    they have the application in  front of  them. This is sort

                6    of the horns of a dilemma. And  in  terms  of the advice that

                7    we would give to the region, as I  hoard  the discussion, is

                8    thatdertain of your activities we  think  are first rat6t

                9    some of the others we don't think are good.  But we really

                10   think that you ought to scrap the whole thing and look at

                     your priorities all over again and put your faith in Dr.
                11

                12   Felix.

                               Now, this could be translated in some way or
                13

                     another, but it does create a problem.
                14

                               MR. HIROTO:  Is there a motion?
                15

                16             MRS. SILSBEE:  No, there isn't.

                17             DR. WATKINS   We move $335,000.

                18             MR. MILLIKEN:  I second it.

                19             MRS. SILSBEE:  The motion has been made and seconded.

                20   that the Bi-State application be approved at the level of

                     $335,000.
                21

                               Is there further discussion?
                22
                23             (No response.)
                24             MRS. SILSBEE:  In favor?

                               VOICES:   Aye.
                25


                                                                           89

   n26           1            MRS. SILSBEE:  opposed?

                                            Ilo.
                 2            DR. JANEWAY:

                 3.           MRS. SILSBEE:  Let the record show there was one

                 4
                    in opposition.

                 5            The motion is carried

                 6            MR. EIROTO:  Am I to leave?

                 7            DR. JANFIIAY:  Yes.

                 8

                 9

                 12

                 13

                 14

                 15

                 16

                 17

                 19

                 20

                 211

                 22

                 23

                 24

                 25


                                                                                  90

  n27            I                              CALIRORNIA

                 2              MPS. SILSBEE:    The next application  to  be  reviewed

                 3   is from California-.,  And  Mr. Firoto is out  of  the  room.

                 4   Dr. Janeway is primary reviewer.

                 5              DR. JATIEWAY: As noted  in  the  May-June  review,

                 6   the program was above  average  and  continues,  in  my  opinion,

                 7   to be above  average  to  superior.  The  May-June  reatest  was

                 8   on the order of $8,170,000,  with-a  DR.MP  funding  decision  of

                 9   almost 7 million dollars -- even somewhat below the

                 10  Committee recommendation.

                 11             The current request  is  for  $5,592,000.  It  is  MY

                 12  opinion in  reviewing  this  -- and'i concur  with  the  technical
   io
                 13  review committee  --  that  the request is  overly  ambitious

                 14  for the time frame  of  accomplishment.  And  the  amount  can
                 15  be effectively reduced to  an  amount  of  3'million  dollars.

                 16             I would  express  onlv  one  administrative  concern:

                 17  Although there seems to  be  a  reasonably  good  relationship

                 18  between the RMP  activity  and  the  various  CFP-agencies,  there

                 19  are some areas  of  clearly  unresolved  conflict.  And  I  think

                 20  that with what I see as  sonev?hat  more  dispersion  of  activity

                 21  in this State  tending  to  get back to the illav it was  before
                 22  reorganization, that the coordinator should     he  cautioned

                 23  in this regard.

                                The recommendation for funding  is  at  the  level  of
                 24

                     3 million dollars.  And I so move.
                 25


                                                                                    91

  n28             1              MRS. SILSBEIC:    Mr. Ogden?
                  2              MR. OGDEN:   I  disagree with  Dr.  JanewAy  on  the
                  3   level of funding.    .And I would like to spend a few     moments
                      on this particular   application  inasmuch  as  I  think  it  is
                  4

                      the largest before   us   today4
                  5
                  6              Those of  vou who were here yesterday and listened
                  7   to the discussion  will  recognize  that  Dr.  Heu8tis,  who  was

                                                                  ded  this  be  funded
                      the primary reviewer yesterday, recommen
                  8
                      in  full,  $5,592,000.  Dr.  liirschboeck  who  was  the  secondary
                  9
                      reviewer, suggested it be reduced to     2 million dollars.
                  10
                                 After  considerable  discussion  among  the   people
                  11
                      around the  Review  Committee  table  about  the  projects  anda
                  12
                      group of other things,  the  final  decision  came  down  to  abit
                  13
                      of dickering. Now,  at  the  risk  of  going  over  things  that
                  14
                      you "listened to yesterday, there  was  a  show  of  hands  on  how
                  15
                      many  would  prefer  3  million.
                  16

                  17             Dr. Heustis said,   how  about  4or 5?

                  18             Then Mrs. Silsbee   said, well  the  motion  has  been

                  19  made at 2  million, how many   in favor.   That was voted down.

                  20  That motion was defeated..
                  21             And Mr. Barrows   said, welli then I  will  move  it  at
                     .3 million.  And they finally got an acceptance at 3 million
                  22
                      without any discussion of whether@these were valuble Projetts,
                  23
                  24  whether the PI-,P.was being cut too far or particulardiscussion.
                      with respect to the quality of the this program.
                  25


                                                                                 92

   n29                          Ilow, you don't have available to you, I don't  think@';/

                 2  1 the yellow printout sheets on this.  Do you have this in

                 3    your books? If you would look for  a  moment  with  me  at  the
                 4   'yellow printout sheets on the California Reaional Medical

                 5    Program, there are some things here that I think are of

                 6    considerable interest to us.

                 7              MR. M.ILLIKEN: These are  numbered.  1-7hich  one  do

                 8  1 you want to look at?

                 9              MR4 OGDTN: Let's  begin  with  the  cover  sheet  for

                 10   just a moment.  There are 83   projects here; 61  of  them  are

                      new, and 22 are requests for   continued support  --  1.3  millioni

                 12 11 of continued support.

                                And if you  look at the next page,  you  will  see  thA I
                 13                                                                   ti
                    I                                                                   I
                    @l program staff  which includes existing  projects  as  well  as-
                 14

                 15   continued projects, is 1.6 million.  Now,  if  vou  add  un  the

                      co                                                            n,
                 16    ntinued support and program staff,  you  are  at  2  9  millio

                 17   which is the 3 million dollars that we are talkina     about.

                 18             Admittedly  program  staff  may  be  possibly-reduced

                      in the event they do nothing on new projects.  But the 3
                 19

                 20   million, I @-suggest, may only continue the projects that     the I
                                                                                      y

                      have and cover programs.   That does  not  cover  new  projects.
                 21

                    i'ln looking across, I see  that there may  be  some  cutback  on
                 22
                      program staff if there are no   new projects.
                 23

                                DR. JANEWAY: May I  make  a  point  of  clarification?
                 24

                      It was my impression, as I  was  primary  reviewer,  that  none
                 25


                                                                            9 3

  n3O           1   of this was for program staff.  That was all funded in   the

                2   May-June application.

                3             MRS. SILSBEE: Is that not  correct,  Mr.  Russell?

                4             MR. RUSSELL:  That is correct.

                5             DR. JAtln7AY:  That 1.6 million has already  been

                6   funded,

                7             MR. OGDEN:  All right.  If  you come down to  the

                8   request for September of '74,to June  of 175 which is in  the

                9   third column, that is under the heading of five in here,

               10   you will begin to see the programs that thev  are  proposing

               11   are those to which they propose to add some additional

               12   funds.

               13             These include a series of kidney  programs,  some

               14   of which were funded at very small amounts in the  July  174

               15   to June of 175 request and for which they are now requesting   i

               16   additional  funds.

               17             And when you come over, come several  pages  along,

               18   don't you have a printout,, now beginning on page 7 you begin  I

               19   to pick up new projects which they are talking about beginning

               20   with about 147T.  And you will find some that are added   to.

               21   But beginning on page 8 they are all new Projects  that  they

                   iare talking about funding for the Period of September 174 to
               22
               23   June of 175.
                              Now, I find some of these to be  of  considers  e
               24

                    intexest and also of value.  There are projects here concerning
               25


                                                                               94

   n3l            1  the health care network in the Imnerial Valley which    involves

                  2  migrant workers.  There is an American Indian clinic     aware-

                  3        roject here.
                     ness p

                  4             There are upgrading of  free  clinics,  ambulatory

                  5  care facilities -- a whole series of  things  that  I  feel

                  6  were simply ignored in the discussions yesterday.  And    I

                  7  came away from  yesterday's  discussion  somewhat  dismayed with

                  8  the manner in which the  California  application  was  handled.

                  9             I recognize that this is a big program  and  it  is

                  10 an expensive program.  It is a lot of money.  But my r6action;

                  11 to it is that the cut from 5.5  million,  nearly  5.6  million

                  12 to 3 million was done almost on  a  bargaining  basis,  without

                  13 much consideration of the actuality of   the needs  of this

                  14 pro ram.
                        9

                  15            And I think or feel that we should  add  back  money

                  16 into this  application.  I  haven't  totaled up  the  requests

                  17 that appear on pages 8, 9 and 10 at all.    But I  would  sug-

                  .18 gest,that if we added back uowards of a half million dollars,,,

                  19 mavbe-even a million, we viould  be  finding money  well  spent

                  20 in a superior program that  has  always  had exceptional manage-

                  21 ment And has done a great deal  of  good  in what is  now  the.

                  22 largest State in this nation.

                  23            MR. WAIIMOCK:  You would take it back to 5 million?

                  24 is that what you are saying?

                  25            MR. OGDEN: I would take it back  at  least  to  4.


                                                                               95

   n32                          DR. JANEIIAY:  Let  me respond  to  that.  Perhaps

                     am speaking not as a member    of the National  Advisory  Council
                  2
                  3  and a little bit  too  much  from a  technical  standpoint.  But
                  4  if you are going to put   1.5 million dollars into a   hyperten-
                  5  sion screening program in 10 months, you had better be
                     pretty well prepared as a physician population to have     some
                  6
                     reasonable idea as to what you are going to do with the
                  7

                     people who you identify.

                                And that is where my comments saying  that  they  are
                  9
                     being overly ambitious: If  there  are  indeed  23  unidentified
                  10
                  11 hypertensives in the United States, and   probably more than
                     that, you can  set  up  programs which build up  peoplo's  expec-
                  12
                   1-Itations to a level which you  cannot possibly meet  within  the

                     limits of  the  delivery  system or within the cost barriers
                  14
                     that would be imposed by defining that population.
                  15
                  16            I think it is an admirable program.  And   I am  not
                     making a  comment  there,  I  am just saying that as  to  the
                  17

                  18 quality of it I think it  is  overambitious.  And  that  was MY,
                  ig interpretation of the technical review that was    also  given.
                     I would agree that on the,surface there would  ap  ear  to  have
                  20                                                    p

                     been somo bargaining as to the level of funding,    at the
                  21

                     outset of which  one  would  got the impression that it  was  not
                  22
                     being done oh the merits of the proposal.
                  23
                                But I thnk ultimately that it was  and  that  the
                  24
                     technical expectation was the one  that  cast  the  deciding
                  25


                                                                             9 6

                                                                                0
  n33                factor. And I would say that I agree with  your  comments  t
                2    a point, but I certainly agree with the  recommendations  of

                3    the Review Committee.

                4              That is just too much money. it would  not  be  as

                5    well spent in that as it would if it were  distributed  dif-

                6    ferently throughout the regions.

                7              MRS. SILSBEE:  Dr.. Gramlich?

                8              DR. GRA14LICH:  Dr. Janeway raises a criticism  of

                9    a  million dollars for a hypertension screening program.  And

                10   I would observe that the same Review  Committee  recornehd6d

                11   a  million dollars for a hypertension screening  program  an

                12   treatment program in the State of Mississippi.
                13             DR. JANET4AY: They cut is by $840,000 svecifically-I

                14             DR. G@-ILICH:  Yes, but from a 2 million   dollar

                15   levelf leavin- them with a million dollars.

                16             DR. JANET,7AY:  The incidence of hypertension in

                17   the  State of Mississippi or prevalence, whatever  you  want

                18   to use, based upon the racial distribution and the character-!

                19   istics of people living in that area, I think you will find

                .20  a striking difference from California.

                21             As I said, I don't want to get into being a

                     technical reviewer on this, but when you have a verv   high
                22
                23   percentage black population,atd in the  entire  Southeastern
                24   United States, if you look at the prevalence of hypert tsion,@,
                25   coronary, arterial disease -- you are dealing with a different


                                                                              9 7

   n34           I   type of population and a different health care need.

                 2             MR. OGDFN:  Let me make one brief comment here.
   0              i
                 3   I think since the time we started the Regional Medical

                 4   Programs in 1966, we have witnessed in America-@-probablv  the

                 5   greatest migration of People in historv.  And 1 speak    about

                 6   the migration of the black peoples of this country from

                 7   the South to the North and-the Tlest.
                 8             We may not all be aware of  this, but  as  recently
                     As probably 1946 right after the war, tome  77  per  cent  of
                 9
                 10  the black population in this country lived in  the  South  and

                 11  was thought of as the rural Southern problem.  Today 65    per
                 12  cent of the black people in this count    live in  the  North
                                                            ry
                 13  and the @7est and are really thought of as an  urban  problem.
                               The black population in this  nation  has  settled
                 14
                 15  in California, New York State,  Michioan,  New  Jersey.  And

                 16  I think we sometimes are not aware of these things that have

                 17  been affecting our regional medical programs.
                 18            And I would suggest that  if  hypertension  exists
                     in Mississippi it also exists in California.  There is a
                 20  tremendous black population in California.  And  it  has  been
                 21  a very rapidly growing population.
                               Dick, nay I just comment too,  then  I  will  close
                 221                                    PI
                   I this off: Many of these projects I asked you  to  look  at  on
                 23
                 24  pages 8, 9 and 10 of this computer printout are not    hyper-
                     tension projects; these are projects spread among a    great
                 25


   n35            1   many other things.
                  2             I plead  no particular  case  for  California.  I  am
                  3   not from California'.  But I simply feel that this is a pro-

                  4   gram that deserves better consideration than it received

                  5   yesterday.

                  6             MRS. SILSBEE:  Dri    Schreiner?

                  7             DR. SCH@REINER:  -1 justuant   to point out that both

                  8   the reviewers have made some  excellent  specific   oints.    I
                                                                         p

                  9   do think, however, we should  put in perspective that 7 million
                  10  dollars plus 3 or something  over that is  roughly  10  ver  cent

                  11  of the entire nation's P-MP funds.
                  12            I don'tthink we should'view California as being

                  13  a deprived State.

                  14            MRS. SILSBEE:   Dr. Komaroff?
                  15            DR. KOMAROFF:  Another  was  to'look  at  the  perspec-
                  16  tive is that California has 10 per  cent  of  the  population  of
                  17  the country.  And we had available about 64 per cent    of
                  18  the funds that were requested in  this  cycle.  3  million@,,--
                                                                                  out

                  19  of a request of 5 is about  60  rer  cent.
                  20            So an average region   ought  to get around 3 million.':

                  21  But I would think that if this   region is, in fact, regarded
                  22  to be superior or above average that  --  just  that  is  another
                  23  context within which one might look At the 3 million,
                  24            I-IRS. SILSBEE:  Dr. Janeway has made a motion that
                      the,application be approved at  the  3  million  dollar  level.
                  25


                                                                              9 9

    6
  n3             1   I didn't hear a second.

                 2             MR. l@IMIMOCK: I will second that motion.

                 3             MRS. SILSBFE:  All right.  The motion has been

                 4  made and  seconded that the California application be  apt)roved.
                 5  'at the level of 3 million dollars.

                 6             Is there further discussion?

                 7             (No response.)

                 8             MRS. SILSBEE:  All in favor say aye?

                 9             VOICES:  Aye.

               10              MRS. SILSBEE: Could you nut your  hands  up,  please?i

               11   That is one, two, three, four,, five, six, seven say aye.

               12              Nay?  Seven.

               13              MRS. MORGAN:  Maybe we should set it  aside and go

               14  to

               15              MRS. SILSBEE:  Dr. Wammock?

               16              DR. 1,7AMMOCK:  You talk about the new Drojects over
               17   here.  I have just been looking at that hypertension.  And
               .18  if y'ou look at on page 9,1 thou
                                                    ght I had it, California, it
               19   seems to have gotten away. But it looks to  me  that  there  are,

               20   lots of hypertension projects over here -- 159C, 159D, 159F,,

               21   159F, 159G, community hypertension awareness nrolect, 15,OH,

               22   'high blood pressure control in Berrett Countv, 159  --  there's!

               23   about 10 or 15 down there that go right on to the hyperteh-

               24   sion.

               25@            'So I think there is a tremendous amount of money


                                                                             100

  n37            I   being put in that  program  there.

                 2                                    Ithink that was brought out
                               ,MRS. SILSBEE:  Well,

                 3   a little earlier.

                 4             DR. T-7AM-MOCK:  It was brought out alittle earlier.

                 5   But this is in.the new projects in which they  are requesting

                 6   this.

