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               UP,lwcot M,%OtLmommt MA  040 20'772 0 Us^ 0 C301) 24@l 1 0





























                                        NATIONAL ADVISORY COUNCIL


                                                TRANSCRIPT


                                               June 14, 1974



                                                                         A
                                  ORIGINAL
                     TRANSCRIPT OF PROCEEDINGS


                           NATIONAL ADVISORY COUNCIL

                          ON REGIONAL MEDICAL PROGRAMS





                                BOARD MEETING












c


                                               Rockville, Maryland
                                               June 14, 1974




              Pages 276 thru 511









                         HOOVER REPORTING c6mpANY, INC.
                                    @l Re@s
                                   W"Wngton, D.C.
                                      546-6666











                                   NATIONAL ADVISORY COUNCIL


                                   ON REGIONAL MEDICAL PROGRAMS





NS





















                                           BOARD  MEETING





                                                        9:00 AM
                                                        Conference Room C-H
                                                        Parklawn Building
                                                       Rockville, Maryland

                                                        Friday
                                                        June 14, 1974



        2                                                                 276


                                          C 0 N T E N T S


                  REPORT                                                  PAGE

                  Mrs. Wynona R. Gordon, ALABAMA                          277

                  Dr. Benjamin W. Watkins, ALBANY
                                                                          279
                  Mr. Mike Posta, BI-STATE                                292

                  Mrs. Esther M. Martinez,. CENTRAL NEW YORK
                                                                          301

                  Mrs. Audrey Mars, ARKANSAS
                                                                          308
                  Mr. Edwin C. Hiroto, CONNECTICUT
                                                                          320
                  Mrs. Audrey Mars,, LAKES AREA
                                                                          322
                  Mr. Peterson., MARYLAND                                 336
                  Mr. Sewall 0. Milliken, NASSAU-SUFFOLK
                                                                          341
                  Dr. George E. Schreiner,
                      NEW YORK METRO                                      344

                      NEBRASKA                                            348

                      NORTH DAKOTA
                                                                          351

                      SUSQUEHANNA VALLEY                                  352

                  Dr. Paul A. Haber,
                      MEMPHIS
                                                                          364
                      WEST VIRGINIA                                       367,
                  Mr. Michael Posta, TEXAS                                369
                  Mr. Van Winkle, WISCONSIN                               3'(8
                  Mrs. Maria E. Flood, TRI-STATE
                                                                          381
                      ILLINOIS                                            4og

                      OHIO VALLEY                                         414

                      WASHINGTON/ALASKA                                   418

                      COLORADO/'WYOMING                                   421

                      FLORIDA                                             426




                                                                          276-A


                                     C 0 N T E N T S
                                                     (continued)

                 REPORT                                                PAGE


                      GREATER DELAWARE VALLEY                          428

                      HAWAII                                           43Q

                      INDIANA                                          433

                      IOWA                                             438

                      KANSAS                                           443

                      MAINE                                            446

                      METRO WASHINGTON.,,D. C.                         452

                      MICHIGAN                                         454

                      MISSOURI                                         459

                      MOUNTAIN STATES                                  463

                      NEW JERSEY                                       47P

                      NEW MEXICO                                       473

                      NORTHERN NEW ENGLAND                             483-

                      NORTHLANI)                                       487

                      OKLAHOMA                                         489

                      OREGON                                           491

                      ROCHESTER                                        495

                      TENNESSEEIMIDSOUTH                               497

                      VIRGINIA                                         501


                      WESTERN PENNSYLVANIA                             503



        3                                                                       277

                                    P R 0 C E E D I N G S
                                    - - - - - - - - - - -


                              MS. SILSBEE:  May we please begin?  I think we have

                 a quorum, with Mr. Milliken.

                              Okay, we are going to start this morning with

                 klabama.     Mrs. Gordon.


                               REPORT OF MRS WYNONA R. GORDON


                                             ALABAMA
                              MRS@ GORDON:  Since we are trying to expedite things
                 today, I'll  not display my ignorance by talking     too much.

                              .The Alabama Project, we are asking    continuation for
                 16 projects, 21 new and eight that have been approved before

                 Dut have been unfunded previously, which makes 29 new.          I

                              As you see, the reviewers have given it an above-

                 average assessment.  They seem to have good rapport with CHP
                 and they have one consumer and one provider from B agencies, the

                 12 B agencies on the Counci'l.

                              I did have a question.  They talked about the

                 3tate Advisory Committee to the Governor and the State Board of

                  ealth and this committee,, the EMS-Committee of RMP was the

                 iucleus for this and does anybody know what        what --

                              MS. SILSBEE:  What is your specific question,

                 qrt.   Gordon?

                              MRS. GORDON:  Well, actually, pertaining to what

                 qe were talking about last night

                              MS. SILSBEE:  Umn hmn.



       4                                                              278

                            MRS. GORDON: -- and so I picked up  on  the  State

                kdvisory Committee to the Governor and the State Board of

                Health and was wondering what the


                            MS.'  SILSBEE:  Mr. Jewell.


                            MR. JEWELL:  Are you talking about the E14S Advisory

                committee, Mrs. Gordon?

                            MRS. GORDON: They said that --  well,  that  this

                committee was-made' up primarily of the EMS.

                            MR. JEWELL: Right, that  was  the  nucleus.  They

                are heavy on EMS in Alabama and the tragedy that  occurred  to

                the Governor recently.  They have established a committee made

                up of the health interests in the state which is advis4)ry  to

                the Governor on EMS and that will be umbrellaed into 'other


                areas.


                            MS. SILSBEE: But isn't it  an  advisory  committee

                Ln the sense that the South Carolina one was  yesterday,  but

                I think that is the

                            MR. JEWELL:  I missed So@-uth Carolina.  I'm sorry,

                f don't


                            SPEAKER:  It is-not.

                            MR. JEWELL:  It is not.  Okay.

                            MRS. GORDON:  As You'll note on your critique,
                @hey suggested that the PSRO project be increased by $1002000
                )ecause it seemed an excessive amount of money  for  $151,000
                 0 Start with and  they also suggested that the project 82 not



        5                                                                 279

                be funded., mostly because it was for making audio-visual

                materials.  I found nothing to quarrel with the suggestion

                of the committee on the funding, so I would move that iie

                accept the funding of $2,028,389.

                            MR. MILLIKEN:  Second.

                            [The motion was made and seconded.]

                            MS. SILSBEE: Mr. Milliken,  as  the  secretary-

                reviewer, did'you have anything further you wanted to  @idd

                to this?


                            -MR.. MILLIKEN:  No.  I agree,.

                            MS. SILSBEE:  Okay.  The motion has been     e and

                seconded that the Alabama application be approved at      level

                :)f $2 028,389.  Is there further discussion?

                            [No response.

                            All in favor?

                            [There was a chorus of ayes.]

                            Opposed?

                            [The motion was carried'iinanimously.]

                            The motion is carried.

                            The next region is Albany.  Dr. Watkins.

                            DR. WATKINS:  Yes.  The report on Albany seems
                uPerior and from a review, I feel this.  I see high visibility
                n new legislation such as PSRO,.,' CHP, HMO., EMS and our first
                concern was that these weren't really true, in-depth working
                )rograms., but this is what the future is going to be at first




         6                                                                    28o


                  ight and I think then, combined with the community involvement,

                 they have several  community  programs  and  overall  they  have

                 followed the goals and objectives  so  that,  to  make  it  very

                 3rief, a superior program can't be criticised, so, to be very

                 Brief, I'd like to say very quickly, let's accept the

                 recommendation of the committee of $1,066,175         less  than

                 their request.  [Sic.]

                              MS. SILSBEE:  Is that a motion., Dr.   Watkins?

                              DR. WATKINS:  Yes, I make the motion that      way.

                              MS. SILSBEE:  Is there a second?


                              MS. MORGAN:   I second it.

                              [The motion was made and seconded.]

                              MS. SILSBEE:  Dr. Haber, did you-have anything to

                 add to   this?


                              DR. HABER:  Well,   I would just  like  to  reinforce
                 ffhat Dr. Watkins has said. "I   think, looking at  the  studies.,

                 nost of them were good.  I had a few comments to make.

                              The feasibility studies-with CHP  and  HMO  and  E14S

                 Look good.  The community hypertension feasibility, I think, is
                 vell-thought-out and we have a favorable record of having
                 ?eferred many of  these  patients  to  their  private  physicians.

                              One of the things that  intrigues  me  is  that  they

                  eally ought to move fast in the HMO area because if I

                  emember correctly, this is one of the regions Qf the country
                 there Dr. Isselston, a pioneer in the whole field of HMO concept



     7
                                                                      281
               'aad a group there that -- oh, I guess it goes back
                                                                  20 years

               when Permanente was still only a twinkle in

                           MS. SILSBEE:  That is the Rip Van Winkle Clinic

               ifi Hudson.

                           DR. HABER:  That's right., and so they., I think,
               can move favorably in this area and they certainly appear to.
               be doing so, although I didn't see Dr. Isselston's name

                entioned in this.

                           One of the real good products is the training for.
               the delivery of home care.  I think they are doing a,very
               Desirable thing'in moving into this area, but I was concerned
               about the Project 039., which talks about expanded concept in
               aome health care.  They really are very vague about that
               expanded concept.  Is there any enlightenment possible on thai
               Issue?  Does anybody have'any information about it?

                           MS. SILSBEE:  Dr. Haber, the Eastern Operations
               3ranch is represented by one person who hasn't been involved
               qith that particular region, so we can get information for you
               but right now we do not have it.

                           DR. HABER:  Okay.  Well, I will desist from further
               3avil.  I would second Dr. Watkin's motion that this be

               approved.

                           MS. SILSBEE:  Mrs. Flood.

                           MRS. FLOOD:  I have a question.  Does the contents
               )f your packet, Dr. Watkinss containing the transcript of the





                                                                      282
                transcript of the review committee process, in any way explain

                cutting back $175?

                           DR. WATKINS:  No.  I thought that was just a

                typographical error.

                           MS. SILSBEE:  I wasn't able to figure that out,
                either, Mrs. Flood.  I wasn't at the meeting.  @Ir. Peterson?
                           TIRS  FLOOD:  Maybe its not really relevant to them.
                           MR. HABER:  Maybe somebody missed some figures,
                is all.

                          .MR.,STEVENSON:  Maybe I should have brought my
                figures down.  I,don't recall -- it may have slipped
                           MS. SILSBEE:  You may have rounded.--

                           MR. HABER:  I've got my notes
                           MS. MORGAN:  You think it's just a round-off?
                           SPEAKER:  Probably just a round-off.
                          SPEAKER:  Maybe we can take up a collection and
                          DR. WAMMOCK:  It's too late in the morning.
                          MS. SILSBEE:  Just for the record, the Albany, the
               iew council members,, the Albany Regional Medical Program in
               ;he past years has had real difficulty because it had gone in
               i direction that committee and council in trying to get changed
               'inally did and brought in a new coordinator and the program
               ;eems to have moved along.  This is one where they had to be
               :)retty hardnosed with them but it paid off.
                          The motion has been made and seconded that the




                                                                                 28
       9                                                                             3

                 klbany program application be funded at si,o66,ooo.

                              Is there further discussion?


                              [No response.

                              All in favor?

                              [There was a chorus of ayes.

                              Opposed?

                              [The motion was carried unanimously.]

                              The motion is carried.


                              The next region in our    alphabetical  order ..s

                 krizona and, Dick, do you want to give some background         first?

                              @IR, RUSSELL:     Yes.  As noted on the green     sheet,

                 there are really three major problems with the Arizona Regional

                 gedical  Program.  These  problems  are  not  new  ones.  They   have

                 been there, I would say, since the Year One.

                              The Arizona Regional Medical Pro-ram is in non-

                 compliance with the DRMP policy on regional advisory groups and

                 grantee relationships.  The  crux  of  this  problem  is  really  the

                 grantee.  As you all know, one of oui- Assistant Secretaries.

                 for Health, Dr. Duval, is  now  back-in  Arizona  and  he  does  seem

                 to have undue influence over the Arizona programs.

                              We have talked  with  the  RAG  chairman.,  Dr.  Richard
                 Flynn.  We have also talked with the By-Laws Committee chairman,
                 Dr. George Bach  as  late  as  yesterday  afternoon.  It  appears  to

                 .is that the Regional Advisory Group and some of-the key core
                 3taff are very sympathetic and would like to see the program in




       10
                                                                          284
                compliance.  Ilowever, the grantee now has other thoughts.
                Dr. Duval called Dr. Margulies yesterday and said that he
                questioned the legality of the policy.  Dr. Margulies could
                only suggest to him that if he chose, he could challenge it
                in the courts.  It was pointed out to him, by the time anything
                was settled, that it would be a moot question, be'
                                                                 cause it would
                all be in a different ball game.
                           We really have no  idea what  Dr. Duvalls,response
                to his conversation with Dr. Margulies is but Dr..Margulies'
                Etssued Dr. Duval that we would hold to the policy and, I
                )elieve, indicated that in all probability a funding,recommenda-
                 on which would just allow the Regional Medical Program LU
               .,3ontinue its ongoing activity would probably'be in order and
                hey should not really start anything new until we had evidence
                I;hey are in compliance.

                           Now, the influence of this representative of the
                ,,rantee has also been witnessed in the Regional Advisory Group
                leetings where the -- it appeared the initial attempt of the
                Egional Advisory Group was to peace a high priority on one of
              'he Outreach Programs which would go into the rural areas.  The
                epresentative of the grantee convinced the group otherwise
              ,:nd it was obvious that he did influence their decision more,
              1 erhaps, than he should have.
                          There are other evidences that -- I d-on't think it
              Js really necessary to go into it too deeply here except that




                                                                       285
                he has advised the Regional Medical Group in some cases when a

                letter would come back to the Program saying, you know, you

                should do this or this is our advice and this gentleman's

                response has been  he only wrote that because he had to   We

                really don't have to listen to that.

                           The coordinator appears to be an instrument of the

                grantee or perhaps some other interest in the community rather

                than a true program coordinator.

                           The deputy has run the show for a number  of years.
                In calling the program and asking for the.coordinator., it

                appears to us that he has not been involved and can give us the
                type of information that we feel the other coordinators do.

                           So his role has always been very, very fuzzy.

                           MS. SILSBEE:  Mr. Hiroto.

                           MR. HIROTO:  I seem to somehow managed to have
                received some of these-interesting ones.  Supporting what
                @4r. Russell has been saying and in referring to the notes -- thE
                transcript of the reviewing team, it'seems to,me that their
                greatest concern of the reviewe;s relative to programmatic
                matters was that, of those programs which reviewers felt were
                nost meaningful to the Arizona RMP would probably be the ones
                bo get the axe and not be put into play, should the request for
                Funds be reduced.

                           I'd like to suggest to the Council tlTat perhaps we
                ight earmark certain funds as has been done, I believe in other




     12                                                                 286


                cases and make-our recommendations with'the earmarked funds

                included.


                            I throw that on the table for comments because

                .Inuch of this conversation of transcripts seems to lie in the

                g.rea of concern that these particular things aren't agreed on.

                            They call them C001, 002 and 003, "Shall provide
                a health education program -- medical manpower.other,served
                Etreas and expansion of health service sites." which apparently
                are moving in the direction that the ARMP claims they want to

                90.

                            MS. SILSBEE:  This was sort of Outreach?

                            MR. HIROTO:  The Outreach, yes.

                            MS. SILSBEE.:  Outreach activities that they have

                Deen slow to take up in this region.

                            I would recommend that we approve the reduced
                t'860,000 and earmark  I think it is $300 and some-odd  for the

                )utreach Programs.

                            MS. SILSBEE:  Mr. Hiroto?

                            MR. HIROTO:  Yes?

                            MS. SILSBEE:  The request   and Dick -,-y@u"ll have
                o    is for $6553400 for program staff. And the recommendation
                Is for $860,000 and so, in essence, you are suggesting that
                )ome of the program staff mon'           cated into these
                                            ies be reallo

                ctivities?

                            MR. HIROTO:  And they would reprioritize their


       13       li@                                                              1
                                                                        287
                program as  well.

                            MS. SILSBEE:  Mrs - Morgan.
                            MRS. MORGAN:  The proposed staff of 20 professional,
                isn't that -- it seems like that is awfully high.for a'few
                ivhat -- even if they took all the programs, they have only
                got six programs and only three of them, I believe, are

                Drogram-staffed.

                            MR. RUSSELL:  I don't have my copy  of the
                kDplication  with me.  They are, Mrs. Morgan, trying to move,
                Into the  Phoenix area, out of the Tucson area to start that
                3ffice there which wai3-closed after the phase-out.
                           MRS. MORGAN:  It just seems like 20 professionals
                Ls quite high for a relatively small program.,

                           MS. SILSBEE:  Mrs.  Flood.
                           MRS. FLOOD:  I might comment that, traditionally,
                ;he.style of the Arizona RM'P"s has done some good in s@te of
                ;he coordinator and perhaps the emphasis here of increased staff
                light be one valid approach to trying, to accomplish something
                lut I would have to agree with Dlrs.-Morgan that it does seem
                  excessive number of people to work with with.only approxi-
              iiiately $389.,OOO both for core staff and the program-projects
              :In that health service site, manpower recruitment and the self
              ]:rovider education because, in essence, that is the only course
              4f operation, as I interpret the print-out.
                          Now, I didn't look at the application.  So I feel



      14                                                                  288

                that perhaps Mr. Hiroto's point is well-taken that  you  do  give

                them this reduced amount, but earmarking the $389-plus for

                their their programs and hoping the staff will produce   more and

                not increase it [partially inaudible] so that

                            DR. WUIMOCK:  I notice this is University  f

                krizona School of Medicine.


                            MS. SILSBEE:  Right.

                            DR. WAMMOCK:  I was out there in March and you know,

                6@lhat is a relatively new school and they have been try.ng to

                2!xpand it as a result and they are doing a very good j b of

                loing it in several areas and I was somewhat impressed with

                qhat the ongoing projects were at that time, although     knew

                nothing about the RMP program.

                            I was just, you know, impressed very much with

                what    how  fast they had travelled in the past few years when,
                what is it,  five years ago they didn't have  anything  out  there

                it all.


                            MS. SILSBEE: That is as,.far as  the  medical  school

                @.s concerned?


                            DR. WAMIOCK: Yes, as far as  the  medical  school  is

                -concerned.  But I know nothing about its relationship
                tlthough I do know that this is the Universtiy of Arizona

                ledical School.

                            MS. SILSBEE:  It is the grantee organization that

                eems to be one  of the issues




      15
                                                                             280
                             DR. WAIIMOCK:  They are probably going to be

                 controlling RAG grantee funds here.

                            MR. HIROTO:  May I ask Mr. Russell

                            MRS. MORGAN:  They are responsible for the'm'and
                 they should use them correctly.
                            MR. HIROTO: -- what your  reactions  to  that  might
                 ie?

                            MR. RUSSELL:  I think one of the     the basic
                 .aroblem here is one of noncompliance with policy and in   going
                 along with Dr. Margulies comments to Dr. Duval and  having  had
                 iscussions with Dr. Paul  it would seem appropriate,to
                 rohibit the PJ,,IP from moving into any new activities until
                 ;hey were in compliance.

                            This., I think, Mr. Hiroto, would permit the
                 Continuation of some program staff Outreach activities-which
                 iave, as Mrs. Flood noted, have been very effective.
                            MR. HIROTO:  In spite of?
                           MR. RUSSELL: Yes, and I--think,  in,-all  fairness-to
                 he deputy and some of the othe@core staff and some of the.
               ]AG members, they have really tried to respond.
                           MR. HIROTO:  Then may I change my recommendation?
                           MS. SILSBEE:  You haven't made a motion yet.
                           MR. HIROTO:  Okay.' May I make a motion -then, that
               'Pe accept the reduced funding for the Arizona  Regional  Medical
               Irogran of $860,000 and divide it     is that it    so they meet



        16                                                                  290
                 he requirements  the regulations of PJ4P relative to grantees.

                            MR. RUSSELL:  I think that the provision should be

                that they could not start any new activities until we were

                9.ssured that they were in compliance.

                            MR. HIROTO:  Yes.

                            [The motion was made.]

                            DR. WAIOIOCK:  That's really.putting them in a bind.

                            MRS. MORGAN:  Do we request a site visit,prior to

                our August meeting, or would this be of any value?

                            You don't want to go

                            MS. SILSBEE:  This Regional Medical Program has

                oeen the subject of a number of site visits.  I believe the
                review committee's recommendation related to'the fact that therE
                was this long history of this going out and giving them advice

                and not seeing much change as a result.

                            I don't know that I think a site visit would be

                ielpful.

                            Now, Mr. Hiroto has moved that the application
                e approved  at the reduced level- of-$860,000 with the provision
                @bat the Region not undertake any new activities until the
                RAG grantee policy is resolved to our satisfaction.

                            MRS. MORGAN:  Do we want to tag that for their

                )utreach activities? Part of  that?
                            MR. HIROTB:  I know we are supposed t-o stay out of

                )rograms.




       17                                                                     291

                               MR. RUSSELL:  I think in the feedback, back to the

                  (iR,I.IP, that we could express your concerns adequately over this

                  Darticular area.


                               MS. SILSBEE: And again,  if  they  come  in  with  an

                  application  in July, we would be able to -- we can ask for

                  Lnformation  about how they do allocate these funds and that

                  night very well relate to this review in July.
                               Dr.lJaneway.

                               DR. JANEWAY:  I am not going to vote on this

                  ,)articular issue.  I would only say that had I been away      two

                  years as assistant  secretary and come back to Tucson or Phoenix

                  and saw that -- as  has Dr. Duval  that  --  since  they  are  the

                  grantee., I would want to have  some  kind  of  internal  reorgan-

                  Lzation of staff, having known   that I didn't have much control

                  Dver them while I was gone.

                               MRS. MORGAN:  If he  was gone that long, I don't knoi,

                  qhy he would want to come back.

                               MS. SILSBEE:  Would  you,please just second it,

                  4rs.   Morgan?

                               MRS. MORGAN:'  I second it.

                               MS. SILSBEE: Okay,  the  motion  has  been  made  and

                  ;econded that the Arizona application be approved at the

                  !,educed level, based on the  $86o,ooo  with  the  condition  that
                  ;hey undertake no new'activities until the RAG grantee policy

                  s resolved satisfactorily.





                                                                              292

                             Any further discussions?

                             [No response.]

                             All in favor?

                             [There was a  chorus of ayes.]

                             Opposed?

                             [No opposition.]

                             Let the record show that Dr. Janeway abstained.
                             [The motion was passed.]

                             We'll have to skip Arkansas because Mrs. Mars did
                iot know we  were starting this early this morning, so  he is
                3till coming in from Virginia.  We'll go to Bistate.

                             Mike, do you have any

                                 -REPORT OF MR. MIKE POSTA

                                          BI-STATE
                             MR. POSTA:  Yes, I think I'd  better, since this was
                L pretty tough review in the ad hoc panel, Bi-State.,.,
                             Although this region obtained triennial status in
                he fall of 1972, it has never been Considered an average
               @lrantee    The request of $1,129,608 was scaled down to a
               recommended $800,000 figure by the reviewers, which is, in
               fssence, 70 percent of the request, 63 percent of the target
               Jigure.

                            Poor leadership, particularly on the part of the
               regional Advisory Group, was noted.  It was also-noted that
               the Regional Advisory Group reduced its leadership to 15 and



        19                                                                    293

                 turned over their leadership to what, in  essence,  was  the

                 Executive Committee. The coordinator has  been  serving  on  a
                                I
                 50 percent basis. However, a new  coordinator,  Dr.  Felix,  is

                 expected to take over on July 1.

                            Reviewers noted that the proposals  do  not  conform

                 with the needs as identified by the joint RI'IP/CHP  conference

                 which met in February of 1974.
                            In @ll due respect to'the region,  it  wasn't  until

                 February 7th of this year that the region  realized  that  the


                 court order had ruled in favor of continuation of -TU4P  and


                 further dollars.  As a  result, the May 1  application  only

                 contained two new proposals.  One was involved with the @oor.

                            To epitomize still further, or to epitomize, period,

                 there was limited discussion during the ad hoc committee con-

                 cerning the possible termination  of  this  program.  However,

                 the reviewers expressed hope that the July 1 request of a'pprox-

                 imately $410.,Ooo will reflect on the identified needs  of  the

                 region, which has had its problems in the  past  in  dealing

                 with urban St. Louis and rural Southern Illinois.'

                            Mr. Milliken, you might wish to continue this a

                 little bit further.


                            MS. SILSBEE:  Mr. Milliken.

                            MR. MILLIKEN:  This special information.which staff-

                            MS. SILSBEE:  Could you use the mike, please?

                            MR. MILLIKEN:  The special information that the

                 staff has provided you' with yesterday indicates that  of  the




      20                                                                      294

                l,lay lst,, 1974 request for the Bi-State RMP  identifies  four

                project sites in Illinois, three  project  sites  in  the  St. Loui

                County, Missouri and 10 project sites in the St. Louis City.

                of Missouri.


                            It seems to me that,  recently,  this  problem  of

                .trying to serve these two disparate  areas  has  improved  in that

                the kind of projects they have are  beginning  to  even  oiit,

                between the two kinds of situations.  It would    seem to  me' that

                they have moved a little in this direction.

                            MS. SILSBEE:   Mr. Zizlavsky.

                            MR. ZIZLAVSKY:  I think because the Februar

                meeting between the CHP and the RMP joint agencies has     led  to

                a common assertion of needs in Illinois as well as    in Missouri,

                they have simply stated that they would be.having    31   projects

                coming in July lst and these would more adequately    address   the

                needs and one of these projects would  be  in  line  with  the

                Outreach than they have'really had in the past.  I don't     know

                if we should prejudge it   until we see their July lst effort.

                            MR. MILLIKEN:  I-think  another  problem  for  this

                agency is the need for staff   expansion.  After reading a lot
                of this material and the results of the committee's evaluation,
                I kind of have mixed emotions. I  feel  that  they  do  need  some

                more limited staff but I do not feel they need the amount of

                staff they are requesting and I think the questi-on is., maybe
                staff can advise on this, what, where  and  how  to  cut  this,




          21
                                                                                    295

                  you know, so that we  don't  shut  them  off  completely  --  confine

                  them to their present staff only, but at the same time, I

                  think we have got to be very careful in how much and vrhat'      kind

                  of encouragement we give them for additional staff.

                              MS.  SILSBEE:  Well,  with  the  recommendations   like

                  $350,000  less  than  they  requested,  that  additional  expanding

                  may be taken care of.


                              MR. MILLIKEN:  Yes.


                              MS. SILSBEE:  Mrs. Flood.

                              MRS. FLOOD: May  I  ask  if  Bi-.State  is still.  using

                  the RFP mechanism for   getting  proposals  in  from  their  regions,

                  especially in light of   the  CHP  conference  and  the  priorities

                  for needs that were established there?

                              MR.  ZIZLAVSKY:  One  of  the   weaknesses that  they  had

                  when they phased out is that they reduced their      staff down

                  to about four or five  people  on  June  30th  of  '73 with a  gal--

                  under program staff doing about three jobs and getting paid

                  for one was their information officer.

                              One of the jobs that was really left vacant was

                  their newsletter.  After this meeting with the CHP in

                  February, '72,  what they did was print this'up in their news-

                  letter.  They didn't go the RFP mechanism, but they used this

                  through the paper releases plUs their newsletter and sent the

                  newsletter out to.previous project directors and others.

                              ME. SILSBEE:  Mrs. Flood.



        22                                                                   296

                             MRS. FLOOD:  I  have  one  further  question.

                  Dr. Stoneman, the coordinator  that  is  apparently  leaving,  was

                  part-time coordinator and is the new coordinator to be a full-

                  time coordinator or will he also devote part-time and'hold a

                  faculty position and private practice, as Dr. Stoneman did?

                             MR. ZIZLAVSKY:  No, he'll be full-time.  He'll be

                  100 percent.

                             DR. HABER:  I think it   appropriate  for  me to   voice

                  an endorsement  of Dr. Felix, whom  I know very  well.  He was,

                  as the brief indicates, former director of the National

                  institute of Mental Health. He  has  been  the  Dean  of the

                  St. Louis University School  of  Medicine.  He  was  the chairman

                  of the special medical advisory group  for  the  VA  and we were
                  bidding for his services at the VA and we lost out.     We wanted

                  him to be the head of our  new  geriatric  research  and clinical

                  -center in St. Louis.  He elected to go this route instead
                  and I just want to say that he is a very capable man and will,
                  I am sure, distinguish  himself in the program.
                             MS. SILSBEE:  Dr. Watkins, did you have any comments

                             DR. WATKINS:  Well, based on what I.have been

                  hearing, I would second Mr.  Milliken.

                             MR. MILLIKEN:  I  don't know what I said.

                             MS. SILSBEE:  Dr.  Wammock.

                             DR. WAMMOCK:  I don't get through my-thick noggin
                  here the reason for Bi-State Medical Program when you have got




      2 3
                                                                                   297
                   two states, !4issouri and  Illinois  that  have  got  two  states

                   here, 1-lissouri and Illinois, that are making applications     and

                   you have got a situation  where  one  is  across  the  river  and

                   they are trying to work together and it is sort of lilce a

                   team of horses and I am not sure how you are going to get them

                   hooked up to the wagon and I'm a country boy.

                               MS. SILSBEE:   Dr. Wammock, that has been ap issue

                   has been a concern for a   long time.

                               DR. WAIIMOCK:  I just

                               MS. SILSBEE:   The medical trade area    is th  basis

                   of the


                               DR. WADU40CK:  I realize it is a medical tr  e

                   area, but I just -- I think, you know, it's trying to fit
                   apples and plums and  something  else  in  the  same'bag  and  peddle
                   out something curious  a@d  I  rather  suspect  that  this  requires,
                   I.mean, some of the inherent difficulties that are arising in
                   there when you have got another state which is goint-to come
                   up shortly is Illinois.  They've got Missouri coming up here.
                   Why can't they just do it, each in their own ballpark?
                               MS. SILSBEE:  Well, being an old St. Louisan, they
                   Just don't  work that way.

                               DR. WAIvU40CK: Well, anyhow,  it  makes  a  headache  for

                   the rest of us.

                               MS. SILSBEE:  The  motion  has  been  made  and  seconded

                   that this application be



        -24                                                              298

                           SPE-AKER:  Wait a second.


                           MR. MILLIKEII:  I will make the motion.


                           MS. SILSBEE: Somebody said you made  a  motion.

                           MR. MILLIKEN: They knew I was  going.to  do'it.

                           MS. SILSBEE:  Well, will you say it, please?

                           MR. MILLIKEII:  I move that we accept the committee'E

                recommendation for the funding decision, 63 percent.of the
                                              [?]
                $800,000, 63 percent of the tiger and $329,680 under the

                request.


                           MS. SILSBEE:  Do.I hear a second?

                           [The motion was made and several seconds given.]

                           MS. SILSBEE:  The motion has been made anct

                seconded that the Bi-State application be approved at  the

                reduced level of $800.,Ooo.

                           Any further discussion?

                           DR. JANEWAY:  Could I ask an informational question?

                           MS. SILSBEE:  Yes, Dr. Janeway.

                           DR. JANEWAY:  Knowing Dr-. Felix, I suspect

                although I have no reason to kmw this -- if this comes in
                $329,000 down, the July request is going to be.bigger.

                           [Laughter.]

                           Because he is a mover. He is an extraordinarily

                competent person and I think that some of the cooperation and
                clerical questions will be solved by that time.-

                           MS. SILSBEE: Mr.  Zizlavsky.




                                                                         299
       25

                             MR.-ZIZLAVSKY:  One of  the things that we  did  was

                 ask the program --  all 53 -- for   an estimate of their July lst

                 request, so this was made approximately  three  months  ago  and

                 one of'the things we have been kind of watching is their

                 making a monthly.total and-then keeping  up  with  this  figure

                 and they've carved the projects down from something around

                 31 to 24 in their own review process and I feel that those 31

                 projects were about $721,000 and it is down to   $410,000,   so

                iwelll keep your comment in mind when we receive   the  July  lst

                 applications so you may receive a surprise.

                             SPEAKER:  Good.


                             MS. SILSBEE:  The motion  has been made and

                 seconded for the reduced level of $800,000.    All of  those  in

                 favor?


                             [There was a chorus of ayes.]

                             Opposed?

                             [There was some opposition.]

                             The motion is carried.

                             Good morning, Mr-s. rtars.

                             MR. MILLIKEN:  There was one further thing that
                 staff recommended, that on the RMP request by Med,, Incorporated

                 on the EDIS that the  request be approved but that funds not be
                 release., until RIVIPS staff and regional EMS staff attempt  to

                 arrange, possibly@through a joint  staff  visit.-some  sort  of
                 unified planning capability.



       26                                                               300
                           MS. SILSBEE:  Is that a result of  their meeting

                the other day?

                           MR. POSTA:  That was a request by the IIEW Region
                VII office and also during the discussion with the HRA  group
                on Monday and Tuesday we did learn that the arch program, the
                CHP "B" agency in St. Louis had been approved for a  plannin'
                                                                             9
                grant and I think that the rationale here is to be sure  that

                there is IJLU.L-V coordination with the funded EMS activities  in

                that area.


                           MS. SILSBEE:  That really does not require Council

                action.


                           The next region -- we'll give Mrs. Mara a chance to
                pull herself together and skip Arkansas and go
                          .MRS. MARS:  I'm sorry I'm late,, but I thought Iwas"

                early.  Nobody told me.

                           MRS. MORGAN:  We decided that after you left.

                           MRS. MARS: Well, I know, but somebody  could  have

                CALLED ME.

                           MS. SILSBEE:  Central New York.  Mrs. Martinez.

                           Mr."Skoloff is the operations offiders for Central
                New York and Mr. Nash.,'As I said.yesterday, could not be here.
                If you need'any additional information, direct them up to that

                end.



      28
                                                                         302
                            14ISS 14ARTIliEZ: 22C.

                            MS. SILSBEE:  It is the EMS.

                            MISS MARTINEZ:  EMS Radio.

                            MS. SILSBEE:  Miss Maritinez, that is on activities
                 that have been going on before and it is primarily equipment,
                 but it represents a partial payment.  The hospitals -are

                 putting up money also.

                            MR. STOLOV:  The review committee did discuss this.
                            MISS MARTINEZ:  You are talking about 22c?
                            MR. STOLOV:  Right, 22C and in its deliberations
                 the review commi@tee noted that the region is'using'matching
                 funds at the rate of 50 percent. local, 50 percent, Niqv. They
                 also noticed that the RAG was astute enough-to give a low
                 priority to putting equipment in ambulances and sticking to
                 their original plan and 'giving it a high priority to putting
                 a central communications systems in the hospitals. So in the
                 event of gettina, an award, there is a least likelihood of
                               C>

                 getting the low prior
                                     ity ambulances,.passed through the RAG.
                           I checked the RAG's members and to the best of my
                 knowledge,, I think they made an effort to show that thei-6 was
                 also membership from, say, the medical society and a gentleman-
                 being on the CHP board but orginally when the RAG was formed.,
                 these gentlemen were chosen by their primary goals.,. say.,
                 representative of.the medical society but Vic Murray wanted
                 to show also that there w@s some representation on his
                 volunteers on other agencies in the community so
                                                                 you were



        29                                                              303
                 right on the 23,but officially the representation is from four

                 of the agencies but -@Ir. '.Iurr-ay-lists the people on his RAG

                 as representatives, primarily from the medical society, but
                 some did have it, as you pointed out, a representation on
                 the other bodies-.
                           MISS I-TARTINEZ:  Is that ususal, to have that large

                 a representation?
                           MS.ISILSBEE:  I thin'k'that it would represent
                 these are people that are seVving in two capacities and the
                 representation is not because they are @HP but because they
                 are particular individuals who happen to be active in two

                 agencies.

                           MISS MARTIIIEZ:  Okay.  ',low, there is a number of
                 the   number 44. I can't remember exactly what it is  nowl
                 Council for Coordinated Health?  Is that it?  That the function
                 of that grant seems to me to be a county function.
                           MR. STOLOV:  4o44, it's a home care health service
                 project and your question, is that It appears to be a county
                 responsibility? May I ask
                          MISS 14ARTINEZ: That one and the Well Baby Clinic,
                 particularly the Well Baby Clinics because, at least in MY
                 state, that Is a county function. Now, is there any reason
                 iqhy the county isn't doing this in the Central New York?
                          DR. SCHREINER:  Maybe I can answer that because I
                 have been up there on a site visit.  It is very hard for



    31                                                                      305

                 period of time so it sort of leaves me hanging.

                            For instance, number 58 -- number 56, I'm sorry
                 gives you the impression that the people who are now  IN ein'g
                 observed by this clinic will be like hanging at the e d of    a
                 certain period of time because there is no mention  --  in  any
                 case,.what I did was, I sort of subtracted the propos  ls  that
                 I wasn't particularly impressed by and I still came  u  with  a
                 higher.*figure than the review committee and maybe you can
                 explain    I can up with $706,879 as opposed to'$600,()16.
                            MS. SILSBEE: Do you want to make a  motion  to  that

                 effect?

                            MISS MARJ'INEZ:  Well, does someone want  to  explain
                 to me how they arrived at 615?

