I
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   are          I             DEPARTNENT OF HEALTH, EDUCATION, AND WELFAPTE

                2                        PUBLIC HEALTH SERVICE

                3                   HEALTH RESO'URCES ADMINISTRATION

                4

                5                      THIRTY-FT-RST kEETING OF THE

                6         NATIONAL ADVISORY COUNCIL ON REGIONAL PEDICAL PROGRABE

                7                                  - - -

                8                           Executive Session

                9

               10                                    Conference Room M
                                                     Parklawn Building
               11                                    3600 Fishers Lane
                                                     Rockville, Marylartl

               12.
                                                     Tuesday,. November 27, 1973
               13             The meeting reconvened at 9:21 o'clock, a.m.,
               14
                    Dr. Herbert Pahl., Acting Director, Regional Medical Program
               15
                    Serviceo presiding.

                    COUNCIL MEMBERS PRESENT:

               17
                              NRS, AUDREY M. MARS
                              GEORGE E. SCHREINER, M.D.
                              MR. EDWIN C. HIROTO
                              DR. LAWRENCE FOYE
                                   M4R]:EL S. @M@RGAN
               20             BENJAMIN W. WATKINS, D.P.M.
                              MR. SEWATL 0. MILLIKEN
               21             MR. C. ROBERT OGDEN

               22

               23

               24

               25

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                                           C 0 N T E N T S

                2   CONSIDERATION OF APPLICATIONS:                                @e

                3   South Central Operations Branch:

                4        Michigan                                                84
                                    Motion                                       86
                5                   Vote                                         87

                6        Alabama                                                 88
                                    Motion                                       88
                7                   Vote                                         89

                8        Florida                                                 89
                                    Motion                                       91
                9                   vote                                         92

                10       Georgia                                                 92
                                    Motion                                       93
                11                  Vote                                         94

                12,      Illinois                                                94
                                    Motion                                       96
                13                  Vote                                         98

                14       Indiana                                                 98
                                    Motion                                      100
                15                  Vote                                        104

                         Memphis                                                104
                                    motion                                      108
                17                  Vote                                        110

                18       Miss iss i ppi -L                                      110
                                    Motion                                      112
                                    Vote                                        113

                20       North   Carolina                                       114
                                    Motion                                      116,
                21,                 Vote                                        ii6

                22       Ohio Valley                                            117
                                    Motion                                      L20
                2@3                 Vote                                        121
                24       South   Carolina                                       121
                                    Motion                                      125
                25                  Vote                                        125

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                                                                                  Page
                 1        Tennessee Mid-South                                     126
                                    Motion                                        134
                 2                  Vote                                          135

                 3        Wisconsin                                               136
                                    Motion                                        136
                 4                  Vote                                          137

                 5  Western Operations Branch:
                 6        California                                              138
                                    Motion                                        144
                 7                  Vote                                          144

                 8        Mountain States                                         144
                                    Motion                                        146
                 9                  Vote                                          147

                 10       Oregon                                                  147
                                    Motion                                        148
                 11                 Vote                                          150

                 12       Washington-Alaska                                       150
                                    Motion                                        152
                 13                 Vote

                 14 Eastern Operations Branch:

                 15       Albany                                                  154
                                    Motion                                        155
                 1                  Vote                                          156

                 17       Connecticut                                             157
                                    Motion                                        161
                 18                 Vote                                          161

                 19       Central  Nev  York                                      i62
                                    Motion                                        i66
                 20                 Motion                                        169
                                    Vote                                          @170

                 21
                    Motion                                                        l@71
                 2-1                Vote                                          172
                 231      Greater Delaware Valley                                 172
                                    Motion                                        176
                 24                 Vote                                          178

                          Maryland                                                   p
                 25                                                               17,,
                                                                                     04
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                                                                                 8-@b

                                                                                Page

                 2
                          New York  Metro                                        182
                                    Motion                                       186
                 3                  Vote                                         187

                 4        Puerto Rico                                            187
                 5                  Motion                                       195
                                    Vote                                         196

                 6        Nassau/Suffolk                                         197
                          Lakes  Area                                            197
                 7        Maine                                                  197
                          Rochester                                              197
                 8        Susquehanna Valley                                     197
                          Pennsylvania                                           1
                 9                  Motion                                       197
                                    Vote                                         198
                 10
                          Metro Washington, D.C.                                 198
                 11       Nassau/Suffolk                                         198
                          New  Jersey                                            198
                 12       Northern New England                                   198
                          Virginia
                                                                                 198
                 13       West Virginia                                          198
                                    Motion                                       198
                 14                 Vote                                         198

                 15 Mid-Continent Operations Branch:

                 I        Arkansas                                               199
                          Oklahoma                                               199
                 17       Bi-State                                               igg
                          Iowa                                                   199
                 18:      Nebraska                                               199
                          New  Mexico                                            199
                 ii)      Missour@- K                                            200
                          North Dakota                                           20o
                 20       Texas                                                  200
                                    Motion                                       203
                 21                 Vote                                         204

                          Intermountain                                          205
                 22
                                    Motion                                       223
                 23                 Aiwndment                                    227
                                    Vote                                         231

                 24
                    lvlotion                                                     231

                 25

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                                         P R 0 C E E D I N G S

                 2             DR. PAHL:  May we now start our executive session.

                 3             Judyo will you continue on, please.

                 4             MRS. SILSBEE:  We have five members of Council here.

                 5             We hope to be able to move this along a little faster

                 6  this mornig, except for one branch operations.

                 7             MRS. MARS:  Mr  Hiroto will be back in a second

                 8             MRS. SILSBEE: In order not to  give  an  impression

                 9  that all regions that we are considering today are problem

                 10 regions, we would like to shift back to kind  of  our  initial

                 11 plan yesterday. We promised to do  this  rapidly.  But  to  go

                 12. through by branch to get a quick overview of all of the regions,

                 13 and then to suggest kind of special recommendations in the case

                 i4 of one or two regions, and actions in terms of others.

