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                     NATIONAL ADVISORY  COUNCIL ON


                     REGIONAL MEDICAL PROGRAMS








                     THIRTY-SECOND MEETING


                     C L 0 S E D     S E S S I 0 N











                                                    Conference Room G
                                                    Parklawn tuilding
                                                    Rockville, Maryland

                                                    Tuesday, February 12, 1974
                                                    2:25 O'clock p.m.






                    -@@ATTENDANCE:


                     @Dr. Herbert B.  Pahl, Chairman
                     Mr. Edwin C.  Ilirotoi
                     Mrs. Audrey M. Ma:es.1'
                     Dr. John  P.  MOrrill/
                     Mrs. MAriel S. Morgan)
                     Mr. C. Robert Ogd6n





                                                                            2


                                      P R 0 C E E D I N G S

                             CHAIRMAN PAHL:  If we may come to order again.

                   Would someone please close the door again so that we  don't

                   have too much noise from the hall.  Thank you.

                             Judy, will you please just oo ahead And introduce

                   the sequence that you believe best for the afternoon session.

                             MRS. SILSBEE: The council may recall  that  there

                   were three council site visits that were scheduled after the

                   last council meeting--to Puerto Rico, Intermountain, and

                   Hawaii.


                             In addition, there was a consultation visit  that

                   was recommended for Arizona. So, the action today in  th  s

                   executive session will revolve primarily around the t ree

                   site visit reports,  because in each of those cases  council

                   had recommended action  with regard to the applications that

                   were considered in  November that required some  information

                   gathering by the site  visit team and report back to the

                   council before the recommendations could be changed.

                             I think the order today should be Puerto Rico,

                   Intermountain, and Hawaii.

                             The staff involved in the Puerto Rico visit,

                   Mr. George Hinkle, who is the operations officer, Mr. Frank

                   Nash.  The council members were Dr. Merrill and Mrs. Morgan.

                             Dr. Merrill, would you lead off on the discussion,

                   please.



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                             DR. MERRILL:  Yes, I think oerhaps it's appropriate

                   that I do present this report, although it was written

                   largely by Dr. Thurman but gone over by all of us.  And it

                   was appropriate because I was the prime reviewer of the

                   Puerto Rican proposal and thought it was very
                                                               ., very poor

                   indeed.  And I'm happy to be able to tell you that I and all

                   of my colleagues have certainly modified that opinion.

                             The people who were involved in the visit were

                   Dr. Thurman, who is the Dean of Tulane, Mrs. Morgan and

                   myself, as you know, and Mrs. Maria Flood, who is Program

                   Coordinator for Texas Techi and she was particularly

                   important because she was born in Mexico and speaks fluent

                   Spanish and this, as we'll hear,, is important.

                             We met with all of the people of the program

                   staff, most of the people in the regional advisory group,

                   and a number of others who had been on the staff in the past


                   and are now listed as consultants for obvious reasons4


                             I won't read this report in detail, but I will

                   simply leave you to read it and to give you some vignettes

                   about it and our conclusion.


                             The grantee organization is the Medical Sciences

                   Campus of the University of Puerto Rico, and we were fortunate

                   in having a good deal of the chahcellor's time; the chancellor


                   is in essence the dean of the medical school.  We met with


                   both the present coordinator and the past coordinator who


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                     now functions as associate coordinator on a fifty percent

                     time allotment, and stillas we found out, had maintained an

                     extremely vivid interest in the program.

                               The problems that they had were of course with

                     staff, which was practically non-6xistent because of funding

                     difficulties over the past year.  The coordinator, the

                     associate coordinator, and the executive officer for the

                     RAG and the administrator, were the only senior personnel

                     present being employed by the program.

                               By  he same token, we talked with a good many of

                     the former staff who are.working in.i"6therdepartments of the

                     university and came  back and who had@obviously maintained

                     contact and@-iriterest'with the staff and'who were very frank

                     to say that if funds were  available  for any foreseen period

                     of time,, they would be glad to come  back.  They  obviously  had

                     been a tremendous help  to what staff remained  in  a  consulting

                     capacity  and I would guess that not all of their time as

                     consultants was paid for.

                               The relationship, as I've mentioned of the MP

                     to the Medical sciences Campus,  secondly  to  the  Department  of

                     Health, and thirdly with the private sectok--and we examined

                     each of these relationships quite  carefully,*  the  relationship

                     with the Department of Health and the university seemed

                     obviously to be excellent.

                               There was some question  about  the  relationship  with






                                                                           5


                   private sector. And although we did talk in  detail  with  one

                   member of the private sector, he perhaps had a little ax to

                   grind.  H6 was very favorably impressed with what RMP had

                   done.  But then he was involved in a new program which he

                   had instituted and which he hoped would be funded.

                             So, Dr. Thurman, who had spent some time  in  Puerto

                   Rico, spent a lot of time contacting approximately  ten  other

                   individuals in the private sector, and he informed us  that

                   almost without exception they were satiisfied that the

                   programs of RMP had been to the best advantage of the

                   private sector as well as the other sectors of health  care

                   delivery.

                             We talked also with the regional advisory  group,

                   and there had been some criticism raised by the fact that the

                   regional advisory group perhaps did not have  enough  consumer

                   representation.  I think all of us came away from this


                   convinced that this was not the case.  We talked with a


                   number of people, particularly a Senor Alfredo Rivera,  who

                   was head of the Poor Peoples Council and who was a  member  of

                    e RAG who gave a very exciting, I think, exposition of

                   what it means to be a consumer representative on a Spanish-

                   speaking organization in Puerto Rico. And one  of  the  ladies

                   who was a housewife gave almost 'as impressive a discussion.

                             In essence, both of these people, although poorly

                   educated, were eloquent.  They were excited about what RMP had


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                    done and what they hoped it would do in the future.  And

                    certainly they represented a typical cross-section of the

                    Puerto Rican community, which may be perhaps a little

                    different than communities in Virginia or Oregon.

                              There are a number of other things that were

                    impressive and which did not appear on this grant total.

                    I think here it ought to be pointed out that there is a

                    language difficulty.  There is a communications problem, and

                    I think  ost of us came away from the site visit feeling

                    that in essence this was why the proposal was not favorably


                    received.


                             As an examplei the regional advisory group met in

                    February and spent the first part of their meeting discussing

                    the phasing out of RMP.  Then then went ahead and reviewed

                    in detail all of the grant proposals which had been submitted

                    to that meeting and their reviews and criticisms were

                    detailed and certainly most true.  And I think all of us felt

                    that was extremely impressive.

                             The second thing, I think, thit illustrates the

                    problem of communication was the fact that we felt--or at

                    least I felt--when we first saw their proposal that they

                    hadn't documented any of the things that they had done.  And

                    that was due to two things.  One', they took very literally

                    the instructions that these proposals be very brief indeed.

                    And so they were really totally inadequate,  And finally after


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                    some pressing--and again I think it was a communcations

                    problem--about one of their projects,,they pulled out a

                    document which I have here, which documents their past

                    performance and in great detail a very good planning proposal

                    for medical and allied health manpower needs for Puerto Rico

                    to the year 1985.

                              This didn't appear in anything any of  us,had  seen

                    before, but obviously they had given it a lot of thought and

                    it's an extremely good proposal, as is some of the@documenta-

                    tioh of  some of'the things that@they have done.

                              In addition to this, they have a series of

                    documents written in Spanish which  are calculated in a  very

                    simple, straight-forward clear way  to give individuals the

                    idea of the technique of how to  apply for a grant, what  the

                   needs are, what the requirements are, and in essence we found a

                    wealth of documents and information which was totally unavailable

                    to us here and which I thik was very impressive to all of us.


                              There were some weaknesses.  Some of the recommenda-


                    tiohs for administrative change had not been carried out.  We

                    were sure that that was in part due to staff problems and that

                    some had been carried out and others were certainly it the

                    process of being carried out to make sure this would happen.

                              The site visit was unanimous in its  opinions  that

                    this  program had accomplished a significant amount and is

                    deserving  of continuing funding.






                                                                            8

                              It is obvious the program has accomplished more

                    than is appreciated at all levels, and it is apparent that

                    they have made a role for themselves in health delivery now

                    in Puerto Rico.  And, therefore, unanimously the site visit

                    team recommended full approval of the amounts recommended,

                    and you can read these amounts for yourselves on page 12

                    of the application.