                            MR. STOLOV:  Perhaps Mr. Peterson is  more  familiar
                 with how the review committee came to that.
                            MR. PETERSON:  6h, I think in this region, as in
                 many of them that were considered, while the  review  committee
                 went-through somewhat the same process that you did,
                 Miss Martinez, examining the projects and the like, far more
                 frequently they made some kind of overall assessment  in  terms
                 of past track record and the like and from checking the
                 Minutes or transcript on this particular discussion,  this  was
                 one of the sort of class acti6ns in a sense -- oh -let's
                 reduce this about.20 percent rather than explicitly reflecting
                 a let's subtract this project, halve this one    some  of  that




      32@
                                                                      306

                went into the thinking so in one sense it was an 80 percent

                kind of region, I guess.

                           MISS MARTINEZ:  Okay, well, I'd still like to make

                a motion at this time to fund it %,*)706,379.

                           I subtracted

                           MS. SILSBEE:  I don't think we need to go  into this.,
                but would you repeat the figure?

                           MISS MARTINEZ:  $706,379.

                           MS. SILSBEE: Is  there  a seconds

                           [The motion was made  and seconded.]

                           MS. SILSBEE:  The  motion has been made and seconded

                that the Central New York application be approved au  Ljiu -Level

                of $706,359?

                           MISS MARTINEZ:  $706,379.

                           MS. SILSBEE:  $706,379.  Is there further discussion

                llrs. Flood.

                           MRS. FLOOD:  I only have one question.
                           Mr. Stolov, is there still a report out as of the
                last phone call that they woulc'rbe-coming in for the July-
                August review at $1,150,000, which is the proposed figure at
                the bottom of our green sheet?
                           MS. @ILSBEE:  Mrs. Flood, that represents an
                estimate that was made in early May.  We haven't gotten an
                update.  That probably represents, though, some-total of
                what started through their review process.  I would doubt



      33                                                                         307
                  that it would be that high.

                              All in favor

                              DR. SCHREINER:  I Just might comment that they had
                  made tremendous progress setting priorities and I am particu-
                                                     with
                  larly happy to see them coming in/the coordinated programs
                  in the North Country.  There are two, the new ones.

                              Some of you may not know that there are over
                  5.,OOO Indians pn the  Regis  Reservation  who  never  signed  a
                  treaty with the   United States so they' get no health care from
                  the Federal Government  and  they  are  dependent  on  New  York
                  State, which has been zero up to this point on the care that
                  has been provided.  At least they had a dental but it had!not
                  even had the cellophane taken off -- the plastic -- and so
                  it looks to me like they are getting down to work and I think
                  Miss Martinez was very generous and I'm happy to          I think
                  that they will spend it weil.

                              MS. SILSBEE:  Thank you.    The motion has been made
                  and seconded that the application be    approved  at   $706,379.

                              All those in favor?

                              [There was a-chorus of   ayes.]

                              Opposed?
                              [There was one nay  and  the  motion  was  carried.]
                              The motion is carried.

                              Mrs. Mars., are you ready to go back to Arkansas?

                              MRS. MARS:  Yes.


       34                                                               308
                                 EPORT OF MRS. AUDREY I-IARS


                                         ARKAIISAS

                           MRS* MARS:  I site-visited Arkansas a number of

                years ago and at the time I was very 'impressed with the program.
                They had an extremely outstanding coordinator by the name of
                Dr. Sillverbladt who, unfortunately, has resigned in the last
                few months. I think rather unexpectedly. He  was  a  very
                Ambitious individual for his program and a very active

                person.

                           Fortunately, the new coordinator has been there for
                the last four years and is a very capable person.  He was
                there, I know, At the time when I site-visited the program.
                           They have a close cooperation with the CHP
                agencies., both the-A and B.  There are eight agencies -- eight,'
                B's and one A that are funded.

                           The planning and development districts are the
                grantee organizations for the agency so that if the agencies
                are disbanded, they -- there still will continue to be a
                monitoring force for the AFJ4P activities.
                           They have imporved their relationship with these
                agencies in the last years and some of the ATU4P proposals now
                have a B agency as a sponsor and their technical assistance in
                the development of a project has been invaluable to them.
                          The entire application of the Arkansas RMP  was
                submitted for comments to each of the agencies and all eight




       35
                                                                         309
                responded.  There were very few differences of opinion
                between the A and the B agencies concerning the projects but
                the CHP B agencies and the RAG agreed in any unfavorable

                comments that were made.

                           Four of the six of the projects that received
                unfavorable comment were withdrawn by RAG and two were sent
                back to staff for administrative changes to be made before
                the approval..  They feel that the projects proposed@will be
                supported by other aspects of the health care delivery
                system when the ARMP funding is no  longer available.,
                           @IP has a  very  well-organized monitoring and
                evaluation division. It  monitors  ongoing project activities
                in relation to their stated goals and objectives, maintains
                a constructively critical posture.  The division of physical
                affairs keeps accurate, up-to-date records,, working in close
                liason with the monitoring divisions.
                           The subregional system has been developed exten-
                sively.  For example, they have a contract with the Arkansas
                League for Nursing and for the-devolopment of a quality
                assurance program.  In nursing homes they have a hypertension
                screenin- program, quality assurance programs with the hospi-
                tals and others.

                          There is very good involvement with the'RAG.  They
                have been successful -in securing funds and political support
                in order to obtain state funding for programs as well as from



      36
                                                                           310
                 charity sources.

                            The quality assurance is being stressed.  This

                 certainly is very necessary in a state such as Arkansas.

                            They have emphasized continuing education as one

                 of their major thrusts.  The ARMP coronary care network in

                 Arkansas is the outstanding one now.  Kidney disease  control

                 program has become completely self-supporting.

                            The expansion of their recovery room services for

                 the,ch:Ddren's hospital project is a very choice example of.
                 multiobjective activity.  It will provide an.improved and
                 expanded primary, secondary and tertiary  care'and will interact
                 with operations of many health care systems and serlices of
                                                                     v

                 health funding.

                            There is no conflict or duplication of activities

                 being funded with the HSA funds to Arkansas.
                            They have 58 RAG members, the coordinator meeting
                 with them, of course, makes 59.

                            The RAG Is well-distributed between  members of the
                 public,, the health professional and private and public health
                 service.  Volunteer agencies are represented.I.There are
                 teachers, lawyers, judges, politicians, nurses,  higher
                 education, insurance, doctors, health agencies, dentists'.
                 hospitals all represented, so it is a very good composition.
                            And they all seem to take a very active interest.
                            The program has stayed    the RAG has stayed the




    37
                                                                          311
                 same, despite the projected phase-out and Arkansas is planning

                 on applying for another $800.,OOO in July.

                            I am perfectly happy to accept the review Iomrhittee!l

                 I
                 recommendation of $1,500,000.

                            The new coordinator, I think, will-be able to do a
                 firmer staff organization.  This is needed.  They do 'eed more
                 people on their staff.  It really is not as complete  s it

                 should be

                            And some of the programs should be reconsidered.,
                 such as their sickle cell  in light of the year's per od time
                 which some of these programs just cannot be completed or
                 successfully carried on so I move that we accept the  eview
                 committee's recommendation of $1,500,000 to the Arkansas

                 program.

                            [The motion was made.]

                            MS. SILSBEE:  D@. Janeway.
                            DR. JANEWAY:  I will, in order to get on the floor,
                 second the motion for approval of the recommendation of the-

                 committee.

                            [The motion was seconded.]

                            I have a philosophical question. 'I think we are
                 dealing with the only game in town, is one thing I read in this
                 and I have two questions, one'of which is rhetorical and one
                 Of which I'd like the advice of the staff., and that is., I think
                 ffe are beginning to see here a fairly sizeable role of the


       38                                                               312
                 CHP B agencies and the implementation of health services

                 which, from a management standpoint bothers me that planning
                 control and implementation should be functionally in one
                 organization.  That is rhetorical because there is nothing

                 we can do about that, I think.

                           The other is, perhaps, just to get educated.  I.,

                 wonder about providing support for the Arkansas Health
                 Statistics Center when it is clearly stated in the proposal
                 that they wish the funds for one year to demonstrate to the
                 state legislature that this is a valuable project.
                           One wonders if the planning funds for this couldn't
                 be derived from state sources, but I don't know wha@ was cut
                 out and I just wanted some guidance from staff on it, but I
                 second 1-irs. Mars'. recommendation.

                           I,IR. POSTA:  Doctor, to respond on the statistics
                 part, the legislature did 'not meet this particular spring.
                 That request to the state legislature for additional dollars
                 for an agency statistics will be pr6sented in the next session.
                 The request to the statistics center here was not approved or
                 was cut down and that was the reason for that.
                           DR. JANEWAY:  I'm glad to hear it.
                           MR. PETERSON:  I think there is one other small
                 item, Dr. Janeway, in the way of history on this one.  Arkansas
                 has a great deal of federal money.  They have a@tatewide
                 experimental health services delivery system project and I




      39
                                                                         313

                 happen to have-been on a site visit to it about six weeks ago

                 and it does appear from looking at it through that end of the

                 tube that the establishment and the initial operational

                 support of this is sort of being traded off between the

                 experimental health services, the R14P and as Michael pointed
                 out, they do have the legislature which still only meets every
                 two years so you'd have that kind of a.problem.

                           That does not necessarily justify it but@it  does

                 explain, perhaps, why there is some ES-RI@.IP coordination.  It
                 is a new operation established less than two years ago.

                           DR. HABER:  Can someone-give us a word of

                 explanation about that expansion of that burn center?

                                       'Yes, sir.  This was 'considered a number
                           MR. POSTA:

                 one priority by the regional advisory group that met.
                           Originally, when they got together, the title of
                 this was a little bit different because the first initial
                 request was for total equipment.  When we negotiated with them
                 and they approached us with this p@ticular idea., we said
                 there was no way that the review groups would support a
                 program of this type if it -was solely for equipment.
                           As a result, they revised it, went back to the
                 drawing board and came in with mostly soft money.  There is
                 a little bit of equipment in it but this is to be funded
                 through children's hospital and it will be an add-on, if you
                 will, to their emergency medical services system.



       4 0
                                                                         314
                            IIS. SILSB7@E:  The motion has been made and seconded
                 that the Arkansas application be approved at the level of
                 .$115002000.  Is there further discussion?

                            [No response.]

                            All in favor, say aye.
                            [There was a chorus of ayes.]

                            Opposed?

                            [Th
                               ?re was no opposition and the motion was
                 carried unanimously.]

                            The motion is carried.
                            MR. PAHL:  Before we proceed with another appli-
                 cation, Mrs. Silsbee has been giving me a little chore to@do
                 here which I am happy to do, particularl
                                                         y because you are
                 doing so well this morning, but I think we might have a frame-@
                 work for todays activities because a few individuals have
                 indicated, you know, what their schedules are and our interest
                 as well as yours is to be fair to all regions, so I think if
                 I outlined for you what we see to be-the framework., you can
                 continue to do as well as you have-'this morning.
                           If we spend about 10 minutes per application,
                 simple arithmetic will show that if you work through the day,
                 including the lunch hour, you will be finished around 4:00 to
                 4:30.  That is no breaks and work through the lunch hour.
                           Now, I know that in some--'Instances yo-u will have to
                 Leave for good and sufficient reasons.  What we don't want to




     41
                                                                       315
                have happen, and I am sure what you don't want to have happen

                either is to have, at the end of the day, either a rush so

                that those regionsreally don't get adequate attention, or
                insufficient people working into later hours so that,, again,
                the regions are not represented by primary or secondary

                reviewers.


                           So, with that understanding, I would like -;o

                sugge@t that., keeping in mind these facts, we decide Mesa

                council how we wish to manage our operations now, rather than
                get rushed at the end of the day, which we know we woixld be.
                           So we have to make a decision, therefore., either to
                observe IIrs. Silsbee's kind of time framework and tha  could
                be done by having the staff present a few highlights and then
                the principal reviewer only add that comment or two which
                would substantively change the recommendation of the review
                committee. If it is an endorsement, the review committee has
                done its work.  If there is a reason to highlight something
                which would result in council discussion or perhaps a different
                recommendation, that is, of course-, what we should do.
                           If that is the operation, then I think one can see
                completing the work in fairness to all regions through the
                day.  If not, we should make our decision to either work
                into the evening hours or stay over till tomorrow . but I do
                think it is unfair not to give this framework early in the day
                and then have people drift off later.



     42                                                                  3

                            Perhaps the council should just decide how it

                 wishes to manage its affairs so that Mrs. Silsbee can be

                 guided by your decisions.

                            MRS. SILSBEE:  Mrs. Morgan.

                            MRS. MORGAN:  Judy, I am sure there are certain

                 regions which, having not gone through everything, had  every.-

                 thing to go through, that have been flagged as  problem  areas.

                 It seems to me you could -- staff could mark these  off and

                 maybe we ought to hit these earlier while we have a'fresh

                 thinking

                            MR. PAHL:  There are  a few that we,have  identified

                            MRS. MORGAN:  Right.

                            MR. PAHL:  -- some of which you have been discussing
                 and that  is what I say, you have been doing very well this

                 morning.

                            MRS. MORGAN:  But I think if those were flagged
                 and you started to do those, then maybe within the next hour
                 we'll have a much better idea of what -- after we  have  gotten
                 rid of some of these more difficult ones-, what our timeframe

                 is going to be.

                            MR. PAHL:  We have, indeed, already identified a
                 few.  You handled., perhaps, five of them and there are perhaps
                 six regions that we would take up -- Dr. Haber.
                            DR. HABER:  I was just going to modify that
                 suggestion.  Is it possible for you to present to us a list



       4 3
                                                                      317
                 of those things that are likely to be noncontroversial to be

                 voted on en bloc, giving us some time, therefore, to spend on

                 the controversial ones., rather than spending an equal amount

                 of time on each?


                            MR. PAHL: Yes., we have  identified  those.  Just

                 taking up for.a moment, let me say that you  must  recognize

                 that this council is handling more at this meeting in the way

                 of total applications than any council has in the last four

                 years because yesterday you had an arthritis discussion both

                 in the morning and the afternoon with 43 applications and this

                 council, in terms of RMP application, at this'meeting is

                 handling 53 applications, not the normal  17 or 1B. So both

                 you and we are under the same kind of impossible time

                 pressures and my comments here are not meant to  state  that
                 any of us, as staff, are in any way dissatisfied or frustrated,
                 but we are indicating to y-6u that knowing schedules and  in
                 fairness to regions, we have to work within that framework.

                            I would suggest, Judy, @hat what we do -- for

                 example, Dr. Schreiner has to Vpqar on the Hill here for
                 testimony -- either this is the real world and we want your
                 advice for the regions and we will try to get through as many
                 of these before you have to leave and I think what we ought to
                 also do is take up tho se regions where we know we  need  the
                 council discussions as we have with some of the others that
                 we have been handling this morning and then we can pace



       4 4                                                               318

                 ourselves during the day.

                            DR. HABER:  Especially  those problems first and

                 then we can see  how they work out.


                            MR.  PAHL:  That is correct.


                            The other thing is, at an  appropriate  time  after

                 some other coffee is brou,7ht in or so forth, staff will be

                 glad to bring in coffee or if you want sandwiches   brought  in

                 .or depending on how you wish to run your day, but

                            MRS. MARS: I just want to  @et  a  sandwich,  that's

                 all.


                            MRS. MORGAN:  Yes, we are not going to work all

                 day without at least a sandwich.

                            MR. PAHL: Yes, and I think a  little  later  in  the

                 morning, but I wanted to say we do  appreciate  that  you'have

                 an unusual workload.  You are doing very well but we also

                 have to recognize fairness" to the regions at the tail  end  of

                 the day when everyone is tired.

                            MRS. SILSBEE:  Well,  in the memo that I  sent  out
                 to the council, I identified about- 11 regions that  I  thought
                 needed some special attention. You  have  already  dealt  with

                 four of those, so the remaining ones are the  ones  that  staff

                 identified, that need kind of deliberations  of  this  council

                 and in terms of the corimittee's  recommendations,  Connecticut
                 Lakes Area, Maryland, liassau-Suffolk., New York  Metropolitan,

                 Texas and Wisconsin.



      45                                                             319

                           !4ow, that would be my agenda.

                           Then we also have, Dr. Haber  has to leave at noon.

                 Dr. Schreiner leaves at 11:30 and Dr. Janeway is going to have

                 to leave this afternoon at about 3:30 so we have got (juite a

                 bit to do in two hours, really.

                           I wonder if it would be helpful in terms of

                 Dr. Haber and Dr. Schreiner, who leave this morning i-' I

                 could ask them the regions that they reviewed.

                           Dr. Haber, you had Memphis and'Washington-,@laska,

                 as I recall, as primary-

                           DR. HABER:  West Virginia.

                           MRS. SILSBEE:  West Virginia.  Are either   f those

                 going to require any changes in the committee recommendations?

                           DR. HABER:  Memphis might.

                           MRS. SILSBEE:  How about among yours,  Dr. Schreiner.

                                          "Yes, well, I can handle them pretty
                           DR. SCHREINER:


                 fast.


                           MRS. SILSBEE:   Okay.  Slnce the next one on the

                 list is Colorado-Wyoming, our record should show that

                 Dr. Gramlich is not here today.

                           MRS. MORGAN:  Do we  want to do that, or do we

                 Want to do the difficult ones?  I'd say, let's go to the

                 difficult ones and then get Dr. Schreiner's and Dr. Haber's

                 and then come back to these.

                           MRS. SILSBEE:  Okay., very good.'  Connecticut is




        46
                                                                        320
                 a difficult one.  Dr. Watkins.


                            DR. WATKINS:  No --


                            TIRS. MORGAN:  No, that is Ed's.

                            DR. SILSBEE:  Oh, Ed, excuse me.

                            MR. HIROTO:  It may not be that difficult.


                              REPORT OF MR. EDWIN C. HIROTO


                                       CONNECTICUT


                            MR. HIROTO: Inasmuch as their  application  is  for

                 continuation of only one month of programs and one year for

                 the staff and there is a considerable amount  of  conversation

                 that occurred between the -- amongst the reviewers     and

                 since the July application will probably bear the brunt of

                 the review, I would recommend that we accept the surveyors'

                 recommendation and recommend $510,000 with, really,  the  bulk
                 of the review to occur at next cycle.

                            MRS. SILSBEE:  Is there a second to that?

                            [The motion was made and seconded.]

                            Okay, any discussion?

                            DR. WAMMOCK: We-1l,otheire is a sentence down  here
                 that says "The RAG chairman's response to CHP, comments, as
                 well as CHP comments themselves, indicated that the IU4P-CHP

                 relationships remain a problem."

                            MR. HIROTO:  Yes.

                            MRS. SILSBEE:  Yes, that's true.

                            MR. HIROTO:  They are.



       4 7
                                                                         321
                           DR..WAI'E@IOCK:  llell, there's nothing new about it,

                huh?


                           I,/IRS. SILSBEE:  There is something the council can

                do about it.


                           DR. l@IAMIlOCK:  Yes, well, I mean, I just
                           I,-IRS. SILSBEE:  It was a problem and it-is not just

                something that has emerged.

                           The motion has been made and  seconded that the

                Connecticut application be approved at the reduced  level of
                $510,000.  Is there any further discussion?

                           [No discussion.]

                           All in favor.

                           [There was a chorus of ayes.]

                           Opposed?
                           [There was no opposition and the motion was carried.]

                           The motion is carried.

                           The next one is Lakes Area -- a problem and
                .-Irs. Mars is the  rimary reviewer.
                                 p

                           MRS. IIARS:  I seem tG, get all the tough ones.
                           MRS. MORGAN:  Tha t's because you do such a good job

                )n them.

                           MRS. SILSBEE:  Mr. Peterson, I wonder if you would
                ind stepping up here, because you chaired that particular
                anel and Ilr. Nash is not here.

                           I-.IRS. MARS:  These microphones seem to be makin- a





                                                                            322

                  funny noise.


                                  REPORT OF IIRS. AUDREY I.IARS


                                           LAKES AREA


                              MRS. MARS:  Again, I think that the funding

                  reduction here is too drastic.  I site-visited this program a

                  number of years ago when it was  in  very  bad  shape.  At  that

                  time, the grantee was taking  a  tremendous  percentage  of  its

                  money.  Dr. Ingall, who is one of the most capable of the

                  coordinators, I believe was chairman  at  one  time  of  the

                  steering committee of the coordinators, i.s the present acting

                  coordinator and has been for some time and at     that  time he


                  was about ready to resign.

                              I think that the site visit helped considerably

                  and all suggestions that were made at the time were followed.

                  The program, was Completely turned around and  I  would  not  be

                  surprised, but if we reduced  the  funding  to  the'degree  that

                  has been recommended here  by  the  review  committee,  that

                  Dr. In-all would not resign, which'would be a pity that he
                  would not be able to see the p;og-ram through to its

                  termination.


                              lie separated the program from the  grantee and

                  formed a nonprofit agency to act as the grantee and'has a

                  five-member board.

                              The program covers seven counties irrnew York State

                  and two in Pennsylvania with  a  population  of  over  three



      49@                                                                   323
                 million people..  They have two CHP B agencies and these

                 agencies have representation in the RAG.


                            The criticism that I would make of the RAG  is  that


                 it is heavily weighted by the medical profession., perhaps  too


                 much so.


                            The two programs which the review committee,  letl.s

                 say, brought to attention and which apparently deserved it

                 greatly and were of particular concern to them  was the request

                 for the funding of the telephone lecture network.   This is.

                 a very unique project.

                            This is an area where  in the wintertime
                                                                       snows

                 pile up to 12, 14 feet and I guess at times, 20-feet drifts

                 which means that there is practically no communication in this.

                 area.  This telephone lecture network is far more  than  that.

                 It is their only means of communication. It  is  a  continuing

                 education program and it i just a unique and valuable

                 dispensable program to the area.

                            It is an expensive program but I felt that every

                 penny that is put into it is wVthwhile.  The other program

                 that they were concerned ab out was the continuation of the

                 cancer registry. This is the fifth year for that  and  as  all

                 of you know, cancer registries are not as much use  or  cannot

                 be proven of use, really, until five years has been completed.

                 So that I felt that despite the fact that we have  been  trying

                 to vet them out of this tumor registry., inasmuch as they  are



       50
                                                                             4
                                                                           32
                 still in, it seems to me that the continuation of the

                 registry at this point would certainly be worthwhile and.,
                 undoubtedly, it will be taken over by the participating
                 Hospitals at the end of this five-year period.

                            The complaint seems to be that we should give a
                 stron- message to the practice of continuing support projects
                 beyond three years.  Of course, this has been our policy, but,
                 nevertheless, there have been other programs t hrouc,-@out the
                 RMP funded over a period of five years' time and there is no

                 absolute set rule, I do not believe.

                            Is that true?  To that degree, that if a  program
                 is worthwhile, that it cannot be continued for a lot iger period.
                            DIRS. SILSBEE:  Council policy is-to encourage
                 three-year funding.

                            MRS. MARS:  @ight.

                            MRS. SILSBEE:  And to have, at the initiation of
                 the activity, some plan for take-over by other resources.

                            MRS. 14ARS:  Exactly.  SQ-that with the tumor
                 registry, the plan is such that the participating hospitals
                 will take it over and I think eventually that as RTIP withdraws
                 its support for the telephone network, I am sure that this
                 likewise will be taken over.  So that I really felt that this
                 was more or less something that did not justify destroying a
                 program to say that we are going to give a strong message to
                 for the sake of this money which.is already being put in.  You





                                                                                2
                                                                               3

                  are simDly scuttling a program that it just doesn't justify

                  doing that.

                              The staff, my criticism  is,  does  seem  excessive  in

                  number. They certainly  need  to  eliminate  some  of  their  staff

                  and replace them with people who are more competent.

                              The CIIP relationships seem good. They  and  the  Rl,!P

                  did not agree on all of  the  projects  that  were  presented,  but


                  the staff and the RAG took heed of this.  The total,dollar

                  request for the 11 approved projects is @780,453 and five

                  new projects were  presented  in  their  application  that  require

                  $260 000.


                              The funding that the review committee has

                  suggested is $400,000.below their current annualized funding

                  and as I say., at this late date  to  deliberately  try  to  scuttle

                  a program for the sake, of teaching them  a  lesson  just  does  not

                  .seem to make sense to me."

                              This program has done a great deal of good to

                  improve the health pattern in the area and I feel that it

                  certainly is an average  prograia,  although  the  review  committee

                  rated it below average and I think  that  it  could  hold  its  head

                  up against any average program,  so  to  sppak.  So  I  would  like

                  to suggest that instead of -- and I will move -- I not only

                  suggest but I will move that instead of the $1 million

                  committee recommendation against the $230723000 they requested,
                  at least to give them the $400   .000 which is now the funding




       52
                                                                        326
                 is less than their current annualized figure.  So I move that

                 we recommend $1,400,000 funding.

                            [The motion was made.]

                           MRS. SILSBEE:  Mrs. Gordon.

                            MRS. GORDOII:  Well, I can appreciate the value of

                 the telephone network.  We don't have drifts 12 feet high,

                 but we do have somewhat the same problems with communication

                 and that sort of thing.  However, I agree that it is a shame

                 to scuttle it at the last yesar.  But it would seem that they

                 could have put more emphasis in -- toward getting other

                 funding.  It was a valuable program to them and there should

                 be those who are willing to support it.

                           MRS. SILSBEE:  Mrs. Gordon, I believe that a part
                 of that support is that there are a number of hospitals in
                 the area and they do   it is a matter- of gradually getting
                 all of the hospitals to take up their portion of the cost.
                           There has been -- costs for @his project have gone
                 down over the years and it is used-as a method for having
                 committee meetings in-the winter and a network in, oh,
                 emergency medical service relay from one hospital to another.
                 So it has been more.  The term telephone lecture network, that
                 doesn't really tell the whole story on that.
                           MRS. MARS:  It should not be termed that, really,
                 because that is too ambiguous, I think.  It do-es, as I said,
                 so many other things besides that-.




        5 3
                                                                            327
                            14RS. SILSBEE:  Mrs. Mars has made a motion to  --

                 for $1.4 million.   Is that seconded?  Dr. Haber:

                            DR. HABER:  I second it.

                            [The motion was seconded.]

                            I,IRS. SILSBEE:  @s. Flood.

                            MRS. FLOOD:  On the yellow print-out,-does the
                 symbol "C" at the extreme right signify funding beyon  the
                 three-year support or funding beyond 175?

                            MRS. SILSBEE:  Beyond '75.

                            MRS. FLOOD:  They are requesting funds her    then,
                 for fiscal '76?

                            MRS. SILSBEE:  Right.   There were two proj cts, I
                 believe, because they were asking for tiqo-years' support.
                            MRS. FLOOD:  Then may I ask who the 'sponsors are
                 of, for example, the telephone network?

                                           'That is the grantee organization
                            MRS. SILSBEE:

                 which is a nonprofit organization.

                            MRS. FLOOD:  Well, it was my understanding that.
                 there would be no funds allotted past June the 30th of 1975
                 for any core staff.  Now, how can it be a grantee project and
                 they request funding beyond that fiscal year' if it is going to
                 take four staff to operate it?

                            MRS. SILSBEE:  Mrs. Flood, in this particular
                 organization, is as a nonprofit organizatio n, @hey have other
                 sources of funds.  I believe they have gotten funding from


       5.4                                                                  328

                other Dlaces.


                           I,lr. Pahl.


                           PIR - PPJIL: I'd lilce to,speak in general terms. This,
                is as good a case as any., but there is a general problem

                which runs through a number of applications, so my comments

                are really not to the application  under consideration,  and

                that is, how does the RMP manage  its affairs when it  makes its'

                awards for activities which will  extend beyond the termination!

                date of the PJIP in question?

                           Since RMP's are to terminate on June 30th, 1975,

                the question is a proper one.  We have been interested in

                addressing this question now for two years because  of  some
                interest in proposed phase-outs-last year and possible

                termination of the program this year.

                           In practical'terms, there is no resolution at this
                time to that question.  Sotne grantees will be able to manage
                affairs beyond the life -of the TU4P because they happen to be
                institutions that have a life of their own and are willing to
                absorb the cost necessary to monitor those ongoing activities.

                           On the other hand, it would be fair to say that the
                large majority of grantees are not  for-profit  institutions

                or are medical societies or schools that do not literally
                have the funds to pay the staff to monitor such activities.

                           Now, staff has recognized this situation for the
                second year running and, actually., I have discussed this



        55                                                                 320

                 matter in recent weeks with Dr. Margulies and  have  proposed  to

                 him that the agency sent out to all RMP  grantees  a  statement
                 of federal policy which basically would say that it i@ the

                 established practice of the government -- and I  can  gLve  you

                 any number of examples out of personal experience --  -,hat  it

                 is the established practice of the Federal Government to

                 provide for the monitoring and surveillance  of  activi  ies

                 which extend-beyond the life of a program. when that program
                ihas been terminated by the government.

                             For example, the chronic disease control program

                 was absorbed into the Regional lledical Program and th-@re  was

                 no more chronic disease control program but we  in  our  organ-

                 ization have spent the last three years manao-ing federal

                 commitments  and contracts in the kidney program area   and  part

                 of my staff has been doing work that was obligated to   three

                 years ago.

                            We had a series  of HEW regional offices.   There is

                 a decentralization thrust to put  appropriate  functions  in

                 these regional offices and there will continue to be head-

                 quarters staff either under  the title of RD4P, Health  Resources

                 Planning., IIRA or some organization.

                            I have in my briefcase a statement  which  has  been

                 drafted by RMPS and will be Forwarded to  Dr.  Endicott  for

                 official consideration as an agency state
                                                            ment for RI,.,IP grantees
                 which merely provides assurance that although  we  have  not



      56

                 identified the manner in which the government will assu-

                 monitoring responsibilities, that this problem is both

                 recognized and the grantee, in good conscience, can let

                 contracts for periods beyond June 30, '75 whether the present

                 grantee is in operation or not.

                             I hope that addresses both this and a number of

                 other issues.
                             MRS@ FLOOD:  Well, but you are clarifying the
                                                                      C>

                 concern we  have for management of T)hase-out projects by

                 contract mechanism, but here we have a grantee who intends to

                 continue projects themself beyond

                             IIR. PAHL:  Well, there is a clearcut statement'

                 by the administration that no costs may be incurred by an
                 RMP beyond.June 30, '75, regardless of what the applicant
                 wishes.  You can't stop the applicant from stating whatever
                 he wishes to do but there Is a clearcut statement in all'of
                 our instructions that costs cannot be incurred by RMP's
                 beyond June 30, so this situation falls into the very one I

                 am mentioning.

                            He cannot go-beyond June 30th.  That is the
                 administration policy.  Therefore, he falls into the class
                 that I am talking about, if the project is to be continued.,
                 then either the individual rdgional offices or some head-'
                 quarters program,.whether we are the same name gr not,, will
                 have to assume that responsibility or we have to make



         57
                                                                          331
                 arrangements for some other organizations to tal,e on that

                 responsibility and, as I say, we are tryin- to develop a

                 policy.  It is very strange that I cannot send to any grantee

                   xerox copy of anything out of HEW as to how to manaTe such

                 an activity.  Yet the Federal Government does terminate

                 proo-rams all the time and there is no grants-manageme,it policy

                 in this area.

                            So we are attempting to develop one and  ho  e,

                 Agency will respond.

                            'MRS. FLOOD:  Then I must inquire regarding the
                 tumor se'rvice registry here, if this, then, is fifth Ind sixth

                 year support?


                            MR. PAHL:  Yes.

                            MRS. FLOOD:  And in that case  it was the same

                 status for the telephone'network.

                            MR. PAHL: No., that is a different  thing  than

                 either one of them.


                            MRS. SILSBEE:  No.

                            MRS. FLOOD: Fifth and  sixth  year.  No,  tumor

                 registry

                            MRS. SILSBEE:  Is fourth and fifth.

                            MRS. FLOOD:  Fourth and fifth.  Can you tell me if
                 the budget reflects decreasing funding in the sixth year of
                 the tumor registry or if there is full support again in the
                 sixth  year?



       58                                                                        332

                              I,IRS.,SILSBEE: I can't.  In  terms  of  the  way  in

                  which they put this money in, in     one lump,  we  don't  know  what

                  the costs for the fifth year would be,     but they  put  it  to-

                  gether as a total..

                              I-IRS. 14ORGA'I'I: Except for Texas, I didn't know  we

                  supported tumor registries for six years.

                              DR. WAM'i,,IOCK:  This is $200,000 here for  a  rather
                  br,oad area andlIld like to address myself     to  the  importance

                  of a tumor registry, because--this has been     a  project  that  has

                  been promoted by the American College of Surgeons since almost

                  the day of  its  inception.  It  is  called  the  clinic   activities

                  record and  it is the only way  that  you  can  have  any  control

                  over survival, not  only  survival,  but  quality  of  survival,,

                  because, actually,   what we are talking about is eradication,

                  paliation, et cetera and so on and if you do not have any kind

                  of mechanism where you can    look back and  see  what  you  have

                  taken inventory [of], then    you do not  know  whether  you  are

                  making any  progress,  so  everything-goes  for  naught  and  the

                  average individual  doing  any  kind-of  clinical  work  says,  I
                  have got a case  of  carcinoma  of  the  colon,  it  is  cured.  But,

                  hell, if he looks at 100 cases he finds out that 95 of them are
                  dead and they died all on the surgical table or something

                  like that.

                              So this does have -- this is a nitty=gri:tty

                  proposition and some  people  do  say  that  the  tumor  registry  is

                  not worth the salt that



        59
                                                                                 333
                               I,IS. SILSBEE:  This is an issue, Dr. Wammock, that


                   the council has dealt with.


                               DR. WPJIDIOCK:  Well., I realize that.

                               MS. SILSBEE: And  in  general.,  they  feel  that  it

                   has been the experience that once you pick up the support of

                   cancer registry, you have got it        they  go  around  seeking

                   one grant program after another., so council has been

                   discouraging

                               DR. WAIT-IOCK:  I recognize that-and   I just  wanted

                   to name that particular area there.  I would not question the

                   councils position.

                               MS. SILSBEE:  Dr.   Janeway.

                               DR. JANEWAY:  Isn't in general this -- I      could

                   ask our administrator      reimbursable per dium cost,-the-
                   patient care thing would   be a medical record, includible in

                   -the administrative costs  crf running a hospital.

                               DR.   WAMMOCK: That has been debated.

                               DR.  JANEIIAY: Well, it has been accepted in

                   North Carolina.

                               DR. WAIT,40CK: I'd say some people here are

                   considering ilk-..  I mean, I'll rephrase my statement.

                               MS.   SILSBEE: If I  could  make  a  statement  about

                   the way in which the committee arrived at the recommendations
                   which, in looking it over, they did'arrive at this differently

                   than they did most of the actions.



      60
                                                                           334
                             Instead of looking at the request and deducting
                 those items that  they really were concerned about, they
                 looked at the current levels and  deducted so, in a sense,  I
                 think the recommendation did need  to be looked at again.

                            We have a motion

                            MRS. MARS: I-lay I, before we -- I just wanted  to
                 tell them a little bit about this network,  I'll only take a
                 second, as to @hat its activities were, just to give  you  an
                 idea that it is far more than just a lecture network.

                            There were, however, 187 one-hour lectures  on
                 14 scheduled series.  The total att-endanc e was 16 743 people
                 and an -- there were two new lecture series were developed
                 in medical librarianship and food service.  There were 600
                 previous network presentations that were reviewed.  There were
                 special lectures offered in anatomy and physiology, emergency
                 medical technicians certification, interpersonal relations,
                 secretaries, alcohol problems, third-party payments.
                           They provided audiovisual support at 33 teaching
                 days and conferences throughout the region.
                           MRS. SILSBEE:   Mrs. Mars, I
                           MRS. MARS:  So  these were things that it did do,
                 which you can see, it is far more than just a lecture series.
                           MRS. SILSBEE:  Thd motion has been made and
                 seconded that this application be approved at the level of
                 $1,4oo,ooo.


         61                                                               3
                            I,IR. IIIROTO:  May I ask a question before the

                 question?


                            I.,IRS. SILSBEE:  Yes.


                            DM. HIROTO:  What is to ensure that this $400.,OOO

                 in addition would be used for the purposes you feel a,e so

                 important?

                            '@4RS. IIARS:  Well, it isn't for that.  It i- simply

                 this is their annualized money.  They used this money,  I

                 can't say as to whther they are goin- to put it     v7h@@re'they

                 are going to put it.

                            MR. HIROm-0:  That was the prior yearls?

                            I,IRS. lfARS: Yes. yes.

                            MRS. MORGAN:  Question.

                            [The question was called for.]

                            I-IRS. SILSBEE:  All in favor of the motion, say aye.
                            [There was a chorus of ayes.]

                            Opposed?

                            [Two voices were raised.in opposition-and the motior

                 was carried.]

                            Two.  The motion is carried.

                            Now, do you want to take a quick break at this

                 point?

                            [General assent is signified.]
                            Okay', the next problem area is Mary@d and I

                 wonder if you, as chairman



       62                                                                       1
                                                                           336
                            DR.; WAYUIOCK:  Oh, my aching back.