                 7             MR. OGDEN:  Can-I make a new motion that we put

                 8   California at 4 million dollars?.

                 9             MRS. SILSBEE-.  Is there a second to that?

                10             DR.  GRA14L!Cg:  Second.

                11             MRS. SILSBEE:  The motion has beet made and seconded

                12   that California application be approved at the level of 4

                13   million dollars.

                14             Is there further discussion?

                15             MR4 MILLIXEN:  I think 3 and a: half.  Try 3 and a

                16
                     half.

                17             DR  JANEWAY:  Pow about 3 million 640?

                18             MRS. SILSBEE:  I might add that the Council dbe n't

                19   seem to be any more deliberate it its setting the fund levelsl

                20   than the Committee seemed to be yesterday.

                21             All it favor of the  motion to approve the aptlic&-

                22   tion at 4 million raise their  hands?  Four.

                23             Opposed?  Eight,   nine.

                24             The motion is defeated.

                               MR. ODGEN:  Dick, you want to move it?


                                                                             1 0 1

   n38                         DR. JANEWAY:  I move approval of the California

                 2  application at $3,640,000.
                 3             MRS. FL06D: I will second that motion.

                 4             MRS. SILSBEE:  $3,640,000.  The notion has been

                 5  made and seconded that the California application be Approved

                 6  at the level of S3 640,000

                 7             MRS.  GORDON:  Iwould like to ask.for a short

                 8  explanation of the magic mathematic&l"formula used  to arrive

                 9  at thAt?

               10              DR. JAIIEWAY:  It is 65 per cent of 5.6 million.

               it              MRS. SILSBtE4  Does that answer vour ouestioh.7

               12
                               Is there further discussion?

               13              (No response.)

               14              MRS. SILSBEE:  All in favor of the motion sav ayo?

               15              VOICES:  Aye.

               16              MRS. SILSBEE:  OnT)osed?

               17              (No response.)

               18              MRS. SILSBEE:  The motion is carried.

                               v7ould someone ask Mr. Firoto to come back?
               19

               20

               21

               22

               23

               24

               25


                                                                                 10   2

    n39                                      CENTRAL @IET-7 YORK

                 2              MRS. SILSBEE:  The   next application is Central

                 3    New York, and miss--Martinez  is  the primary reviewer.

                 4              MISS I.IARTINEZ:  The Committee recommended  a funding.

                 5    level of $450,000.  I was not   quite so generous.  I  found

                 6    that at least two sets of projects duplicated or    extended

                 7    each other in  that  they were two that were, number 77 and      i
                 8    78 were  really  building of facilities,  which  I  don't  think

                 9    is feasible for  one  year   projects.

                10              Two  more  were really  sort  of  education  projects.

                11    The end result is that  I ended up with a funding recommenda-

                12    tion'of 381,372.

                13              MRS. SILSBEE:  Dr. Schreiner?

                14             -DR. SCHREINER:  Yes.  I had perhaps the advantage

                15    of site visiting this area.  And there are a number of

                16    developments from the previous time.     I agree with Miss

                17
                      Martinez on those two particular projects.

                18              I would Also like to  point  out,  however,  that  in
                19    the region's own priority list they are in the low priority
                20    groups, so that they have insight into the problem which she

                21    mentioned.
                22              We helped them actually  set  up  a  very  democratic
                      method for determining the priorities in the various placeb.
                23

                      And I think it has  worked  extremely  well  there.  There  are   i
                24
                25    a high number of inputs, and they have    a verv             of
                                                                       good type


                                                                            1 0 3

  i4O           I   rating system for establishing priorities.

                2             Now, in previous sessions the kidney programs were

                3   to,-,,@d down because-'they did have some problems in getting

                4
                    areawide agreement on a number of the projects.  I  do  think
                5   'that thev made a lot of progress in that particular area

                6   since our last funding.

                7             And the kidney projects have been asked for  at  a

                8   level of 111,000.  The second area that I would give very

                9   high priority to, and I can find in their priority list

                10
                    reasonably highly rated as well, are those relating to   the

                    north country, which is an extremely desolate area.

                12            Even though it is in New  York State, within  easy

                13  driving distance of New York City,  it has one of the  lowest

                14  population densities in the United  States. And there  are  a

                15  number of very uniaue minority circumstances up there,

                16  including an Indian reservation which never signed  a  treaty

                17  with the United States and therefore doesn't come  under  the

                18  Bureau of Indian Affairs and it is entirely  dependent  upon

                -19 this kind of activity.

                20            I can identify about another $135,000 worth of

                21  projects relating to the north country area.  So I am- afraid

                   'that my recommendation would be a little bit  hiaher.  If  I
                22

                23  assumed the program staff figure is correct -- and  I  would

                24  agree it is possible it could be cut a little bit and put
                                        two
                25  the emphasis in these/areas      I could come up with A fiaurel


                                                                           104

  n4l           I   of $562,000.

                2             So then I am a little far away from Miss Martinez.

                3             MRS. SILSBEE:  Well, I don't have a motion.

                4             DR. SCHREINER:  I would like, obviously, to move

                5   the higher figure and she would like to move the lower fiqtre!!.

                6             MRS. SILSBEE:  W6've got three figures before us

                7   now.

                8             MR. OGDEN:  What are tho e, please?

                9             MRS. SILSBEE:  But we don't have a motion.

                10            DR. SCHREINER:  1 would like to move 562.

                11            MISS MARTINEZ:   562 ?

                12            DR. SCHREINER:  Yes.

                13            MRS. SILSBEE:  $562,000.  is there a second?

                14            (No response.)

                15            MRS. SILSBEE:  Is there another motion?

                16            MISS MARTINEZ:  Yes.  I would like to make a motion

                17  for 382,000.

                18            MRS. SILSBEE:  383,000?

                19            MISS MARTINEZ:  82.

                20            MRS. SILSBEE:  382,000.  Is there a second?

                21            (No response.)

                22            MRS. SILSBEE:  Is there another motion?

                23            DR. KOMAROFF:  I move the Committee's recornpienda-

                24  tion of 9450,000.

                              DR. JANET-7AY:  Seconded.
                25


   n42           1               MRS. SILSBEE:  The motion has been made and secondee

                 2    that the Central New York, application be approved at the

                 3    level of  $450,000.-.

                 4               Is there further discussion?

                 5               (No response.)

                 6               MRS.  SILSBEE:  All in favor?

                 7               VOICES:   Aye.

                 8               MRS.  SILSBEE:  Opposed?

                 9               (No response.)

                 10                                              arribd.
                                 -MRS. SILSBEE:  The motion is c

                 1 1

                 12

                 13

                 14

                 15

                 16

                 17

                 18

                 19

                 20

                 21

                 22

                 23

                 24

                 25


                                                                               10 6

    n43          1    4.t                   COLORADO/T,7YOMING

                 2              MRS. SILSBEE:  The next region to be reviewed is
   0
                 3    Colorado/T@7yoming. And le t the record show that  Or.  Gramlich

                 4    is out of the room.

                 5              Miss Ilartinez?

                 6              14iss IIARTINEZ:  I am waiting.

                 7              All right.  I believe the Committee's recommendation

                 8    was for  $200,000.  Again I am a little low in  that  I  recom-

                 9    mend 146,959.  I have a comment to make on one  of the projects
                                                                                     I
                10    in particular -- well, twoi all right.

                11              one, number 59, seems to me  to be Primarily an
                                                                      a
                12    education project.  And I was wondering  whether/Staff   person

                13    could tell me if this was developed in cooperation with the

                14    educational commission of Colorado?

                15              MRS. SILSBEE: Miss Murphv, did  you  hear  the  quet-I
                16 l@ tion?
                17              MRS. MURPHY:  Yes.  I have to checkit.

                18              MRS. SILSBEE: Could you get  over  to.the  microphone!

                19    please?

                20              MRS. MURPHY:  I really know no more about the

                21    project than what is on page 15.

                22              MISS @IARTINEZ: Well, if it is the  information  thati

                23    I read last night, then I just make the  observation  that  the

                24    educational commission or agencies in the State  were not

                25    consulted and that the project description was  extremely


   n44          I   hazy in my mind.  So I have severe questions about that

                2   one.

                                                                              64,
                3             But the one that I really object to  's number

                4   which is entitled, health promotion service, primarily  a

                5   project to reach senior, Spanish-speaking senior  citizens,

                6   sort of an education project. And at one point  the  comment

                7   is made that the money is 'going to be given-to the public

                8   health department to@hire nurses who will go out and try   to

                9   overcome social barriers.

                10            That doesn't explain how it is going to be  done,

                11  it doesn't explain who, you know, what criteria is going  to
                12  be used inthe selection of staff'to do this.  To me, this

                    is an example of a lot of poor planning that goes into  pro-
                13

                14  jects which are supposed to teach minority people and don't.

                              In other words, it is an exmple of the use of a
                15

                16  minority population for funding. And I would  suggest  that

                17  either that project proposal be developed so that it is underi

                18  community control and hires community persons to do the out-

                19  reach or that they be requested to not fund it.

                20            MRS. SILSBEE:  Dr. Haber?

                21            DR. HABER:  I have a serious question about project

                    n)mber 61. Could Staff enlighten us about what  is  intended
                22

                    with the $17,000?  You can't buy bahd-aids for $17,000.
                23

                              MRS. MURPHY: That proposal has been  called  into
                24
                25  EMS for consideration  We will not fund it until it gets


                                                                              r)

    n45             approval.

                 2
                              DR. PAPER:  Very well.

                 3            MRS. SILSBEE: It has not been referred  to  E@IS.

                 4  That was one we wanted to get the Committee's views on,

                 5  because it doesn't conflict with the legislation.

                 6            DR. HABER: I would like to point out  that  a  burn

                 7  center is an extremely expensive operation,  requiring  heavy

                 8  staffing by very skilled people. And I think  that  we  sadly

                 9  or badly need the development of such burn centers.  But

                10  unless this is some kind of exploratory project -- I can't

                11  tell here -- I would say that the scope appears to  be  hope-

                121 lessly inadequate.

                13            The demands of these burn centers ate such  t  at

                14  you should deploy these with the greatest precision and in

                -15 areas where they are likely to be well utilized, and c oncen-

                16  trate the rest on developing transportation svstems to set

                17
                    people to where the burn centers are.

                18            I don't know what this, but S17,000 seems  to  be

                19  so inadequate that it is ludicrous, I would think.

                20            MRS. SILSBEE:  Mrs. Morgan?

                21            MRS. MORGAN: I don't believe Colorado  has  a  burn

                22 -center or such at the lDresent time. They have  applied  to

                23  the legislature and were turned down last spring for money

                24  to build-a burn center.

                25            this $17,000, I believe, mainly is to take a nurse


                                                                                    10 9

    n46           1    who has been working in,@  auote, unquote, what they call

                  2    their burn center where   they treat  their burn patients,

                  3    which is a @12,000.., add to it travel about the State, and

                  4    I think really to  urge  passAge  of  A  legislature  bill  where

                  5    it will be taken  care of by the State at-the    Colorado

                  6    General.

                  7               DR. HABER: @lelit  if  it  is  preparatory  or  educa"

                  8    tional

                  9               MRS.  MORGAN:   Ithink it is really a study to get

                 10    information to  develop one.

                 11               DR. HABER:  1,7ell, O.K.  Under those circumstances     i

                 12    I  will  be mollified.

                 13               MRS. SILSBEE:  I haven't had a motion oh Colorado/

                 14    Wyoming.
                 -15              MISS MARTINEZ:   Yes. I  would-to  make  a  motion  thati

                 16    we fund at the level of 146,959.

                 17               MRS. SILSBEE:   Is there a second?

                 18
                                  DR. KOMAROFF:  Second.

                 19               MRS. SILSBEE:  A motion has    been made and seconded   1

                 20    that  the Colorado/@lyoming application   be approved at t e

                 21    level  of $146,959.

                 22               DR. YOM@ROFF-.  Including that caveat that she

                 23    mentioned  about the,Spanish-speaking

                 24               MRS. SIMBEE:  That is project 54.

                 25               MISS  MARTINEZ:  Yes,  either  it  be  developed  with


                    i;                                                                 I

  n47              1   the safeguards I mentioned or that it not be done.
                   2               @@IRS. SILSBEE:  All right.  Is there further discus-

                       sion?

                                            -7AY:
                   4               DR. JANET       Does that mean, Miss E4artinez, that

                       if  it  is  devel                      tisfactorv to Staff and UU4P
                                       oned  in a manner sa

                   6   that the allocation is increased by $65,000?
                   7               DR. KOMAROFF:  Or $41,000.
                   8               DR. JAIZEIIAY: $41,000, whatever it-is, so it would

                   9   come out   187,000.
                  10               MISS  MARTINEZ:  Yes,  I  would  be  willing  to  go   along;

                  11   with that   idea.

                                   MRS.  SILSBEE:  That   requires a motion, Sentiment.
                  12
                                   MISS  MARTIITEZ4  I would   like to make a motion to        i
                  13

                       that effect.
                  14
                  15               MRS.  SILSBEE:  V7e.still have one on the floor now.

                  16               MISS  PIARTINEZ.:  I see.

                  17               MRS.  SILSBEE:  The motion was not       that.
                  18               MISS  MARTINEZ:  Can I withdraw the      original  rmotion?!,

                  -19              MRS.  SILSBEE:  Yes.

                  20               Does  the second want to v7ithdraw?

                                   DR. YOMAROFF:  Yes.
                  2 1

                                   MRS. SILSBEE:  All    richt.   Start    again.
                  22
                                   MISS  MARTINEZ:   All-right.   I   move   that C61orAdo/
                  23
                       I-lyoming be funded  at  the  level  146,959  and  --  how should I
                  24
                       put it      which would include the elimination of 'project
                  25


   n48           I   number 64, unless that projpct can be developed to include

                 2   a community control policy board and outreach  workers  who

                 3   are from and sensitive to the needs of the particular popu-   i

                 4   lation being served and that if such conditions are met

                     that tl.ie funding level be increased
                 5

                 6             MRS. SILSBEE: No, you have to go  the  other  way

                 7   to get a motion like that.-

                 8             MISS MARTINEZ:  $41,000.

                 9             DR. KOMAROFF:  187, 188, but restrict the $41,000

               10    unless they do it right.

               11              MISS MARTINEZ:  O.K.  Does it come out exactly

               12    187?

               13              MR. HIROTO:  188.

               14              MISS MARTINEZ: All right.  Let's  try  this  once

               15    again.  I move that Colorado/W.voming be funded At  188,182

               16    with the condition that r3roject 64 is to be developed to

               17    include a community policy board and community outreach

               18    workers sensitive to the population in question,  and  that

               19    if such conditions are not met that the funding level be

               20    reduced to 146i959.

               21              MRS. SILSBEE:  You have heard the motion.  Is therei

                     a second?
               22
               23              DR. @7,A-MM.OCK:  Second.
               24              MRS. SILSBEE:: Any further discussion?
               25              (No response.)


                                                                             11 2

  i49            1            MRS. SILSBEE:  All in favor?

                 2            VOICES:  Ave.

                 3            MRS. SILSBEE:   Opposed?

                 4            DR. JANEWAY:   No.

                 5            MRS. @IORGAN:  No.

                 6            MRS. SILSBEE:  Let's see.  Let's have the ayes

                 7  raise their hands.

                 8            O.K.  Let's have the nays raise their han s.

                 9            The ayes have it.  The motion is carried.

                 10           Dr. Janeway?

                 11           DR. JAI@IEWAY:  It seems to me that there must be a

                 12 reasonable balance between fulfilling all the resrbnsibilities@

                 13 and carrying out the policies and statutes of the   R!!P versus

                 14 the selective identification of particular  projects.  r-rhe

                 .15 technical review has been done.

                 16           And there are only two Council  members  who  have

                 17 had the opportunity even to read the forms 15.  1 would just

                 18 hope that we don't-gibt'-like the fellow who went down  into

                 19 the swamp and he saw an alligator down there,  and  he  beat

                 20 that alligator over the head a nd he killed them.

                 21           And he just kept running into more alligators and

                 22 killing alligators and forgot after he was down there with

                 23 all those alligators around that somebbdv sent him down to

                 24 clean out the swamp.

                 25           DR. TIM@IOCK:  Common, Sam Ervin.


                                                                             1 1 3

                                                                        lb6ws in
  n5O                          MR. @III,LIKEN:  You mean he is up to his e

                2
                      alligators
                3              MRS. MORCIAN:  Ile's not quite that far.
                4              DR. JATIFIIAY:  I have to abridge the storv a little

                5     bit.
                6              MRS. FLOOD:  As a matter of comment     and again,
                7     as Dr. Janeway occasionally says, gratuitously    I do think
                8     though that we have some responsibility.  If the technical
                9     reviewers or the Regional Advisory Group itself does hot
                10    take into consideration the problems of dealing with minority
                11    groups and using terminology such as overcome cultural
                12    barriers rather than to address cultural barriers in a
                13    manner that can be adapted to the health delivery system.
                                And we do face the responsibility of questioning
                14
                15    the development of individual projects when th6v are setvingi
                16 @l a population that many times is not articulate in expressing

                17    its own needs.
                18              DR. JANTWAY:  I don't disagree with that one bit.