                 15            Mr. Van Winkle will go through quickly the regions

                 l@(i that remain in South Central and at any point that Council

                 17: wants to discuss the region further, please break in.  Be-

                 18 cause we don't want this to be a recitation on our part.

                               On the other hand, we know that you were only look-

                 20 ing at a piece of the region and staff does have more overall

                 21 view, limited as it may be in cases.

                 2             Mr. Van Winkle.

                 2.3           MR. VAN WINKLE:  I think I would like to start with

                 24 Michigan  if I might.

                 25            This was a region that had been sliding very rapidly

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                 1  downhill until they obtained a new coordinator,  Dr.  Tupper,
                 21 and in a very short space of time he turned this region
                 31 totally around and I thought they submitted an excellent

                 4  application. I was quite impressed with  the  fact  that  their

                 5  request does not include any indirect costs,  either  in  pro-

                 6  ject activities or the program  staff  component.  The  direct

                 7  costs will not be awarded to the project activities so that they

                 8  could maximize the benefit to the Michigan Health Care System.

                 9            @. SI@BEE:  You mean indirect?

               10             MR. VAN WINKLE:  Yes.  The project agreed to absorb

               11   these.

               12,            Their review process is a model.  I think other

               13   regions could well take a look at it.

               14             I think I should point out whereas Dr.  Tupper  is

                    on only fora.;percentap:e of his time,, he did obtain  aideputy

                    whom he has now named as program  coordinator.  His  title  has

               17   been changed, Tupper's title has been changed  to  Executive
               18   Director. And he is giving 25 percent of his  time  in  that

               I!)  capacity.

               20             Michigan does have a kidney component and they will

               21   be aLerted to the provision in the interim  rules  and  regula-

                    tions.
               22
                              They have requested $627,,536 for the support of the
               2ii
               24   program staff component, 16 new operational activities  all
               25   designed to implement the Rfe's priorities and options.

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                1           We would recommend approval of this  applications
                21 stated.

                3           MRS. SILSBEE:  Mrs. Morgan.

                4           MRS. MORGAN:  I have Michigan and I have read it

                5  over.  I think it is  an excellent program.

                6           I do not believe their kidney program is new, though

                7  Isn't it a continuation of an already approved program?

                8           MRS. SILSBEE: Well, approved by RMPS,.may not  be

                9  approved by the Social Security.

              10            MRS. MORGAN.- By Social Security.

              11            MRS. SI@'-BEE:  We are going to flag--

              12            MR. VAN WINKLE:  That is the only reason we are

              13   doing this.

              14            MRS. MORGAN:  Because they have had it prior to this

              115  whether it is an additional thing is something else maybe.

              it;           -An excellent program I feel with coverage.. with the

              17   limitations that were placed upon them as far as submitted And

              18   I move that we grant the Michigan progrEm as requested.

                            MRS. SILSBEE:  There is just one--

              20            MR. VAN WINKLE:  I left out the staff did--

              21            MRS. SILSBEE: Yes, one item. There is  a  request

                   for  t@RFpds in one of the projects, which policy does not per-
              22

                   mit.  So if we could amend that motion4
              23
              24            MRS. MORGAN:  Which one is that?
              25            MRS. SILSBEE: Project 74.

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                           1                      MR.  VAN WINKLE:   These  $2,,OOO worth  of  training sti -

                           2     pends.           We had  recommended  they be deleted.    I  passed  right

                           3     over it.

                           4                      MRS.  MORGAN:    Oh.    Okay.    I move as  amended.

                           5                      MRS.  SII,-BEE:   So  this would  mean  that Michigan

                           ,i    would  be  recommended  for  $627,,536 with a  "no'@  on  the stipend.

                                                  DR. WATKINS:   Second.

                           8                      MRS.  SILSBEE:   Any discussion?

                           9                      All  in favor?

                         10                       (Chorus  of  "ayes.")

                         11                       MRS.  SILSBEE:    Opposed?
                         12,1                     (No   response.)
                         13                       MRS.  SIIBBEE:   That was  the  only one you really

                         14      singled  out2l

                         15                       MR.  VAN WINKLEE:   That's  right.

                         I(;                      MRS.  SILSBEE:   How do you want  to handle  the  rest?

                         17                       MRS.  MORGAN:         That was  due  to  just  the stipends9

                         18                       MR.  VAN WINKLC:   Take  them individually?

                         I!)                      MRS.  SIL,-BEE:    If you can do it  quickly.

                         20                       How  does  Council feel'?

                         21                       We  feel that  these  regions  have  come  in with  these

                         22     applications  and  there  needs  to be a  little bit  of discussion.

                         23     We  know your  time  is  short.   But,  on  the  other hand,, we will

                         2,4     lose  the  picture  of all the  regional medical  programs  if we
                         25     concentrate  only on  the  problems.

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                                1                         MRS. MARS:              I think they should be discussed,, each one

                                2     taken individually.

                                3                         MRS. MORGAN:  This is the only one out of the

                                4     group  that  I  had.

                                5!                        MR.  VAN WINKLE:    Want  to  discuss  them all?

                                                          MRS.  SIIBBEE:               Yes.

                                711                       MR.  VAN WINKLE:    Start  with Alabam,,  then,,  if  I

                                8     might.    We  will  take  them  in  order.

                                9                         Alabama  had  lost  some  staff  during  the  phaseout.    They

                             10       have  hired  a  new  coordinator  to  replace  Dr.  Packard,  Dr.

                             11       Clapper  from  the  university  school  there.

                             12,                          Dr.  Packard  has  remained  available  for  consultation
                             @13'     at      any      time      that      they      need      him.      So       has       their       evaluator       and
                             14       planner,  Mr.  Hinkley,,  and  so  has  their  nurse  consultant,  who

                                      is  just over  the  hill  at  a  small  school   there.

                                                          They also  are  covering  their  staffing  situation  on

                             17       a consultant basis.
                             18                           We have no difficulties at all with this region,  We

                                      think  they are  right  on  target.
                             20                           They       have        requested        $410,312        to        support        a        program
                             21       staff component four discreet program activates and  fifteen

                                      operational  activities.    We  recommend  approval  of  the  applica-
                             22
                             23       ti6n as submitted.