                            TIRS. SILSBEE:  This won't take long.  Mr. Peterson

                 chaired that particular session.  Mr. Mank is not here.  I
                 wonder if you would just make a brief statement, Mr. 'P6terson9i

                                  REPORT OF'MR. PETERSON

                                        MARYLAND,

                           MR. PETERSON:  Well, I think anybody  who read the
                 transcript, as I am assuming Dr. lqammock did, it was summarized
                 lvery neatly by the review committee after considerable
                 discussion because, as you see from your green sheets, they, ir
                 effect recommended phasing out the Maryland RFIP.

                           They said -- I think I am almost quoting  verbatim
                 in the way of summary, this is a region which has been almost
                 since its inception plagued by an ineffective coordinator,
                 an inactive RAG, a self-serving grantee and we could overlook
                 all those things if they had done anything.

                           [Laughter.]

                           Finally., and I think that whoever has got the
                 verbatim, I am not saying it wfy stronger than the review
                 committee summarized it   finally, we don't think this is
                 worth preserving as a building block for whatever comes down
                 the road in the way of health'resource planning.
                           I think those were the conclusions they arrived at.
                 Whether those lead to the recommendation is so@thing else
                 again.  This was one of two regions which they did recommend


       6 3                                                           337

                phasinc- out on the third morninE when my groun reconvened

                briefly.  I, in effect, opened.up ',Iaryland and Ilassau, since
                               I
                .they had had a night to sleep on it, as well as looking at all

                the other actions taken and they decided not to reconsider or

                at least revise their recommendation of the earlier day on

                Maryland.

                           DR. WAI,'U40CK:  I'm going to fool you today, very
                decidedly.  This program was not'approved by the review

                committee.  Therefore, I concur.  It'is difficult to under-

                stand what they are trying to accomplish.  It is not very

                well organized.  Period and that is it.

                           [Laughter.]

                           SPEAKER:  Motion.


                           @SPEAKER:  Make the motion.

                           DR. WAIDIOCK:  I move that we sustain the reviewers'

                comments that it not be approved as a solvent program.

                           SPEAKER:  Second.

                           [The motion was made and seconded.]
                           MRS. SILSBEE:  Dr. Watkins, you were the secondary

                reviewer.


                           DR. WATKINS:  I concur.

                           MRS. SILSBEE:  Now, this is a major step for this

                council.


                           SPEAKER:  Sure is.

                           MRS. SILSBEE:  Dr. Janeway.



       64
                                                                         338

                            DR. JAIIEWAY:  Just one question.  We are not

                 dealing with a very great number of people at the moment.  Is

                 there any provision when something is phased out with re-ard

                 to the people on board so that they are not cast adrirt?

                            MRS. SILSBEE:  That will be negotiated by -,he staff.

                 The intent


                            DR. JAIIEVIAY:  You know  because there is s)me kind
                 of personal element in this and we have to think abou'; it.

                            14R. PETERSON:  It was made explicit
                                                                  altho,igh
                 no figure was arrived at that while they recommended  ])ahse-out
                 and there was a zero figure, it was with the understa ding
                 that staff would need to negotiate if the council co n  urred  to
                 see how much money would be required for a timely but orderly
                 phase-out.  This involves considerations of how much funds do
                 they have on hand that would remain unexpended as of June 30
                 and other considerations so while it shows as zero,  the  intent
                 was not to preclude some negotiated award to permit  the  phase-
                 out,. again, if council should concur.

                           DR. WC-IMOCK:  They only-@described one project in
                 here that I could find of any sort, I mean, that was in the
                           MRS. SILSBEE:  Well, Dr. Wammock, essentially this'
                 is more or less/of a continuation application.  There were
                 other things.  They are comin@ in with the July thing which
                 has had -- been under development.  I have to -=-I was not
                 present at the committee review. @I have read the transcript


       65                                                                 339
                 and I must say, from the standpoint of being responsible    for

                 the -- all the regions, that this region has not had the    kind

                 of staff work -- it was not gone to  see  whether  the  r@gional

                 advisory -- there is a new  chairman  now.  We  don't  really

                 know, so in a sense, this region is being  looked  at  in  terms

                 of the situation as it was a couple of  years  ago-and  we  donI.t

                 know whether it has been changed.or not.

                             l@. PAHL:  I'll make my comments off the-r(@cord.

                             14RS. SILSBEE:  Okay.

                             MRS. MARS:  Well, is  there any program the  e  that


                 could be  taken over that would  be worthwhile to  be  taken  over
                 by., say, Delaware, in order to  supervise  the  phaseout  of  it,

                 or


                             MRS. SILSBEE:  I don't think in this'particular

                 situation that would be a very valid way because Greater

                 Delaware Valley doesn't re4ally  extend.  They  have  trouble

                 enough with their area as covered.

                             SPEAKER:  Question.

                             [The question was called for.]

                             MRS. SILSBEE:  The motion has been made and

                 seconded that the Maryland Regional Medical'Program be

                 phased out.  While no dollar amount is recommended, it     is

                 understood in this motion that staff will negotiate to,make

                 sure that this is done in an orderly, judicious manner.

                             DR. WA,"114OCK: That would be included in my  motion..

                             MRS. MARS:- How long will it take  to  phase  it  out?



       6,6                                                                 340
                            MR.- PAHL:  Off the record, please.

                            [Brief off the  record.]


                            MRS. SILSBEE:  All in favor of the motion.


                            [There was a chorus of ayes.]

                            Opposed.

                            [There is no opposition and the motion  is  carried

                 unanimously.]


                            The motion is  carried.,


                            MR. PAHL:  Off the record, please.

                            [Brief off the  record.]

                            DR. WAMMOCK:  -- it would take., really, too long
                 to describe and everything here,  I can see nothing @hat

                 sustains the continuation of that kind of proiject and I would

                 compliment the staff on doing a very difficult situation [sic]

                 because I recognize that when you phase out something, that is

                 a blow, either above the belt  or below the belt or around  in

                 general.  I don't care what you want to call it.

                            MRS. MARS:  Thank you, Dr. Wammock.

                            MRS. SILSBEE: NasscTu-Suffolk is the  next  program

                 that was a problem.

                            SPEAKER:  I wonder if we could have the staff with


                 us on  this?


                            MRS..'SILSBEE:  The Nassau-Suffolk Regional Medical

                 Program originally was part of New York Metro qnd then it
                 broke off and became the Nassa@-Suffolk Program.  It  had  the



     67                                                                  341

                 unique organizational pattern of havinc- the executive director

                 serve as both the coordinator of the Regional '.:edical Program

                 .and the director of the CHP B agency.

                            The staff was under this one man and the advisory

                 councils and so forth were sort of inter-ieshed.  That has

                 been a problem for us.

                            Last year, they divorced.  The B agency and the
                 RIIP went their@separate ways and'since the phaseouts' the

                 original coordinator., who was the -- kind of the man who

                 developed the B RMP relationship has departed.

                            His deputy was coordinator for, oh, about six

                 months.  He left and we now have the third coordinator in' the

                 course of this year.

                           .The region has not had its review process verified.
                 There is still a problem with the b.y-laiis for the Regional

                 Advisory Group.

                            The reviei--;er for liassau-Suffolk is 'Ir. I-lilliken.

                             REPORT OF 71,!R. SEWALL O.-I.IILLIKEN


                                      ITASSAU-SUFFOLK

                            I'd. MILLI@A'E-'!:  Well, I concur completely with the
                 committee recommendations.  I do have a pro-@lem.  In looking
                 throur-h the material,that was taped, I was trying to find
                 some indication of what appropriate phase-out cost.might be.

                            The closest I could come to a fic-ure on that was
                 $240.,OOO but I do not find any documentation as to details on



     68
                                                                         342
                 that, so I am not sure how reliable that is.

                            1,IR. PETERSOI@L:  I don't think it is necessarily
                 reliable, Sewall.  It reflects, I think, some sort ofia
                 guesstimate but here again, I think'the clear intent  of the
                 review committee was to leave to st aff the termination from
                 negotiation with Nassau-Suffollc  if the council-shoula concur,
                 what would be required in the way of additional funds@
                            Pgain, it is not only determining how much money
                 is needed for a timely, orderly phase-out., but how mu,,h money
                 would they have still on hand as of June 30 and I thiiik3
                 again, whether a quarter of a million dollars or $150 000
                 that is something that would need to be worked out.
                            The figure.was spun off, I believe, in the trans-
                 cript, but I don't think anyone would hold to it because we
                 have not really looked into it until the council takes action
                 and that reflects final action rather than a review committee

                 recommendation.
                           l@IR. MILLIKEN:  @lell, based on the same concept of'.
                 the one we just deleted, it is my motion that we accept the
                 committee recommendation and terminate this program.
                           [The motion was made.]
                           MRS. SILSBEE:  Is there a second?

                           SPEAKER:' Second.
                           [The motion was seconded.]
                           MRS. SILSBEE:  The m6tion has been made and



      69
                                                                        343
                 seconded that ilassau-Suffolk Regional '.Iedical Program be
                 terminated.  I%Ihile no dollars are recommended, it is under-
                 stood that staff will negotiate a figure that will al@ow'for

                 an orderly phase-out.

                           Is there any further discussion?

                           DR. HABER:  Yes, I'd like

                           MRS. SILSBEE:  Dr. Haber.

                           DR. HABER:  Will someone give me a reply t) the
                 question, if the RMP has not complied with the RAG grin ee
                 policy, in what respect has it not complied?
                           MRS. SILSBEE:  Dr. Haber, the board of the grantee
                 organization has -- it is on the'regional advisory gr@up in
                 toto and we have been.concerned about the dominance of that

                 board.

                           Now., they have been sending in various changes in
                 this and it is my understanding at the present time that the
                 numbers of the board that are now on the RAG are somewhat
                 fewer.  There is a jurisdictional dispute between the grants
                 management branch and the eastern operations branch as to
                 whether they have completely complied.
                       -   Since that was just one issue in this whole appli@
                 cation, I didn't think that it was a major thing at this
                 point.

                          We have had the motion made and secon-ded to
                 terminate the pr ogram with the full knowledge that money will




                                                                       344

     70          come forth for orderly phase-out.


                            All in favor?


                            EThere was a chorus of ayes.]

                            Opposed.

                            EThere was no opposition and the motion was

                 carried unanimously.]


                            The motion is carried.


                            We do New York Metro next, Dr. Schreineri

                            REPORT OF DR. GEORGE E. SCHREINER


                                      NEW YORK METRO


                            DR. SCHREINER:  Yes, this is a large
                            MRS. SILSBEE:  Oh, let the record show t@at

                 Dr.  Watkins will be out of the room.

                            DR. SCHREINER:  I won.It say anything until he

                 leaves.


                            There were two reviewers, one who was in on the

                 site visit and one working from the application.  I reviewed

                 the transcript and also the grant request here.

                            This was rated b-y t@t- review committee as average.

                 The projects were given a grade in the 40 percent range.  I

                 think this is a situation that is perhaps    brings to mind

                 something Mr. Rovell said yesterday and that is, we have to

                 be careful not to be prejudiced too much by past performance.

                            New York, as you heard in the speec@yesterday, is

                 a very complex place with 10 million people, the medical



                                                                          345


                 schools, 200 hospitals and there have been a number of

                 conflicting wheels within wheels in terms of internal politics.

                            I think it is a remarkable achievement,  actually,

                 that in the past two years or so there has been a  semblance

                 of coordination and there has been some rallying around  the

                 new grantee and the new director and the RAG has been much

                 more representative, as far as I can see.

                           Taking one program alone, which I  happen-to  know
                 very intimately and that is the transplant situations  there

                 were 12 transplant units working in the city. I  think  there

                 were, at one point, nine typing labs, three of whom were

                 using totally different semantic systems.  It was a real

                 Tower of Babel and there still is a considerable  competition

                 in this area, even the Better Business Bureau got in the  act
                 to try to settle things with regard to transplants, I  was
                                          '@f the directors.
                 'told some time ago by one

                           Now, the one that looks like it is going to survive,
                 to me, is the one that is being sponsored by the  Regional

                 r
                 J.-ledical Program associated-witIT the Blood Bank.
                           Very recently it has come to my  attention  that
                 there iz still another competitor in the field trying to turn
                 the Medicare Social Security reimbursement into a  commercial

                 enterprise so I think it is vbry important that we-not let

                 this little game go down the drain because there are a lot
                 of hawks waiting on the fence, waiting to rush in if this  is



       72                                                                  346

                 not supported.


                            So I think that the committee request is -- I would'@


                 normally consider     I mean the review cor,.nittee's  request

                 for $2.5 million     I would normally consider  quite  a  fair

                 and adequate allocation in relationship  to  the  outlining  of

                 the projects but the two things that have happened recently.,'

                 one is, Dr. Koontz arriving from California,  who  is  one  of

                 the country's outstanding  transplant  surgeons,  which  really

                 mobilized a good core of people around him and a very

                 expanded program.

                            The other is that I suspect that they will probably

                 be asked  to pick up about $96,000 in onmoing stuff from

                 Nassau-Suffolk in the organ  donor  procurement  programs  that

                 ties in, that they will be asked to pick up some of this  so

                 I would, unless the staff has some strong objections, I would
                 like to move that we up this to approximately $2.9 million or
                 even $3 million. I would make a  motion  for  $3  million,  for

                 this area and believe that it will @e well-spent and some.of

                 it will be allocated, it sho-uld be-emphasized, to try to,

                 strengthen this transplant program, which  looks  like  it  is

                 about re-ady to fly.

                            They did 250 transplants last  year  in  the  metro-

                 politan area there so they would do 500  to  1,000  if,it  were

                 adequately banked.

                            [The motion  was made.]




       7 3
                                                                         347
                            DIRS.:SILSBEE:  Dlr. '@lilliken.

                            MR. PIILLIKEIII:  I agree, concur.

                            [The motion was seconded.]

                            DR. JANEIQAY:  Is Koontz Einaudible.]

                            DR. SCHREINER: Yes.  They  had  done   just as an
                 example, they had done no transplants -- well, they had done
                 two , transplants in four years before he came and he did

                 30 the first six months.

                            MR. MILLIKEII: I gecond the  motion for $3 million.
                            MR. PETERSOII: I think there are  acouple of
                 things that ought to be, perhaps, laid on  the table for the
                 benefit of the others.  Many of the projects in this request
                 were for two years.  Thus the request @-,,as a $6 million-plus
                 one but it reflected in large part sort of a two years of
                 activity and I think the review corL,@iittee's recommendation
                 has to be seen in that light.
                           The second thing was, as Dr. Schreiner  I am sure
                 is aware, and if you have glanced at the transcript   the
                 review committee, in making_its particular recommendation, in
                 effect said -- and I don't remember the exact,words, but that
                 given what had happened in the way or turnaround or the kind
                 of health care jungle that New York City is, that certainly,
                 looking at the July application or the council if additional
                 funds proved to be available, that this was,a re7gion that they
                 might well view more generously. I think  that   those are



       75
                                                                         349
                 I am, sure Dr. Bauer of Mississippi was one of them, but

                 don't recall the other two.

                            MR. ZIZLAVSKY:  [Inaudible.]
                            MRS. SILSBEE:  We can't hear you up at this end.
                            DIR. ZIZLAVSKY:  All three of the kidney coIasultants
                 ad hoc technical reviewswere completed from out of st  e.
                 provided the @'Tebraska R';iP with negative comments.  Th
                 allowed $10,000 or $15,000 flexibility.
                            MR. POSTA:  Dr. Schreiner, consultation fr)m staff
                 here to the coordinator, we had recommended that he c ntact
                 Dr. Flanigan in Arkansas to get three certified revie ers that
                 had been approved by DRIIP in the past.  Dr. Bauer was one but
                 I don't recall the other two.
                           DR. SCHREI14ER:  Yes.  The reason I am' not really
                 totally prepared to acce'pt their evaluation because one of
                 these individuals was very"vocal and so evangelistic about
                 home dialysis that he never approves anything that involves
                 satellite dialysis anywhere in the country and in this kind of
                 a situation where you have long distances involved between
                 Places and no real back-up., I am not really sure that every-
                 body can be put on home dialysi s and this was probably the
                 basis for his comments.

                                  part of those areas have depended on
                           The
                 '4innesota for back-up in their satellite di
                                                           alys:Ls and I sort of
                 iew this project as a beginning attempt to try to go it on



        76                                                                       3 -@ 0

                   their own and get units in various are;-zs that are quite rural

                   and with  quite  alow population dens,'L@Uy.  Therefore, I am

                   going to move that it be approved    in the $950,000 level,

                   putting back some of the -- the only project they criticized

                   was that particular project and I'm putting back some of them.

                               [The motion was made.]

                               MRS. SILSBEE:  The secondary reviewer on Nebrasl,:a
                   was Mrs. Kleini.

                               MRS. KLEIN:  [Inaudible.]

                               MRS. SILSBEE:  Could you speak into the microphone,

                   please?

                               MRS. KLEIN:  I couldn't find anything that I

                   disagreed with in the cor@mittee's repor' and so I would     concur.

                             .MRS. SILSBEE:  Would you second Dr. Schreiner's

                   motion?


                               MRS. KLEIN:   Yes.

                               [The motion was seconded.]

                               MRS. SILSBEE:  Okay, then, the motion has been
                   made and seconded that Nebr-askals-R:,@IP application' be funded
                   at  $950,000.

                               Is there any further discussion?

                               [No discussion.]

                               All in favor.

                               [There was a chorus of ayes.]

                               Opposed.



       77
                                                                         351
                             [The motion was carried unanimously.]

                            The motion is carried.

                             REPORT BY DR. GEORGE E. SCHREINER

                                       NORTH DAKOTA

                            DR. SCREINER:  The next one is North Dakota, which
                 was rated average and below average and given a rate of 75

                 percent.

                            The projects are,interesting.   I think that from a_
                 critics point of view., one could question some of t@e
                 priorities which they have established but, nevertheless3,
                 they have established them and they are their  priorities
                 and they are going to do them, I am sure, well, and I think
                 the people'out there have impressed everybody with  their
                 general honesty and integrity so I think the  committee's
                 recommendation on this    which was somewhat of a reduction
                 in the requested amount of"$774 -- the committee reduced it to
                 $582 and I redid from the project and came up a couple of
                 thousand dollars away on the basis of this report'and I think
                 that the committee's recomm-end@,ion is just about on target
                 here so I would approve the recommendation of the committee.
                           [The motion was made.]

                           MRS. SILSBEE:  Mrs. Gordon.

                           MRS. GORDON:  Second.
                           [The motion was  seconded.]
                           MRS. SILSBEE:  The motion has been made and



         7                                                                352
                 seconded that the "4orth Dakota application be approved at

                 the level of @.1,782,517.

                            Is there further discussion?

                            [14o discussion.]

                            All in favor?

                            [There i-ias a chorus of ayes.]

                            Opposed.
                            [Th@ motion was carri'ed unanimously.]

                            The motion is carried.


                            Susquehanna Valley?

                            REPORT BY DR. GEORGE E. SCHREINER


                                    SUSQUEHAN!4'A VALLEY

                            DR. SCHREINER:  Susquehanna Valley is a real

                problem, although it wasn't on your problem list.

                            [Laughter.1

                            All of the programs    the request or the
                recommendation for $400,000 or suggestions [inaudible owing
                to side conversation in mikes] -- that I gather     as I add
                up the program, the most you could get out of the @rograms
                would be $96,000, so we     the taxpayers are,being asked to
                spend $600,000 in order to administer $96,000 program    I

                personally think this is immoral.

                            14RS. SILSBEE:  Dr. Schreiner, did yo@ see  the

                memorandum  that


                            DR. SCHREINER:  Yes.




      79
                                                                             353
                             !-IRS. SILSBEE:  -- the July application.

                             DR. SCHREIDVIER:  It didn't impress me.

                             I,IRS. SILSBEE: I-lell, I didn't expect it  to  impress

                 you, but I  do think, in terms of the way in       I think.the

                 background  of this region is, it is a cautious    region  and  the
                ifact that they could very well have just taken     oPf a lot of"
                 their projects that they were all ready to -o with a year

                 ago and sent them in in'this application so that you would

                 see more activity per staff -- but they chose to go'back

                 through the whole process  again  and  reevaluate  them  and  for

                 that reason we don't see the pro,,r@@ part of this region.

                             DR. SCliREI1,41ER:  Well, everybody knows the RI@IP

                 has a short prospective 1-1-fe and it seems to  me  that  they  are

                 so unrealistic that they don't realize that one of the

                 reasons RMP has been in   trouble is the amount of money spent

                 @fo r staff in relations)-iip'to pro,7rams and to  start  all  over

                .again to build a great bi-  staff  without  any  programs  at  all,

                 it seems to me that the  normal  direction  would  have  been  to

                 go out and scratch for some lo,-,--bi-idget programs.

                             If you can twist  my  arm a little bit,, I might   be
                lwillin-- to give them $200 000 but there is a lot    of   sentiment

                 on the council.  I  personally  think  we  ought  to seriously

                 consider discontinuing it.

                             MRS. SILSBEE:  Mrs. Flood.

                             MRS. FLOOD:  I would like to inquire if historically




     80
                                                                              354
                   this particular proEram had utilized staff effort heavily        or

                   i-thether they founded independent outside agencies, institu-

                   tions, et cetera?

                               I-IRS. SILSBEE:  Jerry.


                               MR. SHOLOV:  Yes.  I believe -- you    were asking

                   whether they were using the money,for force studies?  There
                   is only one force study in the application in front o@ us

                   for a unified health plan in this application.


                               SPEAKER:  He didn't understand.


                               MRS. FLOOD:  Well, yes, there are many proTrams,
                   Ri,TP's, that use heavy staff to  actually  carry  on  prog@ams  or

                   projects throughout the state., rather  than  --  and  car  y  them

                   as core staff functions  to  provide  full  projects  in  the  core

                   staff base and I just needed to know if this is their

                   traditional format?  Otherwise, I would have to agree with the

                   doctor that this is a heav"Y investment in staff just to

                   monitor some projects that they hope to., you know, send to us

                   in the July review.

                               I,IR. SHOLOV:  May I just comment that the only

                   investment that they  have  in  the  current  staffing  project  is

                   funding,a B agency directly and, again, they only asked for

                    50,000 for one unified planning staff and this application

                   is what you see in front of you.

                               MRS.  SILSBEE:  But.,  Mrs.  Flood,  traditionally,  it

                   is.a mixture  of  staff  and  project  activities.  The  14  people





                                                                         355

                 now on board have just come on board.  They had three up

                 until recently.

                            DR. SCHREINER:  Yes, the total project, outside of

                 program staff on the yellow sheet only add up to about'

                 $6 000.  The July projects that we know about are such thin-s

                 as the Fulton County Public Health l@ursing Service, the

                 Huntington County Home Service, the Center County Home  Service

                 the llorth Penn Home Health Agency.  It sounds to me'pretty

                 much like county health-type projects.

                            There is one for consumer health education program

                 and there is a dental program which is $81 000 with the

                 $16,00 in direct costs.

                            It just sounds like an enormous build-up of  staff

                 for a very, very thin program and I am not very  enthusiastic

                 about it.


                            MRS. SILSBEE: Do you have a motion that  you  wanted

                 to make?


                            DR. SCHREINER:  Well., I'd like to -- Iwould  either

                 move for $200                                 -out and I  was
                              .,OOO or move f-or %ero and a phase

                 trying to see if there was.any strong sentiment on the  council

                 or staff for phasing out.

                            MRS. SILSBEE:  Dr.'Wammock.

                            DR. WAMMOCK:  I read this several times'and I

                 can't solve the problem and I concur in the fac-t that the

               ..budget here for staff was extremely large and that sort of
               'turned me off, I am sorry to say, right then, although  I  did




      82
                                                                          356

                 leaf through it.  If you want to take into consideration the

                 location of the Susquehanna Valley and what their medical

                 needs are,, they are not available to them like they are  in

                 some of the other areas.

                            Now, I think that, certainly, some consideration

                 must be given to whether -- what will stimulate them to

                 activity and I would say this would be a token, whatever  we

                 do with $200..,OOO.or $300,000 will stimulate them to@w at they

                 could do for that particular area and perhaps that is what we

                 might do here but, in essence, it is really a  poor  program

                 and I have one of two choices    to give them  somethi@g  or
                 just wipe it out.  I-would be more inclined to show allittle
                 bit more compassion by givina- them some stimulus under  the

                 circumstances.

                            DR. SCHREINER   In that case, I'll move for

                 $200.,Ooo.

                            [The motion was made.]

                            MRS. SILSBEE:  Is there a second?

                            DR. WAMMOCK:  I'll second it.

                            [The motion was seconded.]

                            MRS. SILSBEE:  Mr. Stolov.

                            MR. STOLOV:  Mrs. Silsbee referred to a memo given
                 to Dr. Schreiner on the reading of  the  Susquehanna.grantee
                 RAG chairman and coordinator we had with us.  My only point,
                 did everyone at council hear this?  It was brought up in this



       83
                                                                         357
                 .meeting that the commitee's concern was exactly that,of
                 councils and that is why they did meet with us.  We did
                 discuss this with them and that is in the memo.  My oilly'
                 addition to the factual on this is that they do have '.4
                 people on board now and they came on-board as a recruitment
                 by the newly-appointed coordinator and some of these  eople.-
                 are already experienced in IU,IP and the $200,000 recommendation
                 made was for a reduction of staff at this point and'ttat is

                 my only point right now.

                           I-IRS. SILSBE.8:  The motion has been made an
                 seconded'that this region be   its application be fu ded at

                 200 000.


                           Is there further discussion?

                           DM. CHAMBLISS:  I would simply, in an effort to
                 make sure that the council is aware that this region has been
                 advised about the level of-ttaffing.  I would simply want to
                 reendorse what Dlr.- Strolov has said.  We have had a very
                 @ecent conference with the leadership of that program and I
                 are with him the view that if the-.level of funding as is now
                 ,h

                 )efore us -- is now on the floor -- that level is accepted,
                 'hat it would probably cut into the existing'staff  that that-
                 -egion has.

                          I do feel that part of this was taken into account
                 y the review committee when it reviewed the application.
                           I,IRS. 14ARS: Are you saying, Ilr. Chambliss, that



       84
                                                                358

               if this is cut to $200,000 that, really, there won't be

               enough staff left to stimulate any type of program?

                         14R. CHAMBLISS:  I do., because we did admonish that

               region early on that they were too low of staff.  We have a

               specific letter in the files saying, build up the staff.  That

               was right after phase-out.

                         And they built it up and I must admit3 with you,
               that they have gone beyond that, but I think what I,see the
               council is considering now may get them back actually to where

               they were when we advised them early on that they should

               increase the staff.

                         Now, I do this only -- only so that coun dil may
               have before it as many facts as,we have here on staff.

                         DR. SCHREINER:  Now, I appreciate what you are
               saying.  Ithink this would be a real concern, for example,
               if we were looking ahead tb three years of project development)
               but I think you have to ask the question, build up staff for
               what?  I mean, there has got to be.-a.program that -goes along
               with that build-up and in this.case I can't find the program.
                         MRS. SILSBEE:  liell, that is because the program
               is going to be primarily contained in the July application.

                         Dr. Janeway.

                         DR. SCHREINER:  It is not that impressive in the
               July   I've seen the July projects and they don't require
               14 people, you know, for a county nursing service, a home


         .85                                                             359

                  health nursing service to sponsor does not require all  thaL-.

                  staff monitor strength.

                             MRS. SILSBEE:  Dr. Janeway.

                             MR. CHAMBLISS:I am very sorry,  and'I  apologize  for

                  interrupting. If I may just  further  illuminate  this  council,

                  in a letter we sent to that region, we even suggested that

                  they go out and get former RMP staff members  and  bring  them

                  on to augment the staff and we further suggested that it might
                  be worthwhile to bring on three to  four  part-time  physicians.

                             Now, that was a region that was  operated   without
                  M.D. staff -- M.D. on staff.  So I  can re port to you that
                  they did go out and employ three part-time  physicians  as  we

                  had recommended and they are now on staff and  I  believe  that
                  what you are now considering may wipe out the  staff  that  they

                  already have on duty.

                             MRS. SILSBEE:  Mrs. Flood.

                             MRS. FLOOD:    feel strongly  that  this  particular
                  region has been victim to what we frequently on  a  site  visit
                  call the "yo-yo effect," and  quite  markedly.  Apparently  they
                  took quite seriously their 'phase-out instructions and then

                  were reticent to tool back up because of what you have
                  described as a conservatism of the region and now'are following
                  what they interpret as a directive from DRMP.  But  if  we  can
                  have some insight as to what their core personnel budget is
                  today, with the existing staff that they have on board now.



         86                                                                   36o

                  Can 'l,'Ir. Stolov shed any light on this?

                              MRS. SILSBEE:  I just did a   calculation the other

                  day, in terms of even the committee recommendations.      It  is
                  in salaries alone, about $189,000 on an annual     basis.   That

                  doesn't allow anything  for projects, rent.,.telephone,    travel

                  for the council -- the regional advisory group or any of the.

                  committees.


                              MRS. FLOOD:  Then I would have to add my,v) ce to

                  the expressions of concern of  Mr.  Chambliss  and  Mr.  S;olov.

                  now before us., that with a $200,000 funding level, we would,

                  indeed  then, be better off telling them to close up shop

                  because, in essence, we are doing   that.  We  are  criti  izing
                  them for lack of programs that is   broad in scope and  has
                  sufficient projects in it and  then  on  the  other'hand, we will
                  turn around and cause to .discharge recently-acquired personnel
                  and the first to go will bt the high-priced part-time docs
                  and,they will not gain any, you know, impact on developing

                  programs.


                              MRS. SILSBEE:  Dr. I-lanmock.

                              DR. 14AIU-IOCK:  Th ey have a total of 26 staff and

                  11 vacancies here that need to be filled.

                              MRS. SILSBEE: The $189 was  of  the  staff  that  is

                  now on  duty.

                              DR. WAMMOCK:  Yes.  Now, the other thing is this'.
                  I read this thing through very carefully and I said that the



        87                                                             361
                 original bud-etiof t7OO,OOD when the staff is 'y4322,00,3 was

                 too far and the statement was made, a description of the

                 project that it is perhaps the most  outstanding  achievement

                 of the SVRP over the last few years has been its  -6rassroots

                 involvement and that is where it is, it is -,,-assroots level.

                            Apparently they have made some progress in primary

                 care units.  They have provided a neighborhood health center
                 for some 1,200iblacks -- 12$000  blacks, accordin- to this

                 report in here.

                            Apparently, they have not made an adequate survey

                 of their needs in their particular area and also  as  related

                 to the total program of th6 State of Pennsylvania.  Their

                 endeavor to develop manpower for the primary health  care  in
                             and
                 rural areas,/provi'sion of information on existing services in

                 rural areas, consumer education and use of services and et

                 cetera.


                            Their endeavor to increase  manpower  availability
                 for the primary health care in und6'rserved urban  a.reas,

                 accessibility and so on.

                            They put some em hasis on heart disease and nothing
                                            .P

                 that I can see is related to stroke, renal disease or cancer.

                 This program, it seems, is not well-de-signed.  That is the
                 substance of it here. But if you pull it  down  to  $200,000,
                 that will completely wipe it out, I believe.  That is nothing
                 for a group of people in that area there.  I don't know





                                                                                 362
                   somewhere I have the population of that area.  Ilere it is here

                               MR. STOLOV:  2.3 million, 27,000.


                               DR. WAMMOCK:  Ilow many?


                               SPEAKER:  5.23 million.

                               DR. SCHREIIIER:  I think   you have made some c-ocd

                   points.  I would be inclined to change my motion to @300,000,

                   which I think will give them a warning that their job is not

                   to build  staff.  I'm  afraid  they  have  been  told  to  build

                   staff and not to build programs and -- or at least they        have

                   not  heard  the  admonition  to build programme

                               I think  if  we  do this, they can come back in in

                   July with projects and vTe can look at them fresh and at

                   least it will  be  enouC-h  to keer) the  thin@  alive,  so  I'll

                   @-,iend my motion and  chan:-e it to @300,000.

                               FThe  motion   was arr.--nd,ed.

                               ,wil'IS. SILSBEE: 71"ill the seconder,  Dr.  @-!a=ock

                               DR. 1,11@"-i@,IOCK: I'll second that ,.iotion.


                               [The motion was seconded.]

                               MRS. SILSBEE:  @-he motion has been made and


                   seconded that the Susquehanna Valley R".IP be funded at

                   $300,000, that the aDnl4-cation be approved at that level.

                               Is there -Lurther discussion?


                               MRS. IIARS:   '@'ould we put an amendment on that that

                   not  all  the @Y300,000 be used just for   staff, but that

                   progra.,-,ii-iin,- be included?




         89
                                                                          363
                             SPEAKER:  That ;ron't be. necessary.

                             @@IRS. SILSBEE:  I think that will be taken care of

                 in terms of the advice.


                             Is there further discussion?

                             SPEAKER:  I call for the question.

                             MRS. SILSBEE:  -All in favor?

                             EThere was a chorus of ayes.]

                             Opposed.

                             MRS. FLOOD:  Ilay.

                             [The motion was carr-i'-ed.l.

                             !IRS. SILSBEE:  One opposed.  The motion is carried.

                             !-low, I have an announcement for the staff.  There

                 are going to be sandwiches brouc-ht in for the council members
                 and if any of the staff wants to  get their order in.,
                      -landle is ric-ht over there and it has to be done ri--ht



                             Do you want to take a

                             SEVERAL VOICES:  Yes.

                             [Laughter.]

                             MRS. SILSBEE:  All right, ten minutes.

                             [Brief recess.]

                             i-IRS. SILSBEE:  Dr. Haber has two I would like to
                have discussed before he has to leave.  Memohis.




          90
                                                                                   364

                                  .REPORT OF DR. PAUL A. IIABlw7R


                                              i,riEP-I,PIIIS


                                DR. HABER:  'The  reason  for  wanting  discussion  of

                   14emphis was that I'd like some elaboration of this problem,      01

                   the  escrow  funds.  In  general,  I  heartily  concur  with  the ad

                   hoc committee's recommendations.      I think that the project    is


                   well-conceived.  The  staff  is  vigorous.  The  comment   was   made

                   that this -roup did not consider     the future  bleak  and  I  guess

                   one of the consultants said they     seemed to be sufferina- fro--i

                   unfounded euphoria.  '.'.,Iaybe'that is another word for failure.

                                [Laughter.]

                                But  I  think thatthe  individual   projects   looked

                   very 'Lmp@-essive to me  ard -L was  pleased  with  the  relationship

                   with the CAP and vii-t@lh the establishment of their  reE:,-'-cnal

                   advisory group, well-stafi@e-          '-ent people,  highly
                                                 U3 Conl-ne@


                   interested.  I wil'L have a counle of i.-iords to -say about sri@-,e

                   of the individual projects  but  one  of  the  disturbinc--  things


                   that,ca.me out in the ad hoc cor,-,Pit+.-ee's review was the


                   disclosure that so.-le '@@@OO,OL'JD isbeing held in escro,.,z in

                   two projects, I believe       one of '@00 000,  'one  of  @Y500,000

                   for an umbrella trusteeship which is  euphemism  for  sor,-,etli,-n-.

                                [Laughter.[

                                I don't know what.  Would somebody enlighten me

                   on tl-lat?


                                DR. WAI.,Il,'i)CI@',: lj'hat's that', v'.,ord you used?




                                                                              365
                             DR. HABER:  lluh@,


                             DPL . I-IAIll.!OCI'@:  IIhat's that word you used,

                  euphemism?

                             DR. HABER: Yes,  it's  a  euphemism  something.  I

                  don't know.  i,laybe it's that hole in the mattress they talk

                  about.


                             I-IR. VAN III"TKLE: No, I don't think so. This  is

                  another example of what you discussed yesterday on a couple of

                  projects.  It really isn't any different.  They have set
                  forth these thrusts that they wanted to carry out.  They
                  don't have them -- the individual activities  before  you  at

                  this time.  They will have at a later date.  They will be

                  co--.iinc, in i..ith those.  If these funds are allowed and the

                  review committee had decided that at that point  in  tiie  they

                  could look at them. '.hey didn't  have  sufficient  information

                  L'o cons-i'-de.- t.-.eri and that -.,ias the basis for their reducu-4@on.

                             DR. HABER: I think that is fair. Let  me  com,.rqent

                  on some of these. There is one  project,  C008  for  analysis
                  hypertension which I think is  good.  A couple of activities

                  smack of oublic health concerns.   One of them on the trends
                  for registering of vital statistics. That seems  to  me  to  be
                  kind of not entirely new and innovative and clearly a function

                  of the public health officer-or commission.

                             1-i-R. VA@4 WII'JKLE: Is that 13?

                             DR. T,!,.BER: Yes. And I .-.,ould say the same thi-n@ is



        92                                                                   366
                  on 33, improving the qualit7y of the death  statistics  without,

                  I think, going through-the business of this, apparently they

                  said it would be a single individuals project.

                             On the other hand, some of these. activities are.,  I

                  think, very exciting, health services education activities,

                  the 021, the high-risk for infants with the special intensive.

                  care unit for the infants.  I think that is really great.