                              This document was sent to all of us by Dr. Thurman

                    as a rough draft.  Me all made changes we thought were

                    necessary, additions and deletions, and this represents the

                    final product, which I and Mrs. Morgan have read and which

                    has my wholehearted approval.

                             MRS. SILSBEE:  Mrs. Morgan, would you want to add

                    to Dr. Merrill's report-'

                             MRS. MORGAN:  I agree with Dr. Merrill very much.

                    I think it is probably one of the most impressive site

                    visits I have ever made.  Was most impressed with the

                    people's feelings.  Here was a group of people that they

                    could discuss medical care with at ease and felt that they

                    really were well represented in discussing this with them.

                             The only question we had, and I think this now,

                    as of today has been done away withi we felt two of their

                    projects they would not be able Eo carry out if everything had

                    to be finished by June 30th, and this was eighteen and
                    nineteen, the two projects would re@     additional time.  But

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                   it looks like we now have additional time, so I go along

                   with Dr. Merrill in recommending the full amount.

                             MRS. MARS:  As I remember, we felt that some of

                   their projects really should be controlled or be under state

                   health department supervision rather than being projects  of

                   RMP.  I think that was one of the criticisms.


                             DR. MERRILL: I think their relationship  with  the

                   health department is a very good one, and they have made

                   provisions for phasing out some of these things.  In fact,

                   one of them was already taken over by the state health

                   department.

                             MRS. MARS:  That was part of the council's

                   criticism, they really weren't P14P projects.  They were

                   projects which should be under the health department, so  to

                   speak, and developed by them rather than being RMP projects.

                   You feel that has been corrected, in other,,words?

                             DR. MERRILL:  Yes.  I was impressed with the

                   number of projects which have been taken over by the  health

                   department already.

                             MR. NASH:  Two of these that were in this

                   application ought to be taken over by the health department i

                   June.  The health department has a little problem in that

                   their budget is made up and planned a year or two in advance,

                   and it was the original plan that these projects would be

                   taken over by the health department in June.  When we sent


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                    them the phaso-out notice, it was a  little  bit  impossible

                    for the health department to readjust their  budget  and  pick

                    them up in January. And that's why  they  appeared  in  this


                    request.

                              MRS. MARS: Yes, but with  their  projects  they  ate

                   'presenting how for funding, are these still health

                    department projects? This is the  thing.  Why  should  we  pay

                    for a health department project?

                              MR. NASH:  I don't believe the site visit team


                    felt that the proposals they are seeking  funding  for  beyond

                    June  would be inappropriate for RMP funding.

                              MR. HINKLE:  Mrs. Mars, when I was down there

                    recently with Mr. Nashi I brought up the questlbn--becat8O

                    you had asked it at the last council meeting--and the

                    coordinator And the chancellor both  in  different  discussions

                    brought out the fact that the state department provides

                    about two-thirds of the health services; about  80  percent  of

                    the People down there are indigent.  Through their present

                    health system, the state health department has responsibility

                    of providing health care. They said due  to  the  scarcity  of

                    funds,, they do not have sufficient funds to go  into  these

                    new innovative untried areas for health care delivery.  That's

                    the reason they look to RMP to help them come  out  with  these

                    funds to provide these innovations as long as  they're

                    beyond the trial status., the feasibility  status.  Until  they







                   have been proven, then they are committed to take them over.

                   And that's the reason for their good record in having

                   projects picked up by the government.  It's sort of

                   cooperative effort-between the two.

                             MRS. MARS: Say RMP does go on  under  any  orm,

                   whatever it may be, do they really have prospects of

                   developing something, projects and programming that  will

                   take care of the health needs of the people?

                             DR. MERRILL:  I think we are all impressed with

                   the strength of the organization, which was not at all

                   visible in here. The associate director, who used  to  be

                   the director,  is really  one of the most vigorous, eloquent

                   young men that we met.  He's extkemely knowledgeable.  And

                   in spite of the fact that he is now working half time  in

                   another department retains a great loyalty and interest in,

                   RMP today.  He certainly would be available.

                             MRS. MARS:  What is their full-time staff?  What


                   d oes it consist of?  Very few, isn't it?


                             DR.MERRILL:  Yes.


                             MRS. MORGAN:  At the T)resent time.

                             DR. MERRILL: At the present  time--let's  see--

                             MR. HINKLE:  As I recall it had about 11 full-time

                   staff, but only three of those were professionals.  Some of

                   them are keypunch people or doing data processing.  They have

                   two new ones which they brought on board to help in their


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                    evaluation of old projects.  They have their driver, their

                    secretarial help.

                              MRS. MARS: Are they all  native  born  Puerto  Ricans

                    or are they people who come from the States?

                              DR. MERRILL:  I think with one exception.

                              MR. HINKLE:  The regional advisor's liaison officer

                    is from the Pittsburg area.  She has been down in Puerto

                    Rico about seven years, and she was associated with the

                    RMP up in the Pittsburgh area also. She  is,  we  think,  going

                    to be a big help in their communication nroblem where

                    Spanish-English has been a problem.

                              MRS. MARS:  That is why I asked, because of your

                    talking about the difficulties of communication because of

                    language problems.

                              MRS. SILSBEE:  I think, Mrs. Mars, from having

                    talked with both the staff and Mrs. Morgan at lunch, that

                    the communications problems were primarily between us here in

                    Rockville and our inability to translate what  we  were  saying

                    into terms that they could understand, and that their

                    tendency, on the other hand, to take our words litera  y an

                    not provide the background that we needed to understand.

                              MRS. MORGAN:  I think they are excellent people

                    who Are very willing to come aboard RMT.1 and begin working  if

                    there is a program going on.

                              Because of the extreme difficulty  for  these  people


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                    obtaining jobs in the Puerto Rico island, that  the  minute

                    they,were afraid this was being phased out, the coordinator

                    found these people jobs within the university so that he

                    could keep them attached to him, shall we say.  But where they

                   did have a way of supporting their families.  Because for many
                    of these people, it was their sole support, the jobs they had.

                    But if there is a continuation of the program, these people--

                    certainly in talking to them, RMP was still at  their  best

                    interest, even though,they may be in.,,another position at

                  Ithis   time.

                              MR. CNAMBLISS:  Just to bui
                                                          Id on what Mrs. Morgan

                    has said, counsel should know that this was one of the truly

                    distressed RMP's at the time of the phase-out.  You w
                  irecall that they literall  were being carried by the
                                             y

                    university until that increment of money was put  there  to

                    support staff right at the beqinhing@of the ph6se-out.

                              MRS. SILSBEE:  Mrs. Morgan?

                              MRS. MORGAN-.  I move that we fund Puerto Rico the

                    full amount, as was requested in the original proposal.

                              MRS. SILSBEE:  In the application that was


                    received in November?


                              MRS. MORGAN:  November.


                              MR. OGDEN:  I'll second that motion.

                              MRS. SILSBEE:  Any discussion?

                              All in favor?  [Response]






                                                                          14


                             Opposed?  [No response]


                             The next visit that was made was to Intermountain.


                   And not only was the language problem different, but the

                   geography and the money situation, I think.

                              Miss Mary Murphy and Mr. Mike Posta  accompanied


                   'Mrs. Mars on that site visit.


                             MRS. MARC-:  I had on the team which I chaired


                   Mrs. Flood again, who went to Puerto Rico with you,

                   Dr. Merrill. And Dr. Girard Craft, who is director  of  the

                   Albany Regional Medical Program.  And. Dr. Mitchell Spellman,

                   who was a former review committee member and is currently

                   Dean of the Charles R. Drew Postgraduate Medical School  in

                   Los Angeles. And then we also had Dr. Ossorio, who  is  the

                   Acting Regional Health Administrator, sitting in.  And

                   Daniel Webster, who is the Public Health Advisor.


                             As you may recall, probably do recall, the concerns

                   that we expressed at the last meeting of our council  which

                   caused us to withhold $270,000 until after such a site


                  visit could be made were the need for increased minorities on


                   program And project staff, the large allotment of funds  to

                   the planning area option, the need to sponsor projects through

                   outside health agencies, the re-establishment of an  active

                   inter-regional council to review'all activities to be

                   conducted in the overlap areas with written approval to

                   RMP'S, and the concern regarding the extension of the


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                   poison control project to Boise, Idaho, the question as to

                  who should be funding the health information assistance

                   program to regional legislatures, and the need for further

                   extension of project activity to rural areas, also the need

                   to clarify for RMPS the mode of operation, program staff,

                   project staff, and the need to include salaries in all

                   applications forwarded to the RMPS review.