                19              MRS. SILSBEI?:  Thank you.
                20              The transcript for,Arizona has arrived, and have    i
                21    you had  achance to look at it, Mr. fliroto, or would you
                22    rather  go ahead?  l@7e can come back later?
                23              MR. HIROTO:  All right.  I will  take Connecticut.
                                MRS. SILSBEE:  You'll take Connecticut.  Do you
                24
                25    have that'one?


                                                                           11 4

   n5l                        MR. HIROTO:  No.

               2              MRS. SILSBEE:  we have to hold for just a few

               3
                    minutes while there is a switch -- the changing of the guard

               4 1  here.

                              (Whereupon, at 12:30, a luncheon recess was taken

               6    until 1:00 p.m.)

               7

               8

               9

               10

               11

               12

               13

               14

               15

               16

               17

               18

               19

               20

               21

               22

               23

               24

               25


                                                                            11 5

                1                      AFTERNOON SESSION
                2             MS. SILSBEE:  The meeting i@@ill corie to order.
                3     In the break that-we have had, I've had about three or four
                4     requests of individuals in regions who have to leave early
                5     and I'm prepared to accomodate them as much as nossible, butl
                6     we re going to have to move along. Mr. Firoto.
                7              MR. HIROTO:  Ms@ Chairman, would.you entertain a
                8     motion that should the orimary revier.-@er and the secondary
                9     reviewer have no problems or difficulties with the result
                10    of the Review Committee, that we vote in block on those and
                11    go along the table and list those states that we feel secure
                      with and only review those or discuss those that some oeople
                12
                13    may have questions about.
                14             MS. SILSBEE:  I will entertain the motion.
                15             MR. MILLIKEN:  Second.
                               DR. HABER:  One mechanism for accomplishing that   i
                16
                17    might be if you were to read dov7n the entire list of remain-!
                18    ing proposals and ask if objection is raised oh the part of
                19    primary or secondary reviewer with the colnliittee's recommen-
                20    dation.  A negative answer would seem to indicate that it

                      would then be part of a bloc k to vote on.
                21

                               MS. SILSBEE:  Right.
                22
                23             DR. 11@IOCK:  You said you would read down the     i

                24    list?
                25              DR. HABER:  Yes.  There ate several wavs to


                                                                              11 6

                      accomplish this, but the most expeditious would be for
                      Mrs. Silsbee to read down the list and if anyone feels
                2
                3     that he doesn't q@. along with the committee's report,   he
                4     so states And it is then removed for, individual considera-

                      tion from the Block Vote.
                5
                6               MS. SILSBEE:  I think.the record should show that
                      the entire council has before them the composite recommends
                7
                8     tions of the review committee showing  the  requested  level
                      and the committee approved  recommendation.  I  also  think
                9
                10    that the record should show that this is in view of the
                      fact that you participated as observers  in  discussions  of

                12    the committ6e's deliberations yesterday.
                @13             I-IS. GORDON:  T@,7as there any problem with the con-

                      flict of interest?
                14
                15              MS. SILSBEE: Not  on  block  action.  All  right,
                16    the motion has been made and seconded that  we  go  through
                17    this. I'll go down the list and if  anyone  has  any  objec-
                18    tion to the committee recommendation, we will take that
                19    particular application out for discussion, otherwise there
                20    will be a motion about the block action.  All in favor.

                                MS. SILSBEE:  Opposed.
                21

                22              Motion carried.
                23              I will not only  read the list, but I will read into
                      the record what the recommendation was as fat as the funding
                24

                25    level.


                                                                             11 7

                                                              00 0.
                                MS. SILSBEE:  Arizona   $150,

                                MR. IIIP.OTO:  Object.
                2
                                MS. SILSBEE:  Connecticut    $750,000.
                3

                                DR. GRI-J4LICH:  Object.
                4
                                MS. SILSBEE:  $600,000   Florida.
                5
                                            ware Valley    $684,512.
                6               Greater  Dela

                                Hawaii - $486,7.50.
                7
                8               Illinois   $750,000.
                9               Indiana   $240,000.
                10              Intermountain
                11              DR. KOMAROFF:  Object.
                                MS. SILSBEE:  Iowa - $173,929
                12
                                               Kansas - $363,:')45
                13
                                               Lakes Area   $150,000
                14
                15                             Louisiana
                16              DR.  JANEWAY:  Object.
                17              MS.  SILSBEE:  '4aryland - $650,0004
                18              DR.  WAMMOCK:  I think we had better go over that.
                19              MS.  SILSBEE:  Memphis - $950,000
                                               Metro-D.C. - $250,000
                20
                21                             Michigan - $500,000
                                               mississIT)pl - $2,000,000
                22
                23                             Missouri   $540,000
                                               Mountain States - $300,000
                24
                25                             Nassau/Suffolk


                 1              DR. KO'-IAROFF:  I think we had better discuss that.@

                 2              MS. SILSBEE:  Nebraska - $95,000

                 3                            New Jersey - $1,100,000

                 4                            New York Metro - $950,000

                 5                            North Carolina - $120,000

                 6                            Northern New England - $600,000

                 7                            Northlands - $300,000

                 8                            Oklahoma - $2501,000

                 9                            Oregon - $148,6

                 10                           Puerto Rico - $131,335

                 11                           Rochester - $1,000,000

                 12                           South Carolina

                 13             MRS. GORDON:  Objection.

                                MS. SILSBEE:  South Dakota - $88,850
                 14

                                              Susquehanna Valley - $'500,000
                 15

                 16                           Tennessee/Mid-South - $570,000

                 17                           Tri-State - $610,000

                 18             MS. SILSBEE:  We'll come back to Texas.- Tri-State',-

                 19  $610,000.  Virginia - $960,860.
                 20             MS. MARTINEZ:  object.

                                I-.RS. FLOOD: They have an arthritis program.  it's
                 211
                     not essential, it's automatically taken care of.
                 22
                 23             MS. SILSBEE:  From the previous recommendation.

                 24             Washington/Alaska - $530,000

                                West Virginia   $1,000 000
                 25


                               MS. SILSBEE:  Western Pennsylvania - $450,0004

                               DR. HABER:  Objection.
                  2
                               MS. SILSBEE:  Wisconsin - $200,000.
                  3
                     We'll review Arizona, Connectucut, Intermountain, Louisiana,l
                  4
                     Maryland, Nassau-Suffolk, South Carolina  Virginia, Western
                  5

                     Pennsylvania with Texas.
                  6
                  7            MRS. MORGAN:  I move that we accept the Review
                  8  Committee's recommendations for.funding of the regions
                  9  nor. specified to be taken care of separately.
                  10           DR. KOMAROFF:  Second.
                  11           MS. SILSBEE:  Is there  further discussion?

                  12            (No response)
                  13           MS. SILSBEE:  All in favor.

                                              opposed.
                  14
                  15           MS. SILSBEE:  Motion is carried.

                  16 We'll now  go to Arizona.
                  17            MRS. YLEIN:  This is just a minor thing, but we
                  18  had taken some this morning and the way the motion was
                  19  worded, all those other than the ones that were recently
                      enumerated  so I think the motion should show, exce t for
                  20                                                     p
                      those already discussed and approved.
                  21
                                              I think that was the consensus
                                MS. SILSBEE:
                  22
                      of the discussion beforehand.
                  23

                  24


                                                                             1 2 0

                                           ARIZONA

                 2              %IS. SILSBEE:  Arizona - Dr. Gramlich.

                 3              DR. GRNILICH:  As a matter of principle, Arizona

                 4   has had  difficulty with the organization, the  leadership  andi

                 5   had had  some other difficulties that were technical  with  thei

                 6   DRMP and  counsel said to clear it up, so  Arizona  cleared

                 7   them up and the  Technical-Review  Committee.rewarded  this    I

                 8   function by cutting their allocation --- their  recommenda-

                 9   tion. The question is one  of  principal.  Do  you  reward

                 10  virtue in a negative fashion or a positive fashion?

                 11  There's not much question about the technical capabilities

                 12  of the region to accomplish the @roject  it  had  ordered.

                 13  That was a minor element, but the concern  on  the  art  of
                                                                        p

                 14  the technical review committee was, if you  haven't  been  goodi

                 15  up to now, that you've changed everything we said you shou d

                 16  do, so we're goina to reward you by  cutting  your  grant.

                 17             MR. HIROTO:  I echo that.  I was going to request

                 18  the council to consider changing the amount  of  the  award

                 19  to $240,000 --- $240,718 because at least it meets the three

                 20  component projects in the upper three pro]ects that have the

                     highest oriority.
                 21
                 22             DR. GRP2,ILICn: If that's a motion, I second it.

                                MS. SILSBEE:  The motion has been made and
                 23

                     seconded that the Arizona application  be  approved  atthe
                 24

                     level of $240,718.  Is there further discussion?
                 25


                                                                               1 21

                  1              (No resnonse)
                  2             14S. SILSBEE:  All in favor.

                                               Opposed.
                  3
                                i4S. SILSBEE:  The motion is carried.
                  4

                  5

                  6

                  7

                  8

                  9

                  10

                  12

                  13

                  14

                  15

                  16

                  17

                  18

                  19

                  20

                  21

                  22

                  23

                  24

                  25


                                                                               12 2.

                 I                           CONITECTICUT
                 2               '1'4S. SILSBEE: We will now go to  Sonnecticut.

                 3    Mr. Iliroto.
                 4               MR. HIROTO:   I can appreciate  the  problem  that
                 5    probably we all face with Connecticut and that Connecticut's'i
                 6    program has continued as it was'designed until just the last
                 7    10 months. The  technical  reviewers,  one  recommended  a
                 8    a level of $250,000; the other  recommended  a  level  of
                 9    $1,400,000, which reflects,  I  think,  the  difficulties  we
                 10   all have in  reviewing  Connecticut.  Dr.  Gramlich,  if  you

                 11   have any comment that you would like to make.
                 121             DR. GRAMLICH:  Yes.  Again, these are general
                 13   comments and  more  philosophical  then  technical.  Here,
                 14   apparently and I don't know the region well at a
                 15   may be in error, but it appears this is an  RMP  set  up  with
                 16   a different kind of program from the pattern throughout the

                 17   rest of the States, throughout the rest of the nation and

                 18   therefore, our last Technical Review  Committee  said,  well,,

                 19   since it doesn't conform, we shouldn't give them any money.
                 20   Now, maybe this is an entirely wrong interpretation.  I

                 21   would appreciate staff input on  the  assessment  of  the

                             ication for droppin g the funding because  of  the fa  t
                      justif                                                      c
                 22

                      of the different kind of program#, one  from  the  other.
                 23

                                 MR. HIRBTO: Dr. Gramlich, I  don't  think  that  is
                 24
                      a primary consideration. The problem  seems  to  be  that  all
                 25


                                                                               12 3

                      of the IU4P funding or most of-it has gone into the

                      institutional area, rather than into other    areas and
                 2
                      despite staff eff@rts to spread the program    a little more
                 3
                 4    fully throughout the state and throughout other institutions'!,

                      this was not accomplished.  At  the  last  council  meeting,
                 5
                 6 1  council agreed to reduce funding dramatically because     this
                 7    was the only way that Connecticut  would  get  the  message,

                      so to speak. They have gotten the  message  to  a  deqree  and
                 8

                      so the $750,000 level seemed reasonable to rhe review
                 9
                10    committee.

                11               DR. GRAMLICH:  Rebuttal time.

                                 MS. SISLBEE:  Dr.  Gramlich.
                12
                13               DR. GRAMLICH: To begin with  the  may  request  for

                      funding was not large. It was  something  in  the  order  of
                14
                15    $636,000 dollars.  The major request is what we have in

                16    front of us now. Therefore,  since  the  timing  again  with

                17    Connecticut, was differnt, we are penalizing them even

                18    further by not killing their program  by  refusing  to  accept

                      their major funding request.
                19
                20               MS. SILSBEE:  Dr.Janeway.
                21               DR. JANEWAY:  It is my recollection, Dr. Gramlich

                      that one  of the things that was taken into consideration was'l
                22

                      considerable amount of their funding was going through into
                23

                24    1976.

                25               DR. GRAMLICH:  Correct.


                                                                             12 4

                1              DR. JANEIIAY: And the way I recall  the  technical

                2    discussions, there was a general sense of that  group  that

                3    felt they should not fund projects through '76.

                4              MS. SILSBEE: There  were  several  considerations,

                5    Dr. Janeway in terms of the level.  One of them was the

                6    two year funding request.  The other was a contract that

                7    would have enabled the monitoring capacity.to go beyond

                8    June -'Oth, but in addition, there were the two  University

                9    resources that were funded at a fairly sizable amount.

                10   Other portions of the program that would have been  of  don-

                11   cern was the third faculty. There were  no  funds  requested

                12   for that.  The Connecticut application in May, Dr. Gramlich

                13   was requesting support for staff plus two months o  continua

                14   tion projects.  This amplification asks for 10 to 22 months

                15   for some activities and 10 months for o thers, so it is

                16   complicated by that factor.

                17             DR. GRAMLICli:  Right, but neverthelsssl if you

                18   take all the two year projects and this  iscrud6  arithmetic

                19   but nevertheless if you take the two year projects  and  cut

                20   each of them in half and award them one half of the two year

                21   total, you're in effect awarding them for  one  year.  They
                     still wind up with a figure $1,430,000.  The way I visualized
                22

                     this, it was incorrect, that since Connecticut came  in  for
                23
                     a small'grant request  last May, if we cut them way down thisi
                24

                25   time, weire in effect,  killing their total program.


                                                                               1 2 5

                 1               MR. IAIROTO: There was  something  like  $240,000
                 2    more or less requested just for the monitoring by Yale
                 3    University of the-.second year program, so we might sub-

                      tract further your total by that much.  I may be wrong.
                 4
                 5               DR. GRMILICH: The principal  involved  is  do  we

                 6    want to kill Connecticut or not.
                 7               MS. SILSBEE:  There is no motion on tie floor.
                 8               DR. GRAMLICH:  Since I have done most of the
                 9    screaming  and hollering, I will therefore move that
                10    Connecticut,be awarded a grant in the amount of $1,435,500.

                11               MS. SILSBEE:  Is There a second?

                12               DR. HABER:  I will second it.
                13               MS. SILSBEE: Dr. Gramlicht  what  was  the  total?

                                 DR. GRAMLICH:  $1,435,500.  This  is  arrived  at
                14
                15    by very crude arithmetic, by taking  each  two  year  project

                16    and dividing it in half and totalling it  with  the  ones  o

                17    the one year projects. It's the  only  way  I  could  really

                18    figure   it.
                19               MS. SILSBEE-. The motion has been made And seconded
                20    that the Connecticut application be  approved  at  the  level

                21    of $1,435i5OO.

                                 MRS. GORDON:  I'm  just wondering, there's really
                22
                23    no way probably that we have   of knowing  whether  dividing
                24    the two year project in half   leaves you a  viable  project.
                                 MS. SILSBEE7:  I think in this particular instances
                25


                                                                             12 6

                1     we  have---

                2               MRS. GORDON:  --- it's not a matter of a new activi'@L@@il

                3     so much.

                4               MS. SILSBEE:  I think we may need some  help  here

                5     from Mr. Nash.  The two year projects, are they all new

                6     or are they continuations?

                                MR. NASH:  I think some of them are new.  The
                7

                8     onces, I think, that concern the review committee, the

                9     four projects going to Yale and Yukon are for over $800,000

                10    for the two year period.

                11              MS. SILSBEE:  Mrs. Gordon, because you were hot

                      here yesterday, there was considerable discussion  with  the
                12

                13    committee and Dr. Pahl about the two year requett.  The

                      region recieved its money and has the option of putting
                14

                15    some money away for some activities, if they feel they

                16    shou6l go longer than two years, if they can work  out  some

                17    kind of A contractural arrangement, so this is just a way of

                18    arriving at a level and I don't think that should be a major

                19    worry for you. The Regional Advisory Group  will  make  that

                20    decision.  Mr. Milliken.

                21              MR. MILLIKEN:  My understanding is that  you  have

                22    my understanding is that Yale was just awarded one of the

                      few large cancer centers --- cancer'development research.
                23

                      Are they going to be able to spend all of this with the
                24

                25    limited staff they have there?