                  Some of that stuff gets funded at NICHD but as a planning

                  activity, I think that is great.  And the post graduate

                  intensive care and the hypertension control  I  would  certainly

                  agree

                             One thin- that bothers me is that 052 , rnultit)hasic

                  screenin- evaluation -- it seems to me that has  been  done  and

                  r@-done and reredone and there oucht to be some general rules

                  that are knoiin by this time ivhere i@,,e don't have to keeD

                  plo-v,rinc.- that ground over and over aF.-in.
                                                       CL

                             The project 056 @or t'@-.e nei--liborhood health
                  counselors, expandin- the nursing role 'I think was good ancL

                  0:@)7, the Yalobusha Grenada Leflor@ chronic disease detection

                  center sounds very good to.me.

                             So I would move concurrence with the committee's

                  recommendation for funding at that level described  by them.
                             [The motion was made.]

                             I-IRS. SIL,')B'-rE: ihe motion has been @de and

                  seconded that     .",Mphis    aonlication L,@- approved L,--




         9 3
                                                                                  367

                   $2 600
                      3   ,000.  Is there any L-urther discussion?

                               [71o discussion.]

                               All in favor say aye.

                               [There was a chorus of ayes."

                               Opposed?

                               [There was no opposition and the motion was

                   carried unanimously.]

                               The motion is carried.


                               All right, West Viro-inia.

                                  REPORT BY DR. PAUL A. HABER


                                          WEST VIRGI:IIA

                               Di@l. HABEIII: I-TesL' Virginia 'vias a delight to review

                   because  everybody  was  universally  approvin-  of  it.  One  can

                   only envy 'them their relative paucity of resources, I suppose
                   because in total darkness, a candle  looks  ai-.Tful  bright,  but

                   apparently this -roup has been very highly motivated, has
                                                                         u

                   @-lorked very ..iell, has b-ou,-,ht additional interest and  Money
                   into the state.  There seems to be'- as the reviewer  great
                                                         $                 3

                   concurrence of the effort on all -levels of the state, the
                   medical school, the governors office, the local boards,        RAG.
                   Out VA di-rector of the VA Hospital -Doard  is  a  member  of  the
                   regional  advisory  group  and  everybody  is  very  complimentary

                   of them and I do not dissent from that.

                               I would move that they be approved @u     the present

                          o,:-' @66-jl,'L32.




          9 4
                                                                             368
                             !,IRS. SILSB'-71@:  Dr. Jarieway.

                             DR. JAi'17-,WAY:  I will recommend approval but I

                 would just mention in passing -- thought !Ill second the

                 motion -- that the distribution on the pro,,-ram basis between

                 staff cost to program cost is quite similar to the situation
                 that existed in the Susquehanna Valley.  But I find nothing

                 wron- with this.


                             I second the motion.

                             [mLhe motion was seconded.]

                             f,T4RS. SILSBEE:  The motion has been made and
                 seconded that the West Virginia application be approved at
                 the reauesL-led level of $60'3,132.

                             Is there further discussion?

                             DR. T@,TA@@;!!,IOCK: You are talking about the salary
                 here.  The request was for '?3,085,000.  !.as it been

                 recommended

                             SEVERAL VOICES:  .'-Io, you're in the wrong state.
                             MRS. SILSBEE: @-le are iri' West Virginia now.

                             Is there further discussion?

                             [1@o further discussion.]

                             All in favor, say aye.
                             [There was a chorus of ayes.]

                             Opposed?

                             [There-was no opposition and the no@ion

                 carried unanimously.




          95
                                                                                369
                              The motion is carried.


                              We'll go bacl. -- pardon?

                              MRS. IIORGA14:  We never did get to Texas.

                              MRS. SILSBEE:  Okay, we'll go back to our problem

                   areas.  Or at least, we'll relook at the committee

                   recommendations and let the record show that Mrs.    Flood is

                   out of the room,for the Texas application.

                              Mrs. I,,Iior,-,an.

                               REPORT OF MR. 1"ICHAEL POSTA


                                             TEXAS

                              MRS. MORGAII:  Mike is going to give it.

                              r/,RS. SILSBIT.7 El@ike, do you v!ant to give  an

                   introduction to Texas?

                              @-IR. POSTA:  Well, Ihave a real long one here  but
                   I'll try to keep it short.  iiet  ,ie jus'u proceed as quic'r-Ily as

                   possible.

                              Texas did submit a unique request of $2,333,551
                   but the real problem, as the reviewer  saw  it,  was  that
                   approximately 'Pi.4 million-of tile-request calls for a  series
                   of open-ended contracts  which  would  concentrate  in.the
                   implementation of five -orograriuiiatic areas, RFP'S, and that is,
                   request for proposals for future contracts were submitted to
                   the various consumer provider or animations throughou- the
                                                    9

                   state.


                              On the da,r of 'lie ad hoc oanel review, those




        96
                                                                             370
                   reviewers were notified  by telegram that 62 applications

                   responded to -- responding to those RFP's had been

                   received by the Texas Regional Medical Program.  The total

                   amount of the responses totaled $6.2 million.

                              In the same telegram to the regional advisory

                   group, they requested the review   committee to approve the

                   Texas program in the sum of approximately $1.4 for the

                   implementation of the contracts to be rev  iewed'by the

                   June 28th regional advisory group.

                              Considerable debate took Dlace  during  the  ad  ho-

                   group and they decided that they,  in  all  due  conscience

                   could not approve open-ended application of this sort without

                   seeing the specific 15's and 16's on each.

                              ',,low, we have been notified just this morning in
                   two of the programmatic areas  that the RAG has been meeting

                   this week and, for instance in ',-,he area of the  manoower

                   thrust, 18 contracts  had  been  received.  The  consultant  RAG

                   members and staLf have selected ei'@ht of those, of which five
                   to six will be funded and they ra-'nge in the  neighborhood  of

                   close to $1100'.1000.

                              The access committee, which was   another proEramimac-,c,
                   thrust, received 14 contracts and it   had selected  seven  and
                   together those seven people about $520,000.
                              I think that the question before   th@ council as
                   recommended by the revieo,, co,--,,-,,-;--Utee is to allow the -revi-e,@!






        97
                                                                                   371
                       'ttee that meets on July 17'1-, and  !8th  to  take  a  look'
                   c om -n. L                        u


                   soecif@Lcally at the contracts and the forms sent in with

                   budgets so that they,  in  turn,  could  approve  them  in  order

                   for the contracts to start as quickly as possible.

                               If
                                 .you did not approve that, this council,

                   meeting in August, would  have  to  approve  them  and  it  would

                   probably be  September  at  least  before  these  contracts  could

                   be initiated.  Their "Urack record in the past, through

                   evaluation, is that  the  longer  the  contract  has  been  funded3

                   the better the staff -is in carrying out the particular program.1

                               i-IR@-. SILSBEE:  '!irs. i.-lorgan.

                               iPLS  O,'-LG.C'I. I site-vis2'ed Texas on, oh, 18 month

                   ago, something like '.-hat   At that time, Dr.  1-IcCall  was  the

                   coordinator.  7v'ery ambitious, excitin@- person to'knoi-i, really.

                               Dave @--erEusoii, -.,,.,ho no-,," the present coord@Lii@u@i.L'

                   was his deputy and had been his deputy for some time.

                               Texas has many problems.    In  the  first  place,  it

                   is a huge area.  In the phase-out, it closed down many of its

                   subregional areas.  '@s a matter of 'act, '.Iaria Flood was '-he

                   subregional director of the El -Paso   area.

                               In doing this, I think they centralized their la.--

                   into Austin, i4hich makes  it  just  about  impossible  to  cover

                   the entire  sta@ue from Austin, right now.

                               They have had many Iro.blei,,is since RI.'IP started in

                   Texas.  It started in-the Houston area, where it was






        98                                                                 372

                 Iconcentrated with about seven, eight  medical  schools  right

                  in that area and I believe now Texas has  something  like  10

                  medical schools to work with.


                             There has been a problem with the RAG.  In fact,

                  they did not have minorities on it,  et  cetera.  They  have-

                  attempted to correct this all along.  It has been questionable
                  as to how much @ent into their attempt to correct it, but

                  they have tried.

                             I believe at the present time the RAG is very

                  active.  Dr. 7-astram is still the RAG chairman.  He is

                  enthusiastic about ,-,he R,,AP and does do a fine job.  I beli-.-,
                  in fact, that they have not the minorities we'd  1'ke  on  it
                  and whatnot, is immaterial at the Dresent time  with  only  ayear,
                  to work on it. They could out all the  minorities  on  it  in

                  the world and 4L-@ is not Going to change the fact that  they

                  have only got a year to work on it

                             The biggest problem I s'e'e is in their request for   i

                  proposals and all their work in T-exas is really done by

                  contracts.  We do have a record here.  The current status

                  well, they received 111 contract proposals, I believe,
                  according to this, which means they have got plenty of peo-ole
                  who are willing to do it under contr act proposal.' The w@ole
                  thing is, we do not have their@oroposal.

                             I recommend that committees recommendation o.
                  @Y1,100,000 be approved at t-@his time with the idea that these




       99
                                                                                 373

                   contracts can  be approved at the review cycle and let at

                   that time, prior to the August counci.l.

                               MRS. SILSBEE:  Would you Like, to; reword that in

                   terms of  the maximum that you would approve and then the

                   balance of the pending review committee approval?

                               MRS. MORGAIT:  And then $1.3            for the sake

                   of argument could be approved if all af these- contracts are

                   approved at the present time.  It is $'T,,296-'.,599 were what
                   they were asking for contracts and there iio@,uld not be -- there

                   was not     if  we had approved the $2,3-,33,551, there would not
                   have been an a-oz)licat4-.on in July for any, more fundin- at all.

                               MRS. SILSBEE:  So, is your @.'ati-on aDDroved at the
                   $2,33,551 level  with delegating to the review committee the
                   approval oL' $1,298,599 for contracts once. the specifics are

                   available


                               i;IRS. @'-.IORGAN: Right. They are 15's and 16's.

                               [The motion vias made.]

                               MRS. SILSBEE:  Dr. Schreiner was the secondary
                   reviewer here.  Does anyone on the       this -aioo@lion has been

                   made.  Is there a second?


                               SPEAKER:  Second.

                               MRS.. SILSBEE:  Any discussion?  Mrs. Martinez.

                                    @,A
                               I-IRS. T' RTI@ EZ: Yes. I'd like to suggest that no
                   matter how  short tire vear is and no ri-@@-er ...,haE-'-!)e ic,.:-0
                                                                       U--
                   fund-nr- is, liat .,ie -,rake a successful effort to Einaudi-o-le]




                                                                                  374
                             especially in Texis, I don't think there is anv
                   because,


                   excuse for that.


                               SPEAKER:  Say that again?

                               DR. JANEWAY: I  don't  want  to  be  obstreperous,  but

                   I think that that motion  subverts  the  intent  of  the  review

                   committee. Their  major  complaint  was  that  it  was  open-ended.

                   Now, it seems to me that one either gives the authority to the

                   RMP to grant these without further review or if grants at the-

                   level that is recommended by the review committee and forces

                   them to bring a flushed-out  plan  in  contract  proposals  to  the

                        '@l for revi'ew committee consideration and then cancels
                   counc,


                   consideration in 'M'u,,,ust and does it in two steps,            ou
                                                                         or that y

                   jus,.- say, okay, regardless of what the review committee said

                   i-ie know you are a good ouL-,.L@i-+,-, even though it rated average
                                                                                  CD

                                                   @o ahead and fell revie-,.,@ the-
                   to beloi average and .,ie said,                              u   !I

                   after the fact, after you have already obligated the furds..

                              @'%,Tow, maybe there is a technical way to do  it  or  an

                      I       -Tve way to do it, and if so, I'd like to be
                   admnistrat-


                   enlightened.


                                            -ly only retort. I don't thin'.,,  I'll
                              ,,'R. PO@@TA:

                   zero in specifically on your comment, is that the review
                   committee considered this region to be a o,-ood one, triennial
                   status, developmental component in  the  past,  good.,-  capable
                   staff.  The @rant-ee was changed in December, 19-72 to a nrivate,
                   nonprofit               and the re,-,onal  advisory groll,,)
                                                                               a4.- -ha@






        1.01
                                                                           375
                  time advised the regional staff  to pursul- the contract route

                  and that is what they have done  for the lost year and a half
                  and the iihole purpose, I think, here is ta get these conty.@,,,,,,i

                  going as soon as possible.

                             I.don't think the review committee had any
                  intentions to usurp the council that mee-ts again and I am not,i
                  again  sayinv that I am specifically ansi@.ering.your concern.

                             I would say this and I might @ out of order

                  the chair can rule me out.  I do think that several other
                  applications that you have reviewed today did have, in

                  exxence  openended contracts but they were not in -- not
                  nearly the size of this Texas application and that is why
                  the reviewers put their foot down and said no on this

                  particular issue.

                             1.1@@'S. SILk@dBE-7:  Dr. Janeway, it seems to me that
                  J.,Irs. I'lorgan's motion doesn't take away the review committee's
                  responsibilities, in essence.  It would be approval at the-
                  requested level with that '?1,298,gOO conditional -- not to oe
                  released until the review committee looked at the 15's and
                  16's that made up that balance, specific :Lnformation.
                            DR. JAIIEWAY:  Well, if that is the intent  of the
                  motion, I am less unhappy with it.
                            l@. POSTA:  Well, let me say my understanding
                            DR. JAIIEWAY:  I wasn't worried about anybod@.,
                  usurpin" the council.- I'm worried about t.Tie council going in






       102                                                                       37tD

                   there and sayin- to a review committee, we are goin- to fund

                   them 100 percent   anyway and you have got to look at it

                               MRS. MORGAN:  No, no
                                                          if
                               P,'LR. PAHL: I think that/tlie  moticm,  perhaps,  was

                   made in such a way that the coun-cil    recommended
                                                                        _$2,333,551

                   with the delegation of authority to     the revievi   committee  to

                   exercise its discretion  within that ceilin,-,,funding level

                   following  the.receipt  of  information,  I  think  this  would

                   accomplish what you want and save the Texas program a few

                   weeks time, if you  feel  you  wish  to  delegate  that  authority

                   to them within that fundinc- level.


                               @TRS. SILSBEE:  Mr. Peterson.

                               '@l-R. PETERSON:  Am I reading something  wrong,  or  is
                   it perhaps misdhrased'. I thought, from    looking  at  the  green
                   sheet several L'-4L-,@-s  the fip:ure 1298 has been evoked.  Tiat is

                   additional money they would  be  coming  in  for,  is  it  not?

                                          11  ilo, sir, -it is not.
                               MRS. MORGA':


                               I-IRS. SILSBEE: Texas had opted to come  in  i-iith  one

                   application in this time   and  that  $1  million  represents  the
                   difference between the 1.1 and the requested      amount.

                               7IR. PETERSOII:  I see.

                               IIRS. SILSBEE: Oltcay, let me  restate  the  motion  now
                   so we know  what we  are  talking  about.

                               The council moves to  approve  the  Texas  aDnl-'Lcation
                   up to the an@ount of $2,333,551 deletatin- to the committee the




         103
                                                                            377
                  approval of the balance fo@ the contracts with 15's to 16's

                  to come in in July.


                              Is that clear?


                              Is there further discussion?


                              MRS. 1,@IORGA!4:  Just a note.  There is a letter from

                  Dave Ferguson that they will have all their 15's and 16's

                  available July 10th.

                              MRS. SILSBEE:  Further discussion?

                              [No furl.-her discussion.]

                              All in favor.

                              [The:&e was a chorus of ayes.]

                              Opposed.

                              [There are three nayp.]

                              i.iR@-. SILSBEE:  T,".aybe we had better raise hands.

                              All in favor.

                              ":-here is a siloi@,r- of hands.
                              L

                              Opposed.

                              [There is a small show -bf hands.  The motion is

                  car.-4-ed.]

                              Three opposed.  The ayes have it.  The motion is

                  carried.


                              Now, Wisconsin is next.  l'Ir. Van Winkle, did you

                 want to give a brief overview here?

                              MR. VA!@l WII@KLE:  Very brief.





      10 4
                                                                          378
                                 REPORT OF i'-LR. VAN WINKLE


                                        WISCOTI.iTsil@


                            I,IR. VAN WIlql",LE:  The reviewers felt that this

                 region had had a very illustrious past history but '.-hey

                 certainly felt that they are in a crisis of leadership at  the

                 present time.  Their current coordinator was the-- was

                 previously the evaluator on this program.

                            The reviewers found little evidence that the  RAG

                 had accomplished much during the past year, although their

                 past performance has been quite o-ood. Their CHP  relationships,
                 as in the past, are still good.  Their overall objectives

                 and priorities are extremely vague.

                            Both staff and committee felt that this  proposal

                 was a series of poorly conceived, Lragmented project activi-',-,ie

                 some very researchy in nature, others, such as the major  push

                 in rn,enL@Ial health, not in kiieDing witLa the usual DR,:.,IP goals.

                 Or, I would say, with Wisconsin's goals and we weren"u too

                 sure that this was appropriate for funding and except for  the I

                 evidence of past Performance, there is little evaluation  of

                 what is currently going on in the region.

                            In looking at the lar-e variety of new activities
                                                 CD
                 that they came in with, if you have the application, you  will
                 note that they are basically centered around the University  off
                 Wisconsin and I.I@rquette University. They don"t seem 41-lo <@-c4v-
                 outside of i,iadison an d i"-,L-,-'@iiauzee and they just seem to be


         105                                                                 3 7111

                  pulled together, put in a book and sent forward.

                             MRS. SILSBEE:  Mr. Hiroto.

                             MR. HIROTO:  It is apparent $that this RMLDS is

                  having difficulty realigning themselves with their new

                  leadership and the RAG is somewhat weak in creating the

                  leadership necessary to create the proper point-of viei,@.,and

                  attitude for it.  It seems to me that the committee's

                  recommendation is really a stab at a number hopefully   coming
                  up with something that is reasonable for what has been   going
                  on and to provide them with that support and, hopefully, that
                  they      be able to come up with a clearer program in the

                  next cycle.  I just -ot that out of a conversation.

                             l@IRS. SILSB@-,T@7:  Reading transcripts?

                             T
                             I,IR. HIROTO:  Yes.

                             MRS. SILSBEE:  -I.,Ir. Millil@-en, did you have any

                  comments about @@lisconsin?

                             MR. !,IILLIII)El@T:  Only that I agree with the coL-nit@v--,-,

                  recommendation.


                             'dRS. SILSBEE:  TS
                                             L  there a i-@iotion?

                             MR. HIRO'LO:  Imove that  the recommendation of
                  $2 million be accepted by the council.

                             D-IR. IT TIK-N:
                                            Second.

                             [The motion was made and seconded.1

                             MRS. SILSBEE:  The motion has been made  and



       106'                                                                   380
                   seconded that the Wisconsi@ R14P.  application be  funded  at  the

                   $2 million level.  Is there further discussion?

                               [No discussion.]


                               All in favor?

                               EThere was a chorus of ayes.]

                               Opposed?

                               ,[There was no opposition and the motion was

                   carried unanimously.]

                               DR. JAI-IE!iAY:  Madame ChairDerson, could I ask a

                   question-off the record?


                               MRS. 'SILSBEE:  Yes.


                                               record.]
                               [Brief off the

                               MRS. SILSBEE: All  right,  we  have  got  Dr.  Janeway

                   all cleared up now.

                               There is one -e-ion that was site-visited and I

                   wondered if i-,@aria Ele.-ia, if 'you didn't feel you ;,ian-ued 'u-0

                                                         -o hear your recori@-qenda L
                   hold as manir of the committee here   4u                       t4on@

                               MRS. FLOOD:  If it woul'd  be feasible.

                               l,'I'RS. SILSBEE: 5o I di-dn't have it listed in  this

                   memorandum, but because th-cre was a site visit, it was obvious
                   they did have concerns and the site visit was on I-Ionday and
                   Tuesday and Dr. William Thurman, Dr. James Musser and
                   Tirs. illaria Elena Flood were the site visitors, along with

                       Stolov and @dr. I,.Tash.


                                    -@,ie have copies o' 'he hastily-prepa.-ed site
                                                     L u




        107
                                                                             381
                  visit report and Mes.  Leventhal will distribute them to   the

                  council.


                               REPORT OF MRS. 'IIIARIA ELENA FLOOD


                                          TRI-STATE

                             MRS. FLOOD:  Yes, I think it would be of help to
                  the n@eribers-of the council to have copies of the site visit

                  report.

                             I might comment that the committee has some proble@,s@
                  with this application, as you can see by the recommended
                  fundin- level that they sug-ested to us  and  their  concerns
                        rD

                  were deep-seated'enou.-h that not only were  they  concerned abou@l,
                  the fundinc- level, but they were concerned that  there  was
                            C:.,

                  perhaps inability to truly interpret what Tri-State was
                  attem,ptinc.- to address in their applications and, therefore,
                  there i;as areservation -ado for a site visit if it could be
                  launched Dri-or to council meeting.
                             1-lith that relative short notice to both pul@-tinc@,
                  together a site visit team and  the'burden  it placed on staff
                  and also, I suppose, the burden that it  probably  placed  on
                  Tri-State, this visit was undertaken on  Monday  and  Tuesday of

                  this week.


                            As Mrs. Sislbee pointed out, the   visit  team  was
                  chaired by Dr. @-filliam Thurman and Dr. Mark J.  Musser  and
                  myself comprised "Uhe other tTio 'rier,-,bers. l@!e we@e als'o
                  accompanied by !:Iir. @4'ash and I-"r. Stolov and a representative




                                                                              382

                  from the regional office in Boston, Daniel De!4ates.

                              There was outstanding attentance at the     session oL'

                  the site visit and listed on the site visit report     you will

                  see the Deople that appeared.

                              In the report, I would like to cover the Tri-State

                  region in a-two-part approach and I  might  make  a  note  that

                  there is no ilew Hampshire component, either in our review nor

                  in the present application before us for consideration.  The

                  '4ew Hampshire component, along  with  other  applications  for

                  project proposals, will be   submitted for the next.review

                  cycle.

                              The Rhode Island segment of the site visit was

                  primarily to evaluate  two  very'expensive  projects  and  both

                  of these caused concern at committee level and not all

                  questions were answered by ',,-he documents before them  so  we

                  addressed ourselves Primarily to   these two high-cost uro,4,ects.
                              One is called the RIIIST--'C and that is a term gi ven
                  to the Rhode Island Health Science'-Education Center and this
                  is [inaudible] type of a oroject.-

                              The request in the programs propo,sal is -for fundin,-
                  to include monies for Fiscal '76 and this raised some flak.

                              There had been intention also that there was a
                  larr,e amount of unexpended funds available to this particular
                  project at the close of Fiscal '74 but upon retmest, ,@ie
                  obta@-ned @Lr,+@'orr.-iation re-artft-in- t'iaeir present unexpetak-1).ed
                                                 L.>                           u n',,13




       109
                                                                                 383
                   for RIIISEC project and where information hnd reached  the  RITIIP

                   that there might be in'the neighborhood of $300,000 available

                   to RIHSEC unexpended at the completion  of  the  second  year  'of

                   their funding -- they were originally funde-@T,, I mimht point

                   out, for-close to $600.,Ooo, $598,000 -- we Lr@-ave received

                   reports, documented  that they only have arrunexpended

                   balance of $14,953.

                               Now, we try to  ascertain  why  th@e  seems  to  be

                   this large a discrepancy and we feel stron2fEy that it was a

                   lack of reporting mechanism  from  RIHSEC  to  Tri-State  and  the

                   information received at  DRMP  was  from  the  Tri-State  Regional
                                                                 [?.]
                   Office and there had been some recent encounters, as our site

                   visit renort says, from questionably effective        or  I  think

                   I could use the word, mediocre -- studies in the last 90 days

                   and they were -"@39,000 IL-lo the Rhode Island Health  Services

                   Research, incorporated and $9,000 to the Rhode Island  I-.,@,edica

                   Association for a component -oart of the corL.-tumer education

                   program.


                               DR. l@IAI--'I'L"IOCK: I'@u h ?

                               MRS.  FLOOD:  Yes,,  sir.  The  area,health  education

                   activity in Rhode Island  had  entered  into  a  contract  with
                   the Rhode Island T@,ledical Society in the  amount  of  $9,000.

                               DR. WAMMOCK:  For what?

                               MRS. FLOOD:   For a conti-nuinf- education se-r -,lf-.

                               DR.            [Inaudible.]







        110
                                                                                   384:
                               MRS. FLOOD:  I  might say tL%P-t one of the problems

                   with the RIHSEC development had    in the leadership of R,RHSEC,

                   there was, at its head, a particular p@erson who  because also

                   of what we term the ?'yo-yo effect" of' stability of  fundirl:l

                   had been ineffective in gaining  the  stability  for  RIIiSEC's

                   development that had been expected of him.  Frankly, little

                   was done in the first two years of this operation and the

                   responsibility rested with the board of directors of 'iIHS;-Zc

                   and they still had  not fully addressedithis.

                              'father that discharge a  weak  director  when  they
                   became aware  that they were way  behind., sponsors of this
                   particular project, they relegated Iiii-,L to a secondary role and
                   he is still on b-oar@..-. The on-site visit report and, hopefully
                   the advice letter to them will recommend that some remedial

                   action be tal-%-en very quickly.

                              The decision to  replace the director of RI4aL     w a s
                   made in ',.@'Tovember of '73 and only in ililay of' '74 did they find a
                   replacement for h-im but they  did,-as I say, keep him on in a

                   secondary role.

                              The new director   of RIHSEC is a very capable
                   individual with knoi,@,ledgeability of both regional medical

                   program activities and the concepts of an area health
                   education center.  He seems to ha-ve ra-,gp.,ort @@iith theleadership

                                                    T
                   n the State of Rhode Island.     I.e is reco nized and reE@iDecL,
                   n all of the different associated with the hospital




                                                                               385

                   association. We had  representation  of  the  medical

                   association.   All of them hang all their hopes on    the indivi-

                   dual,  Robert Laughton, who-is not an Unknown name    to the RFPA

                   or RM'@DA and had been at one time the deputy coordinator of


                   Tri-State RMP.


                               In the very short time  that he hard been there, it


                   is evident that he does not intend to reflect the same natterni


                   of inactivity of the RIHSEC project as had been the history

                   for the past 21 months before his arr

                               Now, the site visitors had to take this Tri-Sta'ue

                   visit in two segments and to address myself  to  the  RIIISEC

                   segment of their proposal, the visitor,& felt that they should

                   be approved for the continuation fund:in,- of RIHSEC for

                   Fiscal '75 at their previously   agreed--@upon budget level, but

                   approved at a level of only --   let's see -- $100,000.  ',r,

                   that correct, i@,ir. Stolov?

                                   S'L'OLOV:  Yes, $100,000.

                               MRS. FLOOD:  For the fo'u-r@L.,Il year 0,1'- fundin- for

                   RIHSEC  Fiscal '76.  This would
                                                     force tl.,-e R=SEC Board  of

                   Trustees to face the realisms that    they -"ust,become a,sel'-

                   supportin- entity  and  that  the  participating  institu-4ons

                   and agencies would also support the sarae positions.

                               I!i'.e did also state that we would require' that the

                   pro,,ress renort of the RIu'@C activities be submitted at '-,he

                   end of the  six months period -- Dece.@ber 30th o,' 1"11.

                               There seems to be a great deal of hope in i@hode





      112
                                                                            386
                 Island that with the new leadership, that this Droject will

                 indeed reach the goal that it had been charged to reach.

                            Therefore, we were in support of its continuation

                 fundin- but with the limitation for the fourth year.

                            Now, the next project for Rhode Island's segment of

                 Tri-State was a rather interesting one and I think I used  the

                 word yesterday -- and there is no way to express it except  to

                 call it blatantly political-.

                            This project was based    and the project pro-


                 poser

                                'PAHL:  !,!aria Elena, perhaps before you go on,

                 we have been handed a table, a budget table on IIIIISEC and so

                 forth and it has a question and.if you would just make that  a

                 part of your presentation?

                            IV,S. FLOOD:  All ri-ht. Is the form.,. that I have

                 the same one that you received?

                            IIR. PAIIL: Oh, I cuess we i,,,ere just c-iven our

                 copy of what has been handed to yd-U.

                            j'4RS. FLOOD: We-11, they gave us a printout of

                 this @@Lhode Island and then we found a inath
                                                           ei-aatical error.

                            [Laughter.]

                            MRS. FLOOD:  In addition.  So., apparently, then, he

                 mailed the corrected copies in to the RI"IIP.

                            MR. PAHL:  Okay, thank ,Cil.

                                ---OOD:           -qay go on to the ne,@,L-, c,,,. i e




          113                                                                            87
                                                                                       3
                    the  title  of  this  particular  project  is  called,   "PlanninC   for

                    Health Services  in  a  Time  of  Economic  Transition"  and  IV-he


                    applicant is the Governor of Rhode Island, the Honorable

                    Phillip Noel.

                                 Now, this was a relatively interesting approach

                    and we  pressed  very  hard  for  the  rationale  behind  1-iavin-  this

                    project  based  in  the  Governor's  office  and  there  are   some

                    particularly  interesting  aspects  to  Rhode  Island   at   this   time

                    with  the  closing  of  the  naval  facilities  at  Quonset  @oint   and

                    '-'Iewport -- I thin'Ac.  There  has  been  a  tremendous  economic

                    impact on the co.,=.,unity.

                                 The  application  is  actually  a  little   behind   times

                    in its request because  it  proposes  to  do  an  analys-Ls  of  ,-.hat

                    impact these shut-do,,,.tns will have on the health delivery

                    sys'Llei-I in one segment, and that is aL@'L-,e@- the fact  because

                    those particular ILacilities have closed down and the impact is:

                    alread,, there.


                                 But the second segment of the proposal was to

                    address the impact that the Governor's drive and his

                    Bureau of Economic Development, or whatever you want          to   call

                    it,  has  undert@,,en  to  bring  new  industry  into  the  Quonset

                    area and develop the entire.area into an industrial complex

                    and  anticipatin-  already  having  7otten  some   obligations   fro-.i

                                       d also Favor ins  urance companies  to  i-no,ze  its
                    some industry an

                    major  offices  there.,.they  will  have  an  impact,   they   estimate,




        114
                                                                                 388

                    of about 50,000 employment        or  rather,  families  comino-  in

                    from the  employment,  50,000  persons  as  the  result  of  the

                    Lamilies  employed in these-two new attracted industries       to


                    this area.


                                This  does,  indeed,  present  some  problems  for   the

                    health   care delivery system of Rhode Island.  We question

                    severely that the planning for this project Proposal in

                    Rhode Island had been done by the Governor far the people of

                    Rhode Island and not with the people of Faa(te Island and there

                    shows  obvious  lack  of  understanding  by  L-ep@-sentatives   from

                    the Governor's office as to    the realisms of t-he health

                    delivery system, the capability of the health professional

                    associations and societies to participate @-rr meaningful

                    plannin@ endeavor of this type and analysis of the needs.

                                The Tri-S@uate RI.IP has  been  urged  to  carefully

                    monitor this particular project to assure th:at these

                    component parts are included in the Governor,"s office.

                                It gave a feeling that the Gove@         was really

                    just trying to  develop  a  staff  capability  in.  his  office  for
                    future  economic  Dlanning  and  analysis  and  @ing  heal't@   care

                    as one of the keys for it.

                                Nonetheless, we   again  approved  the  concept   of
                    funding this at the discretionary level the-t,,the Tri-St@e

                    RI@IP placed on the aT)-olication and I might paint- out th2.'--

                    ev.-n thou,-,-h it is at a $250,000 orice tag at this time,    the




        115
                                                                              389
                  the original application td Tri-State was  $472,000  and  the


                  Phode Island RIAG
                                       they have sub-RAGs for each  state  --  cut  I

                  the project funding to that level.

                             There is a desperate need in  Rhode  Island  for  this

                  type of activity.  The question arose as to why hasn't a

                  comprehensive health planning  agency  perhaps  addressed  this

                  long ago were easily answered by a totally ineffective

                  comprehensive health planning agency. There  is  only  the  A

                  agency for this state. There are  no  B  agencies  either  seated

                  in the state health department and  the  Governor's  proposal

                  showed a stark -lack of knowledge as to a-vni lable data  and

                  statistical information.


                             The state health department, indeed, has

                            ini'@m@uon anu"could be  utilized  if  their  original

                  -oroDosal -..,,as roincr to generate all of thi-s inf-'or-,Iation. They

                  wanted to do  impacts on heart disease because  of  the  stress

                  and strain -and ulcers of havinlc- no jobs or  bein  insecure
                                                                   9

                  about one's job which, of course,,there was some     information

                  already and by staff of DRI,IP here -- kir. Stolov and Mr. Hashis

                  able assistance in garnerinr,- documentations'and  I  believe

                  Mr. Stolov contacted in the short time  from  committee  to  site

                  visit somethin@ like 17 different departments and  ac-encies  t,,

                  gather data and  information that  could  have  been  utilized@

                  for the Preliminary sta,es of such an analysis.  !Ie @ot

                  stuff -from the 4',Iavy Deuart,-i--nt, Depar@u:,-ic!iit of 7abcr, o@
                                                                                @,y




           16
                                                                                 3 9
                    many segments of HR4'L and this bibliography    was  provided   to

                    I;lr. Kevin 'L.1c'llenna, a very angry young man who is an  admin-

                    istrative assistant to the Governor in charge of this

                    particular proposal.

                                Still, there was a rallying of support for the

                    need of this by the community leadership of Rhode Island

                    and the Rhode Island Regional Advisory Group had given this

                   ,project its approval at the reduced funding level and we
                   !will [be] in concurrence to continue the funds and potential

                    for this uroject.

                                14ow, if there are no questions about the Rhode

                    Island segTient, I will transfer to the

                                DR. WAPl@@iOCK:  flow, this is the Governor's idea, is

                    that right, because of the phasing out of      a project there, of

                    closing un and brincr-'Lng in ne,-, industry and he th4Lnl-:s they

                    are ,-oinE to have some 50,000 people and he doesn" know what;

                    they are going to  do  as  far  as  their  pulse  and  respiration

                    are concerned?


                                [Laughter.]

                                14RS. FLOOD:  That  is  correct,  Dr.,  Wammock.,  Let

                    me explain that .@Lhode Island has a specifically interesting

                    problem in that its entire economy, practilly, was based on

                    the services ancillary to and the employment potential of the        9

                    naval bases and the%T are mone.


                                           y
                                D;'@ JA,@ll-    It sounds like   it is based on




        117
                                                                         391


                       now.


                             SPEAKER:   J'hat's right.

                             I,.,TRS. FLOOD:  They are now gone and besides being

                  gone and their effect on small business on'the island of

                  liewport, they have had a close-down of 93 small businesses in
                  the past six months.  Also, these people that were employed,
                  Civil Service employment, have not found positions and we
                  have a large segment of retired naval personnel in that part
                  of.the country that utilized the naval health resources and

                  now do not have easy accessibility to the health care and are
                  relying now on their chanpus coverage into the private sector.1

                                             I would raise the question, and I
                             @7iR. CHA,.IBLISS:

                  think it is rather fundamental.  I have looked over this
                  project and I really would like to ask you, would this not,
                  in fact, an economic development type of activity as opposed    I
                  to a health activity.

                             I throw that out simply to get more discussion
                  from council so that vie can be ful'ly aviare of your views

                  regarding this problem.

                             I.,IR. HIROTO:  Imight refer the Governor to the

                  Chamber of Commerce.

                             DR. WAI-11,!OCK:  I think it is unfortunate to drag
                  the Governor into the situation because vie had this situation
                  ,yesterday afternoon with another project T-,,hich@,ias con'.i,,iucd

                  upon anproval of this by the Governor for ethical funds and





                                                                             392
                  we debated this for an hour' yesterday afternoon and here i

                  come along with another, state with the governor involved in

                  this and this looks like it is an economic problem and not

                  originating in the re-ional medical program.

                              The Tri-State situation here, you've got -- what

                  is it, three states involved in here?

                              MRS. FLOOD:  Yes, sir.

                              DR. WA@-IMOCK:  We had headaches yesterday with

                  problems.   We have got some more this afternoon coming up
                  and it is difficult for me -- and guess I got a single trolley
                  car line or whatever it is, to absorb all of these things that
                  are Dut into this and it disturbs me very greatly that Ilhen

                  you co-.@ie to a r-7ri-,Ojtate or a multi-state pro-ra,-l involved
                  and so on, and yet you have the Governor comint- in here

                              MR. @IRO'LO:  T,ror, one of the three.

                              DR.

                              MR. I'IIROTO:  From one of the three states.

                              DR. IIA'I"17, @:-OCK: From one 6L' the three states and
                  it makes it difficult to sort it but.  if we were dealing
                  with it state by state, it would be simpler to do, @."Ladame

                  Chairman.


                              MRS. SILSBEE:  '@j'ell, it is a Tri-State E,!P and in
                  ter.-.ns of the charL-es that the committee made to site visitors
                  You went and rr,ot the information and ,,ou are c@,,.in@::

                                   on@- ard it is up to the council to




      119
                                                                                 393
                   accept or reject or modify the recommendations.

                               I-IRS. FLOOD:- Do you Ti;an@u-to go on to the next slu-ate-

                               DR. HABER:       I would just like to   attest to  the

                   economic  deprivation  and  its  effect  on  health  care  in   that

                   part of the country. We operate a small outpatient  clinic


                   there and have often wondered whether it should      be    continued


                   or not and  felt.,  after  visiting  it,  that  there  was  --  that

                   to remove this  small  clinic.,,vould  have  been  symbolic  of  a

                   disinterest  on  the  part  of  the  Federal  Government  and  in  the


                   health care activities.