                             The first thing that I shall deal with is the


                   restricted funds.

                             We viewed these particular programs, P-1, Q-lt

                   E-1, and K-1, that as really to be part of the  normal

                   function of program staff and not to be dealt with  as

                   specific projects.  We couldn't understand the necessity of

                   requesting funding for these in that category, since they

                   administered individual or clusters of other funded projects.

                             However, we quickly found out that due to the  fact

                   that IRMP has a very new coordinator and also other new

                   professional staff, really an error was made in the way

                   these were budgeted. These activities should have  gone  into

                   Irogram staff and should not have been termed projects.  This

                   was a grave error.

                                                    resented on their  ap
                             The figures that they p                    plica-

                   tion concerning these programs ate literally salaries and  as

                   such should bring up the total budget for program staff up

                   to $415,000.


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                             There was also, you probably will recall, the

                   question of the K-1 program, regional program coordination

                   for kidney disease, as to whether or not it complies with the

                   Social Security Administration, DREW Regulation No. 5, and

                   this was affirmed as being in compliance.

                             As to the activities being conducted in the

                   overlap areas, we had come,@befo@te'ouk team a Dr. Thomas

                   Nicholas, who is director of the Colotado-Wyoming program,

                   and has just retired as chairman,of the interregional council.

                   He was very communicative and very frank in saying that

                   naturally the way the area, region, is set up, there are

                   always going to be  turf problems.  There is no way to avoid

                   them.


                             But he did feel that they are being handled by the

                   council as diolomaticallv and as reasonable under these very

                   difficult circumstances as could be.


                             You have three PMP's involved.  You have five states


                   involved.  And naturally there is bound to be some friction.

                   However, the programs are being coordinated and there is an

                   overlap of duplication being avoided.  Actually this was

                   stated in writing for our benefit.

                             The Interregional Council is active again, and

                   They have been meeting and. they have been solving their

                   problems.

                             Dr. Studt, who is now the coordinator of the IRMP






                                                                            17

                    will be the next chairman; since it is done on a rotation

                    basis, he will be the current and next chairman of the

                    Interregional Council.

                              One of the other projects that the council

                    questioned at the last meeting was the poison control

                    center project No. 62.  And Dr. Anthony Temple who heads

                    this came before the team.  We were very, very impressed

                    with what this program is accomplishing.  It's really quite

                    fantastic.  Dr. Gerdes of Mountain States,with whom we

                    were concerned as to whether or not he was objecting or felt

                    this was overlapping, is in full agreement, and all the

                    areas feel the real importance and the necessity of this

                    poison control proaram.

                             I brought back some literature on it which I

                    thought mavbe some of the members of the council might like

                    to look at at some point.  It has had a considerable impact

                    on lowering health consumer costs, and I know this was one

                    of the things on the site visit previous to this last one that

                    I made when we questioned very much as to whether or not the

                    projects were doing anything towards moderating health costs.

                    And this certainly is an outstanding example.  In fact, all

                    the members of the team felt that this was a program that

                    the RMPS could look into carefully and perhaps develop

                    elsewhere.  It's quite a unique program and the only one in

                    the entire area, except if you go way down into California.


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                   And it's just fantastic what it does.

                             Then regarding the grantee IRMP relationship,  this

                   is on a very happy, cooperative footing right now, and I

                   t hink that there benefits being deruved from both sides.

                   we asked again for a letter of assurance from Dr. Dixon,  who

                   has the full responsibility for the grantee relationship  and

                   the IRMP, and he wrote me a very nice letter. I  think  there

                   had already been a letter written, but he wrote me another

                   one, and I'll read it to you.

                             "I wish to express my appreciation to you and  your

                   team members for the service rendered the IRMP durina the


                   recent site visit to Salt Lake City.  I have been informed

                   regarding your summary of the visit, and feel that it  served

                   a most positive and helpful end.  You requested that I

                   provide a statement regarding the grantee IRMP relationship

                   question, which was of concern in the site visit.  I am

                   pleased to report to you that all issues have been resolved

                   and that a spirit of complete cooperation between the

                   grantee and the IRMP exists.


                             "As you know, I have direct responsibility As a

                   grantee's representative to the regional medical program by

                   virtue of my position as vice president for health sciences.

                   In this capacity and also as a member of the regional

                   advisory group, I share your concern in the need for IRMP

                   to devote increasing amounts of its resouces to support


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                   health care for the rural communities of the area.


                             "I also want to again affirm the cooperation of

                   President Gardner and his concern for achievement for the


                   IRMP goals for improving health services not only in Utah

                  but for citizens throughout the Intermountain area."

                             So, I think we can rest assured that there are no

                   longer any real problems existing between the grantee

                   organization and the IRMP.  And previously certainly this was

                   a great detriment and held back the program considerably.

                   The university has undergone a complete reorganization in

                   its medical department and it has a new president, and it

                   is addressing itself now to the needs of the IRMP.

                             Actually Dr. Dixon was most cooperative, and

                   appeared before us not once but came back a second time.

                   Really it was very difficult for him to do so, because the

                   legislature was meeting in Salt Lake City and he had to
                  jappear before them.  But he is so enthusiastic about the
                  I
                  @program and what they are doing, that he really deemed it of
                  igreat importance to take time away appearing before the

                   legislature to appear before our site visit team.  Soi I think

                   giving such time certainly can give one assurance that there
                  imust be real cooperation between the grantee and the IRMP.

                             It.'s a very peculiar situation,anyway.  When you

                   realize that the university is the,oniy medical center for thi

                   large area which is some 300 miles long and 400 miles wide.






                                                                            20

                              So that you can understand too why the university

                    has to sponsor so many of these programs, which has been

                    one of our criticisms, that perhaps there were too manv

                 I  programs originating in the universtiy and under their

                    sponsorship.  But I think this is a very important point.

                              The medical department under this reorganization

                    is truly now reaching out into the rural areas.  And with

                    the cooperation of the RMP and the university support, I

                    think both ate beginning to make a real imnact into the

                    periphery of the region.

                             As a team, we strongly recommended that RMP, if it

                    does continue, should, however, have more appropriate

                    community agencies involved in the development of new

                    operational activities which should be independently based

                    and sponsored bv them, particularly outside of Salt Lake

                    City.

                             Naturally everything tends to originate from

                    Salt Lake City and concentrate around Salt Lake City, which

                    again as I say is very understandable.

                             However, they are anticipating setting up sub-

                    regional RMP'S, so to speak, and under the direction of Salt

                    Lake City,and it's rather interesting that the man who has

                    been the deputy director, Mr. Anderson, is moving to an

                    area called St. George, which is very much in the desert and

                    very much on the periphery.  It's down on the southwest end


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                    of Utah.  And since we were there, he had intended to
                    completely disassociate himself with IRMP.  But now he is
                    going to, along with other things, do a part-time
                    organization of a sub-regional group down there for the

                    IRMP.

                              Another serious concern of the council was the

                    very limited number of minority ethnic representation and
                    women, both in PAG and on professional staff.  The minorities
                    actually in the area constitute four and three-tenths
                    percent of the population of the region.  The American
                    Indian is the largest of that minority, being two and one-

                    tenth percent.
                              The thing is, however, there are thousands of

                    Mexican-American immigrant workers there who pour into
                    Utah for the cultivation, and it is certainly very vital that
                    their health needs be considered as well as those of the
                    permanent black,Indian,and Chicano Population.
                              There has been a very defensive attitude on the

                    part of the IRMP concerning the lack of minority representa-
                    tion.  But we were public and I was personally assured that
                    the omissions would be remedied as quickly as possible.
                               We were very impressed with Mr. Knapp, the new
                    RAG chairman, who has strong leadership capabilities.  He
                    accepts his resplnsibility verv conscientiously,, and he
                    assured us, as did Dr. Studt, that he would make a strenuous


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                   effort to remedy the sad lack of minority representation.