                               DR. GRA24LICH:  The money that goes into the

                2    Regional Medical Program aspect of this program would
                3    not --- this is their community outreach part of the
                     university budget.  They won't --- I don't think they will
                4
                5    have much of a problem spending money.
                6              MS. SILSBEE:  They have had experience in this.
                     The motion has been made.and seconded that the Connecticut
                7
                8    application be approved at $1,43.0,500.  All in favor.  ould
                9    I see a show of hands?  Five.  Opposed - the opposed have
                10   it.  The motion is not carried.  I will entertain another

                11   motion.
                12             MR. HIROTO:  I move the review committee's

                13   recommendation of $750,000 be-approved.
                14             MS. SILSBEE:  Is there a second?

                15             MR. OGDEN:  Second.

                16             MS. SILSBEE:  The motion has been made and

                17   seconded that the Connecticut application be approved
                18   at the level of $750,000.  Is there further discussion?

                19              (No response)

                20             MS. SILSBEE: All in favor?

                21                            opposed.

                                              The ayes have it.
                22

                23

                24

                25


                   1                                                           12P

                                           INTEP,14OUNTAIN

                 2              MS. SILSBEE:  The next  application to  be  reviewed i

                 3    is Intermountain and the record  shows that Mrs. Klein and

                 4    Dr. Gramlich are out of the room.  Dr. Komaroff was the

                 5    reviewer.

                 6-             DR. KO@IAROFF:  Intermountain was rated by the

                 7    June Council as an above-averacre region.  They  were  awarded

                 8    2.23 million dollars, as a result  of  last  councils  session.!

                 9    They now request a supplement of $48liOOO for 19  new  project!,

                10    Activities.  The last council expressed several concerns

                11    which appear --- most of which apnear to have been resolved

                12    and let me summarize them briefly.  There has always been

                13    a turf problem with the Intermountain  regions,  the  mountain

                14    states and Colorado and 1,7yoming regions.  This appears to-

                15    ha ve been resolved by some interlocking membership of the

                16    advisory groups and frequent reaular meetings of  the  members'!

                17    of the advisory group --- of the members of each of the  threei@
                18    advisory groups as well as by some joint  funding  of  pr6jectsi

                19    which have a geographical overla-P with these three RMP'S.

                20              A second concern has been the relationship  of  this'i

                21    RMP its CHPH agency and aodarentlvt according to the staff     @i

                      review and the CHP letters in the application,  there  is  now
                22

                      a serious  review by CIIP under consideration by the RAG of
                23

                24    CHP.

                25              The third concern that the council expressed    last


                                                                              12 9

                      time involved the role of the  RAG in developing and monitor-I
                2     ing projects.  The region  has developed what they  call  a
                3     drag advocate program whereby  individual members  of  the
                      RAG are responsbile for  shepherding a project  roposal
                4                                                    p
                      through it's passage and  subsequently  monitoring  that
                5
                      pro3ect after it has'been funded. It  seems  like  a  worth-
                6
                7     while idea. There was a.question  of  conflict  of  interest
                8     in the establishment of a  health  development  services
                9     corporation. Dr. Pahl  mentioned  yesterday  that  through
                      action by the State Attorney General  and  through  meetings
                10
                11    with the RMP staff members, this conflict of interest ques-
                12    tion has been resolved. There  was  concern  that  council

                      epxressed regardingthe university domination of past
                14    projects.  In this cycle, 18 of the 19 projects were
                15    sponsored by outside agencies which may have created   a
                16    Problem, but has solved at least the  @concern  of  council
                17    from the last time. The directorship  of  the  program  and

                18    the capabilities of the four staff ate deemed  to  be  good
                19    by those people who know the region  best.  I  have  not
                20    visited there.  The project proposal, however,    seemed  to
                21    me to be exceedingly non specific and  hard  to  evaluate.
                      They have some very uninspiring  continuing  education  pro-
                22
                      jects and they propose to develope their  own  audio  visual  i
                23
                24    materials.  Many of them give the impression of duplicating
                      kinds of activities which have gone on in other tegions with@-
                25


                       out giving evidence that they plan   to build on the experience

                       of others and I have the uneasy feeling  that  they  may  be,
                 2
                 3     repeating the failures and not  the  successes  of  other  such
                       attempts at PJ.!P, but it's hard to tell from these abstracts.,@i
                 4
                 15              One proposal is to establish a workshop on drug
                 6     and alcohol abuse, and I just wonder why they haven't
                       applied through the institute  for  drug  and  alcohol  abuse
                 7
                       or such an activity.  It  seems to me on the fringe of
                 8
                 9     P14P's funding mandate.  S6veral strong proje@dts are
                 10    listed.  One of the most interesting involves a computerized
                       agency referal for extended  services  in  which  they  would
                 11
                 12    try to do,a better job  of  referring  patients  to  apparently
                 13    social service agencies. I would ---  I'm  not  concerned  that
                 14    the projects are over inflated as has been described by the
                 15    past council and  the  review  committee  yesterday.  In  fact,
                 1&    if anything, they appear to underestimate the cost And time
                 17    needed to accomplish local objectives,,but I have a feeling
                 18    there is a lack of cohesion   about the whole package and I
                 .19   take issue with the committee's decision to fund    them   at
                 20    virtually 100 percent of their request and would    reduce
                       the request from --- reduce the award from $450,000 to
                 21
                       $350,000, out of a total request of $480.  I would also
                 22
                       convey to them again, as council  did  at  its  last  meeting
                 23
                 24    that the project --- the corp staff, not  the  project  staff
                 25    should include more minority representation.    particularly


                                                                           1 31.
                     repr esentation of women in professional Positions.
                1
                2              MS. SILSBEE:  Mrs. Flynn.
                3              MRS. FLY'Z4N:  I would have to concur with Dr.
                4    Komaroff, that even though they have answered many of the
                     concerns of council and site visitors, nonetheless, the
                5
                6    weakness of the application and particular project
                7    proposals for which they seek funding demonstrates in
                     this application that they are not addressing the total
                8
                     program in view of their area and I would concur with his
                9
                110  recommendation to reduce the award to $356,000 dollars, so
                     I would second his motion for thatanount.
                12             MS. SILSBEE:  The motion has been made and
                     seconded that the Intermountain application be approved
                13
                14   at the level of $350,000 with advice tr the region reo-ard-
                     ing the employment of more minority representatives and
                15

                16   more women.
                17             DR. KOI.IAROFF:  On the corp staff.
                18             MS. SILSBEE:  On the corp staff.  Is there

                     further discussion?
                19
                20              (No response.)
                21             MS. SILSBEE:  All in favor.

                                              Opposed.
                22
                23                            The motion is carried.

                24

                25


                                           LOUISIANA
                2               MS. SILSBEE:  The next region to be reviewed is

                3     Louisiana.  Dr. Janeway.
                4               DR. JAIIEWAY:  I'm the secondary reviewer --- I'm the,
                5     primary reviewer.  The reason why I wanted to take it out
                6     ofthe block was partly to get some technical advice from
                7     the staffon this. I  am  concerned  about  the  application

                8     for $75,000.
                9               MS. SILSBEE:  Bring Dr. Gramlich and Mrs. Klein

                10    back in.
                11               DR. JANEWAY: I'll hold  my  comment  until  Mrs.
                12    Klein gets back. She's a lawyer and  she  may  be  able  to

                      help.
                13
                                 (Dr. Gramlich and Mrs. Xlein re-entered the
                14
                15                hearing room.)
                16               MS. SILSBEE:  Is staff ready to listen   to  the
                17    question Dr. Janeway has.  Can thcvcome up tothe    table,

                18    please.
                19               DR. JANETIAY:  My questions are technical and
                20    relates to Project C-10 in the Louisiana application which
                21    is entitled "Stud  of      0. Tax  Supported  Clinics Serving
                                        y

                      Title 19 Recipients.'  It's the major reotest in    th6
                22
                      Louisiana Application   and I would like to know whether it
                23
                      is appropriate that RMP funds   be used to evaluate the
                24
                      activities of the clinics supported by other tax funds.
                25


                                                                           1 3 3
                 1  One wonders if that shouldn't be the function of either
                 2  the state, per se or the agency that provides medical
                 3  funding.  It's just a question that I, myself am unable
                 4  to answer it.  I don't have the knowledge.
                 5            MS. SILSBEE:  Mr. Sibloski'-, do you have any

                 6  comments?
                 7            MR. SIBLOWSI:  Not really.  It's a hard one  o

                 8   swallow.
                 9            DR. JANEV7AY:  I brought it up BECAUSE Nobody in
                 10  Technical Review even mentioned it.
                 11            MRS. GORDON:  As secondary reviewer, we only figur6d
                 12  what thev.were trying to do was get an impartial judgement
                 13  on it and the other federal agencies weret't impartial.
                 14            DR. JANEWAY:  It might Pay to have Blue Cross come
                 15  in and do it for them.
                 16            DR. GRA.MLICH:  My impression of the m6dic-aid

                 17  level is extremely low.
                 18            MR. SIBLOWSKI:  'I can't reall  respond..  I really
                                                            y
                 '19 had some concernwhen I was talking to Dr. Savlier as  o why
                 20  they decided to participate.  He was basically saying that
                 21   the I:,14P is in the only neutral Position-in the state to
                      attack it.  Everybody else seems to be involved and it's
                 22
                 23   a non biased review assessment and if you look on Page 16,
                      the people all involved in this---are involved with the
                 24   consulting firm of Shindell and Associates.  The ILouisiana
                 25


                                                                               1 3 4
                                             tion and Planning; the  Division  of
                       Division of Admi-nistra
                                             ivision of Health  Maintenance;  the
                 2     Family Services; the  D
                       Charity hospital @ystems division and  it  seems  reading
                 3
                       in between the lines that many Board members   in   many
                 4
                                              non biased type  of  thing  where the
                       organizations, it is  a
                 5
                                                            u      a certain  role.
                       RMP is entered in and is trying to f lfill
                 6
                                 DR. JANEWAY:  Let me ask you --- try to explain to
                 7
                       me the comments coming out  of the HPC in Lafayette, Louisiana
                 8
                       to which is attached, at least in my copy a memorandum# th
                 9
                 10    last paragraph which says, "This study is intended to in-
                 11    fluence the manner in which HEII funds out patient medical
                 12    services.in the state and may result in increased availabil:UtN
                 13    of these funds.    I'm only asking this  question  because
                       don't want the people in  this  National@Advisory  Council to
                 14
                       be put in the position of approving something which is
                 15
                 16    against statutes. I'm not trying  to  hurt  the  Louisiana

                 17    RMP.
                 18              MR. POSTA:  If I could make a brief comment.
                 19    This is not related directly to your question, wh c -I
                 20    think is quite valid. The  last  council,  if  you  will
                       remember, one of  the  reviewers  specifically  requested
                 21
                       to get them more involved with the REqibnal Medical
                 22
                       Program, more involved with-bringing the-private institu
                 23
                 24    tiohs in and the private sectors into the indigent clinic
                       or the hospital sys@-t-r-1.  I'm not saying this was developed 1
                 25


                                                                               i-i b

                 1    totally as a result of that recommendation, but to me   it

                 2    sort of fits into that cline of the  Reaional  Proaram,---
                 3    Regional Medical @.rouram  through some of its new   leaders

                 4    who are making a conscientious effort to  upgrade  the  care

                 5    of all thepeoT31e.

                 6              DR. SCHREINER: My comment  to  that  comment  is

                 7    the last time --- it's a very unique system.  This  represents

                 8    an extremely high percentage of the state  budget  going  into

                 9    the support of these hospitals which are really state
                10    hospitals and I think it's very superficial to say the

                11    private practioneers should get involved  at  the  expense

                12    Of the state hospitals.  If you have essentially a Govern-

                13    ment hospital and the physicians there are  on  salary,  there
                14    is really no practical way those kind of physicians are going

                15    to get involved and this is what they have.  They have a

                16    network hospital, and a very high percentage  of  the  state

                17    budget goes to it, a very high percentage.

                18              MS. SILSBEE: Dr. Pahl, I'm  glad  to  see,you  back.

                -19             DR. PAHL:  I'm gearing up for Texas.

                20              MS.SILSBEE:   Dr. Janeway has raised the question

                21    with regard to the Louisiana application.  The project

                      C-10 which 7MP funds are going to be used  to  evaluate  the
                22

                      medic-aid services for children---
                23

                                MRS. GORDON:  Tax supported clinic.
                24
                25              DR. jANETIAY4.  Tax supported clinics for Title 19


                                                                              13  6
                                                                       ou   at   least
                 I    recipients and they  are going to contract this    t,
                   i  it says in the memo here they will contract it out to
                 2

                      Shindell Associatds.
                 3
                                MS. SILSBEE:  He is questioning the legality.
                 4
                                DR. JANEWAY:  Far be it from me  to  question  the
                 5
                      legality.  I'm questioning whether it is  legal.  I watt
                 6

                      some technical inout.
                 -7
                                MS. SILSBEE: That's a better  way  to  put  it.  The
                 8
                 9    legality of counsel taking action.
                                DR. PAHL: As usual, I  am  not  prepared,  certainly
                 10
                      on the spur of the moment.  I think what we would like    to   i
                 11
                      have is your recommendation within.what the legalities   Are
                 12
                      and we  can determine then post counsel  and  act  accordingly.
                 13
                      In other words, on a technical matter like  this,  I'm  not
                 14
                      really prepared to give you an answer that  has  any  force
                 15-
                      behind it. What I would prefer to do  is  find  out  whether
                 16
                      it is the consensus of this committee that,  if  legal,  do
                 17

                 18   you recommend that we make the  award  which  would-include
                 -19  that or if not legal, do you  recommend a funding  level  whichl

                 20   encompasses those dollars,, but they could use  those  dollars
                 21   for other purposes, so we need vour assent and we will

                      determine the legality.
                 22
                 23             DR. HABER:  I  too was concerned about this  project,:

                      but in a direction somewhat different from Dr. Janewayi  I
                 24
                 25   thought this was a particularly apt use of funds, Regional     1


                                                                               1 37

                      Medical Program and at a  stage'when winding down is in

                      process and when one  would hope  that  funds  appropriated
                 2
                 3    for the project would  be susceptible to  a final verdictt

                      I think that one of the Purposes of the   Regional Medical
                 4
                 5    Program is the development of innovated   projects   and
                 6    certainly the evaluation of ongoing government mechanisms.
                      I agree with Dr. Schreiner  assessment  that  Louisiana  is
                 7
                 8    hard put in terms of development of medio-aid programs

                      and I think it would be very useful to get independent
                 9
                 10   surveys. I think  it  is  appropriate.  I'm  not  qualified
                 11   to judgethe legality-In terms of appropriateness, I think
                 12   we ought to approve it though.

                                 MS. SILSBEE:  Is there a motion?
                 13

                                 DR. JANEWAY:  In light of the discussion, I move
                 14
                      therefore  that we accept the  recommendation  from  the
                 15

                 16   Technical  Committee that louisiana be funded in the   amount

                 17   of $168,680 dollars, pending review by the staff on    the

                 18   legality and appropriateness of C-10.

                 19              MR. HIROTO:  Second.
                 20              MS. SILSBEE:  Dr. Janewayi does that motion en-

                      compass,  as a rule, if they could not spend money on that,-
                 211

                      that  the region should have the money or have it taken away.
                 22

                 23              DR. JANEWAY:  Noi

                 24              MS. SILSBEE:  Is there any discussion.>

                 25              (No response)


                               MS. SILSBFE:'  The motion has been made and

                     seconded that the Louisiana application be approved
                2

                3    at the level of $168,680 with the condition that the
                     funding for the amount of money for Project C-10 be  contin-
                4
                5    geht on our staff review of the legality and appropriateness

                6              All in favor.

                7              Opposed.

                8              The motion is carried.

                9

                10

                11

                12

                13

                14

                15

                16

                17

                18

                @ig

                20

                21

                22

                23

                24

                25


                                                                                 1 3 9

                 1                              MARYLAND

                 2               MS. SILSBEE:  The next application to review is

                 3    Maryland.    Dr. Wammock, would  you  get  the  microphonebefore @i@

                 4    you   start?

                                 DR. TIAP*IOCK:  Ithink so. I  was  the  primary  judgei
                 5

                 6    in this case and at the May-June Council meeting, there

                 7    was a request of $762,000-dollars and this was denied And
                 8    then they put in a new request for $724,000 dollars and
                 9    786 cents and at the meeting yesterday it was approved     for

                 10   $756,000 dollars. I need  a  little  bit  of  information  here.

                 11   The total program staff - C-0000 -  is  that  $336,604  correct?l,

                 12              MS. SILSBEE:  Let me look At t e s eet?

                 13              MRS. FLYNN:  That was May-Jtne.

                                 MS. SILSBEE:  Mr. Nash, could you come up to the
                 14

                 15   table please?

