1         DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE

2                  PUBLIC HEALTH SERVICE

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HEALTH RESOURCES ADMINISTRATION

THIRTY-FIRST MEETING OF THE

NATIONAL ADVISORY COUNCIL ON REGIONAL MEDICAL PROGRAMS I

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         - - -

Executive Session

Converence Room M
Parklawn Building
3600 Fishers Lane
Rockville, Maryland

Monday, November 26, 1973

The meeting convened at 3:20 b'olock, p.m.,

or, Herbert Pahl, Acting Director, Regional Medical Program

Service, presiding,

COUNCXL MEMBERS PRESENT:

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HOOVER REPORllNGC0,INC.
320 MassachusetfsAvenu?,N.E.
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MRS.AUDREYM.MARS
GEORGE E, SCHREINER, M.D.
MR. EDWIN C. HIROTO
DR. LAWRENCE FOYE
JOHN P. MERRILL, M.D.
BUlND W. CANNON, M.D.
MRS. MARIELS, MORGAN
RUSSELL B, ROTH, M.D.
BENJAMIN W, WATKINS. D.P.M.
MR. SEWALL 0. MILLIKEN
MR. C. ROBERT OGDEN


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CONTENTS
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Projects

Northland

Motion                             16
vote                                17

Hawaii

Motion
Vote

Arizona

Motion
Vote

LouisFana

Motion
Vote

South Dakota

Motion
Vote

Colorado-Wyoming

        Motion

Tri-State

                                       i
Motion
Motion
vote

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        PROCEEDINGS
              ------mm---

DR. PAHL:  May we reconvene the Council, please.

     At this point I would like to turn the meeting over

to Mrs. Silsbee, who will lead us through what we have been
trying to get to for sometime today, and she has it well -'

organized, which 3-s no mean matter in view of the clrcU&

stances that a number of people have rearranged schedules I ar:

so forth.  So without further ado? I would like to have

Mrs. Silsbee conduct, if you will, our session here on the

actual review of applications and discussion of those areas

that we think are important for you to consider.

Judy.

       MR. OGDEN:  I want to enter a complaint on behalf c

one minor member of this Council in that I desperately miss

the existence of the review committee.  I thfnk a great deal

what we are facing from here on out in this executive sessior
is something that the Council shouldn't be doing. And a gooC
deal of what Judy is doing of necessity is being brought to I

at sort of a last minute situation.

     Much of the discussion that we had this morning abc

the thrusted purpose of this program is what we ought to be

spending our t%me on.  That is what we should be doing. Not

trying to review ten applicatrons which are Ln a somewhat im-
perfect state and make value judgments individually, which wf

hope other people will accept.


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      I hope that this is the last time that we function

without an effective review mechanism before these things get

to the Council.

      DR. PAHN:  Thank you.  I appreciate that statement

more than I think you can possibly realize.

      We undoubtedly have the opportunity now, if what

we discussed this morning holds true, of reestablishing such

a committee.  And ft is our interest and we know it is yours

to have such a group.  In fact, if we cannot formally reestab-

lish the committee, we have a fall back position of trying to

constitute an ad hoc group, if you will.

      But we sorely feel the need to give both you and our'

selves that kind of professional assistance and overview, and

we have sorely missed it.  So I appreciate that statement

and I am sure we didn't really bring it up as an agenda item.

I think it is most appropriate.

      MRS. Mms:  Under the current legislation, can it be

reestablished?

      DR. PAHN:  It is not a matter of the legislation,

It is a matter of Departmental policy, which is in part govern*

ed by a federal policy now for reducing and eliminating

rhere possible those kinds of review groups that don't seem

to be necessary,

Ken has his hand up, but I believe It is promulgated

by the Office of Management and Budget and is being enforced


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       1 by them across the federal government.  And, of course, HJ3W4

             2  apart from Defense Department perhaps, has more review

             3  commlttees, study sections and advisory panels, I suspect, thar.
0           4  any other department,
a           5         It is very much in the OMBls purview to look at the

        6 functioning and need for such groups.

             7         Now, the reason that the review committee was term-

             8  Fnated, of course, was that there was a phase out of RMP,   In

             9  all honesty, with other matters pressing, we did not try to

            10  revise the Department 1s impression on that point, because we

          felt we had some .higher priority issues to bring to their

                                         
           attent.ion.  We have not had the opportunity even to get those
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          full attentioned by the Department.

                 But at, this stage, with what seems to be the future

          of the program, however tenuous, we already have, as I say, dis-
       cussed not &ly our interest but our need for and are making

          the kinds of plans internally to see iif we can't reestablish
      a standing ..committee and failing that j  ff we can't call together

          groups that are functioning in the same fashion anyway.

           20         MR. OGDEN:  We have excellent staff people, those
0          21  who remained I think are highly experienced people who can do

0          22  a great deft 1 of this themselves .

           23         You certainly have regional people who can give us

       24 this kind of input prior to the time it gets to Council-.

           2s         DR. PAHL:  That's right.

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        Is there further discuss-ion?

       MR. HIROTO:  Inasmuch as there are many vacancies on

the Council at the moment, perhaps those vacancies might be

filled with people who have a review ca'pacity and they could

become a subcommittee, something of that nature.

      DR. PAHL:  We have taken into account that very point

in making nominations for the Secretaryls consideration, and

if our nominations were to be accepted, a number of individuals

would already have first-hand RMP experience.;, because they co

not only from former review committee members and possibly

former Council metiers,  and ones who have served local RMP Is in

25  various capacities, so we are very hopeful that the Secreta.ry

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       MR. OGDEN:  And they need to be coming around review

ing th1.s with each of us before it got down to this point in

discussion.

       MR. MERRILL:  I think policy matter, you could make--

a review committee would save a lot of time.

      I am sure the eight to ten hours I spent reviewing

this were absolutely wasted, could have been saved for toher

matters if you had a review committee go over the leg work.

      DR. PAW:  There is every good reasonp and I would

say we are in accord with your statement and understandlng, and

the only problem we have is a federal overview one, which is

even beyond the control of the Department.  But we will do what

we can because we certainly are in accord with it.


3       Well, thank you very much, I do appreciate that.

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will help us move ahead quickly by accepting some of the nom-

ina tions .

      MRS. MORGAN :  Do you think we should go on record

on the fact we do have a quorum of the members who are on

Council present, although mybe not a quorum of the total

number who should be on Council due to the Secretary's lack

to appoint members to the National Advisory Council?

DR. PARL: Yes) I think it is perfectly appropriate,

because we hawe investigated this with the Department and I

wouldntt want to leave you under any misunderstanding. We

do have a quorum of the members who are actually serving on

Council and it is Departmental policy, which we have looked

into and discussed with the Department's Committee Management

Office, that this does in fact constitute a quorum for this

Council and we can conduct the government's business.

Mr. Baum, in fact, has conducted this inquiry and ha

confirmed this Departmental policy in writing, so we are not

operating without a quroum.
     All right, Judy, would you please take over.

      MRS. SIURRR:  I am beginning to feel like RI@

coordinators t trying to do the flipflops to keep up with this

review.

This is the first time we have had 53 applications -j

one meeting and we had to take a choice bebeen allowing the


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regions more time to prepare their applications when we sent

out the September 7th instructions,  the choice was between the

regions and staff and Council.  And we felt that under the

circumstanceg the regions probably needed the time.  So we

apologize for the fact these green sheets had to be here wait-

ing for you rather than set to you at the tlm the applicatior

went out, but we were undergoing a review at the same time the

were being mailed to you.

      Just as a little background along this 1Xne # there k

a staff group within RMPS that looked over all 53 of the applj

cations, This included the four Operatfons Branch chiefs,

Mr. Peterson, Mr. Ott, I!&, Chambliss, and Br. Pahl. The

latter two were not present all the time, but as they could be

      This step of an overall group served to identify and

develop some uniform type considerations of the problems and t

issues that these applications presented;

      For example, the kidney projects, the fact that som

regions Indicated that the technical review had been completei
but the RAG was not going to have a chance to look at everythj

until after the applicatin was sent forward to us.

      The requests that were over the a 1 located amounts

for which regions were instructed to apply.

      Negative CHP comments if there were some.

     CHP comments to come, because not all regions were

able to get the comments in with the application.
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     The status of the review verification of the region,

      The lack of full-time direction.

     And then some tougher problems.

      This overall staff review tended to screen out the

problems which needed attention immediately. These were regic
that we felt needed some attention with regard to these partic

lar applications.

     Then in addition, this process screened out those

regions which might need attention if additional dollars are

forthcoming or mandated by court.

     The actual analysis of each application was decen-

tralized to the operations officer who is responsible for that

RMP.

     The green sheets that we gave you this morning for

the regions that you were asked to review and are also include

in these four books in front of you reflect the above consider

ations for the most part.  The discussion today may bring out

others which are n& reflected.

      Time has been very short and staff has worked hard.
The operations officers, the branch chiefs, the support staff,

and the coordinating staff have worked overtime I think in

terms of effort and deliberatfon.

     I would like to call attention particularly to some

support staff who often have the unglorious job of making sure

that pieces of paper are available and on hand in time, but


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don't have the public recognition that the operation staff

has in being able to talk with you and to talk about the

specific RMPgs.

     So I would like to publicly thank Mrs. Edith Leaven-

thau, Mrs. Filimina Green,  Mrs. Joan Williams, and Mrs. Shirl

Sfmon,  This staff has done a tremendous job. Friday afternoc

we made it.  We didn !t think we were going to, but we did,

     We started out with the plan today, that is

why we have these four books, we were going to go through

each of the books by operations branch with having an opera-

tions branch chief identify those regions which staff elt need

ed some attention, and then to give you a briefdescription.

Becausg Mr. Ogden, we are concerned too that we don't have

the review commit tee, nor does this Council at this point have

very much first-hand experience with the 53 regions.

     Then our plan was to go first with the South Central

then with the Western Operation, then with Eastern Operations,

and finally with the Mid-Continent,

     Well, the plan was slightly changed when we knew

that Dr. Cannon and Dr. Merrill would only be with us for

today, and added to that was Dr. Roth, so that plan went out

the window.  So we started with another plan.

     (Laughter)

     But I want to call attention to these books, because

unfortunately, with that plan, that is the way we put material

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together, so we are going to be jumping from one color to the

other.

But the way we are going to do It this afternoon

is to identify those regions by branches that we think -- we

think -- might need some attention, ard then we are going to

ask Dr. Roth, Dr. Cannon, and Dr. Merrill if among the other

regions -- and I will read them out -- that they have been ask

to review, that they feel need special discussion, or whether

we can hold this off until tomorrow.

      We would like to have what we have identified as the

problem regions looked at by this larger group if that is all

right with you.

So we will start out with the South Central Branch,

that is blue.

     The region which we identified that needs some speck

attention is Northland.  Mr. Van Winkel will give a brief over

view and then we will ask Dr. Cannon and Mr. Ogden if they hav

any discussion or any action they would like to propose.

      MR. VAN WINKU3:  Well, if I could, I would like to

start off by saying the staff review was done by looking at

all the things Judy mentioned, I think all of us.

      The staffing, the review processing, liability of RA

CHP review and comment, their ability to find other sources of

funding, their ability to respond to new initiatives, we flag-
ged kidney as a special part of the review, we looked at their


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past performance, and we looked at it in terms of whether they

were in accordance with Council and RMPS policy.

don't hear of those things , you know that they are fully cov-

ered In the application, if I might.

       Our concern with Northland I think was the fact that

when they phased down, they really phased down,  They wound ug

with one professional Staff and a couple of secretaries, Mr.