                                                          MR.  MILLIKEN:    So  move.
                             24
                                                          MR.  OGDEN:    Second.
                             25

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                1             MRS. MORGAN:  I will secondit.

                2             MRS. SILQ-BEE:  Any discussion?

                3             Dr. Foye or Mr. Milliken?

                4             All in favor?

                5             (Chorus of "ayes.")

                6             MRS. SILSBEE:  Opposed?

                7             (No response.

                8             MRS. SILSBEE:  Carried.

                9             DR. FO'YE: Margaret Clapper is like a  cork.  They

               10   stick her in whatever dike is leaking at the moment.

               11             MRS. SILQBEE:  She has been on the periphery of this

               121  activity for a long time, various activities.

               13             MR. VAN WINKLE:  Florida.

               14             Staff was impressed with the excellende of the total

               15   application submitted by the Florida RMP.  This staff has re-

                    mined in tact,  They have continued their program.  This is a

               17   region that has always moved ahead with new initiatives,

               is   oftentimes in advance of priorities being set here at the

               i@)  national level.

               20             We just think this is an excellent program.

               21             They have requested $627,536 for the support  of,a

               22   program staff component and 20 operational activities,,all of

               2t3  which conform to the RMPS priorities and options.

               24             They do have a kidney component that we intend  to

               25   alert the region again as to the interim rules and regulations.

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                                1                        MRS.  MORGAN:    They have  two,  don't  they?

                                2                        MR.  VAN WINKLE:    Yes,  they  do.    Yes.
                                31                       We  will  see  thatthat  Alert  goes  in  and  we  do  recom-

                                4     mend  approval  of  this  application  as  submitted,

                                5                        MRS.      SILSBEE:    Mrs.  Mars,  did  you  have  any  comment?

                                6                                  MARS:    One  thing  in  reading  it  through,  there
                                71    doesn't  seem  to  be  much  being  done  for  the  large  Indian  popu-

                                8     lation  of  Florida.    This  I wondered  about.

                                9                        Could  you  tell  me  just  what  they  are  doing  in  that

                             10       line?

                             11                          MR.  VAN WINKLE:    Nothl ng  that  I  am aware  of.

                             121                         MRS.   MARS:    That  is  what  I  could  not  find.,

                             13                          MR.  VAN WINKLE:    They are  addressing  the  migrant  hea  th

                             14       issue.

                             15                          MRS.  MARS:    Yes.

                             l(i                         MR.  VAN WINKLF,:    This  has  been  a  priority area  with

                             17       them.

                             18                          I will  tell  you,  as  far  as  the  Indian  health  is  con-

                             19       cerned,  that  is  still  being  addressed  through  the--  what  is  it--

                             20       Indian  Health  Service  downstairs.

                             21                          Also  in  the, Migrant  Health  Service  they had  a  great

                             22       deal  of  difficulty getting  into  this;  Migrant  Health  people  not

                             23       wanting  RMPS  involved  in  what  they  had  set  out  as  their  area  of

                             24       endeavor.    So  he  has  had  to  move  slowly  in  some  of  these  areas

                             25       not  because  of  a  lack  of  desire,  but  because  of  problems  in--

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                             IM. MARS:   There just doesn't seem to be any contact

                2
                   at all, and I think this is something that should be recom-

                3  mended.

                4            MR. VAN WINKIE:  All right.

                             MRS. MARS:  To that particular RMP.

                6            One of the things that I thought was very admirable is

                7  the fact that for every RNP dollar that has been invested, more

                8  than $5 In local support has been generated.   I thought that

                9  was a@very outstanding statement.

               10            The transplant kidney system is certainly very

               11  fine.

               12            And I think the workshops they have conducted in qua -

               13  ity care mainte nance have been excellent.

               14            They certainly are continuing education in both heart-

               15  stroke-cancer and dental health services.  So really I think

                   it is a very good program and I certainly move that it be fund-

               17  ed as applied for.

               18            DR. FO'YE:  Second,

               1!)           NRS. SILSBEE-.  Motion is the Florida should be

               20  approved as requested, $627,536, with a word  o them about the

               21  kidney project.

               22            MRS. MARS:  Indians.

               2,3           MRS. PARKS:  There is an error; it should be

               24  $683,048.

               25            MRS. SILSBEE:  $683,048?

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                1             MRS. FARM:  Right.  Sorry.  It is an error.

                21,           MRS. MORGAN:  $683,040 it says here on the yellow

                31  sheet.

                4             MR. OGDEN:  $683,040.

                5             MRS. PAR@q-.  Judy read another figure.  I thought I

                6   would correct it for the record.

                7             DR. FOYE:  Part of the program, I have been urging

                8   to give some thought to the Indian population.

                9             MR. VAN WINKLF,:  Yes, I have that.

                10            To digress just a moment, Michigan came up with

                11  better than 90 percent of pickup on their activities.

                12,           Georgia--

                13            MRS. SILSBEE:  Excuse me,, we have to have a vote on

                14  it.

                I15           MR. HIROTO.-  Question.

                              MRS. SILSBEE:  All in favor?

                17            (Chorus of "ayes.")

                18            MRS. SILSBEE:  Opposed?

                1!)           (No response.)

                20            MRS. SILSBEE:  Motion is carried.

                21            Georgia.

                22            MR. VAN WINKLE:  I will begin to sound like a broke

                2,') record on these regions; they are quite good.
                ?,4           Speaking of Georgia, excellent coordinator, excel-
                25  lent staff.  Again a program that responds to new initiatives.

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                              This is another region that is not giving indirect
                211 costs to their applicant agencies; they are usirgthe  full
                3ii amount of money to extend their operations as far as  they

                4   can for the state.

                5             They also have two kidney components.

                6             MRS. MORGAN:  Correct.

                7             MR. VAN WINKIE: We intend to flag that  also  in

                8   terms of alerting the region.