                 16              MS. SILSBEE: Did  you  hear  Dr.  Wammock's  question?i

                 17              MR. NASH:  I did not.

                 18              MS. SILSBEE: Dr. Wammock  wants  to  know  what  about[

                 19   was it 338 --- ?

                 20              DR. WAMMOCK:  $336,467 was the original program

                 21   staff- -total program staff.  The  original  grant  in  May  and i

                      June, the request was then $762 and the new one is for Progra':n
                 22
                 23   Staff of $233,000 and  $724,000  for  July.  The  Program  Staff
                 24   of $233,000 with the approval yesterday of $350,000 --- no,
                 25   $650,000 --- that's one-third for staff.


                 I             MS. SILSBEE:  Dr. Wammock, ifyou will look  at thel
                                                                                  I
                 2   printout labeled 7-74, you will see that the  total  request

                 3   was @724,000, of which the staff is$302,961.
                 4             DR. T@IP24.MOCK:  That's right, the indirect column is!

                     right,.
                 5

                 6             MS. SILSBEE:  There was no money provided for

                 7   staff because there was no,money provided from the May

                 8   application, so this is it.  The $650,000 as I understood

                 9   the committee recommendation yesterday would Allow for   the
                 10  staff, about half for staff and about half for the activities

                 11  that were proposed.  Is that right, Mr. Nash?

                 12            MR. NASH: I thin,  one  of  the  recommendatiomwas

                 13  that $250,000 for staff and $400,000 for projects.
                 14            DR. IIAW40CK:  400 for projects and 250 for staff?

                 15            MR. NASH: Yes,sir..

                 16            MR  OGDEN:  I think we ought to be aware that a

                 17  great deal of the activities that may go into this   project

                 18  is'staff activities, so that you can't judge the total

                 19  request for a particular project as being the total cost

                 20  because some of that-activity is being carried out bv staff

                 21  people themselves.

                               DR. W@NIOCK:  I recognize that.
                 22
                 23            MR. OGDEN:  So, I don't believe  the action yester-

                     day of say $250,000 for staff and $400,000 for  programs  is
                 24
                 25  any sense out of line.


                                                                                 1 4  1

                                  DR. I-IlvklMOCK: You don't think that's out of line?

                  2               MR. OGDEN:  No,  I don't.  I recommend that it be

                  3    accepted the way-'-it was yesterday.

                  4               DR. WZLT40CK:  'I just reopened it for the question

                  5    of clarification in my own mind as    to which way this was

                  6    going because I wasn't quite sure.  I went through this thing

                  7    and looked at the various projects which I described and I

                  8    don't know whether they're  goingto  be  implemented  or  hot.

                  9    Perhaps it may do some good and perhaps  it  may  not  do  any

                 10    good.  I'll let the motion stand as it is as of yesterday,

                 11    but I wanted to bring this u  for cla   rififation in  my  own
                                                     p

                 12    mind.    I make a  motion.

                 13               MR. OGDEN:  I'll second it.

                 14               MS. SILSBEE:  The motion has been made And

                 15    seconded that the committee recommendation of $650,000

                 16    stand. Dr. Watkins, did you  have  anything  to  add  to  that

                 17    as secondary reviewer?

                 18               DR. WATKINS:  No comment.

                 19               MS. SILSBEE:  The motion has been made and seconde@

                 20    that the Maryland application be approved atthe level of

                 21    $650,000 dollars.  Is there any further discussion?

                 22               (No response)

                 23               MS. SILSBETM  All in favor?

                 24                             Opposed.

                 25                             The motion it carried.


                                           NASSAU?SUFFOLK

                2              MS. SILSBEE:-  The next region to review is

                     Nassau/Suffolk.and-the  prirz,,r-,, reviewer is Mr. Milliken.
                3

                4              MR. MILLIKEN:   I-las this discussed yesterday?

                               MS. SILSBEE:   Yes, sir.  Do you have a transcript
                5

                     on that?
                6

                7              MR. MILLIKEN:  Yes, I  do.  With the information
                8    we had this morning, it would appear that we do have to

                     change our previous decision of no funding.  I have no
                9

                10   evidence to find fault with or change the review committee

                     recommendation of $900,000, although I personally question

                12   if that much is necessary due to the situation therein.

                13   Maybe the second reviewer has something to add.  I'll make

                     a motion later on.
                14

                15             DR. GRAMLIC116.  I find this interesting.  it

                16   appears we re reversing our position of June and July.

                17   They have made a strong appeal and 1 guess if council  has

                18   no major objection to reinstating them, I would have to

                19   support that decision.   So move.

                20             MS. SILSBEE.4  Second.

                21             MS. MORGAN:  Second.

                22             MR. OGDEN:  Could I ask the members'of council---

                23             MS. SILSBEE:  Mr. Ogden, could you use the

                24   microphone.

                25             MR. OGDEN:  Look at the page concerning Nassau/


                                                                              1 4 3

                    Suffolk.  The program staffing  here of $343,000  for  what

                    they have proposed to be slightly over a $2  million   dollar
                2

                    program, now if we're  limiting this to  $900,000  dollars,
                3

                    obviously we cannot let the entire $343,000 for the program
                4

                           o I think there needs to be something said if we
                5   stay' s

                    accept the $900,000. I didn't  hear  the  review  committee
                6

                7   yesterday.
                8             MS. SILSBEE:  They made the point, Mr.  Ogden,   it

                    was not in the motion, but it was in the advice  to the
                9

                    region.
                10
                              MR. OGDEN: That may be in  the  minutes.  Idon't  havel

                12  that in my notes.

                              MS. SILSBEE : The pink slip  says:  "Based  on  the
                13
                141 funding recommendations for the attending  period,  it  was
                15  further recommended that the Nassau/Suffdlk  AMP  be  adjq8tedi

                16  Staffing request to be proportionate to the forthcoming

                17  award.

                18            DR. GRAMLICH: In  relationship  to  the  presentation I

                19  this morning, I was a little at a loss and  wondered  if  the

                20  applicant was fully aware.of the fact that  this  council  felt i

                    they should be in a phase out period
                21

                22            MS. SILSBEE:  Mrs. Flood.

                23            MRS. FLOOD: May I ask  if  staff  has  verified  that

                                                                                o
                24  Projects 021 and '022 of the E,4S projects are appropriate  t

                25  the allowable concepts of our funding.


                  1            MS. SILSBEE: We have had a return fi@r.)ri Mr.  Reardon
                  2  who is EMS Systems Chief and he doesn't see anv problem witn      i
                  3  regard to their Dor@ion of the legislation and we got a
                     telephone call this morning from the part  of  HRA  that  is
                  4
                     Administering the training part of EMS and they also do    not    i
                  5
                  6  see any problem or conflict.  That is not to say they are
                     looking at it from any other standpoint but that.
                  7
                  8            MS. FLYNN:  Those two line items approximate
                  9  $400,000 dollars and  even  though  we're  redommending-from
                10   committee that their staff be  brought  into  line  by  readjust-
                11   ment according to the award, if they're  just  given  an  award
                12.@ without further recommendation,  other  than  staff  limitations,
                     it would appear that their only  endeavor  would  be  emergency
                13
                14   medical services and emergency medical training.
                '15            MR. STOLOV:  We have received the priority    level  on
                16   the projects and the equipment is below the $500,060     dollars,
                17   however, the EMS training is above it,but Again, I feel it

                18   is expensive, but it was their determination where to put
                19   the money once they get this  $900,0004  They  may  not  put  it

                2o   all into that EMS training.      The Nassau County which is  t  e

                21   more populated and richer county is way down  at  the  bottom  of@i

                22   -their priority list.
                23             MR. OGDEN:  would you explain to me what this
                24   $355,000 is, how much of this would be  funded  out  of  the

                25   $900.,Ooo?


                              -rIR. STOLOV:  I believe-Dr. Pahl mentioned yesterday

                  2that we still have not developed policy regarding what happensi
                   in terms of independent @@1P beyond June of  '75, so we  don't
                  31
                  4know IIET,,L wide if this is allowable under grants and administrai
                  5tion practices, but I believe it would have  been  a  contract
                  6in their own  Nassau/Suffolk RD-IP Inc to carry this out in this@i,
                  7scope and amount.  When the-committee looked at this, it did
                  8not consider this in their funding level.  They left it out.

                  9           MS. SILSBEE:  The Chairman suggested the $2,000,000
                  10 request be cut down to $900,000 and that maybe  a  moot  issue

                  11 in terms of continuing the program or putting money aside.

                  12          DR. SCHREINER:  I was primary reviewer on the

                  13 last go round.

                              MS. SILSBEE:  According to the old assignment list,
                  14

                   Mr. Milliken, you had it last year also.

                  16          DR. SCHREINER: I was hoping it  would  be  somebody

                  17 here.  I'm very impressed as Dr. Scherer happens to be an

                  18 old friend of mine and I was wondering if this was in line

                  19 'with his $900,000 speed.

                  20          DR. PAHL:  Mr. Milliken, right, I'm afraid you're it.,

                  21          MS. MORGAN: Mr. Milliken, you were  it  last  time.

                                             I don't recall
                  22          MR. MILLIKEN:                  all the details.

                              MS. SILSBEE: In terms of  making  the  assignments,
                  23

                   I try to keep them as consistent as possible.
                  24

                              MR. MILLIKEN:  On the yellow sheet, the second yelloi@,
                  25


                                                                            14 6  1

                 1 sheet, the second item CO-5,COG-5,  Grantee  Central  Service.

                 2 Could somebody explain what  that is?

                 3           MS. SILSBEE:  That is what we were 3ust discussing.

                 4           14R. STOLOV:  It's an independent R-NIP, therefore

                 5 according to instructions, they should close by June  of  '75

                 6 and they have to issue contracts to extend beyond that period

                 7 and they felt it would be good use of Government money if they

                 8 continued to fund'the grantee should over ride  contracts  be

                 9 issued.

                 10          DR. PAHL: I was about to make a  statement  on  that

                 11 when we got to Dr. Schreiner's question.  we have a policy

                 12 which comes out of the DHEW decision hot to permit  staff  or

                 13 an RMP to Perpetuate itself beyond June '30 of 175.  To

                   merely state that all grantees regardless of what they   wish to
                 14

                   do in terms of contract activities may not  engage in that kindl
                 15

                 16 of situation which would Derpetuate the RMP or the staff beyon

                 17 June 30 of 175.  They may contract with groups to  carry  out

                 18 activities past June 30 of '75, bu  not in such a way to

                 19 perpetuate themselves, so if Nassau/Suffolk, and I don't know

                 20 the details of this, if Nassau/Suffolk or some other  RIP  has

                 21 funds in.,.it which, in effect, would continue to support staff

                 22 eyond that iooint in time, then I believe we would take

                 23 appropriate administrative action with our office  of  manage-

                   tent because welrd applying a uniform rule in accord with
                 24

                 25 epartmental policy. I hope I have  made  that  distinguishing


                                                                               14 7

                     line rather clear.

                              .MR. MILLIKEN:                                     ne
                 2                             I still go with the  action  of  Ju
                 3   and the report of the committee unless there is new information
                 4   or evidence that shows reconsideration should be made.
                 5             Ms. SILSBEE:   Would you state  that  motion  again

                 6   and into the microphone  so we can all hear it.
                 7             MR. MILLIKEN:  I'move the committee recommendation
                 8   of a phase,--out award of $900,000 be awarded to this state.

                 9             MS. SILSBEE : A "phase out" award, do you want

                 10  that stated in the motion?

                 11            MR. MILLIKEN:  Yes, I do.

                 12            MS. SILSBEE:  Is there a second to that?
                 13            MR. KOMAROFF-.  Point of clarification.  Would you

                 14  resolve  your  ambivalence?
                 15            MR. MILLIKEN:   I will remove from the motion the
                 16   phase  out words,  but  Iwould like staff to be instructed

                 17  to have them understand  that this $900,000  dollars  is  for the

                 18  purpose of helping conclude their efforts and tot continue

                 19  the program as they proposed.
                 20            DR. PAHL:  I'm tot sure I'm going to clarify this
                 21  situation at all.  I think we do understand that in all of

                 22  these recommendations, particularly where there has been some    1.

                 23  drastic cuts from requested levels   and I'm sure more so in

                 24  the case of this region, that it will  have  a  very  serious

                 25  impact on their program development.  I  think  it  would  be


                                                                                    14 8

                      really in error for us to    characterize this more than some

                  2   others that we have been    concerned with  here  as  phase  out

                  3   or terminated.  I think we really should only accept the

                  4   motion for  a  funding  level  recognizing  that  probably  what

                  5   you say will  cause  serious  dislocation  from  what  they  had

                  6   anticipated.

                  7              MS. SILSBEE:  Would you restate your motion.

                  8              MR. MIL LIKEII:  1 move that council accept the

                  9   committee  recommendation to fund this agency at $900,000

                  10  dollars.

                  11             MS. SILSBEE:  Is there a second?

                  12             MRS. MORGAN:  Second.

                  13             MS. SILSBEE:  The motion has been made and seconded

                  14  that the  Nassau/Suffolk application be approved at the level

                  15  of $900,000.  Is there further discussion?

                  16             DR. IIAMMOCK:  I would like to ask a question about

                  17  32 family nurse practical and critical care nursing patient

                  18  family nurse, that comes to  $150,000.  Will somebody explain

                  19  that to me?

                  20             MR. STOLOV:  Your addition is correct on that.

                  21             MS. SILSBEE:  What do you want explained, Dr.

                  22  Wamm@ock?

                  23             DR. I-.7APU4OCK:  Are they going to  train   practical

                  24  nurses or  what?'

                  25             MS. SILBEE:  We don't know if they're going to do


                  1  anything because they have had a request of  $2  million.

                  2  Jerry, do you know the purpose?

                  3            MR. STOL-OV:  They are separate projects.  One is

                  4  the university base and the other is a community base.

                  5  one is nurse trained - nurse practioner and the other

                  6  is more of a socio emotional thing to  train nurses in

                  7  giving support to families who have  critical  illnesses.

                  8  They are different projects.

                  9            MS. SILSBEE:  The question is, where do they fall

                  10 on the priority list?

                  11           MR. STOLOV: I'll check that  out  on  mv  paoer

                  12 work.

                  13           DR. GRA14LICH:  May I ask a question?  it does not

                  14 relate to the subject at hand, but it does relate to the Nassat

                  15 question.  In one of the other regions,  we find that the

                  16 regional advisory group apparently worked very  well  and in

                  17 Nassau/Suffolk, they apparently did not.

                  18            S. SILSBEE:  That has a long  history.  I think

                  19 they actually didn't have a combined board.  There Hasa

                  20 combined grantee and we made them have a  different  regional  I

                  21 advisory group and a different council. Thre  was  some  overlao

                   l'butthe combined grantee situation did not work out  andthat  was
                  20&
                  23 was about a year ago September or so.  We had joint staffing   @l

                  24 too, Dr. Gramlich.

                               MR. STOLOV:  I have on both projects my paperwork.
                  25


                                                                                 15 0

                     On  both  projects  -  family nurse practioner which was $142,000

                 2   project, it ranks number    11, which the critical care nursing
                 3   project, Number 16.-'. The  dollars  fall  out,if  they  stick  to
                 4   the original dollars submitted, $860,000 off of projects

                 5   1 through  10  and  it  stops at venereal disease.  These

                 6   are well below the level    again.

                 7              MS. SILSBEE:  So'they would fall out.

                 8              MS. FLYNN: If I  may  just  ask,  does  Project  Number

                 9   29, fall out.

                 10             MR. STOLOV:  Project 29 does not fall out.

                 11             MS. SILSBEE:  That project---

                 12             MS.  FLYNN:  They  left  their  priority  and  spending

                 13  dollars the same?

                 14             MS. SILSBEE :Yes.  There is a motion on.thd floor.

                 15             MR. STOLOV:  Mt. Ogden raised the qu6stion, what waq

                 16  the title  of  the   project.

                 17                          It's a computer analysis of whether
                                MS. FLYNN:

                 18  health educational materials.have been written by authors       in
                 19  a leval that is readable by the health care consumer.  $36,000i

                 20  dollars to have  a  computer  anAlyze  all  health  education

                 21  materials so it will be  at  the  4th  grade  reading  level.

                   2            MS. SILSBEE: @@here's  amotion  on  the  floor  to   the

                 23  effect  that  the  Nassau/Suffolk  applications  be  approved at the!,

                 2,t level of  $900,000 dollars.  Is there further discussion?

                 25
                                 (No response)


                                                                            151

                  1           MS. SILSBEE:  All in favor say "aye".

                  2                         Opposed.

                  3                         The motion is carried.

                  4

                  5

                  6

                  7

                  8

                  9

                  10

                  11

                  12

                  13

                  14

                  15

                  16

                  17

                  18

                  19

                  20

                  21

                  22

                  23

                  24

                  25


                                                                                                 1 5 2

        I,IcLane        I                ',IPS.  SIL@-Bl@IE: l@Irs.  Flood, wc,will convev your
                        2  concern    for this complete documentation at what level health

                        3  education material,,;,need'to be prepared for consumability

                        4  capability,.