Wilkins who had been the Deputy Coordinator under Dr. Miller,

      Now, when they got word that they had some new life

breathed into them, they didn't have the to recruit new staff

nor could they possibly have recruited new staff for that time

period.  So what they have done, they have used RAG and board

members as staff to develop projects, part of their contract

offerings,  this sort of thing.  So on the one hand, these

people are developing projects ) doing the staff work on them,

and then sitting on the other hand in the process of reviewing

their own work, so to speak.

Now, we have checked this out with management in

terms of paying these people and we find that there is nothing

Illegal aboLt this.

I suppose what we are raising is a moral issue or

possible conflict of interest as to whether this should be dor

and Lt is the staff's feeling that the Northlands RMP should

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1  recruit needed program staff so as to elminate any possible

i  criticism on the use of board members and RAG members as paid

staff.

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There is a kidney project in here where the region,

will have to be. alerted as to the new regulations that Mr. SPY  tr

discussed this morning.

They have requested their full allocation of

$458,586 to support ten activities, and we recommend approval

of this application as submitted with advice on the staffing,

and we have some difficulties with their bylaws.  They are not

totally in accord with the NIB that went out with reference

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to bylaws that was sent out by this Council.

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MRS. SILSXEE: Mr. Milliken.

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MR. MILLIKEN:  I think this is related to something

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some of us are concerned about, have talked about. This Ls

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the ability of the staff, this staff, as spa.rse as it is,

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to provide the kind of surveillance necessary to assure this

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Council and staff that lf at any point in time there is evi-

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dence of an inability to deliver on these in the right way, tl: 1t

this be brought to proper attention,

MR. VAN WINKLE:  Could I respond to that? Certainl:

in any areas where we thought we had difficulties, we are in

touch two or three times a week by telephone with these

regSons.  We also had an opportunity to visit a great number

of these regions on the EHS iss :;ie and also on the health

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       MRS.SIISBEE:  Mr. Milliken, we shared some concern 1
terms of this particular period of time, this process is try-
ing to identify those,we feel may need some special attention.
We also recognize that we aren't really on top of all 53 and
we have been able to identify those that don't have the review

I (i   process. We have some that have been identified as having

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known management problems.  We will be trying to bring that

out as we go along.  But we too feel we have a lot of spade

work to do to assure you as Council that these regions are on

top of things.

    But in terms of this particular application, Dr.
Cannon had to go out and make a phone call, but, Mr. Ogden* do

YOU have any comments?

       MR. OGDEN:  I would just read you my notes, which we]
based largely on the yellow sheets which came out,, which I

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education activities,  So we did have first-kand knowledge

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of many of these problems.

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I think we stayed up with them fairly well.

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     These will be revisited under the schedule that Dr.
Pahl mentioned to you this morning, we hope to bring back to

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you at the March Council or whenever that happens to be.

       MR. MILLIKEN:  I think even more, I am thinking
about certain questionable regions would get more attention

9  if they are running on a .more questionable basis.

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1   agree are useless, being what they had before.   On the back 01

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the material sent out.

      This I felt was a well presented application and

I thought it demonstrated considerable advanced planning,

which has been typlcal of Northlands all along.

      MRS. SILSBEE: Mr. Ogden, could you speak up?

MR. OGDEN:  My notes simply read this is a well

presented application demonstrating considerable thoughtful

advanced planning typical of the Northlands effort.

Again, Northlands has used a contractual approach in

what appears to me to be both constructive and a successful

manner.

After review by the HAG and allocation of perspec-

tive funds to the several categories, the funds for Em activi

ties were negotiated for five CHPB agencies for implementation

to state plans and Minnesota State Department of Health for

state@ide .coordination of the EMS effort.

      Funds also were allocated to seven community based

groups for health education and to two CHECls, at University

of Mknnesota clinic; 15 contractees, who have potential

statewide impact, same situation.  Kidney hyper te ns ion.

Application indicates if additional funds are avail-

able on January 1s t, a similar technique will be followed.

     My opinion, this Fs an application well deserving

of full funding, but I would recommend that the HAG needs to


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evaluate the cohesiveness of ti-e program.

      MRS. SILSBEE: Dr. Cannon, as I mentioned, had to

make a phone call and before he left, he whispered he

would go along with approval as requested.

      Do you want to make a motion, Mr. Ogden?

       MR. OGDEN:  I will move that the application be
                            --.- .--_ I ,__._ I"^ _.,..,._.. _,^".l.l. .--`.*.--.---" _,/ _-,,_ -IIII-I.C~-I,I.-I ,...e-=*-- -'*-1-"1'"

approved for the funds requested.
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       MRS. MORGAN:  I second it.

       MRS. SILSBEE:  For the record, the funding that is

being requested by Northlands is $458,586.

      There is a kidney proposal and there will be follow-

up with regard to the staff and the bylaws.

      Before we go on to another applfcation, it is pro-

posed, when we mentioned kidney here, that there will be a

statement made that the RMP may not release funds fortidney

project X, which is being identkfied, to support a new

facility, a new or expanded services. in an ongoing facility,

until the facility receives interim approval or exception from

the Bureau of Health Assurance, Social Security Administration

     Now, the other regions that either Dr. Cannon, Dr.

Roth, or Dr. Merrill have been asked to review, as one reviewe

in the South Central Operations Branch, are Florida, Georgia,

Memphis, Michigan, Mississippi, North Carolina, and Ohio Valle

     If you have any points that you would like to bring

up or would like to have those regions brou@;ht forward now,


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9          DR. ROTH:  Also parliamentarian.

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12        MRS. SICSBEE: Opposed?

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would you speak up.

      DR. PAHL:  Pardon me.  Judy, in the press of time,

I thinftalthough they did move and second, we are just moving

little too rapgdly.  We should take a formal vote, all in favo

say "aye, " just for the record,

[Laughter)

I know I talked too long this morning, but

you shouldn't feel that pressed for time.

MRS. SILSBBE: All in favor?
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(Chorus of "ayes.")

       MRS.SILsBBE:  Motion is carried.  Motion that was
                               ----.....-- -_-_ - _______ a-.----^-.. --- ______. -. .._._ - __.,._ _--.- .- -.
before I talked too much.

(Laughter)

       MR. OGDEN:  Incidentally, before we leave that, I

should have mentioned in reading through this material, I lookt

on RAG, board member, staff, purely as emergency measures and :

can't imagine they looked on it any other way.

      MRS. SILSBEE; Okay.  In the absence of anyone want-

ing to bring up those other regions at this particular time,

we will bring them up when we get through with this other groul

In the Western Operations Branch, two regions that

were Identified as needing some discussion were Arizona and


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1 II  Hawaii.

Mr. Russell.

MR. RUSSELL:  Do you have any preference which one   0

6 jj         MR. RUSSELL:  The Hawaii regional medical program

7  presents some very special and serious issues. Just in the w

8 II  of background for those of you who haven't had an opportunity to

9  read the yellow sheet and green sheet, both of which are quit

10  lengthy, when Council reviewed the Hawaii application in

11 II  October, the program was approved for triennial status. How-

12  ever, Council chose not to award the developmenta. component 4 or

13  the first year since the program had just recently revised  it

14   review and management processes and Council felt, rightly so,

15  that the program would need at least a year to really-test

1 fi   their new procedures.

17         As a result of an EMS visit, site visit in June, we

18   found the program had deteriorated substantially since we had

1!4   last looked at it, when we site visited It and had taken it

20   through Couno&l Peview; we were encouraged through the regu-

21 II  lar processes, a review, staff assistance following review,

*

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22   that we could have continued to asstst the program.

"7
it        The basic problem as we see it is a lack of leader-

24 II  ship in the area of management.  Specifically, the director

          25   is on a YO-hour basis.  However, hSs 40 hours are not

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320 Massachusetts Avenu?, N.E.
Waehinotnn nfl 7llM)7


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       The director has two sets, at least two sets of manage-

ment philosophy.  One is that in the presence of RAG members, as

best we can remember, he readily admits recognized management

practices should be used Ln the conduct of a regional medical

practice.  However, when, under local pressure in the decision.

making process, he reverts to other than sound management

f(i   practices.  Quite frequently he will point out to RMPS staff

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coterminous with the regular office hours.  Therefore, he is 1

not literally available to his own staff or to RMPS staff.

      The director seems to place more emphasis on the

fndividual staff members standing in the community rather

than on professional competence.  I do not mean to imply

there are not competent  program staff members in most cases.

     The program staff has limited rapport as far as

management goes with the director.  Those who do choose to

question him wish they hadn't,

that the multi-ethnic background of the people in Hawaii

precludes obJectlve management practices.

      It appears to us that the director gets his power

from the amount of money available to the program, rather

than from his Regional Advisory Group.

      We have worked with him quite closely on this to

try to get him to use his RAG as the buffer between the decis  otx

that are made and the community.     t

Due to the absence of the director during regular I


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I   off ice hours, we have to rely very heavily on the deputy

2   director, whom we haven't had the opportunity to really watch

3   him in a situation which demonstrates his effectiveness.

4         As a result of the inadequate management of the

5   very large emergency medical services project, RMPS. with Burt  3.U

approva 1, chose to transfer that project from the regional

medical program, pull the administratlon back to the central

level, and with coordination of the Emergency Medical Service:

Branch have gotten that branch now to direct It from a pro-

grammatic standpoint of view.

And the EMS Branch visited the Hawaiian Medical

Association shortly after the transfer and he saLd already

the improvement was very, very noticeable.

So the point I am trying to make is the Hawaii R&P

really failed to adequately handle a very large segment of

the program.

      The next issue, critical issue, at the local level,

national level and regional level, being HEW regional level,

is the Uommunlty Health Services project in the W,aianae. ,

coast area, which is an underprivileged area.  We have pointec

out fn the paper here that the Community Health Services out (

San Francisco, after months of negotiating with the Waf$na.e.

-1, Board, that Board is responsible for administering pro-

jects not only from RMPH but other federal funds, @smmunity

%eaIth Services has laid out specific conditions on the farnil!

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Health Center project.  If the board does not accept these

conditions, then the Community Health Service will have to

terminate its support.

     The board has had, oh, 15, maybe 20 days in which to

respond.  They had to respond within 10 as of Friday. We unde;

stand that the LMaianae 1.:. 3oard had not responded an d the

scuttlebutt is that they will not accept the Famkly Health

Center-Community Health Services Conditions.

     If that is the case, then the WaianaeLCo+St:will ._.
not get the $400,000 for the Family Health Service project.

      Now, the RMPH involvement in the Waianae,CQ@st J

has been significant. Effective as a catalytic agent, it was

supposed to help with administration of the board to get it hr

shape.

      The first conflict that we noticed w,as when the Com-

munity Health Service would not accept the project director--

this gets complicated, so stop me if I lose you, please -- it

has taken me a couple of years to get Lt straight -- the

Waianae --* Board is a voluntary board, its administration,

some of Fts aspects have been funded by the Regional Medical

Program of Hawaii.  Now, the board in turnappoints its adminfs-

trator, who is salaried.  That administrator automatically

becomes the project director for the projects coming Into the

Jaianae <area. .r,

The Family Health Service project would be one.


1        However, the Community Health Service would not

2  accept that ILndivldual, because he did not have the backgrounc

3  in marketing a prepaid plan, so on and so forth,

4       The Regional Medical Program of HawaiZ. was providing

5  that individual's salary.  The director of the Regional

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Med ica 1 Program, for whatever reasons, political or what, en-

dorses that individual.  And so here is where the RMP got

involved and additional conflict came about.

During the last site visit, the site visit team,

and this was fed back in writfng to the Council from the

Councills review, stressed very strongly the Regiona 1 Medical
Program of Hawaif had primary responsibility in seeing that

the EMS project in Hawaii was successful and that the RMPH ale

had primary responsibility in seeing that the total program

cof the WaPanae Cws t was ..he.ldi `. *

      They were, you know, instructed to provide surveil-

lance to help that group meet the other problems.

From all appearances,  the RMPH has failed in that

area too.