                9             They have requested $779,592 to support a program

               10   staff component in five operational activities involving insti-

               ll   tutions.

               12             1 might point out that five operational activities is

               13   all you see here.  Georgials program has many more than that

               14   that were instituted under the October I moneys and any

               15   carryovers they may have had,, and we do recommend approval

               I(;  of this application as it is submitted.

               17             MRS. MORGAN:  I think the nice thing about these, also

               18   in the material I received, -Emory University and  so  many

               if)  of the other universities are able to pick  hese programs up and

               20   continue them should RWS drop out of business.   They are pre-

               21   pared to Pick up many of these programs.

               221            I move that the Georgia region be awarded the full

               2@31 amount of the ir request.

               24             NRS. SIL3BEE:  Is there a second?

               25             DR. WATKINS.- Second,

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                1            MRS. SI@QBEE:  The motion has been made Georgia Region-

                2  al @dical Program application be approved as submitted,

                3  $779,592, with the kidney proviso.

                4            @. MORGAN:  With the kidney flagged.

                5            MRS. SITSBEE:  Any discussion?

                6            All In favor?

                7            (Chorus of "ayes.")

                8            MRS. SILSBEE: Opposed?

                9            (No response.)

               10            MRS. SIIZBEE:  Illinois.

               11            MR. VAN WINKLE:  Illinois is another excellent regior

               12, They are covering an area with very large population and many

               1,3 problems.

               14            In the phaseout they had lost quite a number of

               15  staff,  They are in the process of regaining some of those.

               i(i           We feel that they have the key staff necessary to

               17  carry this program forward.

               18            The coordinator had planned to leave,, but as we

               1!) got notice of new life,, he decided to stay with the program,

               20  and we feel that they are moving forward as they should.

               21            They did,, the RAG delegated authority to the execu-

               22  tive committee of the RAG to act for them last summer, and the

                   did present an accounting of discharge of those responsibilities
               2t3
               24  and received full endorsement from the RAG on the actions
               25  they had taken.

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                                                                             95

                              They have requested $8o6,l42.

                21            There is a kidney component in there, frozen blood
                3i  program.  We still feel this Is an expansion and would have
                4   to bealerted as to the interim regulations,

                5             Their new proposals are predominantly in the area  of

                    VMS, hypertension, quality assurance.

                7             They are going in to engage in a staff contract  type

                8   of activity In areas of problem oriented medical record  assis-

                9   tance and planning methodology assistance to health planning

               10   councils, CHP B agencies., and we do recommend their request

               11   be approved,

               12,            NRS. SIIZBEE:  Mr. Ogden.

               13             NR. OGDEN:  Yes.  Dr. Credit hasalways been ode of

               14   our most innovative andieliable directors, In my  opinion  this

               15   funding a,pplication,represents an excellent continuation of

                    his efforts.

               17             Frankly, the extension of the program in southern

               18   Illinois is welcome and I think it removes som of the previous

                    concern this Council has had about the turf problem of Illinois

               20   and neighbors.

               21,            The proposal includes development of a statewide

               22   frozen blood program which would be available to a select

                    group of users, particularly kidney patients.  Also includes
               23

               24   continuation of computerized hypertension programs.

               25   I assume both of those will need approval under Social Security
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                  1                                                                96

                                The balance of the proposales I read it continues in-

                 2   novative activities we have approved before, this Councilo

                 3   in earlier applications.

                 4              I would recommend that this program continue and be

                 5   funded.

                 6              I would, however, suggest that the staff does  need

                 7   strengthening and that our staff  here  should  visit  with  them

                 8   about the necessity of adding personnel  to  be  able  to  accom-

                 9   plish what they indicated they wanted to do.

                10              MRS. SITSBEE:   Is there a second?

                11              DR. FOYE: Could I ask, what  Is  the  Mid.'-Southside

                12,  Hypertension Registry Project?

                13              It has $100,000 in this budget,

                14              MRS. SIL.9BEE:  Mrs. Kyttle.

                1 @5            MRS. KYTTLE: It is an  activity  that  has  been  on-

                     going in this region I believe  under  Dr.  Williams  fcr  some-

                17   time,, and it is nearing completion.  This Is their last effort.

                18              It covers an area that is coterminus with the

                     CHPB set aside area;that is a,.rpiigh,,,,tough area of  Chicago,
                1!)

                20   they used as a testing ground for certain knowns and unknowns

                     and screening for hypertension and..developed  a  registry  fi,om
                21

                22

                                Hopefully they have made tentative   agreements   with
                2t3
                2,4  some of the hospitals in the area to build a    base  from  that
                25   so that paramedical personnel can treat the people on this

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                                1      registry  and  put  into  this  registry  the  treatment  rendered

                                2,1    under  it.

                                3                         DR.  FOYE:    I  see.

                                4                         MR.   OGDEN:    I believe  also  encompassed  with  that  wac

                                5      the  intention  of  conti                  nuation  of  this  program  under  the

                                       auspices  of  the  hospital,,  they would  pick  it  up,

                                7                         DR.  FOYE:    Yes.

                                8                         MR.  OGDEN:    This  is  what  it  was  for.

                                9                         DR.  FOYE:    Another  reason  I was  asking,,  general

                             10        history  of  most  registry attempts  has  been  total  nonproduc-

                             11        tiveness,    It  is  always  a  very  exciting  thing  to  set  up  a

                             12@       new  registry.    And  there  are  cancer  registries  all  over  the

                             13        world  that  do  nothing.

                             14                           MRS.  SILSBEE:    Sounds  a  little  more--

                             I                            DR.  FO'YE:    This  is  tied  in  withtherapy,  guidance,

                             l(i       help.

                             17                           MRS.  SILSBEE:    The  motion  has  been  made.    I  haven't

                             18        heard  a  second.

                             1!)                          MR.  FOYE.::            I will  second  it.

                             20                           MRS.  SIISBEE:    Okay,  that  the  Illinois  Regional  Medi-

                             21        cal  Program  should  be  approved,  application  should  be  approved

                             22        at  $806,,142  with  the  kidney  condition,,  and  the  recommendation

                             23        that  staff  follow  up with  the  RMP  regarding  strengthening  oi'

                             ?,4       their  staff  there.