                        5                As this discussion went on before you finally
                        6  acted, there was reluctance, but in terms of the final actionl

                        7  ',,Iassau/Suffolk now has $900,000.   lle will be glad to work

                        8  with them further on this.

                        9

                        10

                        11

                        12

                        13

                        14

                        15

                        16

                        i7

                        18

                        19

                        20

                        21

                        22

                        23

                        24

                        25


                                                                        1 53

    rm2          i                       SOUTII CAROLINA
                 2             T,IRS. qlLSBET:  rilhe next application to be

                                                                      e the  pr
                 3  reviewed is South Carolina, and Dr. liaber, you ar        imarvi

                 4  reviewer.
                 5             DR. IIABITIR: I must confess
                 6             @-IRS. SILSBEE:  Could vou talk into the microphone,

                 7  sir?
                 8             DR. HABER: I must confess to a larger  degree  of
                 9  confusion  about this protocol than I felt on first  reading
                 10 it. It seems to me that it is difficult  to  reconcile  the
                 11 reviews that we had in June with those that  are  submitted now.
                 12 I wonder if staff could accommodate me to the extent of dis-
                 13 cussinq one of the major issues of the concerns that we had
                    at our last meeting about the involvement of the Gbvernor's
                 14
                 15 office in the -TAP.  Could that be briefl-I clarified now?
                 16            !,IRS. SILSBEE:  Ilr. Van I-linkle?
                 17            l@. .1,IORGA@l:  The Governor is going to resign tonight
                 18            MR. VAIL WINKLE:  Dr. !.Ioslev has recent y sen  us,
                 19 not a series, a whole bundle of  correspondence,  memos.  He
                 20 has been in touch with these  people. I don't think  it  has
                    been resolved.  Negotiations  are going on.  I am not sure
                 21
                    there is@any resolution in terms of getting them to agree
                 22

                    to agree.
                 23
                               14RS. SILSBEE:  ilould you speak- into the microphone.
                 24
                               MR. VAN WI,.,II"LE:  The region originally responded i
                 25
   0


                                                                             1  5  4

      rm.j        1   very vehemently because they felt that the representatives      I
                  2   of the c@overnor's commission had been a T)art of the  --  both
                      the technical review and the regional advisorv cTroun in
                  3
                  4   iihich the decision had  been made, and there  were  none  of
                  5   these difficulties raised,  and they felt that the broject
                      had had Drooer review, but  we have been explained b,,,  nhone,
                  6
                      the council's condition to  k the consideration, but still
                  7                               Q
                  8   felt there had,to be a  resolution  locally.  That  has  not

                  9   yet occurred.
                  10            DR. IIABER: Wello, that is  unfortunate,  of  course.
                      Nonetheless I feel, and mv contention is that the funding
                  12  review that some of the reviewers  have  recommended  for  this  I
                  13  is undulv harsh. I feel that this  has  been  a  good  orogram.

                      in the face of adversity they ha            0
                  14                                   ve tried t  keeD i@ together.
                  15  They have replaced their losses with admirable fortitude.
                  16  I think that many of the  projects  are  well  constructed  and
                  17  conceived.  It seems to me we are criticizing them, or a
                  18  least some of the reviewers  are  criticizing  them,  for  awide
                  -19 varietyi apparently, of disorganized projects, and yet     in thel
                  20  earlier criticism was that it tended  to be too global     And   I
                      not specific enough, so  we are getting them both wavs,    and
                  21

                      .I think this unfortunate.
                  22
                  23            Again, I feel that rqanv  of the projects are
                      well constructed. I feel that  there  is  no  point  in  our
                  24
                      perpetuating our own indecision or worse, contrary views,
                  25


      rm4         1  towards them.  I think thev have had the endorsement on
                  2  pages 104 and following the CIIP J"'IP annual review conference.
                  3  T thin): that they have; it seems to be indicated the ultimate!
                  4  phase-out of this bi modest extensions of some of these
                  5  activities, and I would suggest that instead of the t)rooosed
                  6  level, that they should be funded at  a level of a million

                  7
                     dollars  for the supplemental request that they have come in,
                  8  which is some $473,000 less than they have requested.

                  9           @IRS. SILSBEE:  Dr. Komaroff?

                  10
                              DR. KO!,4AROFF:  I think a series of T)rojects, 66
                  11 projects which are described here, can both be vaaue in
                  12 their individual description and'disconnected, without  anv
                  13 kind of  sIense of cohesiveness, and I  well, that in  fact is!
                  14 my feeling about reading this aTD-olication.  "',e have aregion
                  15 that is a relatively small state in term of its population

                  16
                     which is alreadv funded at a level of two million dollars,

                  17
                     and I have kind of a qut feeling that their supplement ought
                  18 to be closer to $400,000 recommended bv committee than an
                  19 additional million dollars, bringing our  level ub to three

                  20 m-llion

                  21
                               DR. 1',O?,IAROFF:  I will summarize.  As an example
                  22 of my edginess, I will tell you @.7h,,;, I am odav,  Yesterdav
                  23 there was a question as to whether  the PAG had set anv
                  24  riorities among these 66  projects.  Ilow, in fact, there is
                     p
                  25 a listing of priorities,  but you will notice that the rankingi


                                                                                                  1561
     rm.5            I   of the projects within each groun is in exdct ordinal
                     2   sequence  to  the  numbers  of  the  project.  1--@at   I   mean   is

                     3
                         these projects .,7hich are rated one through 12 are projects

                     4
                         number 91, 2, 3, 4,     5,  0,  7,,  etc.  You  have   the   feeling   that I

                     5   unless the@7 numbered    the   -Drojects   after   thev   set   priorities, i

                     6   that  this  priority  rating  is  simply  a  kind  of   --   a   joke.   They

                     7   just took blocks of projects in sequence as-thev appeared

                     8   in   their   numbering   and   gave   them,'quotes,   "prioritv    rating."

                     9   That mav be unfair to the region, and the staff knows whether

                     10  this  region  numbers  its  projects   after   thev   give   them   a

                     11  priority  rating  which  would   be   auite   unusual   in   mv   experienced

                     12
                         then I would be mollified.

                     13                        T
                                               .@II17KLF,: I   doft't know  when  they  number   then@.1

                     14  @ly guess would   be  that  that   is   one of the last orders of

                     15
                         business before they mail to us.          I haven't been  own to

                     16
                         South Carolina in recent months.          Some of  the other regions
                     17  when thev prepare those, they prepare them bv title only.

                     18
                                     MRS. SILSBEE:  They have their own         local      numbering
                     19  system, and then thev relate it to ours.
                     20              DR. KOI-4@T-ZOFF  It may be nothing, but I had a feeling

                     21                                                      ootlv connected,
                         reading through this that it was kind of Q

                     22  over  ambitious,  in  a  region  that  was   alread-,,   quite   well

                     23   funded for its size, and I would he reluctant to bring             their

                     24   level up to three million.

                     25              MRS. SILSBEE:  We don't have a motion on the floor.


                                                                             1-@7

      rm6                      DR. l'OT4AROFF:  Could I move five hundred thousand?

                 2             DR. ".'A!,UIOCK: I second that motion.

                 3                            The motion has been made and
                               24RS. SILSBEE:

                 4  seconded that South Carolina application be approved   at the

                 5  level of $500,000.

                 6             Is there further discussion?

                 7             (@io resoonse.)

                               MRS. SILSBEE:  All in favor?

                 9             VOICES:  Aye.

                 10            MRS. SILSBEE:  Opposed?

                               (No resoonse.)
                 11

                 12            MRS. SILSBEE:  The motion is carried.

                 13

                 14

                 15

                 16

                 17

                 18

                 19

                 20

                 21

                 22

                 23

                 24

                 25


                                                 TEV.AS
      rm7
                 2               !IRS. SILSBEE:  If we go alphabetically, we come
   0
                 3   to Texas.

                 4               MRS. FLOOD-. 1,7e are going to Texas?
                 5               MRS. SILSBEE:  Mrs. Flood   is going  out of the room.
                 6               lias the Texas pink sheets,  or white, been distri-

                 7   buted?

                 8               MRS. MORGA-N:  No.

                 9               MRS. SILSBEE:  Let's distribute them.

                 10              Off  the  record.

                 11              (Disdussion   off the record.)

                 12              MRS. SILSBEE:  On the record.
                 13              You will recall that the May    application from the
                 14    Texas regional medical program included requests for funds         i
                 15    for a series of contacts of which the idea,,; were spelled but
                 16    in the May application, but the specifics regarding     who was
                 17    going to carry it  out and what institution and the    amount
                 18    for each contract  was missing because that was going through
                 19    their local review process at   the time that it   was cToing

                 20    through the national review -process.
                 21              Council considered   this application and decide
                 22    that in general the goals and objectives of the region and
                 23    the general management of the region seemed to be sufficient       1
                 24    to enable council  to delegate to the review committee which
                 25    at that time had  felt that it was going to meet in June or


                                                                           1 5 9

     rmB            July, to delegate to the committee the authority to look at

                2
                    the individual project proposals and recommend whether that

                3
                    money should be released or not, so in effect council made

                4
                    a recommendation of -- well, let's see if I can find it now.
                5   "hey recommended that the Texas application be funded at

                    the requested level of two million three
                6                                            hundred and thirty

                7
                    three, five hundred and fiftv-one, pending the satisfactory   i,
                8   review of the specific contract nronosals by the July review
                9   committee.  This was to enable Texas to go a-head because it
                10  was a non-profit corporation that had ,-;anted to do their
                11  thing in the 12 months, and thev didn't want to slow them     I

                12
                    down in that process.
                13            The July committee was not able to meeti and they
                14i had met in Atgust, which was yesterday, and they discussed.

                15  the application.
                16                                                    pick up
                              Now, Mrs. I-lorgan, I a,- going to let you

                17  from there.
                18            I-IRS. MORGA-,I: Our nink sheet that has now turned
                '19 white, the application for funding for the various contracts
                20  of one million four hundred thousand dollars was what was
                21  left over from our meeting in June.  m@he review committee
                22  recommended the use of one million dollars.  The reviewers
                23i were still apprehensive regarding the monitoring  capabilities
                  i                                                     -
                24  we,have had, and I don't believe the review committee had this
                25  information, and this is that they are going to activate their


                                                                              16 0

    rm9            1  review committee which will consist of on this      Plus   members
                   2  from the  RAG.  The concern   of the revi-e%.i.committee  was  health
                      professionals  reviewing  these  projects.  if  you  are  familiar  i
                   3

                                               is practically  all  health   professionals.
                   4  with the Texas RAG, it
                   5  About 95 percent of them are ohysici.ans  on  the  RAG,  and  theseil
                   6  physicians are going to be the  ones,  and  this  is  from  the
                   7  material we have received,.T@iho will be  on  the  review  committee.
                   8  There is no question in my  mind  but  that  there  will  be  health'
                                                                                          I
                      professionals  reviewing  these  area  contracts.  They   have
                   9
                   10 sent in their form, which is  a  six  page  form.  It  has  to be

                    'filled out monthly on the various     contracts and  s  nt  in- will
                                                                           e

                   12 be reviewed by their committee.  I    havein my mind  no doubt
                   @13 that these will  be  reviewed  bv  health  professionals,  and

                      I would like to move that  the  level  from  June  meeting  of
                   14
                   15 one million four hundred thousand be returned to the Texas

                   16 RMP.

                   17           MRS. SILSBEE:  Dr.Schreiner?

                                                                                    t
                   18           DR. SCHREINER:  I  am  a  little  bit  confused  abou

                   19 the back and forth thing and the old grant.  If     you   could

                   20 clarify that a little bit?  In other words, are     you  --  I

                      didn't hear  the  discussion  yesterday  on  this  Darti6ularone.-  1
                   21

                     'Ate they proposing any additional new money?
                   22
                                MRS.  SILSBEE:  ilo.  Well,.they  are.  I  was  going
                   23
                      to ask Mrs. Morgan if she would mind rewording her motion.          1
                   24
                      We gave them an award  for  two  million  three  hundred  whatever
                   25


    rml 0            it was, and we  restricted  1.4  million  dollars  pending  the

                 2
                     satisfactory review, so in a  sense  they  can't  spend  that

                 3
                     1.4 million.

                 4
                                DR. SCIIPEIIIER:  It is called internment.

                 5              MRS. SILSBEE:  Internment for a reason.    The action@

                 6   of the committee yesterday would release one million dollars

                 7   of that.  Another  four  hundred  thousand,  presumably,  would

                 8   come back here, and they would not  be  allowed  to  spend  it.

                 9              MRS. @IORGIU-1:  I-lay I change my motion to state

                10   that we released to Texas R-NIP one million four hundred

                11   thousand dollars of impounded funds to them?

                12              DR. PAHL:  @,7e remove al!l restrictions.

                13              MRS. IIORGA:14: In other words,  restrictions  are

                14   rermved from Texas.

                '15             DR. Wpil-MOCK: The restricted finds  is  what  you

                16
                     meant,   and not impounded.

                17              MRS. MORGAII:  Had this one million four hundred

                18   thousand dollars been released in June    to Texas,  they  were

                19  not planning on coming in on this cycle    four, anv money at

                20   all.

                21              DR. SCHREII@@vR:  So this comes out of  the  84,  not

                22   o ut of the 20.  Thatis what I %,;anted.

                23              I-ILPS. '.IlORG@il:  It comes out of that money.

                24              MRS. SILSBEE:  The mbnev that has already     been

                25   a%-7a2!ded.


                                                                                                   1 6 2

        rml 1         1                 DR. SCIIREI@CTER:     I @.7ill second that motion.

                      2                 MRS. SILSBEE:   The       notion has been made and secon,@'e@-

                      3    that the restrictions on the           contract funds in the Texas

                      4    a-v7ard be lifted.   Is there further discussion?

                      5                 MR. HIPXOTO:   Ouestion.

                      6                 TIPS. SILSBEE       All in    favor, aYe.

                      7                 VOICES:   Ave.

                      8                 MRS. SILSBEE:   Opposed?.

                      9                 (No response.)

                     10                 MRS. SILSBEE:   The motion is carried.

                     11

                     12

                     13

                     14

                     15

                     16

                     17

                     18

                     19

                     20

                     21

                     22

                     23

                     24

                     25


                                                                         1 6 3

     rml2                                   VIRGI@IIA
                 2            MRS. SILSBrr,,:    we go to Virginia, and Dr.

                    l@latkins.
                 3
                              DR. T/7ATKIIIS: I have no problem with Virginia.
                 4
                    This is Virginia, and Dr. Perez has changed the face of  the
                 5
                    whole program.  !.,@liss Martinez had a question.
                 6
                 7            MRS. SILSBEE:  Miss Martinez
                              MISS MARTINEZ:  In thinking over the project
                 8
                 9  descriptions, I notice that a great manv of the projects
                    are reallv supportive or extending grants to CHP's for
                 10
                    planning for the normal planning of CHP programs, which I
                 11
                 12 am not sure is terribly wise, even if it is legal.  In any
                 13 case, I think the committee recommended nine sixty-three?
                              MRS. MORGA@I:  It is nine sixtv-three eight sixtv.
                 14
                              MISS P4ARTINE.7i:  And I would like to reduce that
                 15
                 16 sum somewhat to seven-oh-seven seven fifty-nine.  I just
                 17 went through the projects, and eliminating things like number

                 18 48 which is a grant to a ClfP agency for a

                              MRS. SILSBEE:  Miss Martinez, in terms of iyhat, o
                 19                                                           y u
                 20 are recommending there, have you, are you aware, that a
                    message was sent back to the regional medical Programs
                 21
                    concerning the need to do -- or to get geared up for health
                 22
                    resources planning and that this should be done in collaborated
                 23
                 24 with the CHP agencies?
                 25           MISS IIIARTINEZ:  No.


                                                                                1 6 4

       rml3       I             MRS. SILSBrl',: And this was a definite suggestion

                  2  that was given to the regional medical ;Dr'ogram back in I-larch
                  3  or April, sometime  .'l'lke that.

                                                                       it
                  4             !IISS PIARTI'@IEZ: All right. It doesn    seem to me

                  5  that anNi of their projects are  terriblv innovative or foniardi

                  6  looking,  but if that is  with  the IU4P

                  7             MRS.  SILSBEE:  No.   If you don't thinkthe activities

                  8  themselves, that is  fine,  but  as far as being legal, this is

                  9  something they have  been  sort  of urged to do.