Now, I will stop at this point and respond to any

questions.

DR. ROTH:  Geographica 1 ly, where is the :-Ma-pan&e:

C&g&.? ,; I; .*'

       MR. RUSSELL:  North of Pearl Harbor, 45 minute

drfve from Honolulu.  Used to be a large sugar plantation,


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7         I must say it is a very weak application, couched

8   in very general terms without in my mind evidence of careful

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Washington, DC 20002

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which closed down.  Ieft a pocket of poverty.

       A VOIC$:  On the Windward Is land.

       MR. RUSSELL:  Same side as Pearl Hmbor,

23

       DR. MEXRILL:  1 have a couple of comments, having

read this application, give more of the flavor of the vital-

ity rather than actual information which I clearly agree.

planning.  And it looks certainly, at least :. the first part

looks as if it were made to fit very carefully into the so-

called categories.

I note with interest at the end of fitting it into

the categories, they then resolve the theng, that these cate-

gories do not reflect the needs or concerns of American

Samoa, Guam, and territory trust care and would like to go

back to earlier guidelines.

But I think on the whole, the application reflects

kinds of weakness sf-:construction and gives me the idea the

actLvlty  Tn Hawaii is  not a vital and vigorous one.

MR. RUSSELL:  1 think that Is correct.

I would like to say as I tried to point out in

the green sheets that the PacificB.as3.n has really been a

most exciting program, and it is for all practical purposes a

separate program.

Mr. Hiroto was on the site visit and, please, you kl


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chime in.

       MR. HIROTO:  At first I thought I was being offered

a rare opportunity of being a site visitor, now I see It is

rather difficult to attempt to review this with what we have,

and try to come to some reasonable decision.

As you will note, following the site visit of

1972, there were nine recommendations to site visit made, and

these are symptomatic of the poorly managed RMP for which thi:

was gathered.

From what staff has found out in recent past, it waj

apparent we were only discussing, looking at symptoms, not the

problem.

The problem obviously is management, of RMPH,

So I would recommend that we follow the staff

recommendations in regard to the approval of the RMPH;

that is to say, to approve the remainder with the limitations

as Indicated,  And that would be page 8 of the green sheets.

       MRS. MARS:  I the program really worth trying to

save or would it be better to let it phase out and start all

over again?

Are we just wasting money there? Because it is nee  ed

in so many places.

MR. RUSSELL: Mrs. Mars, I think that what is going  on

in the Pacific Basin is well worth saving.  The little amount

of money that--


MEL% MARS:  But if there is no management--

MR. RUSSELL:  In the Basin you do have the manage- f

3 II  ment.                           I

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MRS. Mms:  That is a lot of money.

MR. RUSSELL:  I guess what we of staff hate to see

(:I  is when one has a group of very dedicated, talented volunteers,

0

7   to do away with that system completely.

8          MEIS. I4ARs:  I know that is very hard to accept

9   and very hard to do, but still --

10          MR. RUSSELL:  This is why we needed this group's

11   advice very, very much.

12         MRS. MARS:  It is still taxpayers I money, you know.

13   If it is going down the drain, it just doesn *t seem right,

14   does it?

15 II

MR. RUSSELL: No.

1 (i          MR, HIROTO:  There are certain parts of this

17   which are apparently going quite well,that would be the

18   Basirlb.

l!)         MRS. MARS: You can always phase it out and start all

0

20   over again with new management and still save what Is being

27   gone before, because tf it% worthwhile, it will endure, can be

II                                                                           I

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22 /I picked up again.
/I 23 jj         MR. HIROTO:  Would there be anything to gain, rather

24 Ii  than phasing out--

           23

HOOVER REPORTING CO, INC.
320 Massachusetts Avenu?, N.E.
Washington, D.C. 20002

MRS. MARS: Yes, if you need all new management.


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HOOVER REPORTING CO, INC.
320 Massachusetts Avenu?, N.E.
Washinetton. DC. 20002

MR. HLROTO: -- to get new management.

MRS. MARS: Certainly.

MRS. SITSBEE:  For the benefit of the entire Counci  ,

the recommendations of the staff, Mr. Hlroto suggested, might
`L..v....... ._.x".,",i. . . . . .,   -.-. _,._ ../, .i,   .,, ^ .*. I, ,; .,_ .,,n .._      ..,l

be considered, the Pacific Basin component be approved at the

amount requested of $75,564. But further, that this amount b j

earmarked for that purpose.                       1

    Appm~&l of the remaining $252,688 for the Waianae

component is recommended with the following oonditions: One, i

to be determined percentage -- Dick, you will have to explain

what that means -- of the $252,688 restricted and not availabLe
for expenditure pending further review of the RMPH at the nex';

Council meeting.

     Two, the RMPH be site visited by Council representa-

tives prior to the next Council"meetlng.

       Three, the RMPH should be advised not to fund the

WaLanae Coast Comprehensive Health Center project until
RMPS receives assurance that the RMPH RAG from them that it
clearly understands the issues and problems involved and will
ensure that RMPH funds and program staff activities will be

used in a coordinated manner to strengthen the capabilities  o

the Waianae area to manage local problems.

     Fourth, the RMPH should assure that the kidney pro-

ject for the Marshall Islands is In compliance with the Social


25

HOOVER REPORTINS CO, INC.
320 Massachusetts Avenu?, N.E.
WashinPton. D.C. 20002 II

Then I hear you suggesting perhaps number five.

DR MERRILL:  The limited care facilities in

Marshall Islands was 95 percent completed at the tillK! the

application came.

MR. RUSSELL: This request is for training.

DR. MERRILL:  I see.

MR. MILLIKEN:  It seems one of the basic concerns

here is that the coordinator is not about to deal with this

RAG Ln a proper manner.  The evidence points he has not been

willing to or able to.

      I would agree with Mrs. Mars that if we are going to

deal with the problem,this is the problem we have to deal with

rather than five others.

MRS. SILSEBE: Dr. Roth.

DR. ROTH:  On this Marshall Islands project, maybe

John knows or maybe you can tell me9 they have got one of the

more advanced home dialysis training programs there at Saint

FrancLs Hospital in Honolulu; but if you are going to have

home dialysis for people who get trained on It in Hawaii who

then go back to American Samoa or Marshall Islands, or some-
where, you have got to have somebody there, you have to have

somebody there who can give a li.ttLe backup to it.

Isn't thatessentially correct, John?

DR. MEZRILL:  They propose training of paramedical

person for limited care dialysis.


                                          28

       DR. ROTH:  Isn't this where they go back to after

they.have--

      DR. MERRILL:  Limited care?

HOOVERREPORTIffiCO,INC.
320 Massachusetts Avenu:, N.E.
W~rhinntnn nc 7nnn7  /I

DR. ROTH:  Yes.

DR. MERRILL:  No, no, that is a satellite. It would

be as though we had a five-bed facility out here in RockvFlle,

go to Georgetown for a backup.

      I presume they would fly to Hawaii, Honolulu, for

backup.

       DR. ROTH:  But don't they get their training in home

dialysis at Saint Francis at Hawaii, then they go back to

these facilities?

       DR. MERRILL: Yes.

       DR. ROTH:  So it would seem -- what I am trying to

get at is this is part of an integralwhole.

      I am sure the Saint Francfs dialysis center

in Hawaii, in Hawahu, Honolulu, is an approved thing.   I am

just wondering whether you really need to go through HEW appro-

val of one tech and one nurse for a thing in a special situa-

tion like this?

       DR.. MmmILL:  You do in Massachusetts.   I don't knew

about Hawaii.  That is very definite in Nassachusetts.

       W. SILSEEE:  According to our kidney reviewer,

they would be very wiseto  apply for exception approval.  They

don't think there will be a problem as soon as this is ironed


1'  out, but they do advise they go through this process.

tit i         MR. HIROTO:  May I ask where there have been coor-

  I

3 i dinator difficulties in the past, are there any tools avail-

4   able to solve that problem?

0

MRS. MARS: Fire him,

MRS. MORGAN:  Can you fire them?

7          MRS. SIrSBEE:  There have been coordinator problems

8   in the past.  Council and review committee have used a number

9   of different methods.

10         Council site visit might be one way.

11          MR. HIROTO:  Instead of phasing out a program where

12 i  you have excellent members of staff $ phasing out the program,

13   just to remove the ulcer, would seem to be somewhat a waste of

14   time and effort too.

            15          DR. PAHL:  Let me add a comment as ,I have been in-

            16   volved as some of the staff have in these situations, and it

           17   is a bit difficult but I think under the former leadership

            18   and to a more limited extent under mine, we have been able to

           19   effect some changes, indirectly, by perhaps talking with both

            20  coordinator and at times w-ith RAG chairman and representatives,

e          21   and sometimes things can be ironed out in an informal fashion

0      3p j and at other times the local RMP has to take some kind of
               -- ,
                  I

            2, `3 /I  action which does appear drastic.

           24         But I th,ink it would be inappropriate to recommend

           25  phase out at this stage without trying the next few steps,

HO~ERR~PORT~~CO,lNC.
320MassachusettsAvenu?,N.E.
Wd&ntnn n C 7m-w


1   difficult as they may be.

2          I do think that it would be most helpful if a site

3

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5   whatever support we could, both before and after such a visit.

7

8   next meetLng of the Council, but have such a visft between no

9   and the next meeting.

10          MR, RUSSELL:  Along those lines, some of the other

11   Western Coordinators have also noted that there may be a

12   problem there and have offered to assist as appropriate. So

1)

13   we do have some peer review which we can build into this,

14   which can be extremely helpful.

15          MRS. MARS:  They have been on a triennial basis for

I li   how many years?

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Washiwton. D.C. 20002

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visit with Council representation coyld be made. __ That certai
i.. . . . . _I_  -I _ .,,*e.ll.-... .- ,. I" , ,.  ,,., ".,,
has been effective in the past.  And we would, of course, add

Sometimes these things do drag on a little bit and I would

think the best thing would be to review the situation at the

MR. RUSSELL: Just one.

MRS. MARS: Just one.

       MR. RUSSELL:  And they blew ft.

      I don't thirk this was because of the Regional

AdvLsory Group9 because they were reacting only to the inform

tion they were receiving, and it is very difficult to know fo

sure how much information the program staff fed to them.

But eaoh time we have gone there and it does presen

a problem in working with the RAG members, which we can do in


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HOOVERREPORTiNGCO,INC.
320 Massachusetts Avefw, N.E.
Washington, D.C. 20002

many cases, where we do have a 6,COC-mile difference.  An4 YO

know, some people look at it as a junket, a joy ride to

Hawaii, and I assure yo it is not,

DR. FOYE:  There is, another approach in this kind o

thing where the top man is inadequate and you want to get rid

of him, YOU can Say fundFng is provided for one year and at

that time the program will be phased out unless the following

changes are made, and then you list a series of organizationa

changes that you feel are necessary:  improved relationships

with RAG, better supervision of the office or whatever.   You

List a series of them.  Then you phone a friend on RAG and yol

say this is what we mean, get rid of Joe.

(Laughter)

      And only that will satisfy conditions one through

eighteen,  And that alone will satisfy one through eighteen,

     (Laughter)

And it seems to happeu. That is another way.

MRS. SILSBEE:  Would you put that in the form of a
                                                

motion, Doctor?

(Laughter)

MRS. MARS: I don' t see how any changes that would

drastically affect them for the better can possibly be made

between now and the next Council meeting. Whereas, if the

program is gently phased out and then picked up again and re-

stored, and taking the best elements out of it, then you have


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got something that is worthwhile.

      In the meantime, grant them enough money to grace-

fully get out. You still have your RAG members who will re-

volunteer, who are good. You get rid of the ones that aren't

any good. You get a new coordinator. You start the whole thin

and pick up the programs that are worthwhile picking up.