                               It  is  certainly  theoretically  possible   to   divorce

                   that froii7, any  other  consideration,  yet  one  must  remember  that

                   this area  has  been  a  depressed  area  and  it  has  been  becoming

                   .more so.  Prior  to  the  loss  of  the  naval  operations  there  had

                   been continued loss in L,,anui@ac4v-uring industries in ',-,h!---u r.)art

                                        T
                                        4            @aode  Island  particularly,   and
                   of the coun@ury in ew   LnEland,

                   I thin!-: that the people there are  very,  very  sensitive  to  the
                                                                           L

                   removal of any operations.

                               So I would endorse iihat I-Irs. Flood is sayin,-.

                               I.'IRS. FLOOD: Before I go on to I.'Lassachusetts,'I
                   might add  one  uoint  that  your  comment  that  this  is  really an

                   economic development proposal might be     valid in one comment
                   but the true point of the medical assistance program to try
                   to assist in accessibility and availability of-healt@i
                   does pi,--y aii          uart     did pla@, an important        in




     120                                                                  394

                  our considerations and definitely-this analysis is needed

                  there.  Under whose aegis, council may reach a decision on

                  later, but they have no valid information put together in a

                  coherent manner at this time to address an availability and

                  accessibility problem that they will be facing the major

                  impact of in the very next few months.

                             l@ow, if I may go on to Massachusetts, we have also

                  two component parts of the Massachusetts segment.that

                  presented some  problems.

                            One was a proposal offered by the Institute for
                  Governmental Services of the University of Massachusetts.
                  A-ain, at preliminary review by review committee, it also

                  appeared to be a politically-oriente d type of a proposal but

                  as we saw one of the most refreshing sights that I have
                  observed in site visits or in deliberations of projects

                  proposed, seated around a table, a ,.-.,arm fellowship -- that is
                  the best I can describe it -- of CIIP's out of the Governorls

                  office, human development resources is where the CHP is
                  seated there -- the University of-Massachusetts  Brown

                  University -@ no, not Brown

                            SPEAKER:  !Harvard.

                            MRS. FLOOD:  Harvard School of Medicine and the

                  other one   it begins with B

                             P -7 P.., 1, T3oston University.

                                 -ILOOD:  Oh, Boston University.  I l@nei-., it was





        12 1
                                                                                        395
                      a B -- Boston University          work,ihrr in close liason in res,-----

                      to a desperate need for the       utilization    of    tremendous

                      resources  available  in  academia  in   that   state   to   make

                      legislation addressing health care institutes relevant to              the

                      realistic  needs  of  that   state.   It   was   a   fascinating   process

                      to watch.


                                   I  personally,  and  other  members   of   the   site   visit

                      I  think  would  concur  we'll  have  to  give  the   entire   credit   to

                      this blending of the different phases of that state, the
                      political,   private   education,   public   education    and    physician

                      community  to  the   coordinators,   Bob   Murphy   is   responsible   for

                      stimulating  this  first  agreement   to   agree   to   the   political
                      entities utilizing the Drivate education system, harvard
                      School  of  I'.',edicine's  research  center  for   information,   tied

                      with  Boston  Universi4u-yls  ",--ticular  Institute  .@i@uh  the

                      University  of  Massachusetts'   blendin@   of   skill.s   to   rrovide

                      the necessary information for a jud-ment reachin@ on            lon--

                      ranme planning by comprehensive he       alth planning and the

                      legislators' needs to understand the health care needs             in

                      order to develop responsive legislation.

                                  @-le were very inoressed by this project and we urEe
                      that it be considered no,-, to be withheld in their total

                                                                                                L
                      fundin-.


                                                 T
                                  D@ .             would 14, 1-,st ILI--'@e to add content  L-lo

                      that because if 1-Irs. Flood's observations are true
                                                                                     they    are




         t22                                                                       396

                    all  the  more  remarkable  because,several  of   those   institutions


                    have just completed a Very blood internecine battle, the net

                    result of which, two of those medical schools were uncere-

                    moniously kicked out of the Boston City Hospital grou-o and

                    they had a cannibalistic  orgy  and  if  they  can  be  said  to

                    have  cooperated  in  this  endeavor,  I  would  think  anything  iie

                    can do in the way  of  pouring  on  some  healing  balm  we  ought  to

                    do.

                                MRS.  FLOOD:  I'd  like  to  comment,  one  added   aspect

                    that I think means that the pressure here --  as review

                    co,,,iri@Lttee looked at this application and saw it coming  fro.,.i

                    a  state  university,  an  institute  for   governmental   services,

                    they thou.@ht, here we go, another rip-off and -- but when 'vie

                    got thc@re and saw that,  in  essence,  this  application  i-ias

                    solicited by the re@ional @-,edical  proCraii,  Tri-@OL'ate,  of

                    this a,-ency to be  the  seat  of  this  unifying  endeavor,  it

                    chanr,rlcd the entire co-,Dlexity oL' the situation.

                                i,IRS. SILSBEE:  Dr. Jandway.

                                                I
                                D@'L - JAIIE,,IAY: -k, is my recollect-ton.,  ilrs.  Flood,

                    that at the time  of  the  planning  l-or  the  new  medical  school

                    in I,.Iorcester thaL-1 the 'Uovernor had an office  of  health  poli cy

                    Is that a -- do I misrecolledt about      the l,lass government?

                    He had considerable help from the     IIT-Sloane School of

                    illana-ement and the MIT Harvard iDro-r@-i it that-tiric      far

                    as their legislative liason and date ofL'    production.



      12 3
                                                                           397

                              PerhaDs I am incorrect on that    but I

                              MRS. FLOOD: That was not brought to light during

                  the site visit.


                              MR. STOLOV:  It might just have been formed at

                                                     -hat particular formation
                  the request of the Governor for 4u

                  of the medical school. The  best  we  can  determine  from  the

                  health resources agency which was  there  was  the  agency  was

                  given this responsibility but he did have strong legislative

                  both the Senator in charge  of  the  health'committee  and  the

                  Ilousels representative person [inaudible.]

                              So I felt that there was a need  and  we  could  check

                  this out but to my knowledge., it didnot surface at the

                  meeting.

                              DR. JA',','E'@.-IAY: I present that as  a  recollection,  as
                  best as I can recall at this point in time.

                              i@'IRS. FLOOD: The recommendation for this Droject
                  was unqualified approval,  althou-h,  in  executive  session,  the
                  site  visit team did call attentiop.to what we felt might be

                                        -o the coordinator of Tri-State R',,P and
                  an excessive budget 4L,
                  this budget was in the process  of  negotiation  and  could  be

                  markedly altered.

                             l@loii, there was concern in review  committee  that
                  the programmatic concerns of  Tri-State  might  not  have  been
                  addressed and that their review process might be lacking.
                  This, we did not find.  l-e found  careful- description of '.-he-!.--"





      124
                                                                           398
                  goals and objectives and an adequate review process and,

                  certainly, broad participation in the review and,    in  fact,

                  we found strong review by the Rhode Island components as they

                  chopped back at the governor's project, for example, and then

                  it got strong-review processing at Tri-State.

                             MR. IIIPOTO: I noticed  a  discrepancy  between  your

                  committee's or your  site  visit  of  $1,676-some-odd-thousand

                  as opposed to the  committee  recommendation  of  $800,000.  Was

                 ,that recommended primarily by the  governor's  program  and  the

                  rehash, or whatever it is called?

                             MRS. FLOOD:  Primarily, it falls into those

                  categories, that's correct. l,ilell, actually, it is  three  and

                  I am goin-@ to cover a one-fourth se--ment.here.
                           tD                          CD


                             'IIIRS. SILSBEE:  I wonder if we could hold for a

                  minute?  She has to chanc-e a tape.

                             [Brief off the  record.]

                                   T
                             i.,RS. FLOOD: I might respond, on record,,  if  you

                  wish, to Mr. Hiroto's question.

                             The regional request for   6yl,886,000 in  essence,
                  resulted by our reviewing -only a cut back of $100,000 for the
                  phase out of monitoring and @100 000  on  the  bureau  funding

                  for the .@,IHSr.C.


                             T
                              ow , the last componcn'u that has raised some

                  oricern at rev-Le,.-i co::iriit-uec i-,,ao @,ri item that .,;e have

                  iscussed at council and that is the idea ol-- havinc- a contract
                  et for continuation  monitoring  of  ongoin-  projects  beyond




      125
                                                                             399
                  Fiscal '75 anid since the policies have been clarified that

                  this is indeed appropriate, the  ri-State R'P had proposed    a

                  request  of $275,000 to have a contract given to the Ilarvard

                                                                                   r
                  1.@edical School to monitor the operating projects of .@iscal  '7-.

                              Our recoririendation was that it should be

                  approved  if legal, which-is now unnecessary, but for a

                  bud@et of approximately w@100,000.
                     tD

                              @.-IRS. SILSBEE:  Could you clarify?  Did the

                  RIIIISEC approve it for the two years?

                              r-IRS. -PLOOD:  Yes, but with a lesser fundin- level

                  than they reques'te,-' for the continuation beyond the .-e-ional

                  su-)n@o.-t, a @7,ari:ed reduction.

                              -iRS. SI"@SBL@IE:  ilr.
                                                 Ifiro4-o.

                              '@R. HIRO@'O: Yes, I have one other question
                  int'-@,--@a'Uion for the Jul,7/-"@.uz-L,,--t review listed it as ;@@?-OO,on
                  and ,,Tou 7-ndi-cated an increase to -@-1,800,000.

                                                       u                    -Ion.
                              I",,F,S. FL'JOOD: Yes, I mi hof"er some explana'u
                  !,!hen we reached Tri-State, it was -o'ur understanding that the
                  application for the next review c@cle   would be in the vicinit-,
                  of 6,800,000. '.Iir. 71"iurohy, @he coordinator, informed us on our
                  last day of visit, that there are projects floodin':- in
                  iiave merit and are in the review nrocess and that at this
                  point in time, it looked as if they may come in for Y'1.8   in
                  the next cycle.

                                 '7TO7- O'\T:    ,@cto,, there was also      1 1 -.on
                                                                            L





        126                                                                  400


                  worth of grants processed

                             MRS. FLOOD:  That's right.

                             MR. STOLOV:      by Tri-State for this  next  cycle

                  that is coming up.

                             I-IRS. FLOOD:  They have over,,@!3 million in requests.

                             MRS. SILSBEE:  Dr. Janeway,-.

                             DR. JANEI,,IAY:  May I ask yoii. one qi;,,L-stion?  Was

                  Dr. Weiss at Harvard enthusiastic and mWpo@.ive and is he

                  going to be actively involved in this @alth policy?

                             IIRS. FLOOD:  He was effusive.,


                             DR. JANEI.,TAY: He is solidlT,, t@ehind it.

                             L7,@IRS. FLOOD:  file was in attetmfance, solidi@,r behind

                  it, effusive and told us in no uncertain terms that even  if

                  this fails  in Dutting to@ether surj'ic-tent information  to

                  be of value, it @,.,as stron- in its ,iierit of being the L'@---s@.

                  segment in which these multiple aspec(1-s of 1-lassachusetlu-S

                  community were going to work together and p.@na-os his

                  testimony, above others swayed us to r-azt full support  for

                             DR. JA!iE!-,,-AY: It would si-day r,-,.e, t,oo.

                             MRS. SILSBEE:  Mrs. Flood, would you like to'

                  su-imarize the recommendations of the sTte visit.tea-".?

                             !,IR@. FLOOD: The site visit. tear,-, vias., in the Tri-

                  State Regiona 1 T
                                          Program, feels that the Tri-State has

                  a strong staf-@P. broad knoiiiedc,-e and es-ecial-ty Cor7,@ends

                  Mr. "-lurphy for his efforts in tying together many problem





        127
                                                                           4ol
                  areas in that region.

                              It has a good regional advisory group, a strUI16
                  board and advisory  subcommittees.

                             The commitment of Tri-State to  the  entire  concept
                  of blending the private community with the  public  sector  was

                  obvious.


                             We would recommend strongly to the Tri-State
                  Regional Medical Program that they function  more  strongly  in
                  monitoring roles, especially in Congress in the State of
                  Rhode Island, but recommend to this council that funding be
                  approved at a level of-$1,686,907

                             M-RS . "IOIILGA,@T: 86 or 7?

                             MRS. FLOOD:  I'm sorry.  Jerry, I'll have to
                             I,IR. STOLOV:  I have 1676.

                             17!RS. FLOOD:  Okay, @1,676,907.

                             I-IRS. MORGAII:  Is that a motion?

                             L'4RS. FLOOD:  Yes  that is a motion.

                             14RS. MORGAN:  I second it.
                             [The motion was-made and seconded.]
                            MRS. SILSBEE:  The motion has been   made and
                 seconded that the council accept the site visitors'
                 recommendations and aDDrove the Tri-State application at the
                 level of $1,676,907.  Is there further discussion?

                            Dr. Janeway.
                            DR. JAITEI@IAY: I feel compelled to make what may  be





         12 8
                                                                                402

                   a gratuitous  comment.  If  the  Massachusetts  State  Governr,,ent

                   is go'Ln,.- to have a study of health Dolicies, I would hoDe tha@Ll

                   they would involve   more than the medical schools and that the

                   Mass. ?@ledical Society has some in-out and  I  don't  see  anybody

                   from the I",Iedical Society on

                               DR. WAI.,IrlOCK:  Hope, I didn't either.

                               DR. JANEWAY:  And I think that is a serious error,
                   if they are not going to have effective representation on

                   that.

                               MRS. FLOOD:  That point was mentioned.%.Dr. Janeway,
                   and I can'@u recall -- it has been severa days now -- what the

                   response -,,ias.


                               D@'L . JA@@JIEI@,AY: Tell, it is really none of our

                   business.   As I say, it is a c,-ratuitous conr@ient.

                                                   is,good advice, Dr    Jare,.,,,ay and
                               i.i.LS. SIL"3E": -L U

                   we certainly will convey that to the reSion.

                               ilia. HIRO-TO: 1 a.-,q still unco,,7,L'or'u-able with this
                   project 52.  TIhat happened to the @verall 'Lri-State !I,.iP

                   what .-Irculd happen, if your-recorimendation .@;ere to be  reduced

                   by the amount reelected he-re?

                               I"IRS. SILSBEE:  Is 52 the Governor's Rhode island

                   study?


                               1,@ IT I@
                                     .010:  Yes.


                                    FLOOD:   rinaudible.
                                             L


                                    "ILSB7Z:   Dr




      129
                                                                        403
                             DR. l@@'Al.llIOCK: I didn't get your comment. He

                  asked about what would happen if this 52 was struck out.    Is

                  that v;hat you were talking-about?

                             MRS. SILSBEE: I didn't comment.  I  was  going  to

                  let Mrs. Flood or Mr. Stolov comment on that.

                             MRS. FLOOD:  Ilell, besides a probable very violent

                  temper tantrum. on the part of one angry young man in the

                  Governor's office, I am not sure that there would  be  others

                  who would address this, with the expediencies that the

                  potential is available here.

                             Now, I might broaden the statement.  We questioned

                  that they were tryin- to build staff and  .e offered some

                  counsel and statements about possibly utilizing consultants

                  groups to answer -this in a more massive impact way rather

                  than garner staff and sL-Irenrthen the Gove.-nor's office.

                             This was well-received and I don't know  if  there

                  would be anyone else that would take this up and  address  it

                  and it is a necessary component of some future  planning  for

                  Rhode Island.


                             DR. IqAT@l@-IOCK: I.Id like to call your  attention  to
                  the fact that I read this as, proc-ram staff is $654   3000.,Ooo
                  and the budget you have got up here is $1 million.

                             MR. PAHL:  We appreciate the budget increase
                  Dr. Wamiiock.  That is $654,000.

                                   T',I;j C I,'
                             DT'-' .',"A-, That is a lou of money.




        130
                                                                           4c)4
                             MR. PAHL:  It is, indeed.

                             DR. IIAI.U@IOCK:  And the other thing is, that item

                  52, here, health service time of economic transition.  That

                  may not be the only state that is going through economic

                  transition.  -1--laybe the other states are going through

                  economic transition and I think we have to take this into

                  consideration from the standpoint of what role will the RI@IP

                  play in this when we are trying to provide health care

                  services.


                             MR. PAHL:  Well, I am glad you made your remark

                  before mine, because I'want to merely say from the point of

                  view of the pro@ram staff that I believe pa-e 2 of the site
                  visit resort points out the weaknesses and the stren-ths and
                  from what I listened to the discussion of the site visit, if

                  we can divorce ourselves from the Governor's office for a

                  moment, I think that a good bit of discussion has centered

                  around an appropriate role for PilP, perhaps in this area and

                  I think you could make your decision, not on the basis of
                  whether this happens to be-the Governor's office or not,
                  but there has never been a-consideration in councils prior

                  to this one.  This has been an unusual council in that t,,-iice

                  now we happen to have situations which involve the Governor's
                  office and this outs a different complexion on the R@.I.P

                  pro@r-am than  have ever had in '.-he historx, oT the -o-o-rar,.

                                           T 4-hjiiz the site visit team has done
                            In this case     u J-




        131                                                                    405
                  Ian exemplary job in tryi.ng to   weigh very accurately real

                         ,-hs and real weaknesses   and I think this council should
                   streng4u

                   decide whether it   is in the interest of the RTIP program to

                   approve or not approve this project.


                               You have heard all of the    discussion and I think


                   now comes the decision on-the basis     of.iihat you believe to.'

                   be the merits of the funds in this    area.


                               I would feel that we could support your recoizi-ien-

                   dation Whichever way it happens to be.  I frankly have a

                   personal feeling  about this but I think it is the counci  s

                   job to tal,-e -iin@uever -a-ction appears appropriate.

                               I do not see where a -1-ri-L'itate 7@' 1.P o rRhode island

                   RAG has to do one thin- or another and I don't think you have

                   to do one thing or another, either.  I think you should

                   decide on the basis of the merit of '--,he situation.


                                               "-,--s. Flood.


                               1,M 1-7 . L'@ i'JOOD: I'd to COA-"ren-@ on the

                   staff costs.   'L"hey are all very -@,:el-IL-paid people, bu+.- of

                   ouL'Istandl-nc- capability and- their - numbers are not extrac"
                               CD

                   dinar--'Lly high for the area they serve, but they are still

                   -the most capable peoiD"-e with well-,i)ai-d positions and that

                   does account for high staff budget.

                               ,,IRS. SILSBE'@:  Looking at the p@-nt-out on just   --i

                   the  nroo-ran staff line, Dr. i,lammocl@, in and of-itself does

                   not tell irou ,-iucli I,,,--cause, particularly their contr-@c@L. ccstc





                                                                               406
                  and so forth that have tuilt into staff activities, so we


                  have to look at the


                              DR. IIPIIL@IOCK: I recognize that part of the

                  situation, but I mean, it  doesn't  trim  the  astronomical  part


                  of the total.  Plus the fact that this is a Tri-State


                  situation and I come back-to the question as to    what Dr. Pahl

                  said, that this is the second time that we have    been

                  confronted with this  a  governor  participating  in  a  pro-ram.


                              I%IRS. SILSBAVIE:  Is there further discussion on


                  this point?

                              I-IR. STOLOV:- l,lay I ask just one question? I  am

                  unclear about what Dr. Pahl says and that is in terms of,

                  does the council feel that the@ are holding an economic

                  project? Because Dean Thurman,  I  think,  and  the  site  visit

                  tear, were able to get the ful-IL-blo,.-.rn orojec@u and revie,..T it

                  and the ,-@aiori@uy felt the orojecl@, .7as dealinr- ,.rith the health

                  aspects only of a thrust out  of  the  Governor's  office,  usin@

                  every acency at the Gove@-nor's disbosal to deal with it

                  because of the eimht percent [inaudible] Dr. Haber mentioned,

                  these peoole no lonver have health benefits    and  we  checked

                  -that area about what is !.Iedicaid doin- in the state  and  they

                  said, everybody who is now employed -ets divorced and the
                                                        LD

                  families are separated and we can then take care of them      on

                  Medicaid but  in essence, "Uhe proposals, the ma-jority  of  the

                  ProDosals in  Tri-State are for people who  are  not  d4-rectly



        13@                                                                     407

                   dealing with the health    care delivery sys@uein but usinc-  the

                   method the Hill-Burton Program the laeaT;'@h Department       the

                   state health department currently sitt:Lng- @ the Governor's

                   office., the definition of how they plan tego about it

                   through subcontracts and one of the sut-contracts was with the

                   local group in Newport, $50,000.

                               Again, all of this  has  to  be  negotiated,  but  to

                   pull together the !,,Iedical Society, the hc,,--pital community

                   and give them $50,000 to plan their hea3-th needs in the

                   community, well, I hope by the title in the computer print-

                   out you are not  misled'by  the  economics  af  it  because  Dean

                   Thurman, I must say, focused in on that quite well.

                               MRS. SILSBEE:  Mrs. Flood, @ci you have     something

                   further?


                               I,IRS. FLOOD:  Well, no, -iy response to the co=ents

                   of Dr. l@.ammock was the true Personnel c@(Dst;-T at this time are

                   really closer to $300,000 than the rest ofthe, you l@now
                                                                                 3

                   contracts for staff costs.

                               MRS. SILSBEE:  Well, the motior,., vias been made and
                   seconded that the Tri-Stat-e application be    ipproved   at   @e
                   level of lyl,676,907.  Is there further discussion?

                               [Therewas no discussion.

                               All in favor  say aye.

                               [There was a  chorus of ayes.]

                               Opposed.



       13LI


                                      r,,OCK: No.
                              DR. WAI,'I,,L


                              [The motion was carried.1


                              IYIRS. SILSBEE:  The motion has be@-n carried.


                              Now, the sandwiches are here.  P-re you hungry?

                  Would you like to take a break?

                              [General consensus.]

                              [Whereupon, at 12:00  O'clocl-, n(-@ca, a recess

                  was taken for luncheon.]




LI@ RI'4P                                                                      4o9
rc                                        AFTERNOON SEQ@SION
/17
                                                             (12:25 P.M.)

                               MS. SILSBEE:  We would like to get started again.

                               There are a couple of announcements I wanted to ,,mke.

                               For the record, Dr.  Merrill  was  not  present  during
                    the Tri-State review; he'is not here today.

                               -And with regard tothe Arizona application, after

                    we got all through with discussing it, we noticed that the

                    Arizona Pd4P did. have an arthritis application,  so  we  are  in-

                                                    eview that  that  does  not  ap
                    terpreting the sense of your                                  ply

                    to that earmarked activity, in the program applications,

                               Now we will do Illinois.

                               Lee,did you want to  o,,ive any real  brief  remark?

                               Dr. Janeway, you did a review.

                                          T
                               @Ul,. VAN WII@,@KIC- I would just as soon he Lead off

                    and If he wants me to respond to any question,     I  would  be

                    glad to.

                               DR. JA NOWA Y: If I can find it in my book.

                               DR. WA M40C K: I-t com,---s rioht after "Hawaii."
                                                          C>

                               DR.JANDIAY:  In order to get the'topic on th@floor,

                    I move approval of the  recommended  level  by  the  committee  of
                    $2,8i6,935, which is LOO percent of the request presented  to

                    the Ad Hoc'Review Committee.


                                     O-R
                                       GIN:   I -econd it.

                               Mol. SILSBEE:  I)r. Wammock, secondary reviewer, do





                                                                              4-LU


                    you want to  -say  anything?

                               DR. WAI,114OCK:  Icame across this business of public'

                    awareness  of venereal disease that sort of worried me a

                    little bit.  -And really, there is not much about it; I thought

                    it was a well prepared situation and  there  is  no  point  in

                    nit picking, anything of-that sort,  so  I  would  second  it.

                               DR. JANEW.AY:  In brief comment on the topic,

                    I think that in the general guidelines for following it, it

                    is a superior program. I  think  that  one  bit  of  potential

                    difficulty   that ought to be made  available  to  the  Council

                    is the fact that Dr. Creditor and Mrs. Creditor are both

                    Leavino, the prooram.  And since that represents   the coordina-
                          CD        C3


                    tor and -the -rants manager, the Illinois RMP, I   think it  is

                    a difficult task to replace the@,n.

       r                       Dr. Creditor has a reputation for strong leadership:

                    and advanced planning and.has a very interesting monograph

                    on  the  subject.

                               From the standpoint of --proposals, I would make onL,r

                    one  comment,  in my review2 which-I noticed was covered in

                    the   transcripts also, is that the hypertension control pro-

                    gram that they  visualize  themselves to me rather ambiguous

                    considerino- the amount of time that is available in order to
                               CD

                    carry out the project, but it is worth while and, well designed

                               I am not sure they canattract the s-taff and get the:

                    computer base and all of 'the mechanics necessary to- coriple@uc,.





                                                                              4ii

                                                               ess recommend
                    the project as they see ft. But  I nonethei
3

                    approval as the committee recommended.

                              MILS WRTINEZ:    (Ina uci ib le)

                              DR. J.ANEW.AY: He is going full time at the
                    University of Illinois,. @ledical Branch.  The Dean there is
                    a reliable 'person.  If he said it is going to be a generous
                    25 percent, it will be, and I have known him for sometime; he
                    is quite interest--a in the RMP program.  I am sure that wilk

                    happen.

                              DR..          I would like to asic one question
                    here If I could find the page.

                              It is an amount of *i@b,000 for PO@IR medical care
                    evaluation.  This is a demonstration of the usefulness of
                    'the model system in other settings at KL@EL Reese Hospital,
                    and assessments for adaptability to do amb-ulatory care settin.-I.
                              1,2 S. 'Lfi.ORG-Ali:  What number is tta-.t?

                              I)R. WmZC,-40UK: Page 90, pac-e g@G.

                              It is 33 is what it "@s; pro'ect
                              I)evelopment 'Ves-t and feedback, method for the system,
                    evaluation or first year..of the project anLi promotion  e for@
                    system at the institution.  It is goin- uo oe Cone in one
                    hospital, @@8,OuO. Thau is a good 6ize "chickenl'eed.
                              L)R. JjiN,@-fmY:  They have bit @into the.,plaie- on the'
                    system on the computers capital P, c@,p,-tat H.-

                              JJR.         Ye@.




                                                                                 412

                               -UR. JjilTEW,,iY:  mnd I thinic they nuve been usina, @he
                    PO,MR throughout Ilil'noiz3 for inpatient and medical audit

                       purposes,

                               The extension into ambulatory care  is  a  necessary
                    one in my opinion, but considerably more difficult in its im-
                    plementation than inpatient.
                               DR. WAMOCK:  Yes@ that is what worries meg imple-
                    mentation on the outpatient basis.
                               DR. JANEWAY:  That is where it is goin.- to be at,
                    though, to use an old Western Pennsylvania phrase.
                               DR. W.A NRAOC K: "Where it's at."
                               MRS. FLOOD:  This particular project will be
                   seated in one facility as a test?

                               DR. W.Al,,L@OCK: Yes.
                               MRS. FLOOD: 11-lay Iask an additional question.  L-- t
                   me clarify, Dr. Mort Creditor will now be, 25 percent of his
                   time will   be coordinator of IRI"@IP period?   Or--
                               DR. JANEWAY:  My understanding of the proposal Is
                   that thio   will extend through December of 1974 and it  is  not
                   a 25 percent spread; it Ls 25 percent generously, but -U will!
                  .presLL,ne to terminate at a year or so.  It is more time
                   actually,

                               Is that your understanding?
                               MR. VAN WINKLCT:  Yes, yes, it is.

                               MRS. FLOOD:  I have some reaT




                                                                                 413


rc                              141. VAN WINKLE:  They do have     a ---earch team at the

                     present time.

                                MRS. FLOOD:  They do have a search group formed?

                                MR. VAN WINKEE:  Yas.

                                MRS. FLOOD:  Definitely thtz has. been the power

                    behind the successes of IRMP, and if tthey don't address the

                     sufficient transition  time,  you  kncw,  to  r@-place  the  coordina,'@

                                                                   t
                     toro they would face a lag I think i-r@r, pu u-ing   all  these  piec&sl

                     together and perhaps a crucial time-.w7ben they     must  enter  wiridii

                     QPO

                                MS. SILSBEE:  Dr. Wammock.

                                DR. WANlt4OCK:  Another praj@eat on page L07, -that pro,-
                                                                                            i
                     41, PSRO evaluation of technique in, Cbicago.  Quality of

                     disease information of Cook County phwsial-ans.

                                It bugs me a little bit, it Is a form I am sure of

                     continued education in some on-- form or another, but it

                     costs $L35,000.

                                MRS.  MORGAN:  There are    a. L."zt of physicians hereo

                     though.

                                DR. WAI,51OCK:  I recognize  that,  but  if   you   a@lyzed;l

                     how many attended out of    the total--

                                DR. JANEWAY:  I think the number is goino,- to      go up.

                                DR. WAMOCK:  You think it will go up?  You mean

                     Ju-.t for PoLitic,,iL reasons?

                                DR. JANEWAY:  No,    no.  Reality.




                                                                              4i4

                               MR. H IR OT 0: If they want to stay licensed.

                               DR. WA,,NL'40CK:  That is all I have.

                               MRS. MORGAN:  Question.

                               MS. SILSBEE:  Motion has been made and    seconded

                    that the Illinois application be approved at the    requested
                    amount of  $2o8l6@935.

                               Is there any further discussion?

                               All in favor say "aye."

                               (Chorus of "ayes.")

                               MS. SILSBEE:  Opposed?

                               (No response.)

                               MS. SILIBEE:  Motion is carried.

                               Next one is Ohio VaLley.

                               DR. Jfi@NEi-AY: @ledari Chairperson, the  Delegation f rcm

                    Ohio VaLley

                               (Lau-hter)

                                   WOI-,Tl@LI-1,CK:  Want to cet the Council on this?
                               DR*

                               DR. JANEWPY:  In order -to place @the topic on the

                    floor, I  move approval of the  committee  recommendation  of
                    $2,205,636, plus @@LOO,000 for project 27-D.

                               MS. SILSBEE:  Hold it just a minute until Mr.

                    Milliken  gets out of the room.
                               (At this point @fr. Milliken withdrew from the room.11@

                               MS. SILSBEE:  ALL right.  Excuse

                               He is out.




                                                                          415

                             DR. JANEWAY:  Thank, you.

                             I move approval of the committee recommendation

                   for the Ohio ValleyRMP in the amount of $2,205,636 plus
                   $100,000 for project 27-D, to fund ToLedo, Lima, Dayton

                   Region.

                             MS. SILSBEE: Is there a second@

                             'MRS. MRS:  Second.

                             DR. JA @iA Y: I am a little bit, Less enthusiastic
                   about this proposal than I iias about t@ Illinois proposal.
                             I think that leadership in my. opinion remains to be!
                   demonstrated, both in the coordinator of the program and In

                   the RAG.

                             I think that with the phasing out of other programs
                   in Ohio, that they 'Lace severe political difficulties in bring-
                   ing other regions, other parts of the state into the funding
                   mechanism because it appears to me that the great maor,'Lty o--'
                   their pro.-rams are divided a third, a t@rd., and a third; then

                   the participatin- medical schools,

                             There is no fault in the direction of the great,
                   majority of their proposals but I  do thTnk they underestimate
                   the difficulties that they may  face as they get more vocal

                   from the regions that have not  been in.

                             I am not quite sure how this is going to be resolved
                   i.,,ithin the framework of the proposal they presented.
                             Although the overall program J-z presented In a





                                                                         416
                   well printed forms It is difficult to follow exactly what thel

                   accomplishments of the region have been  to  date.  And  Ithink

                   there Is going to have tobl- a lot of salting out in  this  re-
                   gion before they accomplish what they say they are going to

                   do,

                             Inherently I think in a program  that  crosses  state
                   boundaries is this type of problem and they have ju.,ztv in miti
                   gation of what I said earlier., done quite well in hand L'ing
                   the fact that it does involve three states.

                             MS. SILSBEE:  I should explain to the  Council
                   that Toledo-Lima-Dayton part of the application, bec  use  last

                   year when we were phasing out, two of the programs     at
                   formerly covered Ohiop Ohio State program and the Northeast

                   Ohio, were phased out.

                             At the time that these  applications were being pre-
                   pared, Ohio forces began to wake  up to the fact that there

                   was money to do some things that  they wanted to do  and  under
                   the terms of the court order, the money has to go through the
                   53 existing regional medical programs$ so we suggested to
                   various people in Ohio to-go either to Ohio-VaLLeyp which

                   covered the';part around Cincinnati,, and Kentucky and part  of
                   Indiana,, or to'go to Western Pennsylvania or to Michigan,, and so
                   in this particular round of applications, Ohio VaLley, RAG
                   agreed to take this on.  And Western-Pennsilya-nia applica-
                   tion you will be looking at Later was to try to do portions of




                                                                             417
                   activities in Ohio without taking on the whole state.

                              Lee, did you have anything to add?

                              MR. VAN WINKLE:  I would explain in the rccom'menda-
                   tion that  the 100,000 was explicit for this expansion into
                   Ohio, and  I understand since the committee met that these
                   people have applied and this will be forthcoming, wt-ichwould
                   eventually probably raise this-level to $2.3.
                              ])R. JANEWAY:  My only problem with that 'if $100,,OOO
                   is just for starters.  I don't  think we are going tc have
                   any difficulty with that.  It is when that area getE organizer,
                   what are they going to do?

                              MS. SILSBEE:  I think these are  for speci ic pri-
                   orities in the Ohio Valley programs

                              MR. VAN WINKLE:  That is correct.
                              MS. SILSBEE: Health education  services,  that type
                   of activity.  And they  h'a've made it quite clear to Ohio they
                   are not interested in  a  lot of different kinds of activities.
                   So these are related  to  the goals'of this particular regional

                   medical program*

                              MR. VAN WINKLE:- They have no intention of helping
                   to form a new medical school.

                              MS..SILSBEE:  Okay, the motion has been made and

                   seconded that the Ohio Valley  application be approved  atthe
                   level of $20205,,636., plus another $100,000 foF the Toledo-
                   Lima-Dayton,, Oftiot area,






                                                                          418
  IQ-                         Is there further discussion?

                              All in favor?

                              (Chorus of "Ayes.@)

                              MS. SILSBEE:  Opposed?

                              (No response.)

                              MS. SILSBEE: The  motion  Is  carried.

                              Okay, Washington-Alaska.

                              DR. JANEWAY:  Is there anybody here  from Washi ngton-

                   A Laska?


                              MS. SILSBEE:  No, but we  should get Mr. Milliken

                   back,


                              Okay,

                              DR. JANEWAY:  I thought you wanted to wait for

                   Mr. Id II Ike n.

                              MR. VAN WINKLE:  He may be difficult to find.

                              (Laughter)

                              MS. SILSBEE: Let's  just  keep  going.

                              DR. JANEWAY:  Okay.
                              (At this point Mr,  @ilLiken  returned to the room.)

                              DR. JANEWAY: I move  approval  of  the colmni t tee

                   recommendation on the  Washington-Alaska  RMP  in the amount of
                   $2,,077,,311.

                              MRS. MCRGAN:  Second.

                              DR. JANEWAY:  The program always has been superior
                   In my oPinion with very forward thinking leadership and a




                                                                          419
                  great deal of cooperation with the University of Washington.

                            And Dr. Van Sitters, who is the dean there, has

                  since he has been dean been quite supportive of the RMP

                  program,

                            There has perhaps been some criticism at the very

                  close relationship of the'university -- the medical school

                  with the RMP program.  But I think on balance, It has been to

                  the betterment of the program and that there is no conflict

                  of interest inherent in it,,

                            The constitution of the RegionaL Advisory Group

                  does have some preponderance of providers of medical care and

                  particularly people who are related to the medical school

                  environment.   Once again, I think that both Dr. Sparkman,

                  whom we have seeno and the people who are on the RAG are

                  able to associate themselves and wear different hats at approp-

                  riate times.

                            I am a little bit concerned that although the com-

                  prehensive health planning relationship with RMP has been very

                  goods there is considerable difference in some of the proposals

                  .that were presented this -time,, which strikes me as a Little

                  bit unusual since t@ RMP and CHP in Washington look

                  a great deal Like an interlocking directorate to me.  They have

                  advanced planned to the point of prediction almost, it would


                  seem*


                            It Is nothing explicit.but  it is implicit In the





                                                                        420

                 request,

                           I am also not sure of the integration of Alaska  into

                 the program, but I think thau is not surprising.
                           They made-good strides in their minority outreach
                 programs and are getting representation on the RAG in  minority
                 areas and I think most of the things I would have to say  about

                 it are good.
                           MS. @ILSBEE:  Mrs. Russel; did you have anything

                 to add?

                           MR. RUSSELL:  No, I have not one thing to add.
                           MRS. MARS:  Why did the CHP agency complain about

                 this position extender placement program?

                           I -would think in Alaska that would be one of the

                 greatest boons that there could be.

                           MR. RUSSELL: Mrs.')4ars, I am sorry, I cannot  answer

                 that specifically.

                           I don't have copies of those letters with me.

                           But since the comments have come in to the Washington-
                 Alaska MedicaL Programo the-Executive Committee sat down and

                 addressed each comment specifically and have,reE:pondecl, so

                 those Issues have been cleared up locally.  I am sorry that

                 I cannot answer.