                             25                           MR.  MILLIKEN:    Question.

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                 1           MM. SILSBEE: All in favor?

                 2           (Chorus of "ayes. 'l)

                 3           MRS. SILSBEE:   Opposed?

                 4           (No response. )

                 5           MRS. SILSBEE:  Motion is carried,

                 6           Next,

                 7           MR. VAN WINKLE:  Indiana.

                 8           We feel this region has come a long way during the

                 9 past year.  As you know,, Council had some problems that they

               10 had expressed, or some difficulties with this region.

               11            We feel that they have addressed those.  They have

               12,certainly straightened up their entire review process to where

               13 we feel we can certify them.  We do intend to site visit this

               14 region,, to follow the process through to see how it is working,

               15            They have redone their bylaws to bring them in

               ](; accord with the RMPS policy s'tatemnt on that.

               17            The region has worked on an ENS bill for introduction

                  by the Governor in the upcoming session of the Legislature.

                  And the Indiana RMP, which served as a coordinating agency,

               20 brought some 20 groLps together to develop this legislation

               21  nd we feel they are to be lauded for this endeavor,

               22            They also developed the State Renal Committee,

                   tatewide  plan for renal control, and through the efforts of the
               23
               2,4 3taff, State Legislature appropriated half a million dollars
               25  nnually for the support of transplant and chronic dialysis,

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                1            They have strengthened the relationship between the

                2   health planning and the health program implementation func-

                3   tions in the region.  We think that they have strengthened their

                4   relationship through the RAG with the health care organizations

                5   in the state.

                6            In all,, this program has turned around and is

                i   addressing what we feel are some of the real problems in the

                8   State of Indiana and they are getting out of Marion County.

                9   They are moving out into the state and addressing some of the

               10   problems other thanjust in Indianapolis.

               11            Dr. Beering, the coordinator, is 33 percent

               12,  time on the program,  Heis, however, actively involved in the

               13   management and development of the total program.

               14            He has hired a fu@time program director, executive

               15   director they call him, who is a full-time employee.

               i(i           The present one is leaving the program on December 1

               17   and is being replaced by another member of the staff, Dr. Geor@e

                    Leamnson,, who is now serving as director of the Indiana RMP Cou-

                    munity Relations Division.

               20            We have talked with Dr. Beering and he has indicated

               21   to us that he Intends to replace Mr. Teamnson, or to hire a

               22   man to replace him, but that that position will..not remain

               23   vacant.

                             The state has  or the RMP has requested $304,113
               24                         9
               25   for program staff and three activities,  They do have a kidney

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                                I      component  in  here  that  we  feel  should  be  flagged  in  terms  of

                                2      alerting  them to  the  interim  regulations.    And  we  do  recom-

                                3      mend  approval  of  this  application  as  it  is  submitted.

                                4                          DR.  WATKINS:    I  so  move.

                                5                                   SILSBEE:    Mrs.  Mars.

                                6                          MRS.  MARS.-    Yes,

                                7                          MM.  SI@BEE:    Or Dr.  Watkins.

                                8                          MRS.  MARS:            I have  a  few  comments  to  make  about  it.

                                9      I  am  not  questioning  the  priorities  cfthe  program,  but  it  just

                             10        seems  to me  the  question  is  really whether  or  not  adequate

                             11        funds  have  been  requested,.  or  can  be  allocated  to  do  an  ade-

                             12,       quate  implementation  of  these  programs.

                             13                            There  just  isn't  enough  time  to  do  site  visits  that

                             14        might  be  required  and  to  do  really an  efficient  administration

                             15        jou  of  some  of  these  proposed  programs,   especially  the

                             I (i      emergency medical  service  one,,  because  if  a  state  does  help

                             17        with  that,  take  over,,  that  will  certainly  help  that  program.

                             18        But  it  isn't  --  besides  the  money  factor,  it  is  the  time-

                             l@)       frame  work.    It  Just  seema@to  me  in  reading  through  the  pro-

                             20        gram,  there  just  isn't  time  enough  for  completionof  any  of

                             2,1       these  programs,  and  whether  or  not  they  are  programs  which

                             22        will  be  picked  up and  carried  on  if  RMP  does  go  down  the
                             2t3i      drain  is  very  questionable.    So  this  is  my  only  concern  and

                             2,4       my  comment  about  it.

                             25                            They  are  spending  a  lot  of  money  on  a  hypertension

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                1  program which I don I t thi nk rea 1 ly is a s ignif ica nt hea Ith need

                2  in that area,

                31           I would rather see it put into some of  the  state-

                4  wide projects and it is just-- this is my criticism.

                5            Can you answer that for me? Just how  do  you  feel

                6  about it?

                7            MR. VAN WINKLE:  I don't think that we addressed

                8  that,, Mrs. Mars,, in terms of project review per se.

                9            We looked at these in terms of whether or not they

               lo  were within the guidelines, the options.

               11            MRS. MARS:  I say I didn't question the priorities.

               121           MR. VAN WINKLE: We are pleased that the  region  is

               13  moving out of Indianapolis in some fashion, which they had never

               !4  done in the past.  Most of their activities wore totally

               15  concentrated there.

                             Could I get Mr. Torbert to come to the  microphone?

               17            MRS. SIIBBEE:  Dr. Watkins may have some other'

               18  comments.

               if)           DR. WATKINS:  I endorse the recommendation SCOB.

               20  At the same time, I think that they have a more visible",aftd

               21, more people project than many of the others, not like the

                   peripheral progra4 which I call peripheral,, like the PSRO's an
               22

               2 t3 CHP'S, So I really gave this a strong endorsement for that

               2,4 fact,

               25            MP,. VAN WINKLE: I would like to add one thing If I

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                1  might. Dr. Ron Brand,, who at one time was Assistant

                2  Secretary of DHEW, heads up -- what is it -- experimental

                3  health@cglro- delivery system in Marion County, Indiana.