     All I can see is we are goirmg to pour a lot of

money down the drain.

       DR. FOYE:  I am afraed that kind of move, taken

6,000 miles away, might be misinterpreted by very competent,

productive members, say of RAG or others, as a slap at them as

well.  A phaseout of the program.  And even though its intent

1s clear in your mind, what would it be if it were the

approach?

       I am afraid it would have a deliterious effect on

the entire program.  I don't know.

       MR. RUSSELL:  I have a tendency to agree,  I think a

phaseout would be extremely detrimental to the Pacific Basin

in which so much hard work and effort has gone into it.

      I think that might be lost, because the Regional

MedIcal Program of Hawaii -- real,ly we have to limit th5.s to

Dr. Satura, who has worked so hard, he has sort of gone out an

restored faith in any federal program.

     When he first went out they said, "We aye tired of

people coming out and planning."  Through Dr. Suzitsifs efforts


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320 Massachusetts Avenu:, N.E.
Washington, D.C. 20002

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they have gotten some very effective project.  It is like

dealing with different programs.

      MRS. SILSB3E: Mr. Milliken.

MR. MILLIKEN:  For informatIon, is there any

policy that discourages or prohibits anything other than full

time coordinator?

MRS. s1Lsm:  I wish you hadn't asked that questio

We do have in our RAG grantee policy a suggestion that there

be full-time direction, but in this interim period, this has

been very difficult to really implement and administer.

I think if we used it in this particular instance, '

would have to use it in other instances too.

)I!. CU'NON:  We tried for three `years to get rid
  -._

of a director,  coordinator in Ohio,  We found it almost

impossible even with Dr. DeBakey as the whip. And I would sa,

that our chances of accomplishing this in six months is prac-

tically nil.  I would like to move that we follow the recom-
                                 ,i              1.             . . .I.
mendations outlined by the staff.
                _,_. --

MRS. MORGAN: I second it.

MRS. SITSBEE:  The motion has been made and seconder

that we accept the staff recommendations, which I read.

MR. RUSSELL:  I want to explain.

MRS. SIISBEE: Okay.

(Discussion off the record.)

MRS. MORGAN It has been moved and seconded. He


1   can discuss.

21         MR. RUSSELL:  Under staff recommendation number one, 1

0

a

3  to be determined percentage, all that means is I didn't have

4  time before Council to sit down and come up with a percentage.

5  So what we would suggest is to be determined by RMPS staff if

6  that would be acceptable to the group, we could look at this

7

iI very carefully to make sure we did not harm something as well 1
I/
8ii  as improve the situation.

9 II

MRS.  S IS'BEE :  Is that agreeable to the seconder

10   and the flrster?

11         MRS. MORGAN: Yes.

12 ;         MR. MILLIXEN :  I would like to speak to the point

4B

13  made earlier; would it be helpful in carrying out this motion

14  that there still be a Council visit assumed? In order to

15  put the fear of God, or whatever it is, in the people we are

I(i   dealing with.

17          MRS. s1Lsm:  That recommendation was one of the

18  four points under the staff recommendation.

i:
  1!4

MEI, MILLIKEN: Okay.

    d'
c/

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20 I/       MRS. SIW3EE: If you want me to repeat that, it was

21  approval of the Pacific Basin for full amount and earmarked

0

22 1 approval of the remaining part with a portion to be restricted
  I

     23 11 and not avaIlable for expenditure until the full review at the
           I!

          24   next Council meeting; site visit by Council prior to the next

      25 -- well, I think we had better change that wording because if

HOOVER REPORTING CO, INC.
320MassachusettsAvenu~,N.E.
Wachindnn D C. 20002


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it is January -- prior to the March meeting of Council.

     DR. PAHL: March meeting.

       MRS. SILSBEE:  Advice to the RMPH not to fund the
                    L. --"-...m.syc ..-, /U.nFY" ,_,.,.^ r_lX I _,. .^"-Ie,.Y. I.,. .,.. ", ",,,L-w.- Ai"., ,,`~l_ ,_,-. ,,  _ _
Waianae Coast project until RMPS receives assurance from RAG

that it clearly understands the problems involved; and would

ensure that-, J3&EH..F,#`~~d .st,nd program s,t"ff ,$+;,.yitJ+s vUJ. be
,.--- ~~,`~lni . . . . 6.. I*`)-`*' *'             .,I ,.,. ,.    ,. . ..;                        .. .,i . ),.. I: .,.. i_
                                                                           -u"
used in a-coordinating manner to strengthen things.  And that

the kidney project,undergo:ita exc,,e,ption approval.
                     ,.                       ',.?'i. :.: ..: , I
r.,:;ii ,.,'," I. ` ,. -                                                 .' '-*'"ii- L u ".~~ ,_.. .,: j.,,
       DR. CANNON: Question.

MRS. SILSB;EE: All in favor?

(Chorus of "ayes.")
_I_ -.-.".a." .I _ ..I ,_,  . ..". _
MRS. SIISBEE: Opposed?

@R. OGDEN: Jh

MRS. SILSBEE:  "No"? All right, one "no."

MRS. MARS:  YYJo* "

MJ3, OGDEN:  May I just state what my feelings are,

I think when you have got a situation that is fail-

ing, you might as well face up to it.  And if the management

and review process is extremely weak3 I would simply say so.

And tell them this is not being funded for that reason.

       MRS. SILSBE23:  When you say this is not being fundec

you mean the entire--

MR. OGDEN:  No, I wou-ld go ahead and fund the outer
                . .-.._ I,_. I ._._.,- ^..' "I                                 

islands part of it, Marshall Islands part of it; simply with-

hold the rest of it.  For the simple reason the management

,


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and the review process is not adequate,  And the application

is considered rejected until those things are corrected.

      MRS. MARS:  None of It is adequate, that is what

I have been trying to say.

MR. OGDEN:  So I vote"n0,"

MRS. MARS:  I vote "no,"

MRS. MORGAN: Seven.

DR. CANNON:  Do you want a count by hands?

MRS. SILSBEE:  All right, all in favor?

(Show of hands)

MRS. SILSBBE: Ss.
                   -

All opposed?

(Show of hands)

     ME&S. SILSBEE: The "ayes" have it, six to three.

                                                                  ~.,.a II    ,, ,..,
       MR. OGDEN:  Would you mind entering a minority

report?

      MRS. SILSBEE: Not at all.

       MR. OGDEN:  Send it to them.  That might do them

some good.

MRS. SILSBEE: All right?

MR, RUSSELL:  We would see thls visit unlike any

other site visit.

       MR. OGDEN:  I would hope so.

      MR. RUSSELL: It would be going in to look at that

particular problem, and we would utilize others for just


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                                        37

Council.

DR. FOYE:  Just take the minority voters.

(tiughter)

DR. ROTH:  Don't send me;every time I go over there

a volcano goes off.

       MRS. SILSBEE:  Dick, do you want to go through Ari-
                                                                         A,,.. -.

zona?

w*u ." -.
       MR. RUSSELL: Yes.

Arizona I thfnk we took the last time.
_*.- -                         If you remen

her, at the last Council, after a site visit, the Arizona

triennial status was taken away from it and Council gave

Arizona one more year, and the recommendation was that it be

site visited to determine, you know, funding In the future.

The problem really was the Arizona was involved in

too much process and not very much outcome, deeply involved ir:

planning; not getting out to the community.

     Well, phase out came and it seems now that Arizona

is beginning to get the message, that had been given to

them for three or four years in the past.

We bring this to Council to point out they have be-

gun moving into the community.  We of staff have some concerns

as to whether or not the staff they have now, if this is real1

their bag.  We do know they are adding a couple of staffs-- it

appears these might be real community organizer types.  We are

not sure.  So we are suggesting,as we said in the recommendati


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that Arizona be visited.

      We didn't specify Council at this point, because we

wanted to get your feelings as to whether or not you felt it

was necessary at this point to go back as Council and see wha

they were doing or if you would be satfisfied with staff going

back and getting a feel for what has actually happened.

     We do have to go back to look at their review pro-

cess 8 which we did not get verified prior to phaseout, and

we also, in that process, will look at the organizational

structure which will perhaps get into some of the other prob-

lems in terms of regional advisory group and Its representatil

       MR. MILLIKEN:  How does staff feel about this? Fee

they can handle this at all as backup or do they feel,vlsi.tinl

backup or do they feel Council ought to go too?

       MRS. SILSBEE:  Dr. Cannon, you were one of the prime

site visitors before.

       DR. CANNON:  They sent me out there to do that job

quite a few times.

      I would say looking over this, staff is still grade

two staff, focus is still there, little evidence of teamwork;

CHP hasn~t.Tmproged~and I doubt if'T1.t *ill.

      Yet RMF 1s. progressive,product%ve, CHP seems to be

reactive.

     I vote green for money for the program.  I would sa3

if you are going to visit,  it is nice to visit there in the ri

I.

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season of the year.  But you are not likely to change either

the direction or the action.

     (Iaughter)

That I would focus my attentfon In the site visit

not on trying to threaten them as we have done in thepast, but

to some way win them over and Let them think we are trying to

help them.

       I don't know.  It is a hopeless situation.

MR. RUSSELL:  We have some indication this particula

program is reaching out  to-2 it's recognized as being very

strong programs and perhaps asking for some assistance from

another RMP.

DR. CANNON:  You can't blame them because CHP has

been fighting them, yet RMP has been doing CHP's work.

We ought to fund them.

MRS. SILSBEE:  Mr. Milliken asked specifically if we

thought staff needed help on the visit.

MR. RUSSELL: I think at this point we of the staff

could go out and see what-- just a minute, Dr, Cannon.

(Iaughter)

To verify what we have been told over the telephone

and we do have a feeling that they are attempting, and I am

afraid to bring a Council member out after the way YOU scared

them last time, Dr. Cannon.  They might not let us see them.

[Laughter)


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HOOUERREPORTlNGCO,INC.
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Washington, DC. 20002

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       No, in all honesty, I think this is something --

Mrs. Sadin, do you have any comments?

       MRS. SADIN: No.

       DR. CANNON:  I move that we accept the staff's

                                            ., .., ,.,, , ., SW%-." .'      .,
                                 wc`.."I* _.d. >u`"_ ". ..,.                           .
recommendation, vote favorably on the program, and they can

go out as they see fit,

       MRS. MARS:  Are you including a visit from Council?

       DR. CANNON:  Are you going out there anyway?

     (Laughter)

       MRS. MORGAN:  Just staff.

      DR. CANNON: I think it would be nice 9f a Council

member went along, but I do not think we ought to go out thert

and threaten them.  We have been out there every visit I have
been on, we have been saying, "Look, this is it;" I think th;

doesn't work with them.

      I don't believe it is going to work with them. I

think we need a different approach.

       MR. RUSSELL:  I think we were trying to make the dil

ference here was I see no reason why a Council member couldn'f

go, it would be very helpful, just on a visit, rather than

what we term as a site visit.  I don't think they are ready

for that.

       MRS. SIXZEE:  How about an ex-Council member?

       MR. RUSSELL:  Ex-Council member.

      MRS. MORGAN: Dr. Cannon!


41  I

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(Laughter)

MRS. MARS:  You are elected.

DR. CANNON:  YOU know, they almc6t ran me out of

4 II  town last time.

MRS. SILSBEE:  Dr,*~,?annon,has moved, which has been
                    -,               , ..,,~. w...-, ,~ ,,,, .,..      ._ ._ . . .~ ^.. _ . -

6  seconded, the recommendation be accepted funding as requested,
~~1 $359,623, with the condition that the region be visited to

i'
i 6%:; determine whether they really have changed direction and  respo  -

9  ded to previous concerns.

        DR. CANNON:  That is where Ihanged it.