                           MRS. MARS:  You don't know what the basis for--

                           MR. RUS SELL:  No, I do not.
                           (I)Lscussion.off the record.)




                                                                         421

3                          MS. SILSBEE: The motion has been  made  and  seconded

                 that the Washington-Alaska application be approved at  the  re-

                 quested leveL.. $2oO77,,311.

                           Is there further discussion?

                           All in favor of the motion say "aye."
                           (Chorus of "ayes.-")

                           MS. SI@BEE:  Opposed?
                           (No Responses

                           MS. SILSBEE:  Motion is carriecl..

                           Okay, now we are-goino., back to our original plan,

                 we are going back to our alphabetical.

                           Coloraclo/Uyoming would be the application  under

                 consideration.

                           The record should show that Dr. Gramlich is not here,

                           MISS MARTINEZ: I thought this  was  an  extremely

                 well put together programs very well written.  Very well coor-

                 dinated with other agencies,, and they had a very good  EEO

                 statement, which was unusual on the EEO proposals that I

                 reviewed.

                           About that subject, I am sure it is much too late, btt
                 I did forget to make one comment last time when I  was  reviewi nk;
                 Central New York; that iso their minority representation is

                 extremely poor.   They have one black person on the RAG and
                 that Is it. And I would sort of recommend that  they  Co  some-
                 thing about that.




                                                                                422

                              And also just one more aside,, in looking at the       forml
                   itself, that is used for the statement,, I would suggest that
                   it be modifiedto eliminate possible double counting  f minorit7

                   females.

                              I Con't know if that is a problem here, buti I know
                   it was in our states, so we had     to change the system.
                              Now, I am going tb go    just very quickly, I am pretty
                   much In agreement with the review committee's      funding level,, I
                   just want.to make'very quick note of a couple      of prop:)sals I

                   object   to.

                              One is C002,, which is primarily for    a confe  encel*p
                   C 009, the need for that really wasn't developed      In th  proposaL.
                   it wasn't  backed up; C010 is a small allocation,, but primarily
                   for a series of s'lides.. audiovisual; C013 is interesting becau;e
                   I knew this was going  to  come  up  againp  it  is  $104,000  pri-
                   marily as an insurance policy for extension of trouble the way
                   I read it.  I  may  be  wrong  about  that.  And  there  are  a,few
                   others., such as 041 which the reviewers mentioned also, bone
                   pathology  center  cancer  diagnosis.  I  don't  know  if  that  is
                   appropriate.  I should think the American Cancer Society or some
                   other group would do that.  It is setting up a continuing
                   laboratory for analysis,
                              And' '048 is continuation of a program the funding of
                   which was dropped by NIH.     I don't know if that, :is particularly

                   appropriate either.




                                                                        423

                            In any case, when I  finished  s.ubtracting,,I  came  up

                 with $L,573,592, which isn't  too  far  off.  And  I  wouldn't  mind

                 stick to the committee's  recommendation  If  the  extra  few  thou-


                 sand dollars wasn't used on those small programs     that  are  going

                 to just produce audiovisual materials and a conference.

                            MS. SILSBEE:  Dr.-Wammock.

                            DR. W-AMMOCK: 041,, bone pathologist  center.,  for  the

                 benefit of Dr. Janeway in Boston' Dr.

                            MS. SILSBEE.  Would you   speak  Into  the@mike,  please?

                            DR. W-AMMOCK:  Many years ago a bone pathology

                 register,  used to collect slides and  send  them  all  around  over

                 the country.   There is a great need for  emphasis  on  t  is  situa-

                 tion.


                            The fact these are common to us,   yet they  are  rare,,

                 but they are difficult for diagnosis, I imagine It would be quite

                 a   problem.

                            I would like to address  myself  to  support  this  number

                 41.

                            MISS MARTINEZ: Could I -ask,, is this  a  pilot  project;?

                            There was no mention of its being taken up by--

                            ,DR* W.AMMOCK: It would make no  difference  to  me  whe-

                 ther it Is pilot or not. I thinit- it  is  a  place  where  patholo-

                 gists,not only pathologists but orthopedics@@itnd,orher

                 individuals, even pediatricians, ought  Do  be  cognizant  oL'  the

                 fact of the problem ol' bone tumor we are faced with.





                                                                             424

    15                      I am sure If they have started this, they are going

                  to continue on this.  This is my impression in Colorado.  I am

                  not sure who is on this programs whether George Moffitt-has

                  anything to do with it or not.

                            MISS WRTINEZ:  Woub they be seeking funds    from

                  other sources 'and that wasn't brought out?

                            MS. SILSBEE: Miss Martinez.-in  terms  of  the  change--.

                  you are willing to go along with the committee   recommendation..-

                  we can-give advice'  to the region in general terms,   particularly

                  the audiovisual and the conferences and so forth,

                            MISS YARTINEZ:  It is only something like, $6oooo.

                            MS'* SILSBEE:  But I don't think we should  be In the

                  position of saying yes on this ones no on this ones    unless it

                  is a policy Issue.

                            MISS MARTINEZ:  No,

                            NR. CHAMBLISS:   I think I should respond to Miss

                  Martinez's question.

                            I saw  it  as being appropriate, as far as RMP funded,,
                  the answer to  that  is yes, -it Is quite appropriate for RMP  sup-.

                  port, that being one  of the basic categorial'cares the program

                  started out with.

                            MISS MRTINEZ:  It wasn't so much    the proJect as  lact:

                  of other support.

                            MS. SILSBEE:  WouLci you make a motion?

                            MISS MARTINEZ: Yes. I move it be funded at





                                                                           425
                  $I,,587,,644.

                            MS. SILSBEE:  Is there a second?

                            DR. WAMMOCK:  I will second it.

                            MS. SILSBEE:  Mrs. Flood.

                            ERS. FLOOD:  May I raise a question as to whether

                  or not Intermountain, Mountain States, Colorady/Wyoming's
                  total applications have indeed gone before their tri-regional
                  coordinators conference and ironed out their  problems  of  over-=

                  lap?

                            I can't  seem-to locate it. There  is  such  a  counsel-

                  ing genetic component in Colorado/Wyoming, as I recall it was
                  either Intermountain or Mountain States addressing the sainie
                  particular concept of need for that region of the country.

                            .MS. SILSBEE:  I think they are all related to the

                  one in Denver.  It is outreach part of it,

                            MRS. FLOOD:  But  they haves all three-- now we
                  hashed the Intermountain status of going through--
                            MS. SILSBEE:  All  three applications  went  before  the

                  Interregional Council.

                            We have a letter-indicating that  certain  of  the  ones
                  that were identified for overlap areas are now going through
                  the processor being cleared by respective agents.

                            MRS. FLOOD:  Thank you.

                            MS. SILSBEE: Motion has been  made  aiTd  seconded  that
                  the CoLorado/Wyoming application be approved at the level of






                                                                           426
                 $1,587,,6'44.

                            Is there further discussion?

                                 t
                            MRS. MCRGAN:  Question.

                            MS. SILSBEE:  All in favor?

                            (Chorus of "ayes.")

                            MS. SILSBEE:  Opposed?

                            (No response.)
                            MS. @ILSBEE:  Motion is carried.

                            Next region is Florida; Mrs.  Gordon  is  the  reviewer*

                           @NRS. GORDON: -Florida has ranked a superior regiont

                 and  one  of their great strengths seenEto be their record of

                 attracting  outside funds for their projects   and for the con-

                 tinuation of their projects.  Their funding    agency Is  an  ince-

                 pendent corporation.  They deal in large numbers, both in

                 people and in money.

                            They will ask  for one and one-tenth million in    July,

                 at least that was the forecast, one and a-half million this


                 says,

                            They do have some new programs which are quite expen.-

                 s.ive,, but the reviewers seem to feel that in'Light of their pa@,,t

                 records forgetting continuation  funds  from  other  sources,  that

                 they would continue this good record and therefore they would

                 be  willing to go along with the chance of putting this much

                 money in'.to start,, although they did not recommend full fundin@,,

                 but very cLose to Lt,.about $300,000 off.





                                                                           427
                            So in light of their past track record, I would

                 move that we accept the committee's recommendation of

                 $2 07,00,000.

                            MRS. MARS:  I second it.

                            MS. SILSBEE:  Mrs. Marr4 as secondary reviewer do voi

                 want to comment?

                            MRS. MRS: I think you might point  out  they  have  an

                 exceptional kidney transplant program.  This  was  begun  before-

                 there were any special federal funds given, allocated to it,

                 for this purpose.  And -they developed a statewide plan which

                 described a network per organ, harvesting covering   major   cen-

                 ters for dialysis facilities, and  required  supporting  services

                            So that Florida is I suppose one 'of the best  covered

                 states actually as far as kidney transplant system, as far as

                 I know.

                            MR. VAN WINKLE:  They are very much looking at

                 quality of care right now  in that area.

                            MRS. MARS:  Yes.  So I think they do have some reall@r

                 outstanding programs.

                            There was a Southeastern Interregional Symposium on

                 quality care evaluation.  So other than that,, except to say

                 they do have some exceptionally fine programs, I have nothing ;o

                 add.


                            MS. SILSBEE:  Motion has been made aE-c seconded the

                 Florida application be approved at $2,,700,,000.




                                                                                   428

 19                          Is there further discussion?

                            .MR. MILLIKEN:  Wuestion.,


                             MS. SILSBEE:  All in favor?

                             (Chorus of "ayes.")

                             MS. SILSBEE:  Opposed?

                             (No response.)

                             MS. SILSBEE:  Motion is carried.

                             Next region is Greater Delaware ValLey.

                             DR. WATKINS:  According to the reviewer above


                  average program,

                             I recall this   program was organized around       region--

                  I remember It myseLf., around five Philadelphia.medica  schools.

                             Also there was as@ccession,, if I recall, of first state..

                  Delaware,, but there seems to be a metamorphosis of this region.

                             We find today that it Is controlled or run by a new

                  coordinator who Is really oneof the old members, and that they

                  have involved communities-p  ,especially the Inner city,, In severaL

                  programs.  Their biggest drawback was an inordinate astuteness

                  In financial recommendations,, being they apparently were sub-

                  si.dizing professiorr-ts of the medical schools., and tt still

                  seems to remain   a slim question which I believe we will lnves--

                  tigate because   I don't think over three years the same thing

                  should exist.. so I am sure you are going to investigate that

                  further.

                             But In general., the program has Improved, the program





                                                                          429
                 is following the guidelines it has stromg leadership shows
                 direction.  Proposa Is were reviewed by CHP and the history in

                 general looks good for this program, so I  would  propose  that

                 the $2.3 million recommended by the committee be given'to this

                 program,


                           MS. SILSBE.M   Is'there a second?

                           DR. JANEWAY:  Second,

                           MS. SILSBEE:  lir. Janeway.. did you have anything

                 further t o add?


                           DR. J.ANEWAY:  No comment.

                           MS. SILSBEE:  I have one  thing to add to the record,,

                 because at the Review Committee, there  came a-letter from one

                 of the CHP agencies with a negative comment*  This  was one

                 that had not yet been to the Regional Advisory Group.  They

                 sent It directly In here, So we called to  ask  what  the  pro-

                 cedure was as far as the region in terms of looking at this, ard

                 they said they would-.- because of the particular project, they

                 would work with'the CHP agency before they intended to move into

                 that area.  And if indeed the Cb) agency decided they did not

                 want them,, they would not go.

                           So It seems to me the region was  responding  to  the

                 comments.

                           Motion has been made and seconded  that  the  Greater

                 Delaware Valley program be funded at $2,300,000.

                           Is there further discussion?



                                                                         430


                           MR. MILLIKEN:  Question.


                           MS. SILSBEE:  ALL in favor?

                           (Chorus of "ayes.")

                           MS. SILSBEE:  Opposed?

                           (No response.

                           MS. SILSBEE:  Motion is carried.

                           Next region is Hawaii..

                           Mr. Hiroto.

                           MR. HIROTO:  Madam Chairman, I recommend that the

                 Review Committee's recommendation that Hawaii RMII be

                 funded  for reduced amount of $I,,LOO,000 with $305,,107!of that

                 amount earmarked for the Pacific Basin, be approved

                           Comments I would make is I was a member of a review

                 site visit team in January and In April of this'year.  A new

                 coordinator was named and in the two short months that he

                 has taken overo he is apparently moving towards meeting the

                 many problems that Hawaii RM.P had.
                           is far as the reviewers 6re concerned., he Is obvious Ly

                 moving Hawaii RMP In a proper area,

                           There is only one I think still remaining concernt

                 which had to do with the kidney tissue typing, and we would,,-I

                 guess,, suggest that they solve their problems.

                           MR. RUSSELL:  I was at the RAG meeting when that was

                 discussed and the Regional Advisory Group chose-to put the

                 progress right back where this belong;* on the two Institutions





                                                                       431
                  involved, making them guarantee that either two separate

                  programs were needed or coming up with a joint plan.
                           MRS. MRS:  Has the RAG been changed?  Is  it being--
                           MR. HIROTO:  There is a new chairman of.the RAG,

                 I should have mentioned.

                                            about composition of it?
                           MRS. MARS:  What

                           MR. HIROTO:  As a result of thato they are moving
                 forward,, are they not?

                           MR. RUSSELL:  Yes,, the by-lawstave been re@ised.
                           The Regional-Advisory Group has been revamfed,,bringing
                 on board consumers, more different types of indiv    Is; the
                 medical school, school of public health, Hawaiian    ical
                 Society are delighted withthe change In directors and the new
                 direction the program Is taking.

                           It Is a-completely different program.
                           MRS. YIARS:  I should hope so, because it was just
                 about ready to be closed down.

                           MR. RUSSELL:  No doubt about It.  We were very en-

                 couragecl by the last few months,

                           MS. SILSBEE:  Mrs. Klein,, did'you want to comment?

                           MRS, KLEIN:  I don't have any comment.

                           MRS. FLOOD:  I would second Mr. Hiroto's motion.

                           MS. SILSBEE:  The motion has been made and seconded
                 that the Hawaii program be funded at the Level of $11,100,,Ooo,
                with $305,LO7 of those dollars earmarked for the Facific




                                                                           432

                 Basin programs

                            Is there further discussion?


                            Dr. Janevay.

                            DR. JANEWAY:  CouLcl I ask a question?


                            MS.  SILSBEE:   Sure.


                            DR. JANEW-AY:  Did  Ibeat the call?

                            MR. MILLIKEN:  Right.

                            DR. JANEWAY:  Just for education,, how did'Hawall

                 get  around  to -- let me ask it this way, is It because of 'the

                 Pacific   Basin that Hawaii has no CHP (b) agencies?

                            M.  RUSSELL:  No.


                            MR. HIROTO:    Hawaii Is such asmall-area.

                            DR. JANWAY:   So   is Rhode Island.  This is just for

                 my  own  education  has  nothing to do with the proposa L.

                            MR. HIR(YTO:  You can answer better  than I.

                            DR. JANEWAY:  If  they didn't have  the Pacific Basin

                  In their proposal,, could they have a single  RMP and (a.) agencyo

                  no (b)  agency?

                            MR. RUSSELL:  Ye 8

                            What you have iff this program is you have  a Pacific

                  Basinp separate program from that program conducted    in Hawaii.

                            As Mr. Hiroto said, the very   size of Hawaii and with
                  the population center being In Honolulu, where the (a)

                  agency Is operating,, and it Itself is not very strong In

                  terms of being able  @o move things forward, It has a very




                                                                         433

)4               small staff.

                           At one time there was an attempt to set up some not

                 necessarily areawide agencies,, but sort of subcommittees  out

                 on the outer islands. And that thrust-- I  really  don't  know

                 how far it has gone.

                           MS. SILSBEE:  To answer your question,, yes,, I think
                 in the DistrLct of Columbia that situation;was truep there was
                 an ,(a)@iagency, because that was it,, and 'no (b) agency.

                           We have a motion and it has been  seconded.'

                           All in favor?

                           (Chorus of "ayes.")

                           MS. SILMEE:  Opposed?.

                           (No response.)

                           MS. SILSBEE:  Motion is carried,

                           Just for the records that is the shortest discussion

                 we have had on Hawaii in f'o'ur years*

                           NRS. MARS:  That's trues very true,
                           (Laughter)

                           MS. SILSBEE:  Incliane6

                           Mrs. Klein.

                           MRS. KLEIN: Indiana was rated by  the  committee  as

                 average or below average.  You,can see by your green slips.

                           The comments In the comments  the  committee  talked

                 a good deal about the broad general nature of tlle report its&-If

                 and the fact@there were not very many specifies in Lt.  And  I




                                                                            434

                  had to concur with this when I read it.

                            As a matter of fact, being  a  novice,  I  decided  that

                  I would read the comments of the  committee  first  and  see,if  I

                  agreed with them, and attempt  to  find  points  of  disagreement,

                  as a matter of training myself sort of.

                            The  report showed a good working relationship with
                  CHP, but it didn't specify in  what  manner  these  working  rela-

                  tiohships were carried out,

                            Many of the program E;    and they did  have  mgny  pro-

                  grams    were a little difficult to assess because th y weren'

                  specific in terms of what they were actually doing

                           They were conducting some sort  of  study  to  d  termine

                  health deficits they called it., and  they  were  developing  pro-

                  grams in quite a wide variety of areas,,  including continuing
                  education., legislation for statewide emergency services., neigh-
                  borhood health centers, s@ate stroke therapy, and    hypertension

                  and coronary care units, and quite a number of others too,

                            Most of their-requestecl appropriation was for alloca.-

                  tion of funds, I guess I should say, was devoted to staff.  Am[

                  Although I think the Ad Hoe Committee was  sort  of  in  the  mood

                  to cut them,,a good deal because,of the inadequacies of the

                  reports they decided that since most of it was for staff and

                  they had so many programs, as I Interpreted it anyway,,   that th4,-y

                  were doing something,, and that they should I'@ b-e  permitted  to

                  continue the principal part of the program.





                                                                              435
                            They dido however,, cut the recommended funds by
                  $100,000, and I have a little difficulty determining  on  what
                  basis they did.  But there were-Beveral items they parti cularly

                  questioned.

                            One of Lhem was sort of a teleanswer series in

                  medical education,, sort of dial-a-disease program that the com-.

                  mittee apparently wasn't very enthusiastic about.

                            Also they were studying-- wanted to  study  he  pre-

                  vention of organ  rejection, and the committee felt thaU that;

                  was a basic science study which could just as well  be  funded

                  by some other method.
                            -And they also questioned the continuation @f the
                  emergency medical service program,

                            In any events the committee decided to cut them only
                  $ioo,,OOO and considering the wide variety of progra@ that the7
                  were conducting,, I felt thl, probablyin my uninformed manner,,
                  that thib was sufficient.out,, and that lc@ the reason tha@ I

                  have moved thai; we adopt the committee's recommendation of

                  $ L@ I,,  L59.

                            NR. MILLIKEN:  Second.

                            MS. SILSBEE:  Do you have anything, Mi ss Martinez-t'

                            !)r, Janeway,

                            DR. JANE-WAY:  Perhaps it is in the trans cripts.

                            It doesn't show in the yellow sheets.-
                            Steve Beering is now the Dean at Indiana,  Have they




                                                                                 436
7
                  changedp got a new director coordinator?

                             MR. VAN WINKLE:  For sometime Steve has been the

                  coordinator on a part-time basis.  Even prior to the time       he
                  took over the deanship.  But they do have a full-time program
                  director. I guess  you  get  into  semantics  --  director  versus
                  coordinator.  But Steve still is    maintaining a very a,-tivelrole
                  in the direction of this program.

                             DR. JANEWAY:  Good.

                             MS. SILSBEE:  Mrs. Flood.,

                             NRS. FLOOD:  The Review Committee apparentl
                  raised"some questions about the R4S    activities,   It w     also

                  an area for staff concern,

                             But I see no assurances that this was    an inappropriate

                  EMS activity in Light of the MS action.
                             Was this particular--

                             MR. VAN WINKLE:"WE flag all EMS, not necessarily
                  because of concern but for reviewers' consideration.
                             We saw no problem with th'e EM activity they are en-

                  gaged In.

                             They have been instrumental already in obtaining
                  legislation establishing   a State Commission on  EMS,  and  have-

                  very small appropriation   to fund that Commission.

                             But what you see the funding here was strictly staff

                  work for RMP themselves.

                             MS. SILSBEE:  I think the committee was concerned




                                                                                 437
are 26            about that, maybe trying to get an idea*

                             MRS. FLOOD:  Yes.  The green sheet ref lects the com-
                  mittee believes the support of EMS activity was below private
                      or at least open to question.  But they classify that with--
                  based on the information presented.

                             I haven't looked at the whole application, but I
                  Would guess it was low priority at this point in the EMS,

                  development in   that area,

                             NR. VAN WINKLE:   As I recall the discussion they
                  were raising whether this   EM activity was appropriate for
                  funding  in view of the EMS legislation.

                             They were raising the same question.

                             MR.JEWELL:  That is true.

                             MRS. FLOOD:  But they really didn't    cut funds.

                             MR. JEWELL:  Yes. ma'am,, I think that is the reflee-
                  @ion;as I  read it, Mrs. Flood,, that is the reflection.

                  Because the EMS proposal is $1000000.

                             There is nothing new in this application.  ALL con-,

                  tinuation.

                             M. VAN WINKLE:  -ALL continuation,

                             NR. JEWELL:  That is reflected In the committees

                  recommendation,, I believe.

                             MS. SILSBEE:  The motion has been made and seconded
                  Indiana program application be funded at the level of $1,121,1!9.

                             MRS. YARS:  Question.





                                                                         438
29                          MS. SILSBEE:  All in favor?

                            (Chorus of "ayes.")

                            MS. SILSBEE:  Opposed?

                            (No respo@ e.)

                            MS. SILSBEE:  Motion is carried.

                            The next region to be reviewed is Iowa.

                            A nd Dr. Wammck Is the reviewer.
                            DR. IWAMMOCK:  Well,, some people speak from experience

                  and some people from experience won't speak.

                            MS. SILSBEE:  WILL you 'speak Into the microphone,

                  please.

                            (Laughter)

                            DR. WAMMOCK: Just once only, I  can't  do  it  again,

                           -WeLL,, I caught a slippage hereafter I reviewed this,

                  I find an epistle right back of the green sheet.  But the

                  .epistLe-- this is in all due respect to the reviewers,  under-

                  stand., has no reflection on any characters, living or dead,,
                  past or future; in the first place, this projects  the  program

                  was very well put together-, very well documented.  And as  far

                  as review,was rather easy-to do.

                            And a request was made for $1,06L,349, was so approved

                  by the committee.

                            And I will make reference to the review by members of
                  the staff at a Later moment here as I go thro@ this,

                            This program was well organized.  A few comments I




                                                                             439
                  wish to make, very comprehensive,put together very wellin veryl
                  orderly fashion.  Most of the activities originate under the

                 ,aegis of the University of Iowa.

                            I point this out, it seems to be  controlled  in  that

                  direction.

                            Of course, I take into consideration what goes   on in.
                  the State of Ohio.  I think that would be perfectly legitimate

                  a,thing under the circumstances

                            Family nurse practitioners for use in rural  area,,  I
                  don't know whether you classify this  as  assistant,,physician's

                  assistant.  But you may need to.

                            Primary family care planning program, this Is tio
                  design two statistical models,, one to explain and predict;
                  the other to identify-- (inaudible)

                            The other institute, talking about primary care
                  planning, $24pOOO, number "two is to collect and  use  available

                  demographic health geographic data in testing the model in app:@
                  ing it to past and present circumstances, or pertinent to Ioewz,

                  subregions,

                            Maybe somebody would want to explain all  of  that  to

                  me.  I don't quite understand what it is all about.  But I will

                  pass it up if somebody wishes to refer to it all right.
                            The other plan is a homemaker, home health,  a  train-

                  ing project.

                            This program has been used in other  areas and one





                                                                                44o

                  area I am particularly familiar with, we  fou@  this  to  be  very

                  beneficial to people who cannot  be  contained  in  a  hospital

                  over a Long period of time, but do need the systems et home.

                             We found this a very good  program.  We  put  it  in

                  operation  many years ago.  Politicians in our Local area

                  failed to  take it up and  carry  it on, because they t ought   it

                  would cost too much money  to  do  aprogram.  They wou  d   rather

                  keep them in a hospital than    worry about that.

                             The other point is  the remarks about  the   uriform

                 .record system for quaLity care Improvement.  I    think  I  have

                  no particular quaLms about that,

                             Hospital cost study, this I wonder about whether this

                  Is a part  of the Regional  Medical Program.

                             This Is one of  their projects.

                             I say that is about aLL I have to say abou4v-  this..

                  except for the fact to come over to page    234, maybe  the  re-

                  viewer would want to comment on this,, paragraph here,, we-re-

                  ceived on the twentieth of  May  coordinators--  this  Is  about

                  the CH (b) agencies,

                             Maybe staff would like to comment 'on that,

                             MS. SILSBEE:  What page was that?

                             DR.  WAMMOCK:  Page  234.

                             That has to do  with  the breakdown of machinery.

                             MR. POSTA:  I would Like to have Mr.. Zizlausky

                  talk to this point.  He has gotten additional Information





                                                                              441
 32                from CHP.

                             I would Like to say this if I might,, sir, I woul
                                                                                d

                   say Iowa is considered  a  superior  region.

                             DR. W.AMNIOCK:  I apologize  It  was above tc)

                   superior.  I enjoyed reading it, real pleasure to read it,

                   because -- some of them, you know

                             MS. SILSBEE: It pulled together well.

                             DR. W-AM@IOCK:  Pulled together?  Trash cars

                             I am talking about the way that the project that
                   was being applied for     it was presented to the RMP here.

                             MR. POSTA:  Mr.  Ziziausky.

                             MR. ZIZUUSKY:    That is project 60 you are saying,

                   primary medical services?.

                             MS.  SI@BEE:   Page 234.

                             DR. W.AmMOL;K: Page 234 on'your  transcript.

                             Got  the  transcript? Or  shall  Iread it for you?

                             bM. ZIZLAUSKY:  I  don't  have  it with me.

                             What is the  area  of concern about?

                             DR.  WAMOCK:  It-  is about the CHP, the relationship

                   with the RMP.

                             MR. ZIZLAUSKY:  Fine.

                             What had happened is when they submitted their May
                   Lst application,, they were caught in a lot of the'project de-
                   velopment    last time In this.  We approved a.three-day ex-
                   tension here for an application coming In May 3rd,  They haa




                                                                        442

                 not had all the CHP review and comments in, all the proposals

                 were out to CHP  (b) agencies.

                           Subsequently we received, and we-are still getting
                 in comments from the CH (b) agencies on these project activi-
                 ties, and so far none have been negative.
                           DR. WAMMOCK:  I have three here which are a part

                 of the project request here.  Dated I-lay23rd.  And none of

                 these have been negative.

                           MS. SILSBEE:  The.aclditional ones that have come

                 in?

                           MR. ZIZLAUSKY:  Now, we have additional health pLannino,
                 councils who have submitted additional letters for revie@w and
                 comment, and the program staff is negotiating the differences*
                           There aren't any major differences  We explained
                 what this one project, project number 6    I thought you were
                 taLking about project number 6. family services
                                                                 in Iowa, was
                 recommended for disapproval.  This was one of the Northeast
                 Iowa Health Planning Council recommendations.

                           They have ironed-their problem out and this is on
                 the yellow sheet.  It is the only negative comment, but that

                 negative comment has been resolved.

                           DR, WAMMOCK:  That has been resolved?

                           MR. ZIZIAUSKY:  Yes, sir.

                           DR. WAMMOCK:  Fine.

                           MS. SILSBEE:  Mrs. Morgan.




                                                                           443

                             MRS. MORGAN:  I think it has been more discussed

                  than I can.


                             MS. SILSBEE:  Okay.  Do you want to make a

                  motion?

                             DR. WAMMOCK:  I make a motion it be approved fo@

                  the  sum  of

                             MS. SILSBEE:  $i,o6t.349?

                             DR. WAMMOCK:  -- $i,,o6l,,349.
                             Again.. I apologize for not recognizing the Prepa'ra-
                  tion and   review of this by the staff and calling    attention
                  to this abov e average to superior.  I appreciate   those-- that
                  gives me, youknow,  a  springboard,

                             MS. SILSBEE:  Is there a second to that?

                             MRS. GORDON:  I second It.

                             MS. SILSBEE:  Motion has been made and seconded that
                  the Iowa application be approved at the Level of $1,061,349.

                             All in favor?

                             (Chorus of "ayes.

                             MS. SILSBEE:  Oppose!?
                             (No responsi2.)

                             MS. SILSBEE:  Motion is carried.
                             Next region is Kansas" and Mrs. Gordon, the record

                 should   show
                               will be out of the room.
                             (At,this point Mrs. Gordon withdrew from the room.)
                             MS* BILSBEE.: Mrs.  Morg an.




                                                                         444

@5                              MORGAN:  The Kansas RMP was reviewed as being

                  above average to average.

                            Dr. Browp has been coordinator since 1966 and has

                  done very well in coordinating with the Kansas factors.

                            The Review Committee really only showed  two  concernE

                  one was what they felt was an overambitious  project,  regional-
                  ization of perinatal careo project.number 91.

                            The committee also showed concern over lack  of  docu-

                  mentation that the continuation of these activities after 197-@,

                  we have since -- this was reviewed by committee     receives

                  from Kansas various letters showing that these are-being con-

                  tinued.

                            The Berkely project being continued by a  lung  cancei

                    Mary?  And Dr. Brown is very enthusiastic the perinatal

                  project will be continued by the state.

                            They did,, during phase out, lose an outstanding
                  black professional from their staff. They do  have  female  pro-
                  fessionals on their staff.  Minorities aren't as well repre-

                  sentecl as we would like to-seoo, but this occurred during

                  phase out when I think minorities were the first to Leave the

                  staff when they were afraid of It being phased out.
                            The'Review Committee did decrease their request by
                  $100,000, this being to alert them to take a more  careful  look

                  at the project 91 perinatal care*

                            I move that we accept the  committee's  recommendation




                                                                          445

                 of $i@633,380 to the Kansas RMP.

                            MR. HIROTO:  I second that.


                            I have this one question, I would Like to know  what

                 this community health education program number 51 entails?

                            MS. SILSBEE:  Miss Murphy, project 51.

                            MISS MURPHY:  That is one of the H/SEA's in Wichita.@

                 They are expanding considerably.
                            It is an H/SEA project' in Wichita; they are expandifi7

                 it considerably.

                            ER. HT-ROTO:  Okay, thank you.

                            MS. SILSBEE:  Mrs. Flood.

                            MRS. FLOOD: Mrs. Silsbee, may I  inquire,  you  said

                 you had received communications from Kansa4 possibly from

                 Dr. Brown,, about continuation funding of the perinatal program

                 from the state.

                            Can we know what segment of the state?

                            MISS MURPHY: I have the whole  proposal,  the  cover

                 letter.


                            Ihaven't gone into it in  that detail,

                            Specifically, I think she meant the other, the
                                                                             new

                 projects.  Dr. Brown felt this perinatal care projects
                 differe@t  components of it would be carried on by different

                 phases within the state.

                            MRS, MORGAN:  Not the state legislature., just the

                 State of Kansas,






                                                                           440
                            DR. JANalAY:  That is a fairly common thing for

                  states to support, premature nursing programs,

                            MRS. FLOOD:  My concern is., we'--have gotten some

                  fairly strong assurances of continuation funding for those

                  projects that had some concern to the committee.

                            Why are we cutting them $Ioo,boo for an ab ve average
                  area?  What was the criteria for the $100,000 cut re ommended',

                            MRS. MORGAN*.  I don't thin the committee lelt they-

                  could utiLize that amount in a year's time.

                            'MRS. FLOOD:  Th ank you.

                            MS. SILSBEE:  The motion has been  made and seconded

                  that the Kansas application be approved at  the level of

                  $1@633,380.

                            Is there further discussion?

                            MRS. YIARS:  Question.

                            MS. SILSBEE:  All in favor?

                            (Chorus of "ayes.")

                            MS. SILSBEE:  Opposed?

                            (No response.)

                            MS. SILSBEE:  Motion Is carried.

                            And would someone bring Mrs. Gordon back in.
                            (A tthis point Mrs. Gordon returned to the room.

                            MS. SILSBEE:  Next application to be reviewed Is

                  Maine.


                            Mr. Hiroto,





                                                                             447
,8
                             MR. H IR OT 0: I move that the review co=ittee's

                  recommendation of fundin,, level of $L,,76Q,,OOO be approved,

                             The only comments I have are that the Main RMP

                  is considered superior in all respects and they meet all the

                  criteria and they meet the review requirements,  and  they  have

                  obviously been doing a very superior job.

                             MS. SILSBEE:  Mrs. Morgan.
                             MRSI MORGAN: -It ma'
                                                y be noted that Maine was one of -

                  the few, probably the only IW that when durino,  phase  out  had

                  appropriation from their state legislation to continue that

                  program,

                             I think this speaks well of how high the Maine

                  program   is regardedv7ithin the state and I  second  the  motion.

                             MS. SILSBEE:  Motion has been made and seconded that

                  the Maine application be  approved at the level  of  $1,760,000.

                             IL there further discussion?

                             ALL in favor say "aye,,

                             (Chorus of "aye.

                             MS. SILSBEE:  Dr-. Janeway?

                             DR. JANEWAY: Perhaps I didn't hear  it.  I  may  have
                  been sleeping. But did the staff have any explanation,, why
                  did they cut it $300POOO if it is all that great?

                             MS. SILSBEE:  Mr. Peterson.

                             MR. PETERSON:  One of the running th7reads in panel B,
                  which considered Maine, was looking at not only the amount




                                                                                       44

.9                  requested, but also such factors as what are they funded

                    at presently  and  to  population,  and  it  was  pointed  out  that

                    Maine was a state  of  about  half  a  million  people,,  thatthis

                    level of funding would give them one of the highest per capita.

                               Whether that is a  valid  point  or  not  is  for  this

                    Council to consider.  But  it  was  on  that  basi.%  and  indeed

                    Maine was one of three regions     which  In  the  sort  of  wrap-up

                    session went back and looked at all 25.  They       decided,, well, iie

                    will up this 10 percent.

                               We dealt perhaps a little     too harshly with it.  But

                    that certainly, as I understood it,     was the rationale     for

                    cutting Maine somewhat.

                               DR.  JANEWAY:  Does  the  staff  have  an  opinion  as to

                    whether that will limit their capability for fulfilling these

                    superior programs?

                               MR. PETERSON:  I  can't  speak  to  that  because  I  was

                    acting In  a chairman function.

                               I rea-Ily     in  the  sensd'of  not  that  conversant-

                    with Maine's overall    program,,-I think it is--

                               MS. SILSBEE:  I  can't  really  speak  for  Mr.  Nash,,
                    who is not here, but at the present time @his region is ade-

                    quately funded.

                               I don't think it    is going to be-- it  cut  back  son's

                    of their activities,, but I   don't  think  it  wilt-hurt   them.

                               DR. JA@TAY:  They don't fall peril to the fact the




                                                                            449


0                state government was too forthcoming?

                            (Laughter)

                            MR. PETERSON:  It wasnt that forthcoming,

                            MS. SILSBEE:  Ms. Resnick.

                            MS. RESNICK:  Correction on the  population; it is ove

                 a   million.


                            MR. PETERSON:  I am sorry, it is over a milVion.

                            MS. SILSBEE:  WeII, th
                                                  e motion has been made a'nd

                 seconded that  the Maine program be-funcled at $1,760,OCO.

                            MRS. FLOOD:  I feel like Janeway, probably this is

                 one we are really pointing with pride to ancl,laucling and

                 applauding, and then we  cut them.

                            And although we may feel it doesn't hurt them, per-

                 haps our primary reviewer could tell us a Little bit about the

                 program strength as it relates to,, you know, goals and objec-

                 tives.

                            If it is all there, aLL put together, then why do

                 we buy  at this point a particular philosophy that apparently

                 permeated  one review committee, and we know has In the past

                 been sometimes brought lnto.play; is the capitation dollar

                 spent in a state, which Isn't valid in my f@'eLing as a way to,

                 measure the amount to be spent in a region.

                            MR. HIROTO:  I think there are probably three regions

                 that  have a superior -- and I may be wrong -- ranting, and

                 Maine  and Florida, and there was one others and they all tend




                                                                          450

                 to be reduced.somevhat if I am not mistaken.


                            MRS. YIARS:  Feeling of compulsion.

                            MR. HIROTO:  I just went along with the reviewers'

                 concepts.

                            IC. SILSBEE:  WeLl, do you want to reach all of this

                 by a voting on this motion?

                            The motion is to approve it.at the recommended level

                 the committee gave, $L,76o ooo.

                            All in favor say "aye."

                            (Chorus of  "eyes.")

                            MS.  SILSBEE:  Could we have your ha ticl son that?

                            I think it.is  weak.


                            DR. WAMMOCK:  I am sorry, I was out of the room.

                            MR. HIROTO:  May I suggest we gp backto these par-

                 ticular ones and  review  them.

                            DR. JANEWAY:  I didn't mean to open up a hornet's

                 nest.