                             We were also disturbed by the fact that there

                   were no representatives on the RAG of the major!voluntary

                   health organizations.  And also an adequate number of

                   individuals who could be termed purely consumers.  That's one

                   of the reasons I was curious this morning.  I asked what reall(

                   is the definition of a consumer, because one of the individual;


                   who came before us as a,consumer and  ns sted she was a


                   consumer happened to be one of the leading pharmacists of

                   Salt Lake City.

                             She insisted she was not a health provider, she

                   was a consumer.  So, where do you draw the line, so to


                   speak?


                             But we did feel that there were not enough

                   consumers, and it is rather shocking that the major voluntary

                   health organizations were not represented at all, such as

                   Cincer or Heart.  So, this I believe is going to be remedied,

                   And they said there were a number of people who really  could

                   be moved off of RAG and who would be resigning so that  these

                   people could be inserted.

                             As to the relationship between the CHP "A" and  "B"

                   agencies, this is a very strong and constructive tie, an

                   unusual one, I would say, from what i've seen of other  RMP's

                  t hat I have site visited at various times.


                             The four representatives who appeared before us





                                                                            23


                    conveyed the impression that PMP;has been of invaluable

                    assistance in the furtherance of their program, and thev

                    simply just praised the IRMP's to the skies.  I have never

                    heard such marvelous, complimentary things said about each

                    other.  It was just almost unbelievable.  But apparently very


                    t rue.


                              Then as to this salary thing that we asked for,

                    this is why they did not attach any salary, as you may

                    recall.  Actually apparently it was attached, and I'm affraid

                    staff did not give it to us; is that correct?

                              MR. POSTA:  Right.  It was included in the

                    original application but not the other things.


                              MRS. MARS:  And so this we cannot blame them for.


                    They certainly made no effort to hide them, and they

                    quickly got out the list and presented it to us, and they

                    could not understand whv the council hadn't had them.

                              the salaries are certainly in line and,, if anything,

                    they are very much on the low side.  Dr. Dixon at the moment

                    is negotiating with the university to try and get a t6lease

                    so that salaries can be raised and not necessarily kept

                    within a very low salaried rate which the university has as


                    a limit.


                              Then we discussed the 'subject of continued

                    project support upon the termination of the RMP funding-

                    And while this certainly does not always appear in the


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                   written presentation of the projects, we were assured that

                   the outside sources will more or less be forthcoming for

                   continued support to the majority of the projects that  they

                 I have going.

                             The strength and the obvious impact of the  program

                   on the region, plus the exceptionally high calibre and

                   capability of staff really in the end far outweighed any

                   criticisms that we had.  So, I really recommend that we

                   move for the release of all of the IRMP's funds  immediately

                   in order to let them get on with their work.

                             If there are any questions, I'll be glad to  answer


                   them.


                             MR. ODGEN: Since I'm the one who raised  the  turf


                   poblem, I'm glad to know that this poison control program

                   is something that Dr. Gerdes has approved.

                             MRS. MARS: Ile is so anxious to have it  continued.

                             MR. OGDEN: I had a call from Dr. Sparkman,  who  is

                   the chairman of the coordinators group, who said to me  that

                   the only comment that he had about Intermountain was that  he

                   thought that there still was a turf problem.  There was an

                   agreement worked out pretty carefully about a year ago  among

                   the coordinators out there. And Dr. Studt has now  come  into

                   the picture as the new director,'not having been a party  to

                   that original agreement and they're having a little'difficult

                   in getting him to accept the fact that it's there.  But I


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                   rhink perhaps your visit has reinforced his need to

                   recognize that he has to work with other members of that

                   tri-council group. And as long as he'll do that,  I  can't

                   see that there is any problem.

                             MRS. MARS: And Dr. Nicholas said  very  franklyi

                   as I stated, that there always will be turf problems.  But

                   there is no reason they--

                             MR. OGDEN:  As long as they can work them out.

                             MRS. MARS: Certainly. There is  no  reason  they

                   can't be worked out, and so far there is some clause in

                   that agreement that they can appeal to--what is that clause--

                   if they can't work it out in council--

                             MR. POSTA:  They do have an appeal mechanism.

                             MRS. MARS:  They have an appeal mechanism, but

                   so far they haven't had to use it.

                             MR. POSTA:  I think another dimension, from probabl@

                   about a year or a year and a half ago, when you  discussed

                   the turf problem and the particular resolution that was

                   drawn up there, we found at that time that the three

                   coordinators and the three RAG chairmen met together

                   periodically to discuss the intent to develop a particular

                   program where it would be developed and which RMP would be

                   responsible for drawing up the further refined projects.

                             Upon visiting the region, this time we felt that

                   that's part of it.  The second Dart is Also of the


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                   responsibility of this interagency council, and that is once

                   a project is refined after a particular RMP and goes to the

                   technical review committee in that particular MIP, one  of

                   the three, it would then again come back simultaneously to

                   the interregional council for their endorsement to see that

                   the original idea hadn't been twisted.  I think that's a

                   little bit more of a dimension to the whole problem.

                             MR. OGDEN:  Then there is an organized structure

                   for handling this.

                             MRS. MARS:  Oh, yes.  Oh, yes, Very much so.

                             MRS. SILSBEE:  Mrs. Mars, Would it be your guess

                   that if Dr. Studt is the one that's learning about this

                   process and is now the chairman, that this would make  him

                   feel more responsible for it?

                             MRS. MARS:  Oh, yes, very much so.

                             I think it is just probably his newness, that he

                   just didn't realize how serious the problem could be.  I

                   think that is part of it. Ile has never done this sort  of

                   thing before.  I think--what was he, a neurologist?

                             MRS. MURPHY:  He is an orthopedist.

                             MRS. MARS:  Orthopedist, that's it, an orthopedist.

                   And while he had served on RAG and so on and so forth,  he

                   had never really been conscious,'you see, of these problems,,

                   because the RAG two years ago was not a very good RAG, and

                   there was very little cooperation between--literally  very


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                  1 little communication between--RAG and the  staff.  This  is

                    what was so extraordinary. And now I think  they've  got  a

                  i good RAG, and I think that Dr. Studt now is  becoming  very

                    conscious of the problems, and he's got a lot to learn, but

                    he is trying very hard, and he certainly is  giving  whole-

                    hearted effort and gets A for that if nothing else.

                              Since we were out there, the RAG has met, and

                    they are going to submit a rebudgetin4, but they  did  hold

                    it up until after we met, so that they could see whether

                    they were going to get the money or not.  So, the.RAG meeting

                    was held and it was agreed to postpone actions on the

                    projects in the surplus funds application until we met.

                              MRS. SILSBET:  By surplus funds, you mean t

                    ones that we had withheld?

                              MRS. MARS:  That's right, Yes.  There was $139,000

                    that was surplus.  It was carried over from their last

                    budget.

                             MR. CHAMBLI8S-  I think I should provide the council

                       just a bit more input along the line of the issue raised

                    by Mr. Ogden, in that I was at the western coordinators

                    meeting in'DenVer just-# few weeks.aqo, and there was a

                    persistent problem in the minds of the western coordinators

                    that you touched,on, about this turf@issue.  There is some

                    concern, and7@I was asked to bring hit to the attention of the

                    council to simply draw their  ttehtioh to the question that
                                                 a






                                                                                 2 8


                     there are still problems  in  the  overlapping  areas,  and  this

                     was brought to me both officially and on a personal basis,

                     that Intermountain still has problems in the surrounding

                     territories of other regions and at least council should

                     begin to think about  it  in  futuro,  about  constricting  the

                     region to its natural geographical boundaries.

                                I don't add ;that to get council off of its

                     discussion on the merits of the matter before it, but at

                     least I did commit  myself  to  western  coordinators  to  make

                     this presentation.

                                MRS. MARS:  I think so much of this is influenced,

                     as I repeat, the fact that  there  is  not  any  other  medical

                     center.  What happens to these areas if they do go--if you

                     just confine here to say the state  of  Utah,  all  the  rest  of

                     this big area is left, you see, out entirely, with no

                     connection whatsoever to a medical center.


                               MRS.            Being familiar  with  the  area,  being

                     from the area,  I think one thing  that  council  needs  to  be

                     advised about@is that so much  of  the  hospital  care  and  even

                    the medical care  throughout  Utah,  Idaho,  Wyoming,  Nevada,  is

                     carried on by a church grouo of hospitals which are

                     throughout all of these states.