                  10            MISS MARTINEZ:  All right.  Are you   satisfied?

                  11            DR. WATKINS:  Yes.  When we were on   site, we were

                  12 very hard  on them, and I feel that Perez has done a good  ob
                  13 lin changing that program.  Ile has changed the PAG, he has
                  14  increased the minority representation, minority input,.in   the

                  15  urban areas, and I think I would like to see it  remain    as is.@
                  16            MISS MARTINEZ:  Okay.  I will reaffirm the comLmitte64is

                  17  recommendation.

                  18            MRS. SILSBEE:  lb there a second?

                  19            MRS. f-IORC-YAN:  I am seconding.

                  20            MRS. SILSBEE:  The motion has  been made and seconded

                  21  that the committee recommendation on the Virginia application

                  22 to approve the application at the level of $963,860 be approved,

                  23 recommended.

                  24            Is there further discussion?

                  25            (No response.)


      rml 4                    I-IRS. SILSBEE  All in favor?

                 2             VOICES:  Ave.

                 3             MRS. SILSBEE:   ODposed?

                 4              (@io response.)
                 5             MRS. SILSBEE:   The motion is carried.

                 6

                 7

                 8

                 9

                 10

                 11

                 13

                 14

                 15

                 16

                 17

                 18

                 19

                 20

                 21

                 22

                 23

                 24

                 25


                                                                               IL 6 6

      rrll5                                 1-7ESTEP-q PE@Z'@@SYLVAl,4IA
                                TIRS. SILSBEE:  Now we will go to Western Pennsyl-
                 2

                     vania.
                 3
                                MISS @.IARTI'.NEZ:  In that case I would like to do
                 4
                 5   the very same thing on @,.Iestern Pennsylvania because  the
                 6   number that I cameout with was  about  a  hundred  thousand
                 7   dollars less. I had subtracted  number  49  from  that,  so it

                 8   comes out'nore or less the same.
                 9              MRS. SILSBEE:  ',,,,Iould you move? Would vou put the

                 10 dollar in?
                 11             MISS IlAlrj.IIIEZ:  Four hundred fifty thousand.
                 12             MRS. SILSBEE:  Is there a second?

                                MR. IIIPOTO:  Second.
                 13
                 14             MRS. SILSBEE:  The motion has been made and
                 15  seconded  that the Western Pennsylvania application be   approved
                 16  at the level of  $450,000.  Is  there  further  discussion>

                 17             MRS. I-IORGAil:  Question.

                 18             MRS. SILSBEE:  All in favor?

                 '19            VOICES:  Aye.

                 20             MRS. SILSBEE:  All  opposed?

                 21             (No response

                                MRS. SILSBEE:   The motion is carried, and that
                 22

                     ends the  review of the applications.
                 23

                 24

                 25


                                                                                     16 7

                   1             DR. GRA14LICII:  May I open up one more small subject
     rml6
                   2             DR. PAHL:  We have   that as well-as Mr. Ogden's

                   3  resolution.

                   4             DR. GPM@ILICII:  I mean  relative  to  this  project,

                   5  specifically ilississid
                                              Pi.

                   6             MRS. SILSBEE:    Yes, sir?

                   7             DR. GRMILICII:   There is a very strange request

                   8  and it is  kind of     the  review committee didn't pay an

                   9  awful lot  of attention to it, a two million dollar, roughly

                   10 tvio million  dollar  request  for  hypertension  screening  and

                   11 treatment  program  including  one  million  dollars  for   salaries,!
                   12 and included in  that  salary  scale  was  82  public  health  nursesi

                   13 who presumably are already  on  deck,  so  that  the  RMP  funds

                   14                                                                d
                      as far as I can determine from the grant.request         e   use
                   15 simply to supply what is now being spent bv the state health         I
                   16 department.  Included also is $500,000 plus or mints for
                   17 drugs for treatment of some possible 11,000 hypertensives.

                   18 lloxi, the review dommittee's attitude is, it is a poor state
                   19 and they have got lots of blacks and they need all of this,

                   20 but there  was  no  Darticular  attention  paid  to  the  construction

                   21 of the  budget  which  included  apparent  substitution  of  MIP
                   22 salaries for what Are now state     health department salaries.

                   23 That is one item.
                   24            The other item is, if the treatment to be applied
                   25 to the suspect hypertensive or to discover hypertensive which


                                                                                  1 6 8

       rml7.           is to be administered to    the  county  health  officer  in  each

                   2
                       counter,.  Now, this poses  a problem of practice of medicine,

                   3
                                                                                Ls  IS
                       if you will, by r@    funds.  If the council feels th'

                   4
                       appropriate, this is   fine.  All  I want to  do  is  bring  it

                   5
                       to the council's   attention to  make  sure  it  is  considered
                   6   appropriate.  This has to do with Mississippi only.

                   7
                                  MRS. SILSBEE-  I's there discussion on this uoint?        1
                   8              DR. KOIIAROFF:  Can staff enlighten us as to whether
                   9   this will  supplement the  resources of the state health
                 10    department, or merely supplant them?

                                  MRS. SILSBEE:  Mr. Van Winkle, there are two
                 12    issu
                           es here, in case you couldn't hear.
                 13               MR. VAN WINKLE:  I heard.  I    was trying to hide.
                 14    My answer  is, no, I don't know.    I read the application.

                 15
                       We  did  ask that thev include the full, when they sent in,

                 16
                       hot the center form 15.  That is all vou 1"70uld    have had.
                 17    I presume that Dr.  Vaun  looked  at  it,  beinq  the vtimary
                 18
                       reviewer.  He  aid  not  discuss  that;  however,  as far as
                 19    practice of medicine,  we  have  been  in  the  habit of  doing  it
                 20
                       for  years  on  demonstration  projects.  I  do  know that they

                 21
                       proposed to take these over and continue it after this first         1:

                 22  'year funding.  The government has put already a line       Out   of
                 23    its budget to support it, but I do'not know if these        nurses

                 24    are on bid, or if they intend to hire new ones.  I just don't

                 25  know.


                                                                             16 9

    rml8                                      Dr. Komaroff?
                              ,'4RS. SILSBI',I'@:

                 2
                               DR. KOI,IAROFF: I  looked  at that  application

                 3
                    last night after our discussion, and I had the impression
                 4  that it was an unusually well documented request, but probable,,
                 5  what was going on was that P@IP money @,7as offsetting certain
                 6  expenditures that were Dart of the state department of public!
                 7  health this year, but that the quid pro quo was  that  the
                 8  government was going to take over the support of th e program,
                 9  in future years, and that that seemed to me  a  reasonable
                10  bargain; consider the importance of this problem  in  that
                11  state medically.
                12            DR. GR2UILICH:  T am satisfied.  Thank you.
                13            DR. PAHL: I have two items of business before

                14  we adjourn.

                15

                16

                17

                18

                19

                20

                21

                22

                23

                24

                25


                                                                                      1 70

                                 rl"he first is that the action which ha,@' ',:)een
                       ta'--on,          made 1) y this C'oui-c-i.1 result   a total-
                  2
                       --PCO.Mlrlpncled dollar I'c-vel of @,27,1-5@1,37,@' ,,7hich is @597,n@O-@
                  3

                                          c
                  4    above the total re om,,nendei to you   D  t
                                 41) o4 t@                   currc(: %,:it@l the Co.-@-@@-L'--tee s
                                         j,.e regions you con
                  5
                       recommendations five regions had some amount a@,deCi to t-e
                  6
                       committ6e's recommendations, and in t@.7o cases, \,,our recc-.-endati

                  7
                       were to reduce t.,'Le Committee's reconj-,enc-.at;-ons.
                  8              @Lhe second item of 1-usin-ess I T..-ould l@"-c to --o:-.e
                  9    back to, unless there is discussion on that              !'Or,.arc
                 10                   i,,,n!iT@poFr Does that mean @,.,e apprc@.,e less
                       money than is available to spend?  Ilo%,; does that affect
                 11
                       polic%, @,ye approved earlier today @bout prorating a kin,4" of
                 12
                 13    an extra supplement after the fact.
                                 D-TZ. PAT'          in jus- fire! SI_a,te al- -nese
                                             I,,7e are

                 14
                       levels.      ended the day verv harpil.v.          action ,,c,-,

                 15
                       took this morning and the recommended @iollar le%7c! is

                 16
                       going to permit us to distribute all of          non.,@es ana
                 17    depending on %-.-hat ll,apTDcns over the course of t,e :.alIL "e
                 18    T@,7ill be able to - with the formal order that you
                 19    be able to accommodate any chanae there.
                                  So, managerially everything is okay.
                 20
                                  Dr. Janc,,-.?av?
                 21
                                  7,  J      @,r I @,ias just checl:inc7
                 22                   I' T,   T- I                 am not  so
                                              .'@,,cn you --r,                s Lz- e     s

                 23    are in such good shape.
                 24                                @N7as checking my o,,    t@
                                                                       .-rn ma ..cmat@--S

                       because  I thought ..ze had added $-ilvl,.qOO, but it is suc-
                 2,5


                                                                             171

                   a small amount of difference, onl,,, r3On,nOn.

                2
                              D'Z. PZ-@'@TL: l@-  is a difference,    will

                3
                          tal;-,- it Out Of F,-Iith's salary, or give it to '-,er.

                              T,7e have one o' these fantastic data erratic
                4                          L  i@
                5  aides on sale, or something, and there is  voll@-aae fluctuation
                   and durina one of i.@y afternoon telephone calls, I found
                6
                7  L"dith sitting poking these l@evs.  At the same time, doing
                   evervthino in lon-7 hand '--ecause with voltage fluctuation
                8
                   you don't end with the same digits vou should.  So, I think
                9  we better go back to lead nencil and naper.
                10            T gather the correct fiaure is @27,349,054.

                11 Another one of the rumors.

                12            T have received information, also, again, I don't

                   know whether it is a rumor or not,but presumably it has
                13
                   been announced out of the 'I-7'lite Fous,-- that, as ,,ou I,-no@-,,, there
                14
                           announcement either at 9:',)O -- and no@,, some pec-le
                15
                   say 8:30 - and Congressman @"ord is to undergo his inaugeration
                16
                   at 6:00 p.ri.. toi-,orro@-7. I guess we ,,iill all learn as to
                17
                   go to airports v@heti'ler this is rumor or direct.  This was
                18
                   given to me as a statement.

                .19           The other item of business which I think we are

                20 on more firm ground ab out is to reconsider the resolution

                   that @Ir. Ogden introduced, and which we tableO until hopefully 1
                21
                   you had an opportunity to  look over.
                22
                              The su.---,iarv material pertinent to the resolution.1
                23
                               I think @-,e have distributed this to each perso
                   .-Ir. Ogden,                                              n.
                24
                   Perhaps, vou would lil-e to T-.ake some comments.
                25            @-,TR. OCDNT: I hope that many of you have had an


                                                                                       1.7 2

                      opportunity to lool,. at the material headed "Summarv of the

                      'Tational Yealth Policv 1'31 annin(T and  P,,esources  Pcvelopment
                  2

                      Act of 1074."
                  3
                                 Dr.  l'omaroff, who is sittinc
                                                                  next  to  me  here,
                  4
                     Ihas probably  gone  through  it  a  little  more  carefully  than
                  5
                      .many of you ana  underlined the  areas  and  I  will  call  on

                  6
                      him just in a few moments  for  his  comments.  But.,  in  ooincr

                  7   through this piece of legislation I found no place where I

                  8   could find an thin  g that fitted the function of any existing
                                    y

                      regional  medical  program,  save  perhaps  some  of  the  programs
                  9
                  10  which are in  fractions  of  states,  such  as  some  of  those
                      perhaps in the State of 1'4'ew York.

                                 If the C@ovetnor of the   state were to   decide   the
                  12
                      health service area, for example,     @.,,as 1,Tassau/suffoik - perhaps
                  13  TIassau/Suffoll@ P@IP could become the health service systems
                  14  agency in that particular area.      But,  this  particular   piece

                  15  of legislation while it seems to     encompass Hill@Button-almost

                  16  completely and you will find that  comes  un  on  PacTe  5  on  the

                  17  description of the health resources development          the   only
                  18  place that I find M.IP  perhaps  even  suggested  is  on  Pag6  6
                      under Area Health Services Development Fund.
                  19
                              ,,,Tow, remember here we are  talking  about  a  health
                  20
                      system agency.  T_,qoij, health system agency  is   a   nonprofit
                  21
                      private operation on a local or area-@,,7ide   basis.   Buti   this

                  22 is a  health  service  area  population  of  less  than  half  a
                  23 million.  It  is  not  permitted.  It  ban  be  up  to  about  two
                  24 million, as  I  recall  air.  ?,ubells  comment  yesterday.  But,, it
                  25  would  encompass-the  health  service  area  would  encompass  an'V


                                                                                              1 7 3

                4
                       Istandard metropolitan statistical area,.-@l-l-,,ich is entirely

                    2
                             a boundry      it --,-in cfo over state 14-nes, but there are

                    3
                                     I understand,    l@O's of S7'S.-@  s in the United
                    4  IFtates.   So, that that %@7e are loo-incT     a
                                                                          iier,@- is an area
                    5  1',I--altl-i services develOT)Ment fund          is  cToing  to  be  a
                        localized thing, and indeed -v,,e 'Lind  k--'.-a-L.  the  crant  that
                    6
                        can be made for the development ..iithin one of         those on    page      i
                    7
                        2 - no single grant or      contract inax,, e:.,ceed $75,000 be made
                    8
                        for more than ti,7o years.
                    9
                                    It Simply talked a.-out t.-c area health services

                    10
                        lqbvelor@ment fund.  This is %,,-hv.I have n-oposed this resolution
                    11  That this piece of legislation - it be          suggested that this
                    12  be amended to give each state the stal@-,ator%, and financial
                    13  support to maintain a separate health -,?ste-is development
                       laaencv on a state-v7ide basis.        @o,  -..a@- at least @@,e leave
                    14
                        something similiar to the 7.,',!'D's       have toda-,,, wil-lo can Perez,
                    15
                        a state-iiide mission or function.         1,.nd, indeed, ijc could
                    16
                        even sav, goina beyond state 'in s.           -ut@-, I susT3@ect  the
                    17
                        kind of legislation ,ee are seeincT       cci7i-g up here   is going to
                    18
                        be limited to state boundries and         -,at-'Lol-.al health insurance-
                    '19 mav indeed have in it have some sort of state-wido function                   i

                    20
                        mechanism.

                                                               OlUt4on and    in it, the
                    21              So, I propose this res
                       ilsecond ,-)art of it I have said,       T.- - -@ -c-.--.,ents that proceeded
                    22
                         li-@ --resoltuion and the       lution  4-=cl-'   be   transmitted   to   thei
                                                    reso
                    23
                        members  of  the  liouse  Interstate   an,@   l@oreign   Commerce   ComLmitteei
                    24
                        --  and  by  that  I  meant  to  encor,,cass  the  comments  that   Imade
                    25
                        in  the  letter  from  Senator  I'l@agnuson   to   Senator   Nennedy, @-,-hich1


                                                                                 17 4
              5

                    I read to you earlier-and which s'A iotild  an
                                                                lDear in the transcrin,@
                 2  o'L the minutes of this mecti.ncT. I  can  give  you  that letter

                 3
                    if you @..,ould 1;-r-.c to r.ero-x it. I Gould lil-e  to  have it back.

                 4   Dut, I t,,ill be happ
                                       -.y to hand it   to you.
                 5             I do recommend that we  do this.  I  am  quite

                    concerned  that the kind  of  legislation  that  we  see  coming
                 6
                    out   simplv does not recognize the place that regional medical
                 7
                    proarams have come to serve on the @erican scene.  And,
                 8
                    certainly many of us who worked with this program since its
                 9
                    enception eight years ago this Spring feel that it has accompl.4s
                 10 far more than it has been  given  credit  for  and  that  it  has
                 11  the potential to accomplish a qreat deal that is q6i-ngto
                 12 bb necessary  in  order  to  make  national  health  legislation
                 13 function ,7hen it begins  to  deal  with  the  verv  complicated
                    undertaking O@4 the delivery  of  services  and  the  deliverv  o
                    I                                                             f
                 14

                    care.
                 15
                               And it  seems  to  me  that  unless the  providers   of
                 16
                    !this Nation are given  an  opportunity  to  make  their  in  put
                 17 1
                    through something like P,-,IP, that the success of national
                 18
                    health insurance is Jeopardized and I hope that we are going
                 19 to be able to have the continuation of somethinglike the

                 20 regional medical programs
                 21            DR. PA!zL-. Thank you, vcrv much I P-1r. Ogden.
                 22            There @.7as a motion introduced and seconded, I think
                        nossibly..
                 23
                               DR.            Second.
                 24
                               DR. PAITL:  Thank youi  Dr. 't,@lammoc
                 25            I think there should   be room for discussion by


                                                                                                         17 5

                           Council    on    this     important topic.