                            I thought the staff had morec.dpmmentstith&n they get

                 on whatever color the sheet iir    ltis blue or something like

                 that -- only when It is si-tting on top of ye,Llow.

                            I thought it was green.

                            You know, that there would be a comment that there -was

                 some padding on the part of the budget, or somethings

                            MR. HIROTO:  Doesn't say that.

                            MS. SILSBEE:  The staff member familiar with this





                                                                             451
42                region  is not here todW,, That is why I find It difficult.

                             DR. JANEWAY: It  is  altogether  probable  they  had

                  full and sufficient reasons for doimg it.  I just dorlt see

                  anything--

                             MS. SILSBEF. You are  right.  'They  originally  had

                  approved it at a higher level and went back and it wEs--

                             MR. PETERSON:  No, they had approved it at a some-

                  what smaller level' and added ah,-tldditional 10 percent on,

                             MRS. FLOOD:  Felt guilty and came back'.

                             MRS. MORGAN:  Dr. Thurman was on that.

                             MRS* FLOOD:  No, not really, it doesn't.@

                             I haVe-a thing about capitation -calr-ulatio so

                    @,'d6n't think that the dollar spent  In  sparsely  Populated
                  diverse climates and terrains  can be mea-sured  against a
                  dollar spent In a high impact, highly profe   bsionaL setting,

                  with a lot of availability of services.

                             It bothers me a little, the thought there might have
                  been this thought taken into consideration when    the funding

                  level was recommended.

                             MS. SILSBEE: We-have  a  motion  that  was  haLf-way
                  voted and for $L,,760,000., and the "ayes  were  about  to  put
                  their hands up so we could count them.
                             (Show of hands)

                             MS. SILSBEE:  Four.

                             All right., the nays?




                                                                            452

!4 3                        (show of hands)

                            MS. SILSBEE:  ALL right,, we need another motion.

                            MRS. MARS:  I would like to make a motion that we

                  fund the program to its full request of $2,o2o,875.

                            MISS bMRTINEZ:  Second.

                            MS. SILSBEE:  Motion has been znade and seconded

                  that the Maine application be approved at $2,920,875.

                            ALL those in favor say "aye."
                            (Chorus of "ayes.1t)

                            MS. SILSBEE:  Opposed?

                            (No response.)

                            MS. SILSBEE:  The motion is carried.

                            The ne@t region to be considered will be

                  Metropolitan Washington, and the record should show Dr.

                  Schreiner is not here.

                            'Mr. Hiroto, you are it again.

                            MR. HIRC)TO:  I am?  Oh. my gosh.  I have to

                  remember what I read.

                            The committee reco@nd4 and I   move their recommenda-
                  tion be approved, that there be reduced funding of $1,100,000
                  for the @tro Washington, D.C., RMP.-

                            They are rated averageto above average.  And their
                  estimated request for May of 1974 is assumed('to be $450,,000.

                            There are continuation projects requ@sted and four


                  news





                                                                              453
4                            Several of these relate to kidney disease.

                             Dr. Schreiner isn't here, unfortunately,

                             MRS. MORGAN He  wouldn't  have  been  here  anyway.

                             MS. SILSBEE.  He wouldn't be slowed to speak to

                  that.


                             MR. HIROTO:  No, he wouldn't.

                             But conversation  by the reviewers in regard tothe
                  kidney disease programs tends to make it seem extremely         Locked

                  at with good favor.

                             I don't know why the  reductions  the  $172,385  reduc-

                  tion.

                             MS. SILSBEE:  Mr. StoLov, is he here?

                             Mr. Peterson?

                             MR. PETERSON:  I can't reaLLY      I  haven't  refreshed

                  my memory  on this one by Looking over the transcript again.

                             Some of the discussion certainly about this region

                  was related to the fact that it had  been  a  poor  performer,  an

                  under performer up until  very  recently.  It  seems  to  have

                  some heartening change in thatr regard, and  it  may  be  part of  a

                  general e,4uation that It wasn't all that good.  Butp you    know,,
                  I don't recall on Washington Metro  D.C.  there  was  a  particular

                  rationale.

                             Here was a group of activities that they had questions

                  about, not the kind of consideration  that  went7-into  the  Maine

                  decision. I do6lt  recaLl  anything  from  the  panel  discussion.




                                                                                454
                            MR. HIROTO: There was a  question  raised  about  the
                 $132,,,OOO that was going to be expended for  the  comprehensive

                 health planning, but apparently   that was okay.

                            That Is all that comes to me out of th@t review.

                            MS. SILSBEE: ALL right.  Mrs,  Klein,  did  you  have

                 anything to add?

                            MRS. KLEIN:  No, I don It real Ly.
                            I will second the motion.

                            MS. SILSBEE:  Do yQu move?

                            MR. HIROTO:  Yes.

                            MRS. KLEIN:  I think the motion was made.  I will

                 second   it.

                            MS. SILSBEE: All right.  Motion  has  been  made  and

                 seconded that the Metropolitan Washin.-ton application be
                 approved at $L.,100.,000.

                            Is there'further discussion?

                            ALL in favor?

                            (Chorus of "ayes.

                            MS. SILSBEE:  Opposed?

                            (No response.)

                            MS. SILSBEE:  Motion is carried.

                            The nextregion is Michigan, and Mr. Milliken is the

                 reviewer.

                            MR. MILLIKEN:  I would like to have.-a-rundown by

                 staff on this.




                                                                             455
 46                         MRS. MARS:  Can' t hear you.

                            MR. MILLIKEN:   I would, like to have staff give
                  some backdrop on this before we get Into it.
                            The program has evidently slipped considerably
                  lately and my question is, alternative of..,funding them in a
                  reduced amount or, on the other hand, questioning their future?

                            MS. SILSBEE:  Questioning their what?

                            MR. MILLIKEN:  Their future completely.

                            MS. SILSBEE:  Mr. Van Winkle.

                            MR. VAN WINKLE:  Well, it was considered by the
                  reviewers to be an average or below average region, a.nd
                  if you look at it retrospectively, this region start    off
                  with Dr. Hustis as a coordinator who is quite an able one, and
                  after he retired,, the program slipped badly.
                            Then Dr. Tupper came aboard and brought it back up
                  to an A region.
                            At the time of the threatened phaseout, Dr.  Tupper
                  accepted another position at Grand'Rapicis,, Michigan, donating
                  a portion of his time on a-contin'uing basis to this program*
                            Judging from the- application,, we would kind of feel
                  that it has slipped under the new leadership also, Sewall.
                            We have some concerns about what we see In the packax,e
                  the same as the reviewers did.

                            The RAG is still intact.
                            Again, we had some concerns about the process,




                                                                              456
17                looking at some of the program  activities  that  are  included
                  in this particular proposal.
                             I did raise the concern yesterday  about  the  auto-
                  mated territory peritoneal dialysis, with Dr. Schreiner,
                  a nephrologist., He'-d-idnl.t see,,atiY, serious problem with this,
                  He says it is probably not of high priorltyin the nephrology
                  field.  He sees nothing wrong with it., but he didn't seem to
                  think it held very high priority.
                            The main concern.I think that  the reviewers had'
                  was the EMS activity that durirgthe previous  four-month period
                  or six-month perico, I am not sure, had been funded at a  level
                  about $37,,OOO and, as you can see in thisapplication, it  jumper
                  to $750,000.  And they doubted seriously,, after Looking at it
                  quite carefully, that they could  dven begin to carry out what
                  they had laid out for them to do,, even in this one  proposal,,
                  in a one-year timeframe.
                           IC. MILLIKEN:  I gather from the committee's recom-
                  mendation, it was felt that there V-as a potential of at least
                  effectively using that much uni5er-the  present  circumstances?
                           MR. VAN WINKLE:  Yes.
                           MR. MILLIKEN:  I would then move the committee
                  recommendation be funded at $2@5OOoOOO.
                           MS. SILSBEE:  Is there a second?

                           MRS. MORGAN:  Second.
                           MS. SILSBEE:  Dr. Wammock, did you want to comment?





                                                                            457
48                            DR. WA M/iOC K: I came to about the same conc Lus ion  her

                   that has beenalreacly pointed out by 1-ir. MiLliken and Mr. Van
                   Winkle,, about the project being average or below average.

                              Twenty-four-hour statewide emergency drug analysis

                   feasibility study, I don't know about that.

                              Neighborhood pharmacies aftC hypertension controls

                   I don't know about that,
                              And IEMS, as was pointed out  already,  $36,000  a  year

                   previously jumped to $750,000.

                              These were things I picked out actually before I got

                   this review here, trying to figure out which way we were

                   going.

                              The vocational educational center to plan to develop

                   systems for continuation regional health calls.  Renal

                   .disease, radio and television spot announcements.  And then

                   educational program for automated renal dialysis    ' renal

                   failure, raised some doubts in my   mind, and there are 4L

                   projects here@  And it looks Like    It will take a Lot of sweep-

                   ingto cover all those projects.

                              MS. SILSBEE.-' Do you think  that  the  reduced  funding

                   level will alleviate some  of  the  concerns  that  you  mentioned?

                              DR. WAMMOCK: I think It  would  have  to  reduce  it  to

                   some Level or other,, I would think it would.

                              I am sure that the reviewers  have  gone  over  this  In
                   great depth much more so than we have had the opportunity to doy




                                                                           458

                  to analyze this thing and review it.  But with Milliken Is

                  observation hereo I think that we are all thinking about in tte
                  same direction that there has been overheating of the stove

                  here, you know, and that something has to be done to cut

                  it back,


                            I think the recommendation here--

                            MR. VAN WINKLE:  They cut roughly $1.3 million.
                            DR.IWAMMOCK:  -- $L.3 million    has got to cut
                  something out.  They can't carry no 141 projects.  No way

                  they can do it.

                            Did you get a second to t?

                            MS. SILSBEE:  Yes, we did get a second*

                            Mrs. Morgan was very helpful to second it,

                           .DR. WAMMOCK:  Thank you.

                            MRS. FLOOD:  My only concern would be the advice
                  .letter notifying them of possibly reduced funding, If we vote
                  this particular way., would be that theybe advised that the EMS
                  component would more appropriately"be under the,new legisla-
                  tive actions rather than from this source.,

                            I would hesitate to encourage them, to even use a

                  portion of their now reduced funding to continue this kind of

                  a massive EMS expansion under their responsibility.
                            DR. JANEVAY:  Except there are certain things In
                  RMP, specifically say you ought to get into EMS-areap directed

                  activity.




                                                                           459
:-)o                        MS. SILSBEE: But not $73,000 level  from  $750,,000.

                            Now., the motion has been made and seconded that the

                 .Michigan application be approved at $2.5 million.

                            Is there further discussion?

                            DR. WAINIMOCK: Yes.

                            MS. SITSBEE:  A-11 in favor?

                            (Chorus of "ayes.11)

                            MS.  ILSBEE:  Opposed?'

                            (No response.)

                            MS. SILSBEE:  Motion is carried.

                            The next application to be considered  is  Missouri.

                 A ncl Mrs. Morgan is the reviewer.                         I

                            MRS. MORGAN:  In the comments heret reviewing committee,
                 Dr. McPhed.rin, who used' to be on this Council, was primary

                 reviewer.


                            You can read it and practically feel he is in the

                 room  again.

                            (Laughter)

                            He goes on to say he had received additional materia.

                 since receiving the Missouri application, but he hasn't

                 changed his mind a whole lot.

                            It amounts to really coming down that  Missouri  has

                 had a tendency to go along with what the needs  were  with  the

                 current legislation. It hasclone very well at th-is.
                                                             o
                            When it was computer bloengineering type output, the,,r





                                                                          46o
                 were very very heavy on this.  And it was extremely difficul
                 over the years to get them to turn off of it.  They would far

                 have preferred to stay that way.

                           Finally.. It has, in this proposals be turn d off.
                           There is one question, and this is  among  t  eirrumer-
                 ous    I believe it is 11 proposals of EMS, tota:Ling  bo@t.
                 $600,000, and they appear to be rather  fragmented  pr  osals,
                 none of them are into a statewide unit.
                           Ithink that the recommended funding was  lower  than
                 what they had requested of about $600,000, approximat  Ly  the

                 amount of their EMS proposal.

                           They were rated average by  the reviewers, L  ter  when
                 they compared it to other RMP,S they  rated it superior as

                 far as this goes.

                           MS. SILSBEE: That means there  were  two  reviewers$
                 one rated average and the"Other rated it superior.
                           MR. POSTA: And the superior  was  based  on  grantsman-

                 ship.

                           (Laughter)

                           MRS. MORGAN:  And they have done very well over the

                 years,

                           I agree with the Review Committee in  that  these  many
                 EMS proposals are quite a bit of money for a Lot of little
                 proposals that are not very well coordinated in-to a state EMS
                 statewide organization,  And if they used their money made




                                                                                461
 52               available to them, they should be -- or  we  should  be  assured

                  that.they are working towards a   statewide  comprehensive  pro-

                  gram,


                               go along with committee recommendation of

                  $2@364,333.

                             MS. SILSBEE:  That is a motion?

                             MRS. MORGAN:  Yes.
                             MRS @ MARS:  Second.

                             DR. JANEliAY:  Right on target.

                             MS. SILSBEE:  Does staff have any comwnts?
                             -MR. P 6sTA: I would like to bring Lip just one
                  and,, Leah, feel free-to add anything to the Regional Office

                  as far as comments.

                            .Again, back to the EMS review group, it met on Monday'
                  and Tuesday of this week.  There w@ two planning grants
                  b.obrovedo about $45,000 eacht one to the (b) agency in C'Olumbi

                  right in the center of the state, and one at Kansas City.

                             Now, EMS has been  cons@red  a  number  one  priority

                  of the Missouri R14P. They have put in  an  awful'lot  of  money.
                  It was a concern of the pELnel review group ip n Monday  and  also
                  from the HEW regional office who  submitted  their  comments  to

                  us, that before any further E14S activity lsfunded by  the  RN:P,
                  that the Governort council shouldbe consulted to be absolutely

                  assured of what types of activities would be f-wnded throughout

                  the state in this area.


                                                                          462

)-3                          Leah, Would you like to make any other comments?

                             MS. RESNICK:  Except to emphasize that EMS project

                  proposals  are,really stemmingfrom their state law -- they

                  did not feel that     the new legislation would give them enouEh
                  time to develop a total plan. And so they  wanted  to  go  ahead

                  and try to help the oQ@nities meet their requirements as

                  best they could within the coming year.

                             Sta e law is an emergency medical services standardi-

                  zation   law requiring certain equipment and  training  of  atten-

                  dants on vehicles.

                             MRS. MORGAN:  Is It funded by the state?
                             MRS. iRESNICK:  State law is just a regular authority
                  for them to go ahead. So far they do not have  money;  they  are

                  hoping to get it through legislation,

                             M6* bILSBEEo. 'Motion has been made and seconded.

                             Dr. Jpnewayo

                             DR. J.,",NEWnY:  We may be into it again  I wonder

                  if the primary reviewer or  staff had comments?

                             I hate to ask about proposals    C042..' pilot model,,

                  new health legislation?

                             MRS. FLOCD:  Yes*

                             (Laughter)

                             MRS. MORGAN: Go ahead.  I don It have that.

                             MS. RESNICK:  The reviewers observed that and made a
                  strong pitch against supporting not only C042, which is a




                                                                         463

,4                central program operation, but the liaison district  offices

                  which are part of this total plan, and plan pending new legis-

                  lation.

                            DR. JANEWAY: That will be  In  the  reco,@ndation?

                            MS. RESNICK:  Definttdly.

                            MS. SILSBEE:  -All right, motion has been   e and-

                  seconded the Missouri application be approved at the level

                  $2@364,333..

                            -ALL in favor?

                            (Chorus of ayes.

                            MS. SILSBEE:  Opposed?

                            (No response.)

                            MS. SILSBEE:  Motion carried.

                            I also should say-that ib one of the shortest  re-

                  views of Missouri on the case.

                            Next is Mountain States.

                            Let the record show Mrs. Klein Is out of the  room

                  and Dr. GramLich was not.present durino- the review of this
                                                        C>

                  application.
                            (.At this point,,M-rs. Klein withdrew from the room.)

                            MS. SILSBEE:  Now,, Dr. Wammock,
                            DR. W-4MMOCK: Fotar states:  Idaho, Montana@ Nevadao and
                  Wyoming.  I appreciate thits compliment.

                            The overall request was $2,,4O9o356. -Committee
                  recommended $2,.50,000.  This was above average,




                                                                           464
5                            I am sure the reviewers would like   to discuss

                  this'program and then I will make some comments along
                  here if I have'them-- if I have t lost them.  Yess there they

                  are, right here.


                                                                                  A.
                             MS. SILSBEE:  Do you want the staff to say something
                             DR.WjiMOCK: I -think it.would  be  appropriate  here,
                  because there  is a sit@tion, not an epistle here to this
                  sitauuion, so @e are going to   take a--
                             MS. SILSBEE:  Okay, Mr. Rutsell, do you  want  to  do

                  it?  Or Miss Flythe?
                             MR. RIFSSELL:  Miss Flythe and I just spent an entire
                  week in Intermountain program reviewing, review processed
                             We were extremely impressed with not only the review

                  procdss, but the management.of the program  where  one  has  the
                  regional office, which serves four states, each of thoue statc&c
                  having their own office ads staff. One just  cou.Url  t'help'but
                  wonder what type of management problems might be encountered.

                             We were very., very impressed with the communications

                  among the staff  involvement of the program directors, involve.-

                  ment of the Regionalmdvisory Group; as we told the RMP, we
                  felt there must be something wrong and we kept looking hard

                  and harder -- just couldn't, find it.

                             It was a very rewarding visit.
                             We also got a much deeper appreciation of traveling,
                  .in-7 bhat type of geography, in a rural area.

                             MR S. G ORD ON': In 'mpril.




                                                                       465
6                          MR. RUSSELL:  It is quite an experience.    They do
                 have a travel and communication problem which I think they

                 have overcome very well.

                           I would like to ask Mr. Mereker;..who was t  re at
                 the same timej looking at their management review, t, ir  manage-
                 ment process,'so broad, just fill us in very brief-,,-,, .,,e
                 capability of the Mountain States as management.
                           MR. MERCKER:  The very first of jiprit we conducted
                 the routine administrative review;of.--the.,management of the
                 Mountain States Regional Medical Program.  We found their
                 managementto be complex., but very,, very effective and very well

                 carried out.

                           It starts with the Regional @'dvisory Group, which
                 Is extremely active, all members participating on site visits,
                 all members serving on committees.
                           The work of the Regionalhdvisory Group is tied
                 together-- that is the city work by the Regional m'dvisory
                 Group itself.

                           In the same manner and Paralleling it., the program
                 staff related very., very well to the Regional advisory Group;
                 there were four states as you know, each one having a state
                 office, program staff.  And the work of the four state offices
                 Is similarly pulled together by a regional office -in Boise,,
                 Idaho, the centra-I program staff,
                          The'-,greantee has good sound management practices




                                                                             466
                  which were well implemented by the appropriate staff, some
                  years agoo  They had direct control of the program, both the
                  administration, finance.. and also the program itself,.
                            Thiz has changed and they have assigned functions tc
                  the program staff, which noi-7 carry out the administration of

                  the program.

                            -again., it is complex: the structure would seem to
                  be one that would be difficult to operate, but  it operates
                  extremely well and they have a high Level of interest in  manage-
                  mbnt and they communicate things very effectively.
                            MS.  SILSBEE:  Thank  you,

                           Dr. Wammock,, do you  have anything further?
                           DR.W.'hMMOCK: I think it's a little difficult to be-
                  labor some oi' these programs hereo  There are over 32 here, anJ
                  the recommendation from-$2,409,356 down to.$2,L50..OOO would
                  probably take care of some of  these Little things that I have
                  Jotted down here,  Probably  correct themselves without any
                  difficulty. mnd T don't  believe  it would be worthwhile to tak@
                  up anybody's time to discuss,

                           It has been  reviewed;  as I say.it Is a four state
                  mechanism and it has been reviewed, given "above average."
                           There are a few other things here and there.
                           MS. SILSBEE:  Loucler@ please.
                           DR. WHMMOCK:  Such as activities of the physical
                  assessments skills for nurses, and so on.  Then the other




                                                                                467
-D8               thing was a serious question is raised  as  to  the  validity  of

                  Regional Medical Programs financing supporting the basic

                  curricolum-of nursing schools.

                            Mnother one was shared  service  projects,,  shared  cost

                  of materials at the Nevada Hospital association.

                            Here is one, mechanism of development of      activities,

                  community child health abuse, I understand that is    a pretty

                  serious problem.

                            -nnother one related td PSRO.

                            I would move that this program be approved for

                  $2.,L5OoOoo.

                            MRS. FLOOD:  I will second the motion.

                            MRS. GORDON:  Two hundred or one hundred?

                            MRS. FLOOD:  -$2,150,000.  @'Ithough this region

                  always seems to come up with pluses and.not to lessen the

                  glow that all of you had on  your  recent  assessment  visits,  and

                  indeed their process gives impeccable,  if  possible  --  I  think

                  it also leads to an additional prob-lem  that  Is  sometimes  not

                  viewed by a survey  visit,  such-as-you  have  just  accomplished.

                  @nd that is, from the applicant level  or  the  consumer  level,,

                  if I will, and they find that  this  very,  very  precise  process
                  that began with WICHE@-.aC'th'e' time that it was really  control-

                  Lino, the program., and Hank is ifi@-ttill,";today, it Is a very

                  difficult process to wade through to  get  a  project  funded,  and

                  they find the system Less than responsive.  'Mnd most of the




                                                                            468
 59               proposers of projects in that region find by the time it gets
                  throu-h that process,, they wouIC. have preferred to have soLgh
                  help from one  of the overlappln-  RMP's and  oftentimes  do.

                  Which in some  cases aggravates the turf problem.

                             I would urge, I am in accord they have  got  a  good
                  record and the funding level is  probably  most  appropriate,,
                  but I would urge that staff work with thib fantastic adminis-
                  trative and review process to h'u.ssle the process through,, which
                  I think in the long run will help overcome some  of  the  turf.

                  problems.

                            MR. RUSSELL:  I think this point is well taken,, but
                 ,I would haaeto-- having watched the  process  and  the  type'of
                  programs that are developing, and I will  use  as  an  example
                  what hat; happened in the area EMS.  Recognizing  that  is  a

                  popular program, very much needed one in  all  three  of  the

                  state@; we witnessed in Nevada., Idaho,, anC, in Montana  how
                  the approach o.-L-' the Mountain States Regional Medical Program,
                  throumh its core staff working with  the  communities,  bring?-
                  ing them in; starting out in Nevada$17,,OOO CHP,  in  a  very
                  short period of time t@hi@-- covered the state and involved  a

                  number of the consumers.

                            The Mountain States approach ib one of a programmatic
                  regional approach which I thInK they have  Cone  a  very  nice

                  job among those LA.nes,

                            Now, you are absolutely right, the process involved--



                                                                         469

                 .and thib is where the turf problem has created an-awful
                 lotcf problems, here is where we saw CHP's playing ctie RMP

                 against the other.

                           MRS. FLOM:  Yes, sir.

                           MR. RUSSELL:  Thi@ i--- where we recognized the
                 Interregional Council. It Is referred to as the 'Inter-triba,t

                 Council.

                           (Laughter)
                           But it has not been effective.  'nnll we f@Lt it
                 was that councils job to get their own RMP in shape to elim-
                 inate thi---, type of turf problem.

                           MS. SILSBEE;  But,. Dick, what I hear Mrs. Flood
                 saying, and I think thlsmessage shoulL, get'back to the Re-ion I
                 Medical Pro-ram, that their. very fine structure should be
                 looked at in terms of its responsiveness, in that it is so
                 Long for an I-V to get through the process.  I think they shouted
                 be made aware this concern was expressed,

                           MR. RUSSELL:  We did feed'this bzck at the end of

                 our review process.

                           MS. SILSBEE:  I think we need to do that again

                           MR. RUSSELL:  Fine.

                           ICS. FLOOD:  I will add one further comment.
                 It all falls up there in this turf situation and the Tri-

                Tegional Coordinatorl-@ Council.

                           I see thpt reviewers questioned a portion of the




                                                                          470

                Wyoming EMS project and again that is right back in the Tri-

                 region -- you kno@ Coordinator's meeting.  nnd It will never

                 be fully resolved.

                            But Is there any serious concern that this,c.ompo-

                 nent section is a complete overlap of services?

                            MR. RUSSELL:  I don't think there is really,, because

                 @e found the relationships between the Mountain States proo-ram

                 and the Colorado program to be very, very good.

                            MRS. FLOOD:  Thank you;  Those were my -questions-.

                            MS. SILSBEE:  Okay, motion has been made and secondeJ

                 that the Mountain States application be approved at  the level

                .of $2,150.,000.

                            MR. MILLIKEN:  Questions'

                            MS. SILSBEE:  -nil-in'favor?

                            (Chorus of "ayes.11)

                            MS. SILSBEE: Opposed?

                            (No response.)

                            MS. SILSBEE:  Motion is carried.


                            Will someone c-@ll MM. Klein in.

                            @t this poin4 Mrs. Klein returned,to the room.)

                            MS. SILSBEE:  Next application is New Jersey.

                            Dr. Watkins.

                            DR. W@TKINS:  Finds itself superior in all respects,

                 according  to reviewers.

                            Original request was $3.,970,024,, and the recommendation



                                                                          471

)2                is $3,190,000, and sometimes you start to be concerned  when I

                  say superior in all respects.  The committee concurred   this

                  was superiors a superior program, well utilizes funds made

                  available to it. 'Mlmost $800.,Ooo was reduced. It  shows  therE

                  is involvement in quality of care.0 in excess, shows ther  is
                  inner city where attention setting quality for standards, a  nd
                  so forth, shows an involvement with the CHP groups2  except  one
                  CH (b) sent a letter which was later refuted,, so that that  is-

                  the main question here, why it was reduced,

                            Maybe one of  the reviewers can tell me,

                            MS. SILSBEE:  Mr. Peterson?

                            MR. PETERSON:  One of the chairmen; I think  the
                  principal rationale here had two components to its going  up  tc
                  the nearly $4 million.leveL,requested.  There was some ques-
                  tion whether they could hope to mount that level that quickly

                  and they also saw them coming in at least with an anticipated
                  $600--l think it is $600,,000,, roughly.,

                            They certainly did not, &Ai they did in some other
                  things, say here are a number 'of activities which we think

                  are questionable.

                            It was more along that rationale,  Whether it was
                  valid or not is something else again,, but there was so@ real
                  concern about jumping up to almost a $4 million leveL; althoug.,l
                  'the staff has hung together fairly well, it has-been reduced
                  and that was the principal thin& as I recall it, from




                                                                             472
                  refreshing my memory with the transcript.

                             DR..VZ.TKINS:  With that explanation, I would there-
                  fore move  $3,,190,000 be given to this program*

                             MS. SILSBEE:  Is there a second?

                             MR. MILLIKEN:  Second.

                             MS.-SILSBEE: Miss Martinez.

                             MISS YviRTINEY,:  I only have one comment.      thought
                  the proposal was very good.  My only comment is in New Jersey,
                  which hFd such a-heavy Spanish speaking population,  bsolutely
                  none, no Spanish speaking persons on the @G'in      New Jerseye

                             MS. SILSBEE:  The record should show    there is a PSRC

                  proposal in there to the tune of about $225,000, and I have

                  been trying to reach a man., he calls me  when  I  am  out  of  the

                  office and I call him when hc  Is  out  of  the  offices  with  the
                  PSRO staff, anu@ that will have  to  be  resolved  before  New Jersey
                  can put any money into   that portion. But we will handle    that

                  from a staff end.

                             Dr. Janeway.

                             DR. J,;NEW@Y:  How can an RMP organi@b 4 pSRO?
                             MS. SILSBEE:  That Is the question; we can't.
                             DR. J@NEW.'MY:  It is agin the Law, isn:t it?
                             Ms. SILSBEE:  Right.  It Is just a matter of
                  clarification of what that--  and  it  Looks,  from  talking  with
                  'the coordinator., that is exactly what they are@bout to do.
                  .Mncl we will just no'-u allow itp because it is  against  policy.




                                                                        473

   64                       MR.- HIROTO:  We have hvcl several related PSRO'S.

                            MS. SILSBEE:  Thai, will be generally looked at.

                            MR. HIROTO:  Okay.

                            MS. SILSBEE:  Motion has been made and seconded tha

                  the New Jersey application be approved at the Level of

                  $3,,Igo.,Ooo.

                            Is there further discussion?

                            iill in favor?

                            (Choicus of "ayes.")

                            MSO SILSBEE:   Oppo s ecl ?

                            (No response)

                            MS. SILSBEE:  Motion  carried.

                            The next application  to be considered Is New

                  @xico,, anCA lot the record -show,that Mrs. Moroan is out of the

                  room,

                            (Jit this point,, Mrs, Morgan withdrew from the room.)

                            MS. SILSBEE:  Mrs. Gordon.

                            bMS. GORDON:  New Mexico"was  supposed to have a new

                  director as of May Ist.  I-as@me7that   transpired?

                            MR. POSTii:  Yes.-

                            MRS. GORDON:  'mnd sometime ago they expanded their
                  RiiG to 120 members.  I understand thi-- was in response to

                  criticism.

                            MRS. MNRS:  How many?-

                            MRS. GORDON:  120.,  Which I found to be just--fantaEti6.




                                                                           474
                            DR. JmNEWjY:  hrkansas has 100.  Everybody in the

                  whcile state.

                            MRS. GORDON:  I don't  see ho-..- they can have a mean-
                  in6fuL group of tha6 size functioning.  Somebody wants to
                  fill me in on that a little bit?  I would be happy to have theii,
                            MS. SILSBEE:  Do you want that discussed right no
                            Mr. Zizlausky.
                            MR.IZIZ@USKY:  Dr. 'Gay came aboard 1971.  His
                 criticism was a small gro@p @ad been making decisions.
                            (Laughter)
                            So he decided to increase it and  mak,- it more repre-
                 sentative  of all interests. m'ncl h@ has  brought it up to

                 120.

                            .We were kind of watching to  see  where he was going,,
                 and he brought it clown to 73 people now,  in  the application.
                            One part of the application  it  states L20; in the
                 othcr places there arn 73.
                            MRS. GORDON:  I sort of gathered attrition made
                 :L t730

                            MR. @IzLiUSKY:  They actually sent,out pink slips
                 to unattencing @G niembers.
                            MRS. GORDON:  So they are weeding out the nonpartici-
                 pants.-
                            MS. FLOOD:  If I may-add a point.of-tnformation..
                New Mexico is our immediate neighbor an@- I am a little familia?




                                                                            4 7
 66               with wha- they di.' on that @G and it was phenomenal.  Bua,

   -              they did regional concepts in a sen-e.  The state is ver,

                  diverse in both clima@ue., terrain, attitudes, and service
                  @cappabilities,, and so Dr. Guy's concept was a develogmenu  of

                  a sort of subregional @G concept. ' They were all @C members,

                  all invited to the total @.G meetings but there were also some@
                  specific assignments of responsibility to be spokesman for thel

                  southeastern section or northeastern section,

                            ."ncl icl did., I believe., become a, little unwieldy., be-

                  cause occasionally believe it or not,  they  darn  neax  pushed

                  a hundred something at some meetings.

                            MRS. GORDON:  Then do they have .--LiGS in    ddition

                  to all of these @G members?

                            MS. SILSBEE: No, I think she I,,-, saying they  serve

                  in the local advisor@ capacity,, have functions.

                            MRS. GORDON:  Sdme people then?

                            MS. SILMEE:  Same people.

                            NRS. GORDON:  That mgkes,.it a L.",LttLe better.

                            The reviewers seem to feel that most of'the projects
                  were actually -- or as I interpreted,it,, program staff projects.

                  But as I understand It,, as Dr. Wammock said', the epistle

                  the DRMP staffdJ4 not agree with this assessment.

                            Is that correct?

                            MR. YIZU.USKY: Several oL'  their  project  wtivities

                  were people with the university. This was a problem two years




                                                                             476
 67               ago. We ask-d them tu identify these people  as  project  direc"
                                                                                 I
                  torso provide a project number and @k@ oure It ha6  I;hree-year,
                  funding, notoome under the arms of the university on(,-e. the pio-'.
                  ject ceases.

                            There are'a few project activities here which are
                  program staff people, but they are not all project sloaff
                  people directed to this project.
                            NRS. GORDON:  Says something about being  PILYSically-
                  in@the same building, but not--
                            MR. ZIZ@USKY:  Program director's   program  staff
                  are physicially located on the University of New Mex co cam-

                  pus, and some are in thesame building.
                            MRS. GORDON: The Executive  Committee  of  @G  met
                  twelve times last years so'I assume from@that that the execu-
                  tive committee had major responsibilities.  find., of course,,
                  I think with a @G  of 120 or 73,. or whatever is in between,,
                  that you would almost have t@ have that,
                           They were rated averageo  with recommended funding
                  of $i.,644,754.

                           I gather primarily because they were rather ambitious.
                  Some of their programs, such as the neonatal  infant  trans-
                  portation, In New Mexico -- I would question that activity in
                  just about any place except New Mexico, or some other terrain

                  such as that.

                           Then they talk about project 25., "should have technical




                                                                          477
  68              reviews site visito by out-of-state consultatns who are

   -              familiar with the RMF project."

                            Could you comment on that?

                            MR. ZIZLUSKY:  Yes.

                            MS. SILSBEE:  Would you speak up a little.

                            MR. ZIZ@USKY:  This project was originally, oh,
                  about two years ago, originally requested about $400,000.
                            The site visit team recommended approximately a,
                  $100..OOO level.

                            The phase-in and phase-out, now increased their
                  request again., reviewers thought they would perhaps  were
                  quite ambitious for theirrequest for their activity, and they
                  suggested since everybody -- well., discussion from the Review
                  Committee was since everybody is involved with this type of
                  activity maybe they need soxm out-of-state reviewers to come
                  in and take a o-ood.. hard "Look at It,

                            MRS. GORDON:  This is health education and as I read
                  the project, it seemed to be they were going to produce or had.
                  hoped to produce audiovisuals-and this sort of thing on their

                  own,

                            MR. ZIZ@USKY:  Yess that is correct, they submitted

                  seven or eight audiovisual films., HEW clearance.
                            MRS. GORDON:  Beciuse of the particular nature of

                  their population,

                            MR. C@MBLISS:  I think the Council should know that




                                                                         478
59                we had a demonstration of health education to the public fromi
                  New Iliexico@ right in thi.D room,  jind we were Less than

                  impressed with the entire approach.
                            We felt that a good bit had been made of it, but
                  Little was coming from it,

                            I simply throw that out, just for your information.
                            NRS. GORDON:  ns you can see, the committee recom-
                  mendation Is quite cut,, and I assume that. this particular

                  project 25 would be--

                            MS. SILSBEE:  EMS project proposal is for $91L.000

                  alone.

                            NRS. FLOOD:  If we took their funding from January
                  throuoh December 3Lst,, annualized it., what'would be their

                  current funding?

                            MS. SILSBEE:  It Is apprcKimately $1,L million,

                            MS. FLOOD:  Thank you.
                            MRS. GORDON:  So in view of these considerations.. I
                  would recommend-$ I move the adoption of the committee recom--
                  raencation of $1,644.,754.
                            MRS. KLEIN:  I think I am going to second that.,
                  but; I would LIke to ask a question first, if I may.
                            I notice that these reductions--

                            MS. SILSBEE: We can't hear you.
                            MRS. KLEIN:  I am sorry.

                            jis was pointed out., the reduction is substantial in




                                                                           479

70                 comparison with the amount of money requested, and it says

                   that the project objectives could not be accomplished within

                   one year*  mnd then on the estimated request of May L974,

                   they haven't requested anythinm,
                                                 CD

                             I was wondering particularly in these emergency
                   medical services in a state 121-ke New @xico with a variet.y'of
                   topography and problems of transportation., similar to what we

                   have in Idaho I think, if they were not able to attain project
                   objectives within a year,, consequently the funds were not--'
                   the total requested were not c-ranted for that particular pro-
                   ject number L8? Would they have an opportunity to come in

                   and ask for additional money if they haven't made th"
                                                                       is request

                   as of May 1974?

                            In other words, the funds for that particular proje'a@
                   would be cut off at the end of the year, to which this grant
                   applies?

                            MS. SILSBEE:  That Is true.

                            MRS. KLEIN:  @nd they won't have anything to go

                   beyond that?

                            MS. SILSBEE:  That's right.

                            MS. KLEIN:  Even tough they haven't accomplished
                   all their project objectives.

                            I wonder If that is a good idea?
                            MS. SILSBEE:  Well  that is sort of-the basis on whLch
                   most of these programs have requested their funds.




                                                                                                        480

                                        ms a matter of fact,  New Mexico has not requested

                         anything beyond June 30th, have they?

                                        MR.  POSTM:   No.

                                        MRS. FLOOD:-.   ht  least the printout doesn't  show



                                        MRS.  KLEIN:   Maybe they failed to request   t on the

                         basis of     having requested this more than adequate fu din-,  in

                         this one.

                                        MS.  SILSBEE:      I think     some background Oll t@Le EMS

                         proposal is in order,

                                        Frank.,  could yougive an Idea how  long that has been

                         s uppor  tecl  ?