                4            Dr. Brand has become intimately involved with the

                5  Indiana RMP and is chairman of their committee,, who reviews

                   all of their work and prioritizes it and brings it before

                7  their RAG for consideration.  We think this is a real step

                8  forward in the Indiana RMF.

                9            Prior to this year, there was absolutely no contact

               10  between these two agencies.

               11            MRS. SIIBBEE:  Any further discussion?

               12,           There was a motion.

               13            NRS. MARS:  I think you were going to ask Mr,

               14  Torbert a question.

               15            MR. VAN WINKLE:  I wanted to ask if Mr. Torbert had

                   anything to add on the hypertension.

               17            Do you know?

               is            MR. TORBERT:  I don't know.

               11)           MR. VAN WINKLE:  I am afraid I can It speak to it

               20  further.
   0           21            NRS, SILSBEE:  That was in the October award, not of
               22  this particular application that is already in operation.
   0
               2t3           MRS. MARS:  No, but the other, apart from that, is I

               24  said the rest of the programmin& I just don't see the time or

               25  adequate funding really to make these strong programs, to

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                1  bring them to a completion.

                2            MRS. MORGAN: Aren't they getting moneyl, though,,

                3  from the state government?'They could continue on?

                4            MRS. SILSBEE: That Is true, in the EMS area.

                5            MRS. ARS:  That is what I am asking.

                6            MR. VAN WINKLE:  And certainly kidney.
                71
                             MRS. MORGAN:  Yes,  Half a million dollars from

                8  the state government in kidney,, and theyalready have an EkV

                9  bill before the legislature which may continue most of these

              10   programs in other funding.

              11             I second the recommendation they be granted.

              12.            MRS. SILSBEE:  The motion has been made and

              13   seconded that the India,na--g             Program be approve@

              14:  at $304,113., with the kidney proviso.

              15             MR. MILLIKEN:  I think Council should recommend

                   that the staff give very close attention to this program in

              17   terms of the factors Mrs. Mars brought up.   So we are

              18   indeed on record as being concerned.  And if there is early

              1!)  indication of this program developing this, we should take

              20   this Lp again at the next meeting or whatever meeting.

              21             MRS. SILSBEE: Then the motion has been amended  to

              22   approve the application at $304,113 with the kidney proviso,,

              2rll and with the advice to staff that they follow this region and

              24   monitor the region with regard to concerns about adequate

              25   pickup from the region and adequate followup of the proposals

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                   contained and to report to the Council at its next meeting.

                2            MR. MILLIKEN: Right.

                3
                             MRS. MARS: I second the motion.

                4
                             MRS.  SILSBEE: Is there any further discussion?

                5            MRS. AARS:  I second the amendment I should have

                   said.

                             DR. WATKINS:  I accept the amendment.

                8            MRS.  MARS:  Iaccept the amendment.

                9            MR. MILLIKEN:  Question.

               10            MRS. SILSBEE:  All in favor?

               11            (Chorus of "eyes.")

               12,           MRS.   SIMBEE: Opposed?

               13            (No response.)

               14            MRS.   SIMBEE: Indiana application has been approved.
                                            r
               15            Memphis.

               I             MR. VAN WINKLE:  Did I skip that one?  @emphis.

               17            This region we think is a very strong, viable region,

               18  They have retained very strong staff complement.  They still have

               1!1 19 full-time employees.  This is a region that even during phase-

               20  out, remained totally optimistic in moving ahead at all times.

               21  I don't think that they were ever of the belief that they were

               22, going to phase out.  And their activities so indicated.

               2t3           They roughly are in this application,, they are de-

               24  voting about 33 percent of their moneys to local planning,

               25  about 10 percent quality assurance, 19 percent ENS., about rOUgiLly

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                 1  10 percent in kidney, 6  percent  in  hypertension,  32  percent  in

                 2  other.

                 3             They have been highly successful in generating
  40             4  monitoring and evaluating their activities and they have devel-

                 15 oped an excellent profile locally as a broker for health intei-
                 ,31
                    est in that entire area,

                 7             The experimental  delivery  system  contract  awarded  to

                 8  Health System Management, Incorporated, had very heavy RMP

                 9  staff input into the application itself and into the future

                10  implementation of the program.

                               We had indicated earlier to  Council  thaLt  there  was

                12. somewhat of a turf problem here.  We think that Emphis has

                13  addressed this,

                14             They have developed a very close working relationship

                15  with the State  of Mississippi, the Mississippi  RI,4P,  and  have

                I   invited both Mississippi and Arkansas  to  attend  all  'of  their

                17  RAG meetings and have full input into the proceedings,

                18             They have requested  $494,,788.  We  recommend  that  the

                I!) application be approved.

                20             There is a small contract   in this, in  the  kidney  di-

                21  sease area., and here again we intend to  alert  the  region  as  to

                22  the interim regulations.

                2@l            NRS. SIT.SBEE:  Mr. Hiroto, do you have any comment?

                24             MR. HIROTO: Yes,, I  only  have  a  question.  Was  there

                25  not at one time a guideline relative to screening as being

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                   something this Council might discontinue?
               2            @q. SITSBEE:  Sorry, guideline?

                            MR. HIROTO:  Multiphasic screening.
               41           MRS, SILSBEE:  Multiphasic screening?
               5            The Council did have a policy at one point of
               6   not initiating any new ones, but as I recall, this one was
               7   in  place,
               8            MR. VAN WINKLE:  Not only that, but the moneys to bE
               9   utilized here, Mr.Hiroto, are for evaluation.

              10            MR. HIROTO:  Evaluation.

              11            MR. VAN WINKLE:  They hate to lose all efforts that

              12@  have gone into this.  This is for the evaulation,, windup

              13   evaluation.

              14            DR, SCHREINER:  What are they going to do with this@,

                            MR. VANWINKLE:  What they are doing in northern

                   Mississippi is lending assistance to the creation of a kidney

              17   foundation, if you will, that will pull together all of the

              18   administrative aspects of that program that is being developed

              if)  there.