                               MRS. MARS:  I didn't want to get into the religious

                     angle.

                               MRS.  m         It is, I think, a  big  reason  why  it


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                    does pull into these other states, is the fact that they

                    are operated out of a  church group of hospitals.

                              MRS. MARS:  Mormons do it all.

                              MRS.          Another reason reason why you don't

                   have very  many women.

                              MRS. MARS:  That's right.  Is I say, I carefullv--

                   you brought it  out--but I carefully avoided it.

                             MR. OGDEN:  There are some things we can change

                   and some things we may have to live with.

                             DR. MERRILL:  flow big an item of the budget  is it

                   approximately?

                             MR. POSTA:  Actually it's two small projects, 67

                   and 53, both of which were ten thousand each.

                             MRS. MARS:  Direct costs were eight thousand, one

                   hundred; and the other one was nine thousand, two hundred and

                   sixty-one.   It's a very small amount.

                             MRS. SILSBEE: Mr. Posta?

                             MR. POSTA:  I would like to mention just one

                   specific thing.  If you look at your red book at tab H, if

                   you recall, one of the big questions about this region for

                   several years is the fact they seem to keep their money close
                   to the university.  And the site visit team went into quite

                   a bit of detail to find out just how much money are we

                   talking about or grants, if you will, or contracts, if -vou
                   will, that had been contracted out of the university.  Look


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                     through the sums. I hope you  can  read  the  last  sheet  in

                     that group. We did earmark  about  $817,1540  both  from  last

                     year and this earls  award,  which  was  about  25  different
                                     y

                     activities  that  had been funded  outside of  the  university.

                     That  counts  grants, contracts  subcontracts,  And  what  have

                     you.  Four  of  those 25 were in the university.  The other 21

                     were outside  of  the university. And two  of  those  at  the

                     university had terminated.

                               You'll note from looking  at  the  dates  of  these

                     that quite a bit of this particular earmarking of funds came

                     from last year's budget", and because  of  the  restriction  on

                     this particular year's award,  they  have  not  entered  into

                     any contracts, to our knowledge.

                               MRS# SILSBEE:  Do I hear a motion?


                               MRS. MARS:  I made the motion.


                               MRS. MORGAN:  I second it.


                               MRS.  SILSBEE:  Any further discussion?

                               MkS.  MURPIIY:  I'd just like to make comment, if I

                     may, and it is  in regard to minorities, and I'll just read a

                     paragraph from my report. "An  action  on  the  part  of  IRMP

                     following the site visit  is  worthy  of  mention.  On  January

                     21st, which was the Monday following that site visit, a

                     Mr. Alvin June, a Navajo Indian from Tucson, Arizona,, applied

                    in person to the IRMP for  a  position."  They  don't  seem  to

                     know who sent him,, but he appeared.  "Mr. June is a





                                                                             3 1


                   vocational rehab specialist with a Master's Degree in

                   social work. The IRMP employed him  immediately,  and  I  have

                   since been informed that  he has been a very  noteworthy  asse

                              [Laughter]


                              MRS. SILSBEE:  The motion has been made and


                   seconded that the restrictions on the funds approved for

                   the IRMP at the last council meeting be removed on the basis

                   of the sit e visitors' recommendation and report.


                              I'.wonder of council would mind if I would add


                   something else in terms of the feedback to the region, and

                   that would be to mention how important you felt this

                   interregional coordination and council was and that you were

                   pleased that there was action taken and Dr. Studt was now the

                   chairman and you would be following it with a  great  deal  of


                   interest.


                              MRS. MARS:  Very good.

                              MRS. SILSBEE:  All in favor?  [Response]

                              Opposed?  (No response]

                              Let's take a five-minute break before we go  on  to


                   the  Hawaii.


                              MR. OGDEN:  If you have no objection, Mr. Hiroto

                   and I have a cab to catch at 3:45, which doesn't leave us

                   very much time.

                              MRS. SILSBEE:  Okay, let's not take a break.  There

                   won't be a break.  We are going on with the Hawaii report.


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                              MR. OGDEN:  At the advisory council meeting on

                    November 26-27, the council restricted the expenditure  of

                    certain of the funds of this program until a council  survey

                 I  team had visited the program and could report back to you.

                    The concerns that we had out there I'll go into just in  a


                    moment.


                              There $375,901 dollars available for expenditure

                    for the program in Hawaii.  $145,249 of it has been

                    restricted by council. Dick Russel just put  some  figures

                    up here on the board. And $58,665 budgeted for  the  Waianae

                    Coast comprehensive health center pro3ect cou   not  e

                    awarded--we agreed would not be awarded until RMPS had

                    received written assurance that the RAG clearly understood

                    the problems encountered by the Waianae board and  assured

                    appropriate use of the funds.

                              There was an additional restriction that was  made


                    a-r-ross the board for the fiscal year '73 monies. And I m3ght

                    say here also that the Pacific. Basin portion of the program

                    was not a part of our concern.

                              I might remind you all that the Hawaii  Regional

                    Medical Program includes not only Hawaii, American  Samoa,

                    Guam, and the Trust Territory of the Pacific Islands.

                              The major problem in Hawaii has been the coordinator

                    of the program. This problem has been there for  some  time.

                    Dr. Hasegawa has been the coordinator since the program


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                    started.  He was unpaid until about two years ago.  He has

                    been doing this as a  part-time activity.  He is a full-time

                    pediatrician. He has  been doing this as a  part-time  ictivity

                    running it nights and  weekends and occasionally in the office.

                    We have all had for some period of time  concerns  that  the

                    management of the program was weak and it was lacking in

                    leadership.

                              The survey team that went out included myself,

                    Ed iIiroto, who is of the same background as Dr.  Hasegawa,-

                    and Ed has been out there before on site visits;

                   .Dr. Hirschboeck, the former coordinator of the Wisconsin

                    program who is now at St. Mary's Hospital  in  Milwaukee  as

                    Director of Medical Services; and Bob Fernandez, a psychiatris

                    who is on the staff of Region 9 in San Francisco.  And, of

                    course, Dick went out as the Western Operations Branch

                    chief.

                              We agreed in the session, which lasted really all

                    day before we began meeting with their staff and  the  RAG  and

                    the grantee, that we would conduct this not as a site visit

                    nor as a management survey visit.  It was a council surVev

                    team.  There would not be a feedback session with the

                    RMPH staff. That we would not be led  into  discussion  of  the

                    failure of particular projects or  the  problems  concerning

                    the projects that existed out there, particularly the

                    waianae coast project which I'll talk a little  more  about  in






                                                                           3 4

                   a minute, and their emergency medical project; that we

                   would keep an open mind as to whether or not to  recommend

                   a change in the staff leadership, and we would attempt  to

                   see whether or not our feelings about poor management  and

                   lack of leadership were confirmed by observation.

                             And, frankly, we also concluded that this report

                   would be considered confidential-administrative; and I rather

                   fear that if it weren't, if it ever got into the hands of the

                   press in Hawaii,, we would see some fur fly.

                             At any event, we met with the PMPH staff.  We felt


                   that what we were hearing was a surface glossing over of

                   problems that are still there in internal communication.

                   And indeed staff members told us privately after the

                   presentation done by their deputy director that there was  a

                   substantial lack of communication within in the staff,

                   problems of staff morale, lack of unity, lack of leadership,

                   lack of direction. And it all stems from the fact  that  the


                   coordinator simply is not available on a full-time basis.

                            We then met with Dr. Richard Lee, the  director  of


                   the Research Corporation of the University of Hawaii'.  It was

                   very blunt. He said that the RAG had protected the  staff.

                   The RMPH lacked full-time professional leadership because

                   Hasegawa wasn't there. He termed the RMPII staff  weak.  The


                   medical professionals in Hawaii would not call on RMPH for


                   assistance.  Statements that have never been made to us


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                   before, to the best of my knowledge.

                             Instead, he said flatly that he didn't feel that

                   Dr. Hasegawa had done the job and that he would not now

                   hire him as director of PIIPIII.  Now, the grantee doesn't

                   really hire him. They approve the action of  the  Regional

                   Advisory Group.