11 I
II         MRS. SIXSBEE:  SO that should be amended to--

12         DR. CANNON:  I changed it to go out there with a dif

13  ferent attitude, one of--     t

14         MRS. MORGAN: Helpfulness.

         DR. CANNON:  One of assistance.  Not to change direc-

16  tfons, but see if you can't coerce them a little bit.

17         MRS. MORGAN:  Take your box of candy.

18          MRS. SILSBEE:  The problem is how to word them.

l!)

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(Laughter)

DR. CANNON:  You can't threaten them and change

21 1 them, that is what we have done.

22         MRS. SILSBEE:  Be visited in a nonthreatening

  manner to determine how they are doing.

DR. CANNON:  Be helpful, consultative vis2t.

MRS. MARS:  Are you going to fund this program,  then

HOOVERREPORTING CO,INC.
320 Massachusetts Avenu?, N.E.
Washifmtnn DC 20002


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before the site visit by staff? In other words, whether

they change or not, they are still going to recei ve the money;

is that what you are saying?

      DR, CANNON :  That 1s my recommendation. Because the

are doing a job, they still.. have the momentum, they still hav

the staff,  They are not going in the exact direction as RMP

asks,Council would like for them to go, but they are doing a

job In Arizona.

      MEG. MARS:  You feel they are filling the health

needs of the community?

      DR. CANNON:  Yes, but they are filling the needs of

some other programs, too, they shouldntt be.

      MEG. MORGAN :  In other words, they are doing CHP.

      DR. CANNON:  They are doing a lot of work for other

organizations that other organizations should be doing.

       MR. RUSSELL:  I think at this point, if 1 may say SC

we have some indications that they are attempting to change

and as has been pointed out,  I think on a number of occasions,

we as staff have had very little face to face contact with

any of the RMPrs, and I do think we should give them the bene-

fit of the doubt.

       MRS. SILSBEE:  Motion has. b,een made and secondea to
                                                          
          c

recommend fund ing as requested, $359,623, with the condition

that the RMP be visited in a consultative manner.

       All in favor?


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MRS. SIISBEE:  Motion is carried.
                   --1-e.. (,.  ".  -*`,,`"-I .I%. . ...,.. ., ,, _ ,I , .j,l,
NOW we are going to move-- this is a swftch, Frank o

6

to the Mid-Continent Branch, and that is red.

7

The reason for that is there are two regions in this

8

group where there will be nobody who was a reviewer here tomol

9

row ) so we have to get at it today.

10

w first.

11         MR. POSTA: Thank you,

12        I would like to note from the green sheet, Mr.

    13
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Zi,zlavsky & the operations officer.

This region is brought up for problems I guess more

15  like the one that `I;ee just brought up with reference to

7 1;   Northlands.

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    We are concerned with the number of staff now on

board and the staff that is proposed for the calendar year

1974 o

Just a little background, the request that you are

looking at now calls for $270,000, Oddly enough, another

$269,000 has been approved for the region for the same amount

of time for the topic of pediatric pulmonary.

The grantee is a free-standing corporation.  It has

had good management in the past under their past grants

HOOVER REPORTING CO, INC.
320 Massachusetts Avenu:, N.E.
Washineton. D.C. 20002

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(Chorus of "ayes. ")

MRS.  S ILSBBE :  Opposed?

(No response. )


25  consider coming onboard 100 peroent of the time.  He is now on

HOOVER REPORTING CO, INC.
320 Massachusetts Avew N.E.
Washington, D.C. 20002

44

management officer.

     RMPS has made a management visit there. They came

through with flying colors.

     Last December, the satff also had a verification re-

view process visit there, and RMES did certify the review

process.

      However, I think we are concerned not with what it 1

was a year ago, but what it is going to be, what it is right

now ) and what it is going to be in there next three or four

months.

      When they came in, when Louisiana came in for their

extension plan back in March, the staff went down to one

grants management officer and a 25 percent program coordinator.
     Staff did approve nine continuing activities. A  I

couple of tha; e were for only two months.  However, the seven

that they did approve through l/31/74 was primarily under

contractual arrangement and s,jlnce this is a free standing

corporation, incorporation, those contracts were considered

binding and there was a good chance for continuing once they
had been consummated, and therefore that was primary reason

why seven additional activities were approved for a small

staff.

Now, we have been notified by the coordinator if

he did get a good review by this particular body, that he woul


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HOOVERREPORTlNGCO,INC.
HOOVERREPORTlNGCO,INC.
320 Massachusetts Avew, N.E.
320 Massachusetts Avew, N.E.
Washington,
Washington, D.C. 20002
     D.C. 20002

board 25 percent.

     That might be good. It might be bad. I think maybe
you folks might like to discuss that a little bit further.

       However, upon being notified that Congress had ex-
tended the program for another year, Dr. Sabatier did go back

and has hired his former deputy coordinator, a dentist.
And also one of his evaluators, on a part-time basis.

    Also the grants management person who has done a go
job in the past fs available for consultation purposes with

reference to grants management.

    We as staff, if you will, back in December 1971,

had an official site visit.  That was an application for

triennial status.

      The Council and review bodies did not think that

they had qualified and therefore gave them an approval for a
two-year period for one million dollars each of two years.

      This past December, the program decided not to come

in for a triennial appli..cation but to only come in for their

one million dollars.

     Again, to reiterate,,a year ago, when staff went

out and looked at this review process, we could find nothing

wrong.  This is a particular program that has specialized in a

ca tegorica 1 approach.  Most of their activities that they have

solicited has been to more the leading institutions and those

institutions themselves have gone about their particular job


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17         DR. ROTH: No.  I don't have anything to add on that

18         Louisiana is sort of a place apart in many of its

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HOOVER REPORTING CO, INC.
320 Massachusetts Avenu?, N.E.
WashinPion. D.C. 20002

46

in their own individual way.

In other words, what I am trying to say is that ther

are net too&wfully many cooperative agreements in many of the

activities that have been funded to Louisiana.

      A good example, this last July, staff went down and

took a look at three or four VMS activities. Each of those

activities were being funded by a particular fnst

itution, if

one progrm

you will, and there was very 1Tttle evidence that

So, again, I bring attention to the fact that this

regfon has not been in the past one of our better ones.

      We are concerned because of the number of staff on

board and we would recommend perhaps that you would consider a

site visit to this region before fvIarch.

     Dr. Roth, I notice thatyou were one of the reviewers

Did you have any comments?

relationships and things medical, and this information about t

program director Is something that I did not have available.

     I would support the recommendation of staff.
                        -                         .
      DR. CANNON: If that is a motion, I second 1;: _,_II
                  A----                    -L----.-,,.

       MRS. SILSBEE:  Dr. Merrill was the other reviewer.

Did he have an opportunity to talk with you, Dr. Roth?

DR. ROTH:  No, I didn't talk to him about It.

e


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Of course, in the view of my earlier comments today,

I found the grant application and the track record along
categorical lines as probably being on the credit side of the
ledger with relatively little of th3.s other stuff, but I didn'

have a chance to talk to Merrill at all.

      MRS. SILSBEE:  The staff recommendation for2-._--
record Ls that the request for $270,323 be recommended for

approval, but the program should be encouraged to recruit

additional staff, particular reference to the program direc-

tor+ ~gaause of the marked change brought about through planne
phaseoug $ite visit to the region is recommended prior to the

March Council meeting.

      MR. POSTA: Right.

      MRS. SITSEIZE: Do I hear --

       DR. CANNON:  So move.

MRS. SILSBEE: Second?

DR. ROTH:  Move approval.
             7-------------_
DR. CANNON:  Second *

MRS. SIISBEE:  Any dicsussion?

DR. CANNON: Question.

m&s, SILSBEE: All in favor?
                  -..             -..
(Chorus of "ayes. `I' 1

MRS. SITSBEE: Opposed?

(No response. >

MRS. SIISBEE: South Dakota.

                   ~-I-.__.- .------ -------


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       MR. POSTA:  South Dakota.  Staff had no real

concerns with this particular application or with the region

Again, they have a very small staff. However, the total

amount requested is $120,680, $42,000 of which is earmarked

for staff.

As a result, you only have about $78,000 rounded

off for four or five activities.

We do feel that four full-time staff can handle.

      The reason we brim it to your attention today is 1

fact that this region has been considered a soLCal,led plannir

region after its divorce with the Nevada program about a yea]

and a-half ago.

     I think that the program has quite a bit of poten-

tial, could probably do an awfully lot more with additional

money, because of the fact that they were in planning status,

because it fs a 9-l starting date application, meaning that

when they came in for their terrenial application last March

1st s neither review committee nor the Council had the oppor-

tunity to review it.  As a result, their funding level of the

so-called percentage of the formula is extremely small.

I thfink if I am right, Judy, our main consideration

today would be to consider them now an operational program?

MRS. SIISBEE: Yes.  This was the recommendation of

staff.  We felt that the planning grant was a fluke in time;

whereas,  its compankon, Nebraska, broke off also.  It has bee


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320 Massachusetts Averw, N.E.
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operational for somet-ime; South Dakota hasn't.  It is carry-

ing on activities and we felt it would be neater if it re-

mained operational.

4

5

      MR. POSTA:  This program is rather unique in that it

has a Regional Advisory Group which serves as the council

`i

for the CHPA agency.  So every time either one of the groups j

called to order, business is conducted for both.

8         As a result, during this past year, when Regional

9   Medical Programs was in a more rather shaky status, this reglc

10   did continue to meet with its Regional Advisory Group and has

11   been quite active with things directly concerned with RMP as

12   well as with the CHP agencies.

MRS. SIrSBEE:  Dr. Roth or Dr. Cannon, do you have

any comments?

      MRS. SICSBEE: Suggestions?

       DR. ROTH:  Well, they stressed in the material I hal

available that this was entirely concerned with salaries,

wages, fringe benefits, and indirect costs.  And no program-

mic support other than what they had going.  So I saw abso-

lutely nothing wrong with it if they were to continue

Fn RMP at all.

MRS. SIISBEE:  This is one of the things, the appli-

cation that you have is just a portion of the program.  They

have money from the first award we gave this year, and then

in the case of South Dakota, they had a couple of activities

49


                                           50

1  funded during phaseout, so there is more to the program than

2  staff.

@

3'        DR, CANNON:  I gave it a grade one on staff and pro-

4  jects, but thought they ought to have their money and thought

51 they ought to be operational.  They are just barely making it.

  I

       fi j /         MRS. SItkcgEE:  Any other discussion?

              7 li
       i/         MR, OGDEN:  Could I ask if the regiona,l director--
    $11 do you really feel the small amount of money involved in
                   I

             9 1  these projects will do any good at all?

            10         MR. POSTA:  Lil, would you like to respond to that?

            11          MRS. RESNICK:  They had a great deal of voluntary

        12' support, which hasn't come through 3_n the application, but et

            13  has come through on their estimates, available funds from other

            14   sources.

            15         MR. POSTA:  Mr. Webster, from the Regional Office

            16   in Denver.

            17          MR. WEBSTER:  If I might, I have watched the South

            18  Dakota Regional Medical Program for quite awhile., and like

            1 !I   both of the Dakotas, those people seem to know how to stretch

           20  a dollar pretty well.  They don% have that many to begin with.
0          21         Actually only I think of the total amount requested,

0          2" 1 they only have four staff right now, two professional and
    ~~1 / two secretarial backup.  That accounts, with fringe benefits,

          24   for the some 44.

          25         The have tknTee major projects, which would have

tiOOYERREPORTlNGCO,INC.
320MassachusettsAvenu~,N.E.
Washinaton.D.C.20002


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320 Massachusetts Avem, N.
Washington, D.C. 20002

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continued even had the RMPS actually terminated.   One was

support the EM3 program with the moneys being directed to

the State Health Department, tih ich heads up that program;

one to Mount Marty College for an extension health educa-

tion program reaching on to Indian reserva.tions, and similar

one in the northern part of the state at another university.