              20            It will have input, Dr. Schreiner, both from  the

              21   Mississippi program and from the Memphis  rogram.

              22            Dr, John Bower is in the process of developing a satel,

              23   lite unit in that area and this will be the administrative unit

              24   that administers that total program there.

              25            It is a small amount of money. I know that Dr. Bov(.@r

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                                1     had  requested  that  Memphis  furnish  him with  a  trailer  and
                                2     they  didn't  buy  that,  instead  put  it  into  the  development
                                3     of  this  organization  that  would  administer  the  program.
                                4                         So  I gather  the  trailer  would  probably be  bought  with

                                5     local  donations.

                                                          DR.  SCHREINER-*               It  strikes  me  as  being  kind  of  token-

                                7     less  to  spend  this,,  kidney area,,  33  percent  of  the  planning.
                                8     Technically  they  are  in  the  last  year  of  their  thing;  they

                                9     ought  to  be  pushing  some  stuff  in  the  program.

                             10                           MRS.  SILSBEE:    Mrs.  Kyttle.

                             11                           @,  KYTTLF,:    It  is  time  to  stop  planning  and  start

                             12,    doing.    That  ought  to be  the  message.

                             13                           MR.  VAN WINKLE:    I  think  that  program  in  Mississippi

                             14       ought  to gO-t-loff  the  ground  even  if  Memphis  didn't  put  any

                             15       dollars  into  it.

                             I(;                          I  think  as  much as  anything,  this  is  their  effort

                             17       in  the  collaboration with  the  Mississippi  program.

                             18                           MRS.  SILSBEE:    The  Mississippi  portion  of  the  pro-

                             J!)      gram has been funded well in the past few years, renal

                             20       for the Las.t,ten -years,

                             21                           I don't believe that Memphis has even in the past

                             221      put much effort into the renal area.
                                 1
                                 i
                             2,3                          I am not aware of any dollars in the,, past.

                             24                           Loraine, could you speak to that?

                             25                           MRS. KYTTLE: Shortly before I had this regional

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                 1  assignment, I noticed in reading back into it Memphis sQb-
                 2 11 mitted a rather ambitious renal,ptogram to  RMP.  It  got  shot

                 31 down.  They have never recovered.

                 4             MR. VAN WINKLE: Yes.
                 5i            MRS. KYTTIE:  This, Dr. Schreiner,, is a response

                    to a request from the budding northern Mississippi Kidney

                    Foundation, to help them with the tubulo  operation,  and  they

                 8  asked for assisance with the director's salary,, and that is

                 9  what that represents, the director's salary in tubulo to

               10   fortify Bowers I satellite there.

               11              DR. SCHREINER:  Yes. What I am saying is I think

               12,  that is a very, very much needed -- it is a real poverty area

               13   with very  little going on.  It seems to me it is kind of a

               14   small pebble in a big pond.  They ought to be doing more of

               15   it.

               l(i             MRS. MORGAN:  Maybe Mississippi is taking it up.

               17              MR, HIROTO:  I move to approve,

                               MR. MILLIKEN:  Second.

                               MRS. SILSBFE:  Motion has,,,,,@ en made that the Memphis

               20   application should be approved at the requested level of

               21   $494,?88; with the even small kidney portion being flagged

                    with regard to the Social Security regulation.

               2t3             MRS. MORGAN:  Could we add to that if more moneys

                    become available,, that they may look towards helping  more  in
               24

               25   this   area?

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                               MRS. SILSBEE: With advice to the region that they

                 2!  consider greater programming in the kidney area.

                 3             MRS. MORGAN: Right. I think so.

                 4             MRS. SILSBEE:  Mrs. Kyttle.

                 5             MRS. KYTTLF,: The local Regional Advisory Group

                 6   gets its  kidney money elsewhere and does not come to us.

                               @q. MCRGAN:  Doesn't need it.  This is fine.

                 8             MRS. SILSBEE:  Maybe we could amend that,

                 9             MRS. KYTTIE:  That would be a difficult amendment

               10    for them  to work with,

               11              MRS. MORGAN:  Well, it wasn't seconded.

               12.             MRS. SILSBEE:  Do you want to withdraw It?

               13              MRS. MORGAN:  I will withdraw my amendment.

               14              NRS. SILSBEE:  We will amend it with advice to

               15    staff to give a better picture of the kidney programming

               1(;   that is occurring in the region for Council next time.

               17              DR. SCHREINER:  They get the direct program, they

               18    are the biggest state with vocational rehabilitation, but

               1!)   private kidney foundation matches it.  They get $4 for every

               20    dollar they raise, which is a very effective program. However,
   0           24    it seems to me that, you know, that is patient care money,
               22    and this is what I am trying to develop is that where such
   0
                     possibilities exist,, that is where the RMP ought to be very,,

               24    very aggressive to get up the facilities.
               25              They have been doing that for four years'.t- for

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                1   example, and question could be asked as to why wasn't,,

                2   you know -- if all it took to utilize vocational rehabilitation
                31  money was to get a truck or store front or part of a manager',,:,

                4   salary,, that is precisely where our RNP ought to be aggressivE,,

                5   where the other part is already being taken care of.

                6             In other words,, how to put the small tap into the

                7   big well, that should be the secret of RMP.

                8             The fact that they are getting money elsewhere for

                9   patient care is not an argument to me that RMP shouldn't

               10   be in there; it is the argument why RMP should be in there

               11   full fledged.

               12,            M. MILLIKEN:  1 think your suggestion would be

               13   adequate for now, staff come back to this Council with more

               14   information.

               15             MRS. SILSBEE: Okay.

               I(;            MRS. MORGAN4.  I think it was moved and seconded.

               17   I withdrew my amendment,

               18             MRS. SILSBEE:  All in favor?

               l@)            (Chorus of "ayes.")

               20             MRS. SILSBEE:  Opposed?

               21             (No response.