                             We asked him who might be a successor.  He


                   mentioned Dr. Satoru Izutsul who has been the head of  the


                   Trust Territories of the Pacific, Samoa and Guam portion of

                   this project.  Dr. Izutsu is not an M.D.; he has a Ph.D. in

                   behavioral sciences.  And we had some concern about the


                   acceptance of him by the professionals in Hawaii.  Dr. Lee


                   felt that this would be no nroblem.  We find later that


                   Dr. Izutsu is somewhat of a protege of Dr. Leels, which may

                   present some problems also.

                             We went on to a meeting of a regional advisory

                   group where really the only critical input came from the

                   head of the CHP agency, Sylvia Levy, with whom we all  had

                   A very informative session the following dav.  She  raised

                   some questions about a series of things involving the

                   waianae board, that even though their regional advisory

                   group proceeded I think with some lack of information,  we

                   did agree that they have recognized the problems that have

                   occurred in this Waianae project.

                             To be very brief about it, and Dick can go into it


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                   at much greater length if he chooses, the Waianae project is

                  ithe outgrowth of an OEO program, an OEO clinic, which when

                   OEO funds were withdrawn scrambled to find money wherever it

                   could.  And RMPH put money into it, has tried to keep it

                   going; it hag applied for 314(e) funds.  The man who was

                   running,,, whose name is David Palley, had been a truck driver

                   for a Castle & Cook sugar plantation which had closed.

                   Mr. Bryan, who  is the chairman of the RAG, was the man who

                   closed the plantation for Castle & Cook.  So, he has a

                   somewhat ingrown relationship with this Waianae project.  we

                   found we were treading on eggs wherever we went.  And not

                   only that, we were treading on all sorts of political things

                   that we didn't fathom completely.

                             We indeed have a letter todav from Dr. Lee, which

                  ;I'm sure is merely covering his traces and saying these two

                   men who are resigning--this just came to me from Dr. Lee--

                   "As you probably heard, Dr. Hasegawa, who has been coordinator

                   and director, has offered his resignation, and so has Mr. Brya

                   Because of@'the,timing-'of these two actions, approximately

                   coincident with your recent visit here, there has been a

                   misinterpretation of the reasons for the resignations, and I

                   believe this misinterpretation reflects unfairly oh the

                   individuals concerned And unfavorably upon the activiti6g of

                   RMPH., I am particularly concerned, since the two individuals

                   involved have given much time and effort to the program here."

                             Well, he has no choice but to write a letter like






                                                                             37


                    that, in spite of what he told us.  And he has probably sent

                    a copy of that to the two of them to make sure that they

                    are all still friends.  I consider that just a political

                    letter.  I wouldn't pay any attention to it.

                              But, in any event, we met following the RAG meeting

                    and felt that we had to talk a little longer with Mrs. Levy,

                    which we did.  We talked then to Mr. Bryan.  And I must

                    say that two things occurred in the visit with  Mr.  Bryan.

                    I asked him why he and the RMPII people thought we were  in


                    Hawaii.


                              lie said, "Well, it's cold where you come from and

                    it's nice to come out here, isn't it?" which somewhat

                    dismayed us because it simpl           he  impression  that
                                                y gave me t

                    they didn't take the visit very seriously.

                             And then the more serious thing  was  Mr.  Bryan's

                    comment that he was surprised when  RMPS  recommended  that


                    the emergency medical services project be taken out of  the

                    hands of RMPH and turned over to the Hawaii Medical


                    Association, because he simply hadn't realized that  things

                    were that serious, which made us Question how closely  that

                    RAG and Bryan in particular had been keeping track  of  the

                    program and how effective the leadership has been.

                             We had a verv frank conversation with  Mr.  Bryan.

                    He then volunteered to go to Dr. Hasegawa and suggest  that

                    Hasegawa resign, and he said the only wav Hasegawa will do it


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                    would be for me to go with him and for Bryan to resign     along

                    with Hasegawa. The two of them  met  over  lunch,  came  back

                    to us and said that's what thev were going to do.

                               And they wanted to know if that  would  provide  some

                    assurance  that the program would be strengthened because of

                    it, and we told them it certainly could, depending upon who

                    the new coordinator would be, what freedome he had to

                    restructure the staff and provide leadership to the


                    program.

                               At any event, Mr. Bryan said that they would

                    need some time to contact members of their executive

                    committee and hold an executive committee meeting.  Now, at

                    that poin t, the time for the site visit team  to  leave  had

                    come.  Ed left.  john ilirschboeck went back.  Bob

                    Fernandez went back to San  Francisco.  Dick  Russell  and  I
                    stayed on. I stayed on hopefully  to  be  on  vacation.  And  it

                    didn't all work that way.  I think the rest of the time

                    Dick and I were in conference almost constantly.

                               But at any event, after a  few  days--and,  incident-

                    ally, the letter with respect to  the  Waianae  project  came

                    out, and that has come back here, and the money on the

                    Waianae has been released, fifty-eight some thousand dol ars.

                               Dr. Itutsu, who has been on leave  of  absence  in

                    Thailand, working for the Agency for International
                    Developmentt came  back      through Hawaii rather fortuitously.


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                    Dick Russell met with him.  I felt my meeting with him might

                    be misinterpreted, until RMPH at least had talked  to  him.

                    Izutsu indicated that he was interested in  taking  the  job

                    but only if he could make some major staff  changes  and  only

                    if he could apply for it on a competitive basis so that it

                    would not appear that he was being pushed in  in  place  of

                    Hasegawa for political reasons.  I can understand Izutsu's

                    situation.

                              Vinally on Thursday the 17th, they  held  a  special

                    meeting of the executive committee  and  resignations  were

                    submitted.  Mr. Burkett, the Executive Secretary of the

                    Hospital Association, former RAO chairman, is  to  become  the

                    RAG chairman again.  Hasegawa was to see Izutat and encourage

                    him to accept the directorship.

                              They all agreed out there that  an  acting  director

                    could be appointed until itne 30th.  Since then the  somewhat
                                                                         y

                    changed their minds on that point.  And as Dick and I left

                    Hawaii,, Hasegawa and Bryan were in the process of resign ng.

                    No new director or RAG chairman had  yet  been  chosen.  No

                    announcement had been made to the staff nor to the press, but

                    it hit the press after we left.  And that came from the

                    chairman of their executive committee, who should have known

                    better.  But in any event, it's out.

                              All the groundwork for changes in  RMPE  has  been

                    laid. And I think it's going to go ahead  in  spite  of  all






                                                                          4 0

                   the political things that may come up out of it.  Mr. Bryan

                   will stay on and work with the Waianae project, because he

                   has a personal interest in seeing it be successful.

                   Dr. Hasegawa will continue to be an advisor to the pediatric

                   pulmonary projects because as a pediatrician he is very

                   much interested in them.  And hopefully the way is going to

                   be cleared for a new coordinator to be selected in due


                   course.


                             The final caveat in our report on the last page

                   I don't think is something we need to go into because I

                   don't think it's going to happen. But I will simply  leave

                   it there, and you all can read it for what it's worth.  It

                   simply says that if they want to appoint the current

                   deputy or Mrs. Rosie Chang, that we on the team would

                   recommend that the further expenditure of funds for the

                   RMPH be restricted permanently.

                            This is the first time that the council has  gone

                   out and shook the tree. I don't recommend that we do  this

                   very@often.  But there may come times when there isn't much

                   choice.  And as a consumer sitting on this council, I'm

                   appalled when I see things that should be running well simply

                   not running at all.  And I'm also concerned when we see a man

                   who is a full-time pediatrician making a very substantial

                   income, making $35,000 a year for running this program on

                   nights and weekends. Because it's the kind of thing  which


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                    can make this entire Regional Medical Program criticized,

                    and it's the kind of thing somebody points to, but it's a

                    freak situation.  It doesn't exist anywhere else.  And you

                    must remember that he was not paid until about two years

                    ago.  I don't know the sequence of how it came to be that he

                    was paid.  I think he intended to move out of private

                    practice and do this full time, and that has not occurred.

                    So, he is still in practice.  But at any event, Dick, you

                    might follow up on any other comments and@thdn, Ed, if you

                    have anything to say and we'll qo catch a cab.


                             MR. RUSSELL: I will defer to Mr.  Hiroto  here.