                                        NR. ZIZLI.USKY:   This pro'ject activity started July
                         L,  1972., so we are going into the              third year.

                                        Essentially the project          director put a third and
                         fourth year request into           a one-year request.   That Is why
                         the money has ballooned,           youknowo quite substantially.   That

                         is basically it.

                                        MS.  SILSBEE:  Wo-UIC4  you      speakLp.,  please., Frank?

                                        We Just can't hear you down here.

                                        MR. ZIZ@USKY:   This is in its third year of fundi@.,
                         and they started July L,,  1972.  'nncl  they essentially put a
                         thircT and a fourth year request together aW  this is what

                         causes the huge expansion of the project in the request.

                                        MRS. FLOOD:   Could I as@ Dave,,   Frank is familiar




                                                                             48,
72                with what the.status is of the Governor's Division of Highway

                  and Traffic Safetys and their purchase of radio communica-

                  tion6 equipment.

                               one bime the Governor was going to allow',some

                  funds availabilty for radio communications linkages from

                  vehicles to land bases, hospitals,, and perhaps even make

                  available equipment to link into the mass helicopter poten-

                  tial that Is based In Fort Bliss, at El Paso,, Texas-,, which rektl-

                  ly serves a greater region in El Paso than it does-Texaso 'jincl

                  if the Governor's office. does indeed fulfill  this  equipment
                  part of it, what do they want almost a million dollars  for;tha;

                  -sounds like equipment money? For one year.

                           MR  ZIZLIUSKY:  I am not'familiar with what they are

                  doing in southeast New Mexico part-of the EMS proposal.

                           They have had a very close linkage with the L)epart-

                  ment of Communications, as well as their own L)epartment of

                  Transportation.

                           -All these people'around the Governor's  Blue  Ribbon

                  Committee,, when the state receives their Defrrtment of

                  Transportation fundso the project director for New Mexico

                  RMP sits clown side by side and they select the sites.

                  The same thing goes for the communication equipment; they

                  have 3ust received-- Robert Woods Johnson grant for  EMS,  for

                  communication equipment.  I haven't seen a copy of that grant
                  and I don't know where that equipment is intended to  be,  the





                                                                        482
'3               -site selection.

                            MS. SILSBEE:  Frank, am I not correct that they
                 were trying to put in this application those things @h@'they

                 might need if the Robert WoodsJohnson money Cidn't come thro  h

                 and if some of the EMS money did not come thro-gh?

                            ER. ZIZL.-.USKY:  Right.  We have learned th4Lt the

                 Navejo health authority has also  received money,, but a third

                 of it spills over into the corner of New Mexico.   kol)er't

                 Woods Johnson has come through for them.

                            Possibly we have to check it out, but possibly

                 Presbyterian Medical Services also in New Mexico has received

                .a Robert Woods Johnson Foundation &rant.

                            If they received the grant, you know, I am pretty

                 sure it is-safe'to say there won't be any duplication,

                            They may have a Little excess,

                            IARS. KLEIN:  Madam Chairman., I will second the

                 motion.

                            MS. SILSBEE:  t'A'LL right.,-'motion has been made and

                .seconded New Mexico application be approved at the level of

                 $I.,644,,754.

                            Is there any further discussion?

                            MR. MILLIKEN:  Questions

                            MS. SILSBEE:  'nLI In favor?

                            (Chorus of "ayes.11)

                            MS. SILSBEE:  Opposed?




                                                                           483
 74                         (No. response.

                            MS, SILSBEE:  The motion is carried.

                            The next application to be reviewed -- would someone

                  have Mrs. Morgan come in -- which is Northern New  Eng'land@

                  which is really@the one.
                            (At this point, Mrs. Morgan returred to the room.)
                            MS. SILSBEE: Northern New  England,  Mrs.  Morgan.
                            (Discussion off the record.)
                            MS. SILSBEE:  Northern New England, Mrs.-@organ.-
                            MRS. MORDAN:  I never did quite get this   through
                  here,, what all is included in Northern New England.

                            MS. SILSBEE: It is really Vermont.

                            bES. MORGAN:  It is really Vermont?  Okay.

                            The Review Committeea-i Northern New England did

                  recommend quite a cut in what they had requesteCp even though
                  the region Is rated above average to superior.

                            Their feeling is that the program as requested

                  as proposed was all a continuation of  projects  with  quite

                  an increase in funding.

                            Program staff was $430,800,, almost 47 percent  of
                  the total amount requested.

                            Because these were on-going projects,  the  Review
                  Committee felt that this was a little high, particularly in

                  program staff portion,




                                                                            484


                             Th-. committee recommended that the application be
                   reduced to the level of '@4700,000 with a stipulation that

                   hlgh-priority be given to thi,- rea-ion for Increased level wit

                   the July application seeing what the new programs were going  o

                   bet were going to consist of when they come in with the

                   July application.

                             In going through this, it does appear  to  be  a  very

                   good program,

                             The coordinator has been there approximately a year,

                   They do have a good review system. I  feel  they  just  did  not

                   have the time to put in for n--w programs, which  will probably

                   be coming in in July.

                             Therefore,, I will go along with the committee

                   recommendation of the reduced level of funding of $700,000,

                   which will certainly keep them in operation, ready to do

                  .many of their programs, anC with the fact that this region be

                   considered for high  priority  depending  upon  the  committee's

                   review for the July application,

                             MS; SILSBEE:  Do- you move?

                             MRS. FLOCD:  I -will second Mrs. Morgan's motion and

                   for my information, the present grantee is a nonprofit corpora-

                   tion?


                             MS. SILSBEE:  The present-- M-r. GardeLlp I will neec

                   your  help.

                             The present grantee as of thi-- moment  is  still  the




                                                                          485

                   university,, Ls,it not?

                             NR. GNRDELL:  (Inaudible)

                             MS.  FLOOD:  @s of July I it becomes--

                             MS. SILSBEE: That has been an action  under  way  for

                   sometime and has to do with the concern of the Reoional
                   -ndvisory Group at the himh indirect cost rate the university

                   poses,, so thi. doesn't have anythina, to do with the new'.Look
                   or anything,l This is outcome of that concern.

                             MS. FLOCD:  My question was pointed towards that

                   because I recall the high indir@-ct rate from Northern New

                   England program and wondered how long this endeavor had

                   been undergone in the process of development, because some
                   of the vacant position-@ that they'reflect in their  personnel;

                   core personnel, accountant, comptroller., and I wondered why
                   these positions weren't filled if the transition had  been  ac-

                   domplished sometime ago.  @'nd these were the services that

                   had always been questioned as bein- high priced from  the  uni-

                   versity.

                            But again, it is one of  tho@e gold stars type of
                   areas that did a lot for the region anCA I can do nothing but
                   confirm the recommendations in light of the high staff costs
                   to await the quality of review for the secondary  application,,
                   iihd offer advice for strong consideration at that time.

                            MS. SILSBEE: The motion has  beef  made  and  seconded
                                                             I
                   tha'u- th-- Northern New England application be approved at the





                                                                          486
  77              level of $700.,000.

                           DR. W-MMOCK: Qu@stion.

                           MS. SILSBEE:  All'-In':favor?

                            (Chorus of "ayes.")

                           MS. SILSBEE:  Opposed?

                            (No response.)

                           MS. SILSBEE:  Motion is carried.

                           Yes, Sir.

                           DR. JANEI-TAY:  Now, sometimes I feel compelled to
                 .Come to the defense of what is termeci.more or less PE!rjora-
                 tively indrect cost,  And I wished that someone woul  come up
                 with a name that Is better than "indirect cost" or    verheacl,"
                 or whatever you want to call it.  Because if you are an honest
                 grantees grant recipient, the calculation of indirect.cost, tc
                 use that term, is additional costs caused-by reception of the
                 grant.  And pursuant to it.  And is demonstrable as a very

                 well accounted item.

                           I understand how everybody feels about -it.  I just'
                 .felt compelled to make that comment.

                           (Laughter)

                          Because it  bothers department chairmen too.
                          MS. SILSBEE:  Well, in this particular instance,, you
                 would be interested to know that your fellow dean., Dr.
                 Lukenfield, is one of the leading proponents of getting this
                 omt of the university and into a nonprofit organization,



                                                                           487

                            DR.  JAl4Zv,'AY:  He and I share many common ideas,--.-
                            Ms* SILSBEE:  You are right,, you can't just make a

                  blanket state@nt.

                            But in this particular instance@ they felt they

                  weren't getting the services sometimes.

                            MRS. FLOOD:  That was my only wish to add also -- n)
                  one is unhappy to accept the high perhaps percentage of indi-
                  rect cost ratling by an Institution when It Is a grantee If
                  indeed the program gets the support@it needs.  But we do
                  @ind regions who have full accounting staffs, full  personnel
                  departments,, full evaluation -- even planned separate compute:,
                  systems while their grantee gets this high percentage of in-
                  direct costs for supposed services offered.

                           .DR. JANEUAY:  That is not right.
                            MS. SILSBEE:' All right, having resolved the indire(,

                  cost issue

                            (Laughter)

                               we will go to Northlands Regional Medical Progray,
                  And the reviewer there is Dr. Watkins.

                           DR. WATKIINS:  We come to Northlan(Js and find that
                  the reviewers regarded overall as below average or average.
                  And, of course, it would seem that that was based on the fact
                  that it is low staffing, lack of activity, and primary care,
                  and possibly fundina, of PSRO.

                           However, this program has a history of excellence





                                                                            488

  79               in its'performance so we are going to  say  that  denotation  is

                   not'the best, I guess, for this program.

                             However, it does show that there are  Li  EMS  and 4

                   QNP    11 emergency medical services programs  and  4  PSRO,  or

                   what have you. -And run the gamut  through  the  nonspecific

                   programs from clinical pastoral  ministry  tothe  Mayo  Clinical

                   based health education.

                             Even with all  this and with the,fact it  seems to la-dk

                   some kmgination, I would  ask that the $1$700,000 as opposed
                   to requested $1,889,395,  $lo7OOoOOO be given to  this  program.

                             MS. SILSBEE:   Is there a second?

                             NRS. MORGAN:  I will second it.

                             MS. SILSBEE:  I)o you have a comment, Mr.  Van WinkLe'

                             MR. VAN WINKLE: -Yes,, if I could, please.

                             The committee was concerned about one activity  than-.
                   they considered to be a PSRO activity.

                             Mr. Wilkins was on the phone  only  yesterday  morning
                   with usp and the foundation for health care evaluation,

                   which was to be the recipiento---'-these funds,, has indeed

                   been declared to be tt P6RO in Minnesota, and, Mr. Wilkins  said

                   that thp.-t particuk.,r contract will now be givew @o the  State
                   Hospital -Association to carry out the Intent of  the  contract,

                   which would eliminate, as I understand it, the  concern  of  the

                   committee.

                             MS. SILSBEE: The motion has  been  made  and  seconded




                                                                     489
   80            that the Northlands application be approved at $1,700,000.

                           Is there further discussions


                           MR. MILLIKEN:  Question.


                           MS. SILSBEE:  ALL in favor?

                           (Chorus of "ayes.")

                           MS. SILSBEE:  Opposed?

                           (No response.)

                           MS. SILSBEE:  The motion Is carried.

                          .The next application be b,-- reviewed is from

                 Oklahoma.


                           Mrs. Mars is the primary reviewer.

                           MRS. MARS: This program was rated average  nd  below

                 average, which means there were two reviewers.

                           The latter was based on the review of the applica-

                 tion before they had a chance or he had a-chance to study the

                 comprehensive statement, regarding their concept and objectiv es.

                           Actually I like their present concept as it seemed t)

                 reach out to the grass roots and w6'rkecl upwards.

                           Their program thrust and emphasis seems to be on the

                 under-served rural areas of Oklahoma, and certainly this

                 should be that way since Oklahoma is a very rural state.

                           The major thrust of the program have been successful

                 ALL their original continuing education centers are functional

                           They have a teleconference network wh-ich will soon

                 be expanded to include most of the state areas for programs




                                                                            490
  8i              of health manpower development skills improvement and education.

                            The RAG composition includes Indians and blacks.

                  They have not neglected their minorities.

                            They have a weIL-balanced RAG with 54 members.  This

                  has retained really a remarkable continuity of membership,

                  which has provided a very high level of understanding of both

                  health needs and capacity and function of the.RMP to meet

                  those needs.

                            They have budgeted for staff   increase of  seven more

                  additionq,which doesn't really seem to be justified.

                            There Is apparently no assistant director   and cer-
                                                                       i
                  tainly the director does in this case  need  an  assistant.

                            -Also there are some secretarial positions which are

                  vacant at the moment.. and which would be necessary even to

                  help terminate the program if nothing else.

                            The four (b) agencies have  been  approved,  the.

                  Individual proposals and the (a) agency generally concurred.

                            On the whole, I think it"is a fairly good prograbu

                  And I would concur with the reviewers' recommendation for

                  $1,C)62,237, against their -request of $L,382,243.

                            MS. SILSBEE: And you so move?

                            MRS. YIARS:  I so move.

                            MS. SILSBEE:  Is there  a second?

                            MRS. MORGAN:  I second  it.

                            MS. SILSBEE:  Our seconder will second it.




                                                                           491
 C 82                       (Laughter)

                            Is there any discussion?

                            Okays it has been moved and seconded the Oklahoma
                  application be approved at $L.,o62.,237.

                            ALL in favor?

                            (Chorus of "ayes.'I)

                            MS. SILSBEE:  Opposed?
                            (No response.)

                            MS. SILSBEE:  Motion is carried.
                           The next application to be reviewed is  Orq!gon,
                 and let  the record show that Miss Martinez is out of the room.
                 And the reviewer is Dr. Wammock.

                           Just wait until she gets out.
                            (At this point, Miss Martinez withdrew from the
                      room.)
                           DR. WAZEAOCK: This application is for $1,201,357.,
                 and it is approved and it was assessed as being superior.
                           There is another epistle with this, and I would
                .address this to the reviewer for his comments on thisp because
                 I think he has this much better than I do:  W. Russell, do
                 you have Oregon?

                           MR. RUSSELL:  Yes, sir.
                           DR. WAMMOCIC:  If you wouLcl,, pleasep then I will com-
                 ment on it or come back to it.
                           MR. RUSSELL:  I have nothing tDadd other than what is




                                                                          492
3                 in the green sheet.

                            Historically this RMP has had an outstanding record.
                            DR. WAMMOCK:  So the green sheet has really covered,
                  in essence,-twhat you have covered in your review?

                            MR. RUSSELL:  With the Review Committee., yes., sir,

                  the transcript.

                            DR. WAMMOCK:  All right.

                            Oregon has continued to be an exemplary well-
                  managed program with strong leadership. 'The regio@ has a,
                  viable Regional Advisory Board with a good review process.
                            The relationships with CHP's are good. These agencies
                  are apparently involved in program planning.  New staff has

                  and is being recruited to fill existing vacancies.  The on-
                  going and proposed activities are well developed and in Line

                  with program objectives.

                            I was rather interested  in the statement here about
                  how many of the new activities are going to be processed
                  through or managed by the University of Oregon, because a great
                  many of these are around the Lhiiversity of Oregon.  And just
                  the n@ers.-I out,!;of LO or 10 out of 10, or number of these
                  projects will be managed through the University.
                           NR. RUSSELL:  I am not quite sure what-you are Look-
                  ing at or what the reviewer-was looking at when those comments
                  were made; but., of courses the University of Oregon is the

                  grantee.




                                                                            493

B4                           Now,, there are a number of program staff activities

                  which  the program staff monitor  provides surveillance, so

                  therefore  as a subsidiary of the  grantee, it shows up University
                  of Washington -- University of Oregon is the sponsor.

                             DR. WAMMOCK:  That is what, in essence, it boils

                  down to.

                             MS. SILSBEE:  That's right.  It just so happens there

                  are ten.of them, staff,'  I just counted them.

                             DR. WAMMOCK: One.-individual pointed  out  here  Oregor
                  is  trying to keep the people from coming into Oregon and also
                  led the story in  gas rationing.

                             This struck me very interesting in description of

                  one of the projedts,, about family and  self-help  education  pro-

                  grams, and I think it worth-while   taking a moment to read this,
                           "Citizens frequently make   poor decisions regarding

                  .common day-to-day health problems.
                           "Injudicious action often   Leads to Inappropriate
                  utilization of scarce health resources.  This problem can-be

                  particularly acute in isolated rural communities or in other

                  health scarcity areas,'
                           "Major cause seems to be lack  of  'practical  guidelines

                  for making health related decisions.  As a results people are
                  prone to seek professional care when it is unnecessary,
                  avoid expert care when It is necessary,, impose-improper folk

                  remedies and fail to employ simple useful  and  proven  home  care




                                                                          494

                  areas.  This not only applies to the rural areas, but

                  applies to the urban areas."

                            I don't see anything     I felt it was a well p repar d

                  document here, the  Oregon pro-ram. It is easy to reed, to go

                  through,, and table of contents, et cetera.

                            I come to this peer review quality assurance proo-ran,,
                  again, that crops up, and also shared service progral for

                  hospitals and related agencies in the south coast  of  Oregon,

                  the only two areas I Looked at.  But wouldn't make tco much of

                  a quibble about that.

                            So I would therefore move that the  recommended
                  sum of $I,,201,357 be approved for the Oregon program.

                            MS.. SILSBEE:  Is there a'second?

                            MRS. MORGAN:  I


                            MRS. FLOOD:  I second.

                            MS. SILSBEE:  All right.

                            Mrs. Morgan, you were the secondary  reviewer on that.

                  Would you like to second?

                            MRS. MORGAN: No,, just knowing Dr.  Reinschmidt  and

                  being familiar with the program, you can rest assured it will

                  be well spent.

                            NR. HIROTO:  On this 028 group purchasing,, is  that

                  Institution-"L hosp:Lt.-L group?

                            They really didn't have to do that. -It  is  covered

                  under Meclicare-Medicaid laws.




                                                                       495

  86                        That is all.

                            MS. SILSBEE:  O@ay, we will make a note of that.


                            The motion has been made and seconded that  the

                  Oregon application be approved at $1,201,357.

                            Any further discussion?

                            All in favor?

                            (chorus of "ayes.@')

                            MS. SILSBEE:  Opposed?

                            (No response.)

                            MS. SILSBEE:  Motion is carried.


                            Dr. Janeway,, thank you very much.

                            (Discussion off the record,)

                            MS. SILSBEE: Could someone call Miss Martinez

                  back again.

                            (At this point Miss Z4artinez returned.)

                            MS. SILSBEE:  The next application for review, you wLLL

                  be pleased to know we only have four more to go.

                            let's have a slight break.

                            (whereupon, a short recess was taken.)

                            MS. SILSBEE:  Would the Council come to.order.

                            The next application to be considered is the

                  Rochester application, and the primary reviewer is Mrs. Klein.

                            MRS. KLEIN:  As you can see by your I guess aqua col-

                  ored  sheet


                            MRS. GORDON-. Now she has got it.




                                                                            496
     87                     MRSI KLEIN:   -- the reviewers rated this program

                  as superior, and recommended that all of the money they reques-
                  ted be allotted-.to them. And I certainly would  go  along  with

                  this,

                            I think the two reports that I reviewed show the

                  difference between a bad report and a good report.

                            This one, even a person as uninformed as  I  am  could

                  be very well"-very readily understood.

                            They set forth their  programs  with  clarity.  They

                  even outlined their objectives and in great detail,  and  put  a

                  dollar value on each one of them.   And gave a  graphic  history

                  of the staff.  And had a number of  other  informative  graphs

                  ln'this report that I thought were  excellent.

                            It was a short report and very readily-- it seemed

                  easy for me to understand anyway.

                            I enjoyed it.

                            bMS.' GORDON: Is this Rochester?  Is th%,Rochester,,

                  New York?  Minnesota?

                            MS. SILSBEE:  YeB, @ i-s Rochester, New York.

                            We should be clear. That  is  the  headquarters  and

                  it covers that tier of counties below Rochester.

                            MRS. KLEIN: As I say, it set  forth  its  goals  and

                  its objectives very clearly and the funding and asked only

                  for really a continuation of very small program  and  a  small

                  staff of I guess about ten people.  And just gave them a



                                                                              497

  88              small increment in salary.  And they had several well defined
                  projects which /were, as I say, outlined ingreat detail in the
                  report.  And I certainly would feel that they ought to be

                  allowed this amount.

                             I noticed,  too, that they are asking for about over

                  a million dollars in   new funds on the next application, probably

                  to institute some new   proposals with a good nucleus of a

                  staff.


                             So I would move that the amount that the committee

                  recommended,  $361,,437, be alLowed.,

                             MS.  SILSBEE: Second?

                             MR.  MILLIKEN: Yes.

                             MS.  SILSBEE: Mr. MILLikensas secondary reviewer do

                  you have  some  comments?

                             MR.  MILLIKEN: No, I have been on a site visit,there.

                  .It is very good.

                             MS. SILSBEE:  The motion has been made and seconded,

                  Rochester  application be approved 6t $36Ls437.

                             All in  favor?

                             (Chorus of "ayes.11)

                             MS. SILSBEE:  Opposed?

                             (No response.)

                             MS. SILSBEE:  Motion is carried.

                             The next region to be reviewed is application

                  from Tennessee Midsouth, that covers Nashville and the eastern




                                                                         498
   89             Tennessee an(I-the area around Nashv'iLle.

                            The reviewer is Mrs. Mars,

                            MRS. MARS: The assessment of  this  program  is  that

                  of being average.  However, I think it is a fantastic'program

                  since September of 1973,  they  completely  dissolved their  RAG

                  in fact., the RAG dissolved itself,  and  reorganized itself  as

                  an entirely new Regional Advisory Group,

                            This apparently was very necessary if the   program wals

                  going to-succes@fully continue,

                            The significant improvements Included  were  in  the

                  bylaw revisions and grantee  responsiblities were limited.

                            A definite Limitation was placed on the   size of  the

                  RAG, bringing it down to 36 members.  The @erm of   office  for

                  RAG members was  limited,, and there were adequate conflicts

                  of Interest provisions Included.

                            So@this has changed the whole more  or  less  course

                  of the program.  And now they are beginning  'to move into  an

                  outreach program where the needs were so  great,  Tennessee,  of

                  course, being again a very_rurtLI state,

                            The new chairman is medical director of the Universi;y

                  of Tennessee, and they aiso have  a  new  coordinator.  He.was

                  with the program from L968, but he has now been  acting  and  is

                  coordinator as of Septembero I believe, of 1973,, somewhere

                  In that area.  He hasn't been in that position@oo long.

                            The former coordinator got fired and I  think  by  the



                                                                       499

  go              grantee, and both the men, the one that was fired and the

                  present one is  a University of  Tennessee man, so they  all

                  seem to get along all right.

                            The money that they have requested to the  sum  of
                  $2,133,972, seem-- to be in order.  Howevero I would suggest
                  that when they request another $850,000 in July and   August

                  review, that it be looked into very carefully  and  examined

                  before it is granted.

                            They have a-gooa past performance.  They did carry cut
                  their priorities in the past.  They funded 68 separate activi-
                  ties'in the past two yeax4 and the budget as now in the applica-

                  tion 49 percent is budgeted for continuation activities  and
                  37 percent is budgeted for new projects, 14 percent is budget-

                  ed for staff.

                            There are eioht new projects. Six  of  these  relate

                 ,to rural application health districts one  concerns  a  disad-

                  vantaged areas and although some of these new activities
                  are'classified as continuation,  Many of them have come about

                  since November of 1973,, since the-reorganization of the  RAG.

                            So.that in a,way, I suppose you can term  them  both

                  new and continuing projects.

                            I therefore move that we do accept the recommendation
                  of $2,133,972.

                            NRS. MORGAN:  I Will second., to get tt on the table,,

                  then I have a question.




                                                                             500

                              MS. SILSBEE:  ALL right.

                              MRS. MORGAN:  I wonCer., on their current staff, how

                   one can be considered full-time professional and still be

                   located as a fuLL-t@ professional outside of the RM.P

                   office?


                              MS. SILSBEE:  Lee?

                              MR.,VAN WINKLE:  Which one are you speaking of?
                              MRSI MORGAN:  Under six full-time professionals,

                   one of whom Is located as fuLl-t@ professional outside.

                              Is he fuIL-time professional still in the RMP but

                   outside?

                              MRS. YARS:   His work,,,yes.  Carries  regional  t'hrouch

                   the   state.

                              MRS. MORGAN:  All right, that is all I wanted to say*'

                              MS. SILSBEE:  Mrs. F lood.

                              MRS. FLOOD:  I  notice  reviewers  questioned  the  logic

                   of a cancer program for the timeframe of potential funding.

                   But yet the topic listed in the pr@intout  is  that  of  lung  cance
                   detection and in this part-icular-region of the country, this

                   Is a particular problem.

                              Could someone expound as  to  was  the  project  perhaps'
                   that of screening detection and planning for Long-range care,,

                   or something of  this natures that It was not feasible within

                   the timeframe?

                              MRS. 14ARS:  Which program are you referring to?




                                                                            50,

2                           MRS-, FLOOD:  It is numbered 93, Mrs. Mars, and in

                  the'printout it is called lung plan, lung cancer detection.

                            MR. VAN WINKLE:  Life adjustment, Life adjustment.

                  to can-cer.

                            MRS. FLOOD:  That is, 92 is being questioned; 92 is

                  beino, questioned

                            M. VAN WINKLE:  Yes, ma'am.,

                            MRS. FLOOD:  Thank you.

                            MS. SILSBEE:  The motion has been made and seconded

                  Tennessee MidsoLith application be approved at the  level of

                  $2,,133o972.

                            Is there further discussion?

                            DR. WAMMOCK:  Question,

                            MS. SILSBEE:  ALL in favor?

                            (chorus of "ayes.")

                            MS;@ SILSBEE:  Opposed?

                            (No response.)

                            MS. SILSBEE:  The motion"is carried.
                            IncidentaLly., Mrs. @rs-p the rejuvenation of the RAG

                  and so forthi was not done.without a good deal of prodding

                  from staff here.

                            MRS. MARS:  Staff here.  It certainly needed It

                  obviously.

                            MS. SILSBEE:  That has been a problem for some years

                            The next application to be reviewed is from Virginia




                                                                          502

  93             and let the record show Mrs. M,-rs is out of the room.

                            (At this point, Mrs. Mars withdrew from the room.)

                            DR. WATF,.INS:  Virginia was reviewed and regarded

                 as average.  They are asking for only $L,000,000.

                 It seems that Dean Perez is still doing the job that he has

                 done before, that is allowing some of his staff to remain--

                 positions toremain vacant.

                            It shows a preponderance of similar projects reflect no-
                 some lack  of imagination,  However., he has followed'the guide-

                 lines of RIP objectives and authorities.

                            He also, I saw,this over there, he also has accom-

                 mocated a  number of disciplines,, Including RN's,, and it shows

                 dental hypertension projects pharamacisto  and he does have

                 these on his RAG'S.  I saw this when I was there.  In factx he

                 does have even a dietician program.  So I would like to recom-

                 m,--nd that he-gets' the $L million  in fact,, that is my propos),L,

                 he gets the $1 million.

                            MS. SILSBEE:  Miss Martinez.

                            MISS MARTINEZ:  Secorld.-@


                            MS. SILSBEE:  She seconded It.

                            The motion has been made and seconded that the

                 Vir-inia application be approved at the level of $L million.

                            Any discussion?

                            All in favor?

                            (chorus of "ayes.")



                                                                             503

                             MS. SILSBEE:  Opposed?

                             (No response.)

                             MS. SILSBEE:  The motion is carried.

                             But I would like to clarify the record, Dr@.Watkins,
                  their  request was at $1,290,000.

                             DR. WATKINS:  Thank you.

                             MS. SILSBEE: Okay, could someone bring Mrs. M,-rs
                  back in  and  we will do the Last application,, which,is from

                  Western Pennsylvania.
                             (At this point, Mrs. Mars returned to the room.)

                             MS. SILSBEE:  Yes.

                             MISS MARTINEZ: Western  Pennsylvania, rated as an

                  average.

                             I agree with the,rating of the committee.

                             I would like someone from the staff to clarify the
                 'concern that it had with the kidney project, or the Review
                  Committee had with the review project.

                             MS. SILSBEE:  The concern was primarily in the wordi 9
                  of the page 15, which  made one-of the reviewers think thatthey
                  were developing  transplant centers in more than one place.
                             This was not the case; they have got one center, and
                  satellite  hospitals that relate-- in other kinds of services.

                             So we feel that concern has been alleviated.

                             MISS WRTTLNEZ:  Okay.

                             I do have two other shortcomings-- I hate to sound



                                                                              504

    95            Like a broken record,, but they have no Spanish speaking

                  persons on their RAG, and secondly, I noticedsomething when I
                  was Looking at  the staff, In administration, they have someone@,
                  a woman,, called "administrative assistant, 11 who receives

                  a lower salary than it executive secretary."

                            N014P I think if she is a secretary or.clerk, she.

                  should be so named.  Because I have seen this happen so often,
                  when people want to count a woman in professional administra-

                  tio@ to give her a title which has nothing to Co with her

                  salary or duties or anythin& else.

                            That is a question- I am addressing,to whether that

                  is the case or why the title  if she is not an administrative

                  assistant.


                            MS. SILSBEE:   I really don' t know the answer to that

                  but I  will be most happy to ask the region that question.

                            As a matter of fact,, Miss Kettle, who used to be wit.,i

                  this staffo made a big point of that in site visit one time.

                            MISS YIARTINEZ: Okay.  In that case I would Like tD

                  move that the committee recommend_@@L,370,,285 for'the program..
                  PLus $170,285 for the heart function be approved.

                            MS. SILSBEE:  Is that plus or--

                            MISS IMRTINEZ:  Isn't it plus?

                            Oh, it LncLudes?  Sorry.  Amend that to Include,

                  including the Mahoning--,Shenango  project.

                            NRS. MORGAN:  Is this to make sure the Ohio project




                                                                             505

-)6               is good.?

                            MS. SILSBEE:  Yes.

                            MRS. MORGAN:   I seconclo then I will get it on the

                  table.


                            MS. SILSBEE: Let me explain a little  bit  about  the

                  Ohio-project.

                            This is one of the activities that  was  supported

                  in that special ear-mark a couple years ago, health services

                  educationactivities,

                            At the time the Northeast Ohio RegionaL Medical

                  Program was phased out that program had been  funded  for  a

                  couple of years, money was provided there.  It was m ving along
                  well. -And so for a year we Were able to fund it as a 910
                  activity.  Because of the court order and the worCing of it,

                  we could not continue in that capacity,, so we asked Western
                  Pennsylvania-if they would agree to fold this into its program

                  and monitor the activity and they did agree.
                            So $170,,285 for that project represents the  request

                  .of the project.

                            Mrs. Flood.

                            NRS. FLOOD:  I am not familiar with this region, and

                   am not sure who the  grantee institution Is.

                            MS. SILSBEE:  University of Pittsburgh.

                            MRS. FLOOD:  University of Pittsburg@    So  there
                  would be no problem in continuation monitoring of  projects  25


                                                                              506 1 i@
   97             and 26 into fiscal 76, which their request does reflect fundin@

                  for,fiscal '76?

                             MS. SILSBEE:  The action of the committee   in duttin-I

                  back on the funding was to -- they felt that those a(Icliti'onall

                  dollars should not be allowed at this time.

                             MRS. FLOCD:' Fiscal'76 portion of the fund"
                             MS. SILSBEE:  However, in terms 'of your initial

                  question,  the capability of the'university to contin,ie' I

                  don't think there would be any problem along that litieo

                             MRS. FLOM:  This was the rationale.

                             MS. SILSBEE:  They didn't put any kind of restric-

                  tion on that,, but at the d6LI@-r level they were maki g that

                  suggestion.

                                 FLOOD:  Thank  you.

                             MS. SILSBEE:  Mr. Hiroto.

                             NR. HIROTO:  Ye@'s.  I am repeating myself, but there
                  is something, $31,000 in there, about quality assurance.  Agair,

                  is-that going to make certain--

                             MS. SILABEE:  Yes, we w-ill make certain on that.
                            .Let's see., you were the secondary reviewer.  Did you

                  have any further comments to make?

                             MR. HIROTO:  No.

                             MS. SILSBEE:  The'motion has been made and seconded
                  that the application from the Western Pennsylvania Regional
                  MedicaL Program be approved at the Level of $1,370,285, which




                                                                           507

3                 includes $L70,@85 for the Ohio health education Project.

                            Is there further discussion?

                            All in favor?

                            (Chorus of "ayes.

                            MS. SILSBEE:  Opposed?

                            (No response.)

                            MS.,SILSBEE:  Motion is carried and  that ends the
                  review of thel53 applications.'

                            (Applause)

                            DR.  WAMMOCK.   have one other comment if I may.

                            DR. PAHL:
                                       Go ahead.

                            DR. WAIC40CK:  Article about RMP,"As I knew himo

                  the rise and fall of an idea," and it ends with a quote,

                   mourners are -urged not to send flowers but money."
                            (Laughter)

                            MS. SILSBEE:  That is from the New England Journal

                  of @dicine.

                            Before closing, I thought the Council might be Inter--

                  ested in the overall recommendations that have been made.

                            You have  add-eC funds to the committee's recommenda-
                  tions to the tune of about $3.7 million.  You added money to
                  Central New York., Int;ermountain, Takes Area, Maine, Nebraska,

                  New York Metro, Texasp and Tri',State.

                            You took money away from Susquehanna-Valley,
                            The total difference in the amount of all of these




                                                                         5o8
  99              actions was @3'.648,458,  This means that the committee

                  recommended the level of @@85,047,597.

                            MRS. MARS:  What?

                            MS. SILSBEE:  $85,047,,597.

                            The Council recommendatiotis'-total6d $88,696,055.

                            DR. PAHL:  Thank you very much, Judy.

                            Dr. Watkins,
                            DR.IWATKINS:  Tell me'brevity Is the soul of wit,,
                  so I wiLL'be very- brief,

                            This Council shows a,mix of jocularity, mental
                 agility, and mental alacrity and I want to say   I am happy to
                 be back,

                            (Laughter)
                            bR. PAHL:  Thank- you.

                            MRS. WRS:  Very happy to have you.
                            DR. PAHL:  Before we adjourn, I have just one or
                 two coimnents, particularly for the new members of Council.
                            It has been a baptism by--fire and I am sure it seems
                 like almost ages when I--welcomed ;you yesterday morning to sit

                 on the Council.

                            MRS. GORDON:  "Sit" is the word.
                            (Laughter)

                            DR. PAHL:  I am glad to see we have solved the
                 long-standing problem of "indirect cost.".. I wi-LI pass that
                 word on to the appropriate authorities in HEW and elsewhere,


                                                                                 i
                                                                         509

DO                          It isiparticularly Interesting also to see and listen

                  to the humor, and I think I will remember about Czechoslovakia

                  and sheriffs for sometime.

                            (T,aughter)

                            Very seriously, again, I remind y6u that you have

                  probably worked harder with greater workload than  any  Council

                  I have been associated with In this pro@ram.
                            MRSJ @IARS:  Except for' the last one.

                            DR. PAHL:  We were somewhat reduced in numbers.


                            MRS. MRS:  Yes.

                            DR. PAHL: But you have also set a  precedent  today,,
                  and I have just been doing some calculating and I think @he

                  August Council meeting should run no Longer than about two hours

                  and eight minutes if you stick with the same kind of good

                  activity.

                            But very seriously, you should know thk  the  recom'-

                  mendations that you have made wiLL,, of course, be Looked at

                  and I am sure there will be great Interest by  the  individuals

                  who sat here yesterday morning, and indicated to you their

                  interest in the direction of the program and charge you with

                  various kinds of responsibilities at that time.

                            I feel very, very comfortable. I would  Like  you  to

                  know, to represent both the Review Committee and -the Council

                  In Its recommendations on each and every prog3Lam, I feel  that

                  you faced up to some very difficult decisions.



                                                                           510

                            There have been so,-,e Sood discussions on complex

                  Issues.  The record Is w
                                           ell doc,-z,,entecl.  And I would want

                  you to kncwthat I am probably more comfortable  at  this  time
                  than any @ime In recent months in defending to o-ur own

                  -Administration the quality of the review throughout this entire

                  process,


                            It will be a pleasure to be able to  sit  with  them

                  and indicate ust what recommendations have  been  and  why  we

                  have reached those.


                            SO Without holding you further, I hope that we can

                  see you and others back August 8 and 9, and we  will  be  most

                  happy to-respond to questions and inquiries  in  the  interval

                  should you have any.

                            Sew a:l L?

                            I,IR. MILTIKEN:' Your remark about productions, I don't

                  think we could have done It without the unusual staff work that

                  has been done, very well done,

                            NRS. MARS:  We owe you a. vote of thanks.

                            DR. WAMMOCK:  It has been a great help and I am

                  sure the constraint of.tim'e here has really  been  something.

                            DR. PAHL:  Mrs. Silsbee may indulge In a predinner

                  highball this evenings for a job well done to her and the staff.

                  A lot has been done behind t-he scenes# as you all.know.

                            Thank you very much.




                                                                           511

,2                          I declare the meetino, adjourned.

                            (Whereupon, at 3:27 o'clock, p.m.p the meetin@

                       was concluded.)