They have in here put in a number of small starts,

all of which would be to support other organizations and

agencies to do their thing.  They really were not trying to dc

much except to coordinate and try to stimulate.  They are

a farming out type of operation that has been looking for good

applications even though very small in money, and I think it

is quite viable.

DR. ROTH:  I move approva 1,
           c ----_ .."-~~.r^n_n.nl~.--r'
MR. POSTA:  I think your point is quite well taken.

DR. ROTH:  I move approval as recommended by staff.
             .- -U'""-' `-' -*"`-.N-l",l-* .a-*.-- ,*Y,.,... _"~:. . . ~II;.. .lu,L . . . . ,=__lql_ ,_._,
DR. CANNON:  Second.                           .., I,. 11. ...I . ,_.

_. a.7 ., ,hil,:/.< .,._ .a<.. _i .J.*";, , "`"rr,urr~~T""`"yr~~

MRS. SILSBEE:  That is approval at $120,680,

Does that include operations?

DR. CANNON:  Change to operational status.

DR. RCYJJH: Yes.

MRS. SIL`%EE:  Change to operational status.

Any further discussion?

MR. WILLIKEN: Question.

MRS. SIKSBEE: All in favor?


2         MRS. SILSBEE: Opposed?

3        (No response.)

4          MRS. SITLS33EE:  That is carried.

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HOOYERREPORTlffiCO,lNC.
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1        (Chorus of "ayes. ")

      Now I the next one is Colorado-Wyoming, which Dr. Rot

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                                                 r~T( .:rr**w-,~`ic~ ./, 3.2 i __,,. -..`<x.qI
is going to be gone tomorrow, and Mr. Hiroto are the two revfe

ers on that.

MR. POSTA:  Minor point concerning this particular

region, their share of the 44-l is actually $335#608.

      This region, for one reason or another, has come in

for about $37,000 too much.  We recommend that the exact amour:

be given to them.

To give you a little bit of background about the

region, Dr. Nicholas is the coordinator, has done a rest, good

job in about a year and a-half he has been there.

Colorado-Wyoming,  like Mountain States in the Wester

Branch and Inter-Mountain in the Mid-Continent Operations

Branch, has had turf problems in the past. We haven 1 t heard

too awfully much about the turf problem this past year pri-

marily because closeout directives, phaseout directives, has

stipulated that there would be no new starts.

      As a result, the Interagency Council of the three

medical programs have not met on a periodic basis.

We will be discussing Inter-Mountain a little bLt

tomorrow, more in detail, but we do feel that the Colorado-


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53

Wyoming program as well as Mountain States would be in a posl
tion to respond to us, meaning RMPS; that the monthly ses-

sions would be convened to discuss all activities to be funde

In each of the three Regional Medical Programs, in order to

avoid duplications of services funded by one or more Regional

Medical Programs.

The CHP comments from Colorado have been quite

favorable.  We have not yet received those from Wyoming. Eve
though we are not anticipating any problems. They have good

ma nageme n t .

    The only thing that you might notice in the green

sheets, the allocation by option seems to be an awfully lot o:

money earmarked under program staff.  However, if you would

look at the similar graph located on the yellow, page 2, you

will note that they have about 17 feasibility planning and

central servfce activities earmarked.

2 b pf+f$   w e would recommGnd that the application be approved
             I-.-M/m**lCm/IYI ,--..-. ".vp.".. ", .   . . ..-. )llll_ : .I,.. :..`.--*. ./.    .._. ._   ,...   ,,.
not as requested, but in the amount of $335,604,
  `1 . . . . . . .                               ,.
             1' ,  ..,  .,           ""I ..
                      _ ,.,, ~~_. ..I                    _ ,/~ ,. ") .,_
      MRS. SILSBEE: Dr. Roth.

DR. ROTH:  I have no particular quarrel with any

of that.

You recommended what amount?

    I got into a little mathematical problem with this
thing and I wouldn't quibble over $184, but one place it said
they over-applied for $36,682 and in another place it says


0
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1  $36,796, and I come out with $184 difference in that,

2

3

       MR. POSTA:  Doctor, what they actually did, if you

will look at the yellow allocation by option --

4          DR. ROTH:  Yes.

5         MR. POSTA:  -- project number 34, Regional Pediatric

I3  and Nephrology Center, calling for $22,210, was not initiated,

7   nor will it be initiate&. 230 they, meaning Colorado-Wyoming

8  program, came in for that.

9       In addition, they came in for $14,472 over that.

10        So what we were trying to state is just go back to

11  the former approval, whatever the former may have been.

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      I agree with you9 some of those figures don't add up

to 100 percent.

       DR. ROTH:  Well, my intent, as I say, I have no desi

to quibble over that odd amount of $184, but whatever the

thing really works out to be, on their percentage formula

application, I move it be approved.
                        --al+ *~"'-'=--rs e w` ..II -..,;l,lli"-,i, * ,_/._. ,.I *_
       MEG. SILKBEE:  We had another consideration in this

19  particular application which Mike'sort of glossed over, becaus

20  he happened to be missing from staff review, happened to be

27  on review of the Mountain-States Medical Review Program.

23

      You may remember, about a year or two years ago,

it 1s hard to remember, we had a problem with the regions

24  Inter-Mountain, Colorado-Wyoming, and Mountain States, which

24

had overlapping areas.  That was not the problem so much as th

HOOVERREPORTlNGCO,iNC.
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54


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9  something and certainly before they funded anythinGthat they

10  would keep one another informed on a regular basis on what

11   they were doing.  And theLr respective RAG chaIrmen would als

12,   be involved.

13         We have found during the phaseout that particular

i4  methodology seems to be working better with two of the region

15   than with their two with the third region,  So we feel this

ltj   needs to be put in as a condition again, to get this back on

17

18

target.   Beoaxase it is creating some problems.

       So we would like -- I don't know that Mike would, b

l!b   I think we would like to have a proviso put on each of the

20   applications of these three.

DR. ROTH:  I-+move,,what Mrs. Silsbee just said.
                       .._.:.
                            " .-,
                                 "r~-~~ c, ._ ..z. * "    .' I `. . . . . .  , _" "./_.
,DR. CANNON:  Second.
.,--h-".. -,-- ""-ww-, '--.,. l.*l^".., . . . ~.l-?e,,;,_l, .,_I ,.,,
(Laughter)

24

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       MRS. SILSBEE:  We took that proviso, we receive

written assurance this procedure is still in process and bein

HOOVERREPORTfNGCO,INC.
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55

way in which the regions were not working with one another.

And so in some instances, the localities were being split apa

depending on which staffs they were relating to.

SO two Council members, Dr. Milliken and Dr. SPelln:

from the Review Committee, were sent by Council to go out and

try to work out some kind of a procedure, and they were met

by the three coordinators with a proposed procedure in which

the three coordinators agreed that before they started on


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implemented.

56

      MR. MILLIKEN: Question.

      MRS. SILSBEE: Okay?  Motion has been made and

seconded.

      DR. CANNON:  Question.

       MRS. SILSBEE:  Does anybody have any further comment

      DR. CANNON: Question.

       MRS. SILSBEE: All in favor?

      (Chorus of "ayes.")

      MRS. SILSBBE: Opposed?

      (No response.)

       MRS. SILSBEE:  Mike, there was one other aspect of

Colorado-Wyoming,1 dont t know whether you want to bring Ft up.

It didn't have anything to do with review of the applicatLon,

but the letter that came from the RAG about the genetic counse

      MR. POSTA: Right.  Last December, the Council

approved a genetic counseling program that was Initiated in

January of this last year. When they came in -- well, the

comments from the various reviewers, including some staff

consultants, they felt that entirely too much effort was being

placed in two areas, one sicklecell anemia and one in Tay-Sachs

disease,

      The program completely revised the program and de-

veloped some genetic counseling based in the areas of heart,

cancer and stroke.  They have had considerable interest on

?


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57

the part of the Regional Advisory Groups that program was

subsequently funded in those particular areas of heart, can-

cer and stroke.  And about, oh, $35,000 or $40,000 at the

most was spent for the first six months.

      Because of the negative comments that staff related

back to the region, the region decided they had better not

come in for a request to continue the application.  Howe ve rs

when the .RAG did meet this last time, the RAG chairman and

the coordinator were directed to submit in writing to RMPS

their concerns that they had received relatively negative

rrtomments because they really wanted to carry on this particu-

lar activity.

     The reason I bring it up here and had hoped that

we-- 1 am glad Judy reminded me of it -- that in case this

particular region comes in for request with unexpended balance

in December, whether or not you would wish to reconsider

further funding of this particular program for the next year.

     They have not come in as of this date, but we do kn-c

we are going to get several letters from the coordinator

as well as the RAG chairman,

       DR. ROTH:  Well, I don It know how much -- what kind

of price tag are they putting on that one?

       MRS. SIIXBEE:  They haven't put any price tag on it

yet, Dr. Roth, but if you are looking-- in the letter you are

looking at there now, there just seemed to be such a point of


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the kind of conflict of the national priorities as to how the

Regional Advisory Group saw tremendous need t that previous

action had kind of interfered with what they saw as a regiona:

need that was befng met.

DR. ROTH:  Because my reaction to it, to be con-

sistent with all the oratory I heaped on you before, was I

would heck of a lot rather see them spend some money in the

genetic counseling concept that they have out there rather

than most of these ten or twelve projects that they have listx L?

under supportive quality assurance.  Working with PSRO in

Wyoming and utilization review organization, PSRO in Coloradoa

and so on, I just thfnk it would be much better use of RMP

money and I would rather switch and I would put that motion,

to them.

MRS. SITSBEE: RAG.

      I don't think you need to make a motion.  It just

gives us a sense, because it will probably be coming to us.

       We don't need a formal motion.

     Now, we have about five or six regions that we have

identified that don't have to be considered today, but we will

have to look into them tomorrow.

Originally about four of those we were going to take

up when Dr. Merrill was still here.

MR. NASH:  Excuse me.  I have one Dr. Roth is review ?r

on, Tri-State.


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       MRS. SLISBEE:  Okay, there are a number of those

kinds.                          I

      MR. NASH:  This is one I have flagged special.

     MRS. SILSBEE: Okay, fine, let's do that one.

Tri-State, orange book.
=.-"~~`""I*"~ i ,,l. ~,.~,,-;, " __
           . ,"6+`?4jur

       MR. NASH:  This would be in the orange book.

        ldRs. MARS:  Which one is it?

        MR. NASH:  Trl-S tate.

      MRS. SIMBEE: Mr. Nash.

       MEi. NASH:  This is a request for $569,609, which is

the remainder of the FY-74 Tri-State fund.

      Mrs. Murphy is executive program -- replaced Dr.
Bwartner.Dr. Ike Taylor has recently reJoined the program

on a full-time basis as deputy coordinator.

      This region received triennial status in 1970. It

was last revlewed by Council in February of 1973. Council

at that time considered recommendations from the Review Comrni  tee

staff anniversary review panel, which met in December of 1972

expressed serious concerns over this region's progress,
recommended a funding level of $2.5 million in lieu of

the requested $3.4 mlllion.  Council concurred in the lower

funding leve 1,

The key issues at that time were lack of adequate

minority involvement, lack of discernible program thrust amoq

projects in contract activities, and evaluation process faFle i


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60

to identify achievements related to the regional's objectives

      Prior to the phaseout notice, Tri-State RMP main-

tained four subregional offices plus a central office. The

subregional off ices were in western Massachusetts, eastern

Massachusetts, Rhode Island, and New Hampshire.

Each had subregional advisory group and representa-

tives from each subregional advisory group were also members

of the 'IN-State RAG.

During the phaseout, that 1s between February and

June, the subregional offices were closed. The subregional

advisory groups were no longer active and the central staff wI

reduced to three professionals and four secretaries.