                             MR. IIIROTO:  I would just add you have to

                    understand that although the report has its humorous side,

                    these things were done in deadly earnest.  And each decision

                    that was made  had to be made based upon the factors that

                    the site visit team saw, and I think that we were extremely

                    fortunate in being able to come out with the results that

                    we were able to come out on a voluntary basis.

                             MRS. MARS:  The way it stAnds now,  it just

                    frankly ought to be closed up, shouldn't it?

                             MR. OGDEN:  Well, I don't think so.  I think

                    Dr. Hasegawa has expressed an intention to resign, and I

                    think he will. I would be in favor of continuing to  let

                    them have enough money for that staff to keep their

                    projects going.  There are aoing to have to be changes in


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                   the staff.  But,there are some projects there, and I think

                   the Waianae coast project, this clinic, should be kept

                   going.  The South Pacific portion of it is doing well.  There

                   are major oroblems that need to be attacked, including the

                   problem of leprosy, which is coming back into Hawaii through

                   the Samoans moving up there.  And I don't think it! s an area

                   we,want to ignore, and I don't think I would be in favor of

                   closing it down at this point.  I think we need to allow

                   time for these changes to occur.  And I think they are going

                   to happen.  I think they are going to happen.

                             MRS. MARS:  What sum of money is required to keep

                   the projects going?


                             MR* OGDEN:  Fortv-some thousand dollars I think


                   at this point.

                             MR. RUS8ELL:  Yesi if I could get into this now,

                   the figure that we are dealing with now really is the

                   $511,352.  The top figure was a total award, the fiscal year

                   '73 restriction.  That was the across-th6-board restriction

                   for all programs receiving the money at a particular time.

                             As a result of council action at this last meetital

                   $145,249 was restricted, leaving them three sixty-six, plus

                 ,available, which has been budgeted from January I through

                   April 30, leaving,the two months loose.

                             What I would like to suggest to this group is that

                   for the seven ongoing projects, their commitment for May and





                                                                            43

                    June comes to approximately $41,000.  If this group would

                    consider releasing $41,000 of the $145, 000 currently

                    restricted, this would enable the program to meet the

                    commitment to their individual projects.  It would not

                    permit them to do anything in the core staff area until

                    the other part of the recommendation is reflected in the

                    report, that that be restricted mending the appointment of

                    a new coordinator and the election of a new RAG chairman.


                    What this would do--I would hope they would get the

                    message.  I'm sure they will get the message.  I'll put it

                    that way.  That it would say, "Okay, you may tell your

                    projects, the local people, that the  may go through RMPH's
                                                        y

                    full commitment to them." However, the program staff is

                    really limited until they do appoint a new director.  And

                    then this wo-ld put the new director in a much better

                    position to control the program.

                             MRS. MARS:  Then we can see what happens.


                             MR. RUSSELL:  Then we can see what happens.


                             MRS. SILSBEE:  Dr. Merrill?


                             DR. MERRILL:  Your bomb shell at the end here raises


                    some concern with me, because you knocked off the first

                    three people in a row here, and I gather there is some

                    weakness in the rest of the staff too.  So, is it only the


                    executive director we need be concerned about?


                             MR. OGDEN:  No, it's probably mote than that.  I


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                    think if Dr. Izutsu takes this on, there are going to be

                    some major changes in the staff.  He feels that way.

                               There has been some attrition also.


                               MR. RUSSELL:  Doctor, along these lines,

                    Dr. Izutsu told me that in talking with Dr. Hasegawa--and

                    I've since passed this message on to the other key

                    individuals involved, that whomever takes the job will have

                    to restructure that staff.  That is becoming common

                    knowledge in Hawaii.  And communications there travel very,

                    very quickly.  Too fast.

                               DR. MERRILL:  One other brief question.  Did

                    anybody in the site visit team get in touch with Dr. John

                    Lowery?


                               MR. OGDEN:  Yes, we talked to Dr. Lowery.  I think

                    he would welcome a change.

                               MR. RUSSELL:  He was the gentleman quoted by the

                    press.  He was deeply involved, yes.

                               MR. OGDEN:  I think he would welcome a change.  He

                    feels there is a great deal RMPE could do if it had different

                    leadership.

                               MRS. MARS:  Are you making a motion then?


                               MR. OGDEN:  I will move that--Dick hag written this


                    out--approximately $41,000 of the@-$145,249 restricted be

                    released to RMPH for continuing support of its ongoing

                    projects.  The remaining $104,249 continue.to be restricted,


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                     pending the appointment or a new coordinator and the

                     election of a new RAG chairman.


                               MRS. MARS:  I'll second that.


                               MRS. SILSBEE:  The motion has been made and


                     @seconded that $41,000 of the  $145,000  plus  that  is

                     presently restricted be released to continue support of the

                     ongoing projects; the remaining $104,249 will continue to be

                     restricted, pending the  appointment  of  a  new  coordinator

                     and the election of a new RAG chairman.


                               MRS. MORGAN:  Then also before that could be


                     ,Released it would have to come before council again?


                               MR. EIROTO:  Yes.


                               MRS. MARS:  What will happen now on the release

                     of these past funds for '73?

                               CHAI@N PAHL:  We are not going to be distributing

                     any of the 173 funds until  the  June  council  meeting,  And

                     that  would be accordance with'specific proposals, and by that

                     time certainly we should have  all  of  these  matters

                     resolved.       that would be 'contingent  upon  this.

                               With  regard to  the,question  about  whether  this

                     would automatically come back to  council,  not  as  this  is

                     phrased.  I think if you wanted it to come back before it--

                               MR. OGDEN:  Then let's add that no further funds

                     can be expended without it  coming  back  to  council.

                               MRS. SILSBEE: As  I  read  the  motion,  once  they

                     appoint the RAG chairman and the new coordinator, these






                                                                               46

                    funds could be released.  That's the way I read it.  Is

                    that not the way you mean it?

                               CHAIRMAN PAHL:  That's the interpretation.

                               MR. OGDEN:  I'll buy that.  I think that would be

                    all   right.

                               MR. RUSSELL:  We are anticipating and hoping that

                    perhaps Dr. Izutsu will accept this.  We're not sure.  But

                    we do expect to have a replacement by April lst.  If we

                    should run into any snags along this line, we can come

                    back to council at the March 29th meeting.

                               MRS. SILSBEE:  That is really keeping the

                    Regional Medical Program in the perils of Pauline.

                               MR. RUSSELL:  No, I am not recommending that it

                    comeback   to council.   We're not suggesting  that.  What  I

                    wn saying  is that as a matter of information, we  will  have

                    an opportunity to keep council informed.


                               MRS. SILSBEE:  Mr. Gardell?


                               MA. GARDELL:  I was just wondering if it was

                    clear here, the roles of the grantee and the RAG with

                    respect to the selection and the appointment of the

                    individuals.  It wasn't quite coming through to me that

                    Dr. Lee has responsibility for the coordinator; is this so?

                               MR. RUSSELL:  This is quite clear, Jerry.  This is

                    the first thing.  We would not respond to the bad

                    publicity until we got something from  the  grantee.  So,  we


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                    were well aware of that.


                              MR. OGDEN:  He approves.  The grantee has to

                    approve the selection of the coordinators but does not


                    select them.


                              MR. GARDELL:  No.  He selects them, according to

                    our policy.  That's why I was a little bit concerned about

                    it.  He has recommendations from the RAG and then he makes


                    the selection.  That's why I was a little bit concerned

                    about it.  I wasn't sure that Dr. Lee understood his role.


                              MR. OGDEN:  Then I am in error on that.  Lee


                    understands this?


                              MR. RUSSELL:  Yes,, he does.

                              MRS. SILSBEE:  I'll repeat the motion that has been

                    made and seconded.  Approximately $41,000 of the $145,249

                    now restricted be released to the RMPH for continuing support

                    of its ongoing projects.  The remaining $104,249 will

                    continue to be restricted pending the appointment of a new

                    coordinator and the election of a new RAG chairman.


                              Any further discussion?

                              All in favor?  [Response]

                              Opposed?  (No response]


                              The motion is carried.


                              CHAIRMAN PAFIL:  I would like to thank both of


                    the council members for carrying out a most delicate task,

                    and I would like to bring to the attention of everyone in


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                                                                          4 8

                   this room the request made here that this written report

                   and this information presented be treated as confidential-

                   aaministrative.