                      2
                                         Dr. l,,o-,Aaro'lcf?
                      3                             AFF      As I   look through      this, the Bi
                                               O'@AR                                                  11,
                      4    the thing     that      concerns me is   that all of the various
                           aaencies which      would     he created bv the Bill seem to relate
                      5
                           to planning and to the monitoring             of facility expansion
                      6
                           within  Ithe region.   That there is          no   sense   or    very    little
                      7
                           language that would relate to what you might think of -as
                      8
                           anoperational arm       of     such an aacncy     or    group    of    agencies
                      9
                           to    actually    do    demonstration    projects    in    health     services.
                      10   And, the funds that are alluded to 314a and b funds,  I
                      11   believe,   are    by    title    9,    Planning    Funds.    Not    operational

                      12   funds.
                      13                  So, as I understand your motion'Bob -- I am
                           unclear about your first -- the first component of it.   Do
                      14
                           you-mean that this operational agency would be independent
                      15
                           of   the   agencies   proposed    in    this    Bill.
                      16
                                         "-IR. O('@DETT:   Yes,  I do.
                      17                 DR.   @vO@iP@ROFF:  That    is    reall.y the nub of the

                      18
                           question.      1-7ho reports to who?   I believe that there ought
                      19   to be a separate and clearly defined and funded operational
                      20   Arm that looks like rl,!P.   I am bothered, though, at the
                      21   prospect of having that agency wholly separate from the
                           leadership, or whatever,  supervision of the planning agencies.j
                      22
                                                             I ',Vill vi6ld to you.

                      23
                                         DR. JA@,'T',I,@7AY: 30 seconds?

                      24
                                         DR. 1,7jv@,IOCK:    30 seconds    of my time.

                      25                 O@R. PAIIL:   Dr. Janev?ay.


                7

                                 DR. JA,1,71'1-7AY: I would sunport, quite frankly,  the
                    Ieparation  of  the  planning  function,   particularly   the
                  3   strategic nlanning function, to use a managerial term, which
                  4   is  im7Dlicd by the summary of the legislation      proposed
                  5 ile islation.
                        9
                                 I thin!, that to  have  planning  and  control  -  when
                  6
                      I say operational control      the  implementation  mode   of
                  7
                      any kind of  management  function  in  the  same  agency  is courting
                  8
                      disaster and, although, I  -v7OUld  agree  with  you,  Tony, that
                  9
                      there  has  to  be  a  responsive  inter-relationship,  that there

                  10
                      is so much to be oained by having the planning function
                      separate  from  the  implementation  function.  That,   I   would
                  12  certainly be Prepared to support a resolution of this nature.
                  13             DP,. YO'.!'-..rZOFF:  ',,7hv do you feel it would be courting
                      disaster. Are ,7ou thinking  back  to  e-,,T)erience  between
                  14
                          and Ci"@P?
                  15
                                 DP,. JA" ET-.7,t@Y: rO. I am thinking in  terms  of  the
                  16
                      management function and there is room for      disagreement    in thisi
                  17
                      but if vou read L@,nthony's book oh Planninq Control Systems,

                  18
                      the  possibility  of  the  planner  becoming  so involved  in   the
                  19  plans  that  the  implementation  becomes  impossible,  or   that
                  20  there is no outside regulation of it.  It       uts too much.
                                                                     p

                  21  power in one place.
                                       there are admit4@-cdly some managers who disaar6el
                  22
                      with that  and sav the  planning  control  ought  to  be  in  the
                  23
                      same agency, If  you  set  planning  or  isolate  it  you  develop
                  24
                      thin]-, tanks that don't,clrain anywhere.

                  25
                                 But, if you  put  planning  and  control  in  the  same


                                                                               1 7 7

                     aacncy, you go to the opposite ex,-remE,- @@,here vou thin], that
                 2
                     @D@, creating an infinite niiL-ibc-r of i.,ivstacks @,:ill give- you

                 3
                     an infinite supply 'o'f ncej!cs.
                 4                                  s @,,o-l @.,avs, but the for
                              TIT>. KOP'Ai@OFF: It cut
                 5   the reason iou just cited, it se@-'s to me that the providers
                     would more likely be attracted to these kinds of o'Lanning
                 6
                     agencies, and therefore, -the doing of- reasonable planning.
                 7
                     If there were some - or more tangible operational components
                 8
                     that they could be involved with.
                 9
                            1 think one of the problems i-7ith CHP has been that

                10
                     the T3roviders have found it unattractive because it was

                11
                     so abstract and so unrelated to subsequent tangible accomt)iisnt
                12  ments and if there could be some iLnitinci of this OT3erational
                13   arm,and the planning arm, so that ..i,',at the operational arm
                     was doing didn't in fact thv,latt the rational plans of the
                14
                     region, then it would seem to me to r,.akemore sense.
                15
                               DR. JA-@7,ETo7AY:  T,,-,hat I @-7as trying tC indicate is
                16
                     that I would hope that the planning -Function would not thi-7art
                17
                     the normal-operational arm.
                18
                               MR. OC-,DEi@i:  I think that this, perhaps, could be

                19
                     corrected by having the development component also report
                20   to the state health planning and development acencv, which is
                21   assumed to exist under this piece of legislation.    It has
                     to come into being.  --@ut the legislation just simply doesn't
                22
                     spell out sufficiently how that development is going to tA'@,e
                23
                     place, except for these very local agencies.  And, I would
                24
                     like to see drafted into this piece of legislation the

                25
                     provision that there be a separate health systems development


                                                                             17 8

                    agency .,7ithin the state health nlannina development aaency
                2
                    structure.

                3
                                            llu+- it would rep
                              L)P,. l,'O'4A,@OFF:            ort to the state
                4   health planning aqenc,,7. I @,,ould support that.

                5
                              .,,R. PGD@-17: Idon't see how it could do otherwise.
                6   I don't think it would report to a central body in !,,7ashinaton,

                    D. C. It would have to be on a state level.
                7
                8             DR.          I have been somewhat disturbed since
                    I have had the privilege and the opportunity to serve on
                9
                    this council, and in particularly in fact seeing the ministries
                10
                    fractured or other number of states or group, region - what
                11
                    ever you want - try to plan a health. program.  It see@-s @o
                12
                  ,me to be a rather difficult situation to put two or @-',-ree
                13  states on the 1,7estern side or the Eastern side together to
                14  wed -them, in the @,'ilorth and @-outh - to wed them, in o-.e

                15  program.
                16            I don't see how this is possible to develop any
                17  worthwhile health svstem care delivery, or whatever you want
                    to call it, unless you have it on a state-wide basis and
                18
                    you have all the components of all the agencies that are invol  e
                19                  a system.@iorking .. toqether4  Because if YOU
                    in this kind of

                20
                    are going to put it in one community or another community,
                21  or 15 different projects, unless it comes under one    tells,
                22  they are going to ',-,e in difficulty. I I)as-c this on ..!-at
                23  little  hit that I know about the operation of the regional
                24  medical program, and from the standpoint of a state-@-,-ide
                    operation that something has come out of this.  But, if
                25


                                                                                    1 7 9

               1 0
                      it gets dissolved -- and I haven't read this -- and if T
                  2
                      read it i am qui4k--e sure I -.!ouldq't l@-,no@@., what Ircaalna.

                  3
                       ray '!iave to read  it '*-aciz the third or the .fourth time
                  4   or the fiftli  time, and -,nay not kno@,,7 what I @,!as rcaa-ina.
                  5                 oi,,,,i T)ersoTial feelin(7 is that I am -Iro'-,abl-,, too
                      close to  the trees to see the forest,  or  the  forest  to  see
                  6
                      the trees. Or i..,@hatever you  call  it.  rorest-trees,  trees-
                  7
                      Lorest.

                                 !,ITZ. OGDE',':.7:  Woods.

                  9
                                 DR. I,.7:LVUIOCIT,": I think that, as @ir. Ogden has
                  10  pointed out and someone else,  that  people  don't  knovi  about
                  11  the good that the i@l"P has done and I think it is TDretty
                  12  hard to get across to people @,lhat'@7,"P is and I am sure
                  13  that there are a lot of -nil-,7si.cians that do not unc:ers'@-@-@-id
                      the operation and the mechanism o--F                       S---e o--
                  14
                      them feel that it has not been Worthwhile       but I Personally
                  15
                      feel that it has been worth@,71)ile and I think this resolution
                  16
                      ,here drawn up !--)y 'Ir. Ogden. I ,,,ant to conqratu'Late him
                  17
                      for the foresight and the merit and the courage and the
                  18  good  common sense and judgment to draw  this  up  and  I  tlin':
                  19  we need to support this resolution and somehow or another

                  20  get it across.
                                      effective it 1.7ill    as far as Concress is
                  21
                      -concerne(,', I r@'on't
                  22
                  23                         I:., there further discus-lion or
                                         4                                                  1
                                        @iA  ,F:             --e to add scm     anguaae
                                      T< (7  @@
                                  DR.      @,OT'  I v7ould lill

                  24
                       that makes it clear that    this health systems development

                  25
                       agency will Support demonstration health services T)rojec@@s.


                                                                                  180

                                                                                   n
                                I don't tilin--
                                               @hit health services is written i

                  2
                      Iam not  sure 1,- is quit
                                     4         c clear how this agency would be

                  3
                    Idifferent from  the planning agencies that are    in the current
                  4                                               tate that   this
                      '-)ill, and se--ondly, I tliinlz we ought to s
                  5  separate agency would report to the state     health plannina
                  6   and development agency that is described in the Bill.
                  7             DR.,-J-,@l@IM-7AY: Would you read it to us?
                  8             DR. KOI-IAROFF:  Read  the  proposed  language?  I
                      haven't written it yet, but I will.
                  9
                                How would this be: "'.resolved:  That the Congress
                      in adopting HR 16204 or similar legislation give to each
                  10I
                  11         he statutory and  financial  support  to  maintain  a
                      state t
                 .12  separate health systems development agency which supports
                  13  demonstration projects and health services,  This agency
                  14  would report to the state health planning and development
                      agency, or siImilar independent      I am sorry    agency
                  15
                      and be devoted exclusively to such work.  And be it further
                  16
                      resolved.
                  17
                                 DRo WAZLt-,IOCK: Dr. Komaroff, I  am sorry,, but you
                  18
                            tting too wordy  there.  l@7e  are  going to  get  lost
                      are ge

                  19
                      because I think the first sentence-what you say - the health
                  20  systems  development  agency  on  a  state-wide basis -- and I
                  21  think  health  systems  development  aqency  is very comprehensive.,

                      TO  me it is.
                  22
                                 DR. IIADER: Ilight I suggest Health system development
                  23
                      and, demonst ration agency.
                  24
                                 I'lP,. OGDEN: On astate-wide  basis  for  similar
                  25


         2
                     independent commissions in a publicly accountable i,7ay
                 2   in reporting to the state health and development agencv
                 3 iand  devoted exclusively to such work.
                              DR. 7@'O@,!Ar-,OFP All right.
                 4
                              DR. T@ili-ii;IOCK: I yield.
                 5
                              DR. P,@-ITI,: I-lay we have the final @vording before
                 6
                     we have the question?
                 7
                              @'IR. OGDEi@,,: The ;.7av that I have this drafted
                     at the moment reads "Resolved: That the Congress"in adopting   1

                 9
                     IIR 16204 or dmilarlecjislati-on g-ve to each state the statutori@;
                10   and financial support to maintain a separate health systems
                11   development and demonstration agency on a state-@,7ide
                12   basis, or similar independent c
                                                    onmission appointed in a
                13   publicly accountable way, reporting to the state health
                     accounting and development agency and devoted exclusivel,,,
                14
                     to such work, and be it further, Resolved:  @@hat the
                15
                     comments preceding this resolution and the resolution
                16
                     itself be transmitted to the members of the House Inters@-Fte

                17
                     and Foreign Com@merce Comtmittee and the Senate Labor

                18
                     and Public Welfare Committee for their consideration.

                19             DR. PAHL:  rLhan'jr, you.
                20             DR. IIP@@-T.!nCK:  Tir. Ogden, for clarification.
                     Accountable i-.,av anct reporting?
                21

                                        7
                                P. .OGD.@@@-        Y.  APT.Dointed in a publicly
                                             am sorr

                22
                     accountable @,7ay.  That has to do @.7ith
                23
                                   T  4?"rOCK.
                               DR. -i:,VL i  But you put another word in there.
                24             i'tR. OGDE,@,! We inserted the words "reporting to
                25   the  state health and planning agency."


                   I- 3
                                                   @..,as Tony's  -Point,  that separate health

                        2
                             systems development           has to report to somebody.   @,Te are
                             going to have ;it rt,31)ort to the state health planning
                                                          A:
                        4                   ;)R.                 T,-@'Ouldn't that be under state,  or not?
                        5                          0(7,D;-,N:   @@Tell,  I c,;on't think that' this
                             damages the sense of what I am tryin- to accomplish.
                        6
                                                                @Lr.  Chairman.
                        7
                                            D-;-\..  PAIII, -Yo-s,  ;'Irs.  l@lein.
                        8
                                                    YLEIi"j':   This reporting bothers-- me as to whether

                        9
                             i.L-  should be to the a4encl7 or,as in Idaho,  the planning
                        10   groups report to the Governor,  who is responsible for admiiis-
                        11   tration of all programs.   And,  that would keep it on the
                        12   state -- As I understand it,  the rpurpose of that insertion
                             is to keep it on a state-wide basisi  rather than reporting
                        13
                             to any federal agency,  'or example.  So,  I %.,.,-ould lil@.e to see
                        14
                             it made more general,  rather than a specific title,  because
                        15
                             some states       don't have that type of agency,  or one that is
                        16
                            IIL-itled that way.
                        17
                                                    1',OR(.'@A@7: -,hey will ",'lave    this Bill.

                        18
                                            rAR.   OGDEN:   Under this Bill,            they will have to.

                        19                                                                    at do you moan
                                            DP.    (7P-ld.',-LICH: in the resolve, @,7h
                        20   by,  "in the comments ,oreceding.this resolution?"

                                                                        as the letter from Sen   or
                        21                         n(7 E@7    rrh i s

                                gnuson.
                               a
                        22
                                            r,'R.  PATTL:   Ts  --hcre furtlier discussion by Counsel?
                        23
                                                S
                                                                Question.

                        24
                                                              T
                                                   0(7,T,)E'-:': .@Tait just a moment.   On the matter

                        25
                             of information.   Tony            and I have decided that this should be


                                                                                                          1 8 3

                                                                   health coorclinatinc, counc
                            reporting   to    t-e    state----,
                       2                        cc,?,  e  tha4- hav,@ tl-ic JC) mom,!)-r3rs.      'Have
                            -liosc are the r,

                       3    he @,iron(7  rroi-in to      report to.

                                                                                                e health
                       4                 T,-e are  (-,oincT  to report   to the state7v7id

                       5    coordinating council.
                                                                                                            it?
                       @6                is  cvcry.-Iodv terribly confused?   Can we vote on
                                         Di?. PAFL:   @-7itla that change, namelyo, the state-wide
                       7
                            health coordinating council.             T@iith no f rther di
                                                                                  u           scussion,

                       8
                            would ask the question - all            in favor ofthe resolution as
                       9  I                                    it
                          ,last amended, please say   aye.
                       10
                                         VrjICES:   Ave.

                       11
                                         DR. PAHL:   onposed?

                       12               (,T!o res,2onse.)
                       13                D,2,. PAITT, -  '"Lhe motion is carried.
                                         In closing,  I @7ould life to tliani-           I.Irs.  Silsby
                       14
                       15   and the staff verv much for again going through an unusually
                       16   difficult Period and specifically say that I am hot quite
                            certain under flat circumstances this council -- @-Te may or
                       17
                            may  not meet aaain.   1-@le have not set a future meeting date.
                       18
                            I would, hoiTever,  like to thank you individually and collective'.
                       19   as a council for vour guidance and support throughout a
                       20   rather di   .fficult Period,  and not this particular review
                       21   cycle.   Since i.!e are uncertain what does face us,  I want
                          i-you to understand that terms of appointment continue until
                       22
                            such time as we inform you otherwise because of the passage
                       23
                            of legislation or other unforeseen               circumstances.
                       24
                                          But,  I do loo'r', forward,       as I know the      Staff does
                       25   to working with vou again in some               way as we enter   into


                                                                                     1 8 4
                     lour ne%.7 error.
                  2             Unless there   are furti-icr comments, I then

                  3
                     adjourn this T-,eet,-nd.

                  4              Than!,: you.
                                  T-7hereupon, at 3:15        the meeting was adjourned.)i
                  5

                  6

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                  8

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                  10

                  12

                  13

                  14

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                  17

                  18

                  19

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                  25