     Thus we find that in June of this year, with only

seven staff members I and,by the way, in this particular pro-

posal they are planning to reopen the subregional offices and

boos their staff to a total of seventeen. There is no men-

tion in the application of the reactivation ox' the subregiona,

advisory groups.

Now, Tri-State,Regional Advisory Group iis a 57-

member body which met only three times last year.  We aren f t

really sure of their continued interest in the program.  On ly

19 members were present when this application was considered.

      Moreover, the Tri gave approval to more projects in

the region's FY-74 support.  Their answer was they would

meet again on December 12th to prioritize the program, select


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activities actually to be funded.

This region's review process was given conditional

approval prior to our phaseoutactivities and we noted that

although the application was sent to the appropriate CHP agent

to review and comment, the comments from those agencies were

not received in time for true consideration.

       It was also noted comments from some of the technica

reviewers were not received in time for consideration by the

RAG.

      Now, this particular proposal, as far as staff can

determine, all of the activities proposed appear to fit the

RMPS options built on previous staff and operational

endeavors.

      I note 41.9 is in quality assurance, 5.1 percent in

strengthening local planning, the remainder is in program staf

support.  There is no request for kidney in this partfc ular

application.

     I think if you go back to my former statement, that

back in December of 1972, the staff anniversary review panel

expressed some serious concerns about this region.  I think

these still remain.  I think we are not really sure of theLr

review process.  We have some concerns about the management

capability for the program.

I think an example of this is that in the writeup,

will find that a site visit was made to the Rhode IsLand


1   health actrvity in June and that produced a favorable report.

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However, Dr. Margulies visited that activity subsequent to th

and he has some concerns that this particular program perhaps

is deviating from the RMP concept and is drifting into the

usual university-based type of activity.

We also hear the program director for that activity

either has or plans to resign.

In the prior application, this region was awarded a

sizeable EMS project to develop an EMS program in three state1

and in the region.

Massachusetts was supposed to get about $775,000.

A visit to the Massachusetts EMS activity revealed

the fact that the plan they developed was not at `all accep-

table so RNPS restricted use of those funds until an accep-:

table plan could be presented.

This was done and it was finally approved by the EM

technical review pane 1.  But I think some of these things

give you an idea of our concern over the management and direc,

tion of this particular program.

MEG. SILSBEE: Dr. Roth.

MRS. lvms:  But YO~.....~~.~~ ,.,, $ill reco~endiw funding
              vrm..~-rmri...           --.I. s .,.,.. _ .l,)",j -,, .._ -.. ../ _(.    ,,      ,..  ~.

of half a million dollars?
    ,. ~_y,.l..~..l, -r.r-l-r",r. ,..nl.
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       MR. NASH: Yes
                          ????? ?? o

DR. ROTH:  Well, I have familiarity with this reg iOl

because of a site visitation that took place on a peak betweer


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1   two valleys evidently,  This is a region that had been fn dee

2   trouble until Dr. Leone Baumgartner went up there and direc-

3   ted them out of it, and now that she has left, apparently the

4   are going back into it,

5         I certainly have nothing to add to that staff

6   analysis, but Lf one looks at their projects out of that half

7

8

million dollars, roughly, $302,235 are direct contract sub-

sidies to medical schools, Tufts University School of Medicin

9

Boston School of Nursing, one thing and another, for the

10   development of PSRO s tandards.

11

Ithink it is just a beautiful example of the kind

12

of inept use of our RMP money.

13

MEG. MMLS:  That is just what I think, too.

14

MRS. SILSBEE:  Mr. Hiroto, you are the other review1

15

MR. HIRCTO:  I don 1 t have much to add, except it

continues to have the same problems that were pointed out in

17

the earlier review.  And I don't know what importance was

placed upon this thing called minority involvement and evalua'

procedures , but apparently those who had those problems in the

past continue to have them.

       MRS. SILSBEE:  Well, this region did decide when

the phaseout to lower their staff considerably, theyhad--

Dr. Roth, they had, I think the high continued beyond the site

visit, but they did get rid of most of their staff.  And

Mr., Murphy, who 1s a very adept coordinator, had decided he,

63

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having gotten rid of a lot of the staff, he did not want to

get them back until he saw which way the program was going.

And he has been doing sort of a holding operation as far as

4

employing new staff.

5

However, he is employing consultants to work on

6

7

programs.  And there has been a, difference in view I think wil

in the staff as to this Tri-State program.

8        I don't think any of us have a real understanding,

9  certainly not from being up there and observing how the Regior

10  al Advisory Group works, how the staff works.  That is a

11

mFsslng piece of intelligence.

12          DR. ROTH:  Everybody optimistic enough to think

13  you can get a bunch of those New Englanders, get the New

14

Hampshirers agreeing with the Rhode Islanders agreeing with

15

the Massachusetts people --

16        (Laughter)

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MRS. SILSBEE:  You are suggesting the concept of

Tri-State--

       DR. ROTH:  That was the big outstanding trouble thai;

was left over that not even Leone had solved at the time of

our site visit, and it just frictionates more.

     About the one thing you can put your hand on, get a

handle on here in the present activities :-is limited to Rhode

Island and coordination with the Rhode Island program and

Brown Medical School.

HOOVERREPORTlNGCO,lNC.
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       MRS. SILSBEE:  Well, having put all the problems oud

on the floor, do you have a motion to make* or, Mr. Nash, do

you have a recommendation?

       DR. ROTH:  Well, as I understand this whole procedure,

which I very freely admit I don't completely understand just

what we are doing here now, we have a sort of one option; ther  Is

a maxttmum thing we can do, which is give a formula grant appl  -

cation to whatever money turns out to be available after a  fe

more Divine revelations come about.  And so what would be  the

effect if I said I want to give them half of what they

asked for, and I said this on the basis that it would shut down

some of this quality support thing but not interfere with

their other programming, is there any way you can do that?

       MRS. SILSBEE:  Well, there are ways to restrict

funds.  There are also ways of not recommending the award of

those funds .  But fn that latter event, we would have to spell

out very clearly why we were doing It and under what circum-

stances,

DR. ROTH:  Well, this strikes me as being an inequi  -

across the board, I would be in favor of it. But as it stands

their formula amount.
            ,, ,_ _,il.z.-~l .a"Aw--*-- -'  `-a
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       MRS. SILSBBE:  Then an alternative in that situation

would be possfbility of restricting some funds.


66

1       On the other hand, Dr. Roth, the very words that are

2  coming out of this Council meeting, that these optionS are

3  options and not restrictions my solve some of the problem  th

4  you are talking about if they have an opportunity to go back

5   to the drawing board.

(i          DR. ROTH:  I would hope so.  I would hope so.

7

8

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     I will move approval of the staff approved formula
             _y_"..- 1.-.--'11~~._   ..i `.` _ __ , ___                       . . .
                                             . . .                _) .,

amount,

MR. MILLIXEN:  Second,
   -",ll.-(.l. .,_c .,.. _,,w a:*- " .-"t -'   ..,

MRS. SIUBEE:  Any discuss&on?

DR. CANNON:  Just another comment.  I would really

12 1
i  like to know how do they get started so quickly in the PSRO's?

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     We.have been in quality audit, buS; you know, new
legislation comes out and it seems like across the board,

I.5 II  every RMP gets the action started.

16

17

18

19

20       What you are talking about is tryirg to make Policy

I         Who started it? We didn't.

        DR. ROrlCH: No.

        DR. CANNON:  The Council didn't, We just see it

after the fact.

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22         DR. ROTH: Yes.  Well, Bland, you have got to under

23  stand that out of a PSRO legislation, those that are still

           24  working on funds that have not been released and not one of

          25   these outfits has a federal buck from the Professional

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Standards Review Organization to pay the salaries of staff the

have already hired all over this broad Land of ours.

      DR. CANNON:  So we pick up the tab.

       DR. ROTH:  So where are they getting it?

      I haven't looked at the Pennsylvania Medical Program

Review, but I will tell you right now, the State Medical

Society is paying $10,000 a month out of Medical Society

funds to keep this thing alive until they can get their hands

on the first federal buck, and I assume they are going at it

through PSRO, CHP, and any other way they can get it.  And I

am sure Massachusetts is doing the same thing.

      DR. CANNON: Tennessee, at a meeting the other day,

presented a program f3.r R&D money.

      MRS. SILsrn:  Mr. Nash, do you have any comments

about what this project number 31 is?

      MR. NASH:  Do you have a project 3S?

       Use the microphone.

       MR. STOLOV: Yes.

       DR. ROTH:  What is project 31?

      MRS. SILSBEE: The big one.

      MRS. MORGAN:  Southeastern Massachusetts.

       MR. STOLOV:  I know it by heart.  It is Dick Egbert!

project, also is an adviser to the President on this issue.

       DR. ROTH:  Not on this issue.

       MR. STOLOV:  Well, on other issues. And it is


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for southeastern Massachusetts, which is part of the eastern

Massachusetts region.  They divided the State of Massachusetts

western Massachusetts and eastern Massachusetts, and the State

of New Hampshire is a subregion, and Rhode Island Is a sub-

region of the Tri-State.  This is a $177,000 project to develc

PSRO group that is called the Pilgrimage Foundation, which is

an independent foundation of the Medical Society of the south-

eastern region around the Cape and above the Cape.

DR. ROTH:  Does this interlock with the Commonwealth

Foundat ion?

MR. STOLOV: No.  In the first allotment period,

Tri-State gave a similar grant of bver $100,000 to the

Commonwealth Poundation for development of the Boston area. '.

This is south of Boston.

       DR. ROTH:  My unders tand ing

petltive.

is the two are not com-

MR. STOLOV:  That is correct.  That is my understand

ing also.

      The overlaps I see Zs the nursers project which link

up to that which is in the grant, but they are both separate

corporations, Pilgrim Foundation and the Commonwealth.

DR. ROTH:  Well, this clues it in perfectly, because

Dick is one of the directors of the American AssociatFon of

Foundations for Medical Care that covers the country2 started

in San Joaquin Valley in California, and so on.


1         MRS. MORGAN:  Came to New Mexico.

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       DR. ROTH:  So they are getting operational money out

of any federal grant program.

      DR. CANNON:  And you voted for it.

     (Laughter)

      MRS. MARS:  You just recommended it.

      DR. CANNON:  Recommended --

MRS. MARS:  Recommended us approving Lt.

DR. ROTH:  I expect to thank you later.

(Laughter)

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       MR. NASH:  We, of course, will be, remaining staff

will be taking a look at the review process.     ' ',

Travel fundshave been unfrozen and we have been directed to

do that.

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      I do think some sort of site visit to this region

could be made if not too distant future, it would certainly

help us get a better handle on exactly what is going on up

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MRS. SILSBEE:  By site visit, do you mean weth

Council?

       MR. NASH:  I think it would be helpful if we could

have a Council member.

       MRS. MORGAN:  I hope you get more Council members,

because we are going to be a busy group.

MR.HIROTO:  Dr. Roth, have the guidelines and

69


1  regulations related to PSROls been established yet?

2         DR. ROTH:  No, sir.  They haven't made decision num-

3  ber one yet,

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MR. HIROTO:  I didn't think so.   HOW is it possible

then, that you fund a program -- are you establishing it? Is

that the idea?

DR. ROTH:  My earlier speech today against using RPM

money -- you know, I think it would be just great if this Count

would move on notifying all regions ef RMP that the money

that they use should not be used in support of PSRO,

it.

DR. CANNON:  Seconded.
                _"".e ". ._,, ,,.. ,  ,,

MRS. MARS:  Nake a motion.  We are all for it.
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DR.. ROTH:  All right, I will make it9 be happy to ma

'DR. CANNON:  I second it.
                -i-..s-"lr -.' ,(,",_ ",.,

DR. ROTH:  Be glad to make such a motion.