                             You can see that we cannot be effective in these

                   kinds of matters if this is not adhered to.  So, we make

                   special plea that the confidentiality of these meetings be

                   strictly understood and adhered. to.

                             MR. OGDEN:  Sorry, but we must go, but we have a

                   cab to catch and planes to catch.

                             CIIAIRDIAN PAIIL:  Thank you again for a very fine

                   report and fine activity.  And we look forward to a

                   successful conclusion.


                             MR. OGDEN:  I looked at the material on Arizona,

                   ana i think it looks very good, and I would approve going

                   along with the release of funds.

                             MRS. SILSBEE:  Thank you very much.

                             [Mr. Ogden and Mr. Hiroto departed from the

                 i meeting.]

                             MRS. SILSBEE:  The final item on our agenda
                 @today is a report from Mrs. Sadin on the Arizona consultation

                   visit.  There is no action involved.


                             MRS. SADIN:  I was wondering, if there is no action

                   involved and you all have that report, do you want to have me

                   present it anyway?


                             MRS. SILSBEE:  Yes.



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                                                                           49


                             I think we all recognize that there is  a  different

                   flavor sometimes in a verbal report and it gives us an

                   opportunity to ask you some questions.

                             MRS. SADIN:  This does not require  any  action.  It


                   was not a site visit. And the reason we had  this  consulta-

                   tion visit to begin with was because Arizona has kind of been

                   visited regularly, I think, once a year, because  council  has

                   continued to have certain concerns, and these concerns  have

                   kind of remained the same over a three-year period.

                             I think when they came in for triennial status  at

                   the end of '71, they were approved with certain kind of

                   conditions, that thev needed to visit again in 172.  They

                   were visited in '72 by a site visit team, with representation


                   from review committee and council. And some  of  the  concerns


                   have been addressed,, some have not. Specifically  those  that

                   had not were that they were still continuing to put a  lot  of

                   money into data collection activities and these were all

                   supported by the RMP, not shared with CHP.  And also that

                   the CHP-RMP relationships continued to be a problem.

                             So, that site visit team in '72 recommended that

                   they be visited again in another year.  And in the interim

                   we had, as everybody knows, phase-out. And so thev  were  not.

                             When they submitted their '74 application, it  was

                   looked at by the last council.  There was tome evidence in

                   the application that some of the issues had been  addressedi


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                                                                              50

                    that they had been working with CHP  rather  well,  that  they

                  11 were addressing some of the health service needs, and the

                    council recommended that we have a visit with staff and

                    Dr. Cannon who, up until the end of November,  was  a  member  of

                    council. And he had been to Arizona,  I  believe,  on  the  other

                    two visits.  So that he knew the region rather well.

                              Unfortunately there was fog  over  Kansas  City,  and

                    Dr. Cannon didn't get there until the  end  of  the  consultation

                    visit.  And so the consultation visit really consisted of

                    yours truly and it was kind of too late to cancel things

                    because I had just gotten the news the  night  before  and  we

                    just decided we would go ahead as vlanned.

                              Mr. Ron Currie was there   from Region 9, and  riyself;

                    Dr. Cannon came about 4:00 o'clock   that afternoon.  Ile  did

                    have a chance to meet with the  staff,  ARMP  staff.  The  RAG

                    members had already left.  Ank the CHP people had alreadv left.

                    But he also met the following day with Dr. DuVA1, who is     a

                    member of their RAG and, you know, was here  and  has  quite  a

                    bit of influence in that area.

                              The purvose of our visit was to  find  out  if  they

                    had addressed orevious concerns, to find  out  how  their  plan

                    evolved, and what they were going to plan to do in '74.  And

                    most of the Arizona RAG members were present at the meeting,
                    and they had many--I think except for  two--they  had  most  of

                    the CHP "B" agencies represented there and some other


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                    organizations.


                              The Arizona RAG had insisted that RMP staff

                    work with CHP.  And they had.  They really had been around

                    to all of the CHP "B" areas and the "B" people there

                    really attested to the fact that they had been trying to

                    adxdress the needs.  The two people missing were the

                    director of the CIIP "A" agency, and there are still

                    problems in that area.  The director of that agencv never

                    did respond to the letter written to him by ARMP, didn't

                    show up at the meeting.  The Mericov Accounting, which is

                    the big "B"' agency in the area, the director was supposed to

                    be there.  He was invited.  lie said he could come, and he

                    didn't show up for whatever reason.

                             He did, however, respond to the application, made

                    some comments which again were responded to by ARMP staff,

                    by the coordinator.

                             So that we felt that the ARMP-CHP relationships,

                    except for the "A" part, were moving along well.

                             The remaining concerns and the only thing we still

                    have a little bit of reservation about were the composition of

                    the RAG.  They still don't have minority representation.

                    They're still largely provider oriented.

                             The excuse we had  been  given up until this time

                    was that there had been a regulation that the ARMP RAG be

                    part of the Arizona Health Planning Authority, and that's why


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                   it could never be very large. And it  had  maintained  its

                   small size because they thought that was the only  way  they

                   could manage it.  But  that restriction had been  removed.

                   They still haven't expanded it because--well, they said

                   their enthusism was, you know, kind of dampened  because  of

                   phase-out. You know, they met  regularly.  They  didn't  see

                   the need.


                              Dr. DuVal, who was present when we discussed  RAG

                   composition, didn't respond to the issue.  And  Dr4  Cannon,

                   when he met with Dr. DuVal the next day, said that this


                   didn't come up.

                              The staff has expanded.  They do have some people

                   that ate working out in the  areas.  Decentralization  was

                   another problem that council had before, but now  they  have

                   six people in Phoenix, and they have people working out with

                   CHP areas in the field. They  have  field  representatives


                   now.


                              But they still don't have any minorities on staff.

                   They said  they can't find them. And whoever sent  that  man

                   to Intermountain, I suggest that he send somebody to

                   Arizona, because they can't seem to find anybody.

                              We think that because of phase-out--I have talked

                   to Dr. Cannon--Dr. Cannon, Ron Currie, and myself feel that

                   since there was a lot of--not disorganization necessarily

                   but dampened enthusiasm and problems because  of  phas6-out,


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                   that really they are to be commended for doing what they

                   have done in working with CHP. But I still think  that  they

                   ought to address the minority problem on RAG and staff,  and

                   that they ought to expand their RAG because if, as everybody

                   tells us, you know, we're going to move towards having

                   more representation of consumers and third-party payers  and

                   government agencies, then I think would behoove ARMP to move

                   in that same direction.

                             MRS. SILSBEE: Any questions?

                             MRS. MARS:  How large a staff have they got?

                             MRS. SADIN:  They have 14 now.  They started out

                  with 30.  They reduced to nine during phase-out.  And then

                   they have added another five.  And these five individuals

                   are--well, some of them are going to be area representatives.

                   But I think the  strength will be in w6rkinq,with the CHP

                   "B" agencies.

                             MRS. MARS:  What is the population of their area.'

                             MRS. SADIN:  A million.  They have been working

                   with the Indians on the reservation.  And there was a

                   representative of the Navajo Health Authority.

                             MRS. MARS:  What did he have to say?

                             MRS. SADIN:  He was positive.  He said they have

                   been working together and that he had seen some changes.

                             CHAIRMAN PAHL: Thank you for the report,  Rebecca.

                             Is there any other business that you feel should


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                                                                            54


                   be taken up before we adjourn?  I believe we've covered

                   everything that was on our agenda.

                              Bob has been working trying to establish what  date

                   is most appropriate for this national meeting of the

                   coordinators  and tying it into the various schedules of

                   those that we  certainly would like to have at the meeting,

                   and it's not possible today to do this.  So, we'll be in

                   touch with you very shortly as soon as we can establish that,

                   And presumably we will have that rather quickly.  So,  in  the

                   next few days we'll be in touch with you  about it.

                              Thank you aaain.  it has been most difficult with

                   a dininshed council, and you suffered through many reports

                   very patiently and helped us considerably on all the site

                   visits and recommendations, and I for one am very  pleased  to

                  il hear the outcomes of these three site visits, which again

                 ,ip roves that it's worthwhile going and talking, not  depending

                   on just what comes in the application.

                              MRS. MARS:  It's very necessary.

                              CIIAI   PAHL:  All right, our meeting stands

                   adjourned.  Thank you.

                              (The meeting was adjourned at 3:53 o'clock p.m.]












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