MRS. SJXSBl3E:  Could we just for a moment--

MRS. MARS:  Get back to this program?

MRS. SILSBEE: No, I think we can hold on that. But

I think some reading of what our guidelines said.

Jerry, you have got September 7th guidelines?

Might be timely here.

DR. ROTH:  I have great faith In the Fngenuity of ti

coordinators and directors if you just tell them this isn't tc

go into PSRO support, put it some place else, then we are


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       DR. PAHL:  Let me add a note here while Dr. Garde11

is looking for the right piece of paper.

6       It hasbeen the policy of RMPS to permit regions to

7  engage in those kinds of activities which would assist in esta1

8  lishing standards of quality, and so forth. But not to use ful

9  to actually operate or have the RMP itself become a PSRO.

10       I am not familiar with this particular project under

11  consideration and what Mrs. Silsbee just showed me, it seems

12  to me we are walking very close to a line of what I have just

13  said.

14        I don't want to take a position,tEcause I just gave

15  it a quick glance now.  But the thought has been that the RMPls

l(i  would be allowed to support quality of care efforts, but that

17  is not meant to be operating or becoming a PSRO in itself.

18          DR. ROTH:  Well, I would submit if there is anybody

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on the Council that is not aware of tlz present state of PSRO,

Implementation, that that is a biit of an unnecessary injunct-ior

cecause the first PSRO has not cracked its shell yet.

There is no such thing as a PSRO.

DR. PAHL: Right.

      DR. ROTH:  We haven't even gotten out of HEW the

lefinition of what a PSRO region will be as yet.

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      MRS. MORGAN :  Everybody is trying to make one, and

hope they will head it, I think.

ning around in support of their own peculiar notion as to what

PSRO is eventually going to turn out to be.  It is sort of

inept for our slender funds to get caught up in that whirlpool

      MEG. MARS:  In other words, we are just going to giv

them $X'gtOOO to try one?

       DR.,RQI'H:  I would be very happy, but I think it

should be an injunctive sort 6' thing for all PSROls, not

just pick out Tri-State, because it happens to be the largest

amount of any of the ones that were in my group.

that.
/""`- `12' `"

MR. OGDEN:  I really fee 1 I have to speak against

,/-*--"",. _Llll;~p_l  `-..=...   . ," ,_,                      `, `-.     ., 1,
                                 ,/ d., -. ,~.~ ,.,. ,.,   

      I think one of the things we are charged with, I boy:

as Council, issome effort of cost containment as well as quali

assurance.  And even though nobody knows yet what a PSRO is

necessarily going to be , people didn't know what HMO's were
going to be either and we have allowed a lot of money for that

We have allowed a lot of money for PHRO in the past.   I think

a region, that is its regional advisory group, has determined

that this is something that they want to expend funds on, I

for one would be will,ng to see it done.

I really think this is something that we want to lot

into.

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       DR. ROTH:  I think it is a very-- well, I think it

very unsound to build on past mistakes.

       MR. OGDEN:  I just donLthink it is a past mistake.

       DR. ROTH:  Well, I gave my earlier opinion that tha;

is the reason we are in the shape we are in with this whole

program.  And I would also submit that the only reason that t1

RAGS are now or the coordinators are now couching their requee

In terms of PSRO support, quality assurance support, is becau:

out of this office they got a directive that was priority

number 2, when HMO support was high on the priority list, that

was the popular set of initials, and that is what has been

wrong with the whole bloody effort.

MRS. SILSBEJE:  Dr. Roth, I thjlnk,if I can find the

wording, that what you were saying is sort of in our guideline

     If indeed we are proposing the approval of moneys

that are to set up a PSRO, then there is difficulty in our

staff workup, which if Council would direct us, we can--

       DR. ROTH:  You aren't doing that,though,'Judy.

     I read this application and, for example, just

take number 1, A, rumber 1 on your white sheet under PSRO,

"Quality assurance criteria , pulmonary ambolism and Venus ulce

     This is a single well circumscribed diagnosis.  It i

an addFtion of one single diagnosis to a list that was started

in an EMZRO in Albemarle County, Virginia, with the Universit

of VirgLnia, in Charlottesville, which took carcinoma of the

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breast with biopsy proven.  It took fracture of the femur in a

person over age 65.  It took middle ear disease in children.

So It is seven diagnoses.

Now, here is another one adding an eighth.

The federal government has just given half a million

dollars to the Kaiser Foundation in Southern California, Los

Angeles, to do another kind of these things.

Now, you could use ten times the total amount of

money we have got to parcel out around the country to do these

outcome s tandardss, outcome evaluations for the approval of

standards .

You have got the College of Surgeons and the AMA work

in@; on projects.

We in the AM have poured $200,000 of our dollars

down the same drain.

      Just because they did it doesn't mean that I think

any higher or anybody else should do it right now.  When the

federal government has passed a law, there is an appropriation

to make the thFng work9 and all you do by diffusing the expendi

tures for this effort is hide how much it is going to cost.

Because one of the inevitable things about this is it has a

chance of fmprov-lng quality of care in which it may be worth

the extra amount it costs, but auybody'; that :;%htnks that this 3.2

a cost-saving mechanism Is whistling Dixie and that is just

what the Congress has been so enthusiastic about.


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This has been our trouble with so much of the frag-

mentation in the entire health care field.  You can't idenfity

what it costs to educate a physician today because the moneys

come in through the VA, NIH, and every other doggone place.
     We ought to be knowing what we are paying for edu-

cation. We ought to be knowing what we are paying for quality

control.  And a diffusion into a program like this, which

started out categorically, can't get much-further afield.

       MR. OGDEN:  Might I just interject here for a moment
I had thought that this material that is in the enclosure

mailed out to us and is the application instructions for FY-19

which went out to all the RMP'swith a letter from Dr. Pahl on
September 7th, had been approved by this Council. And it unde:

part B, on page !j, simply states:

'Under strengthening focal quality assurance

"2 *  Assisting with the development of norms

criteria, standards and techniques associated with

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     So if you get the cost piecemeal between RMP and

CHP,and OEO and SRS, and AMA and--

      MRS. MORGAN:  American Hospital Association,

       DR. ROTH:  Nobody is ever going to know what it is

going to cost.

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DR. ROTH:  .I don't';know, but having lost round one

                      in the ring in

doesn't mean I am not willing to get back

I(;   round two.

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(Laughter)

I think the Council made a mlstake on this.  I think

it is good to reognize mistakes.

DR. PAHL:  Mr. Ogden, I think it would be appropriat

to state again, since I believe you were absent at the last

meeting of the Council, that these options were prepared basic

ly by the Department, ourselves included, at a time prior to t

July meeting of the Council,  because that was the timeframe

work in which the Department was operating. What we did was

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      implementation of the PSRO Division, Social

      Security amendments of 1972, RMP?; will be engaged

      in pilot efforts only and will not be responsible

      to the actual operation of PSROls."

        This is the material this Council sent out In

September.

7           DR. ROTH:  Sure.

8          MR. OGDEN:  Asking for these applications to come

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in.

10         Now, what you are saying is the meeting in which

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these applications come in, you tell them you don't want this,

But this just went out from this Council. How

13   flipflop can we be?


77

present to the Council in July what was a fait accompli,

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4  course of the summer and fall months frozen into restrictions,

5  which were incorporated into the instructions for preparing

6 !  the September applications.

7         I don't think we need to make again apologies for

8  the Department or RMPS, but this was never-- these options

9  were never developed by this Council.  They were given to the

10  Council as Departmental policies, soft as it was at the time,

11  which subsequently became frozen as Departmental policy, and

12  which we have been operating upon.

13         So you are correct, the regions were advised by us

i4   to respond to these in these applications.  They have so re-

15   sponded.  And In that sense, the country has been following

Ifi   Departmental announcement.

17        It hEfj not been following what undoubtedly would have

  been a different set of priorities had the CouncLl had that

            l!)  option of being in on the ground floor, rather than coming

            20   afterwards.

0          21          MR. OGDEN:  That may or may not be the case, but  tha t
a           22  j  is what we asked for and certainly the applications came in in
     93!
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           24  what they want to do, I am willing to let them do it.

           25          DR. ROTH:  Well, I would remind you that I maile the

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speech once this morning.  Most of these things this Council,

long before you got on it -- Dr. Cannon is about the only one

that can bear me out on it -- I am not being critical; this

hours that have gone into this thing around the country, it

ought to be outstanding.  And unhappily it isn't outstanding.

      We haven't got much chance left to do anything abou'

it.

      Now, I doubt that any coordinator is really inter-

ested in losing hlls money down his quality assurance drain

right n& for the next six months.

      Sure, they have got other things, but if this is the

only way thware going to get their grants approved, they are

good grantsmen.

MRS. MORGAN:  It is the same way we got funding,

WasnIt it? It seems it was the first Council meet$ng I

attended a couple of years ago that unless we took HMO, or by

taking HMO, we got additlonal money that we could spend for

RMP by taking a certain percentage, and this is how it happens

We got stuff,so much money for HMO's, then we had a little

additional money we could use for RMP.

       DR. PAHL:  Unfortunate as it is, I think it is fair

to say present circumstance, by having the agency develop a


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79

set of options which were known to be favorable to the

Administration, we were over a period of months able to pry

loose in fiscal I.974 funds.  The shame of it Is that the duly

mandated Council was basically bypassed in this, and instead

of asking this Councal for advfce as to program direction and

priorities, the Department presented the Council with the

priorities and asked for endorsement -- and, very graciously,

the Council gave endorsement.  But that is the posture of the

program.

       DR. RUTH:  I have to point out for Mr. Ogden, I arg

ed about it then, too.

      (taughter)

       MEL OGDEN:  Had I been here, I think I would have bet

on the opposite side from you.

     I do feel this is something that we really should

be involved in.  As a member of the public I speak now. I
think this is the kind of thing that the public is interested

h-3.

       DR. ROTH:  You think every agency in the government
ought to be interested in it because it is good, not just
the agency that is given the responsibility for running the
program but they ought to be getting money out of NIH grants,
VA, and everybody that fs interested in medicai care ought to

be contributing to this thing?

I think that is ridiculous. I thfnk we are giving

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money to do a job and we ought to do it instead of giving

our money to other people to do their job.

      MR. OGDEN:  I think it depends on what you cons

quality service.

       MRS. SILSBBE:  The Tri-State application has a

ider

                                                       ..:., _"
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motion it-should be approved for the remainder of the RMPrs P
r;,,~-A~..~ir.~ . . ., .I -ec        'I _. .                          ,, .., I, -.-. .= .,..        .\"   
74 allotment,,, 5;.%%703.

There hasbeen a good deal of discussion about some

of the aspects of that application, but I haven% heard the

motion amended, and I wonder if there is any further discus-

sion?

MRS. MORGAN: Question.

MRS. SILSBEE:  Or can we take action now?

MR. OGDEN:  I move it be approved.

MRS. MORGAN:  It has already been moved.

MRS. SILSBEE: It has been moved and seconded.

All in favor?
-,,___- _ ._ ..,--.._ -,_ I-.,. ", ^C--".. _-_-_ __,a,
(Chorus of "ayes.")

MRS. SlX3BEE: Opposed?

(No response.)

MRS. SILSBEE:  Okay.

DR. PAHL:  I think this will conclude our executive

session for today.

We might reconvene tomorrow morning at ni.ne o'clock

in open session, and again before we do adjourn, I would like


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to thank Dr. Cannon,and.Dr. Roth for their many years Of

participation.  They won't be with us tomorrow.  I believe we

are going to miss them sorely.

So again, thank you very much.  Perhaps we will see

you on site visits.

     (Applause)

fWhe re upon, at 5:30 olclockt p.m., the meeting

was recessed, to reconvene in executive session followin;

open session Thesday morning, November 27, 1973.)