               22             MRS. SIISBEE:  Next application is from Michigan --

                    I am sorry, from Mississippi.
               2.,3

               24             MR. VAN WINKLE:  Mississippi.  This region has re-
               25   tained its key staff.  They have nine professionals left that

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                I  represent medicine education, plar,,i-,Lng and evaluation,

                2  demography, sociology, psychology,, fiscal management, and

                3  program development.

                4            They have an excellent coordinator.  Their RAG has

                5  remained very active and so have their task forces.

                6            They presently have 13 contractual activities and

                7  5 operational activities that were proposed to be ongoing

                8  through June.  The 13 contracts are all new.

                9            I would Like to point out the State  of  Mississippi,

               10  with the few resources, economic resources that they have,

               11  they still have been able to find funding for 80 percent of

               12. their terminating activities which I thirk is commendable.

               13            We feel that they certainly have been a change agent

               14  in the region's health care delivery system.

               15            The coordinator at the present time is involved with

                   the Governor's office in the total health care planning for

               17  the State of Mississippi.  So we feel he is getting some

               18  recognition there.  And the RMP some Visibility.

               1!)           They do have renal projects in this application.

               20  We will alert them to the provisions as we have  stated  before

               21  of the interim regulations. They have an  excellent  renal  pro

               22  gram that really is covering the entire state in a very

               2,3 commendable fashion,,end I think this is one state say they

               24  have done as much in cost containment in renal disease  as  any

               25  state I am aware of.

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                1             They,have requested $325,836 to support 18 activities

                2   and we recommend approval of this application.

                3             MRS. SILSBEE:  Mrs. Mars.

                4             MRS. MARS:   I move it be approved,. as',stated,
                51  but I would like to make a few comments.
                6.            In reading through the application, they suddenly

                7   have come up with some 39,, is it,, newactivities, not all of

                8   which have been accepted.  But it looks and sounds like a sort

                9   of feverish and unnecessary attempt to add a show of strength

               10   to the program.

               11             I felt that many of these are of really little

               12,  permanent value as a contribution to the benefit of the healt@

               13   needs of Mississippi.  And suddenly organizing a lot of one-

               14   day seminars and hurriedly organized workshops,, and I can't

               15   find that a constructive way to create any permanent effec-

               I(;  tiveness.

               17             So I do think that this programming should be watcheJ

               18   carefully and the staff should be alerted to that fact.

               1!)            So that they carefully examine the new activities

               20   and try to get Mississippi to eliminate some of then

               21,            MR. VAN WINKLE:  You are particularly referring to

               22   those that-- what is the lady's name in Mississippi who is

               2t3  responsible for most of their continuing education?

               24             MRS. MAR,-: It looked like just a way to spend money,

               25   so to spec* and use up the fund in a panic.

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                  1              MR. VAN WINKLE:   All right.
                  2              Some of these activities, though, that have come
                  3   in have been a result of an -- I would say a two-year buildup
                  4   on the part of the Mississippi program, in getting around the
                  5   state and  becoming  recognized.  And  I  think  some  of  that  mo-

                      mentum is still rolling right on forward.
                  7              MRS. MARS:  Yes . that may be true.
                  8              There  is  also  in  the  staff  recommendation  here a point
                  9   that must  be brought in, the region should be alerted        to  the

                10    provision contained in    the interim  rules   and   regulations under

                11    Title 2.0,, Chapter 3. of SSA-DMW Rewulation
                                                                      ,,,5;,. Part   405,,

                12,   Federal Health   Insurance for  The Aged,  This regulation     per-

                13    tains to payment   for services in connection with kidney

                14    transplants and renal dialysis to entitled beneficiaries,

                15               So this Is a recommendation being included in the

                      motion which I   have moved for acceptance.

                17               MRS. SIL'--BEE:  Do I hear a second?

                18               MRS.  MORGAN:  I second it.

                                 MRS.  SITSBEE:  Any discussion?

                20               All in favor of the motion?
   0            21,              (Chorus of "ayes,

                22
   0                                   SIL'Q-BEE:  Opposed?
                23               (No response.)

                24               MRS. SIIBBEE:   The application is approved as re-

                25    quested and with the conditions noted.

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                1              MR. VAN WINKIE: North Carolina?

                2              MRS. SILSBEE: North Carolina.

                3              NR. VAN WINKLE-. This region accepted the phaseout
   is           4   instructions very literally,, I might say, and had  submitted
   is           5   a plan to terminate their entire program as of June 30th last

                               This plan was accepted and then when they got  the

                7   word of the turnaround,, they picked back up, they retained

                8   their key staff, and you will find that this application does

                9   request support for 11 activities.   Those are continuing

               10   act@ivities.  And funding of 16 new ones.

               11              They,too, have a backlog of approved RAG  projects
               12,  that are sitting in the wing, so to speak.  They are requesting
               13   $586,504 to support a total of 27 activities.

               14              They do have an application in here for care of

               15   patients with chronic uremia,, and again we have put in  with

                    our recommendation the alert as to the provision under the

               1 7  interim rules and regulations.

               18              This is not a new program that they have,, but  it

               I!)  is an expansion.

               20              MRS. MORGAN: Is this with dialysis or  they  don't

               21   really --

               221             MR. VAN WINKLE: Yes,, ma I am,, it is.

               2.3             NRS. MORGAN: They really don't say,

               24              MR. VAN WINKLE: It is expansion of an existing

               25   program,

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                 1             DR. SCHREINE.R: Community hospital satellite  system

                 2   Dr. Robertson runs.---

                 3             MR. VAN WINKIE:  Yes.

                 4             MR. MILLIKEN:  I don't see any item here for program

                 5   staff,

                 6                   SILSBEE: This is one of  the  anomalies  of  this

                     method.  December 1, the region will be submitting plan

                 8   for their funds that were not expended  from  the  October  award

                 9   and it is not program staff in that?

                10             MR. VAN WINKLF,:  Yes, it is.

                11             MR. MILLIKEN:  How much will it be?

                12,            MR. VAN WINKLE:  On  their  program  staff?  They  will

                13 .,be requesting approximately $260.,Ooo for support of program

                14   staff and staff activities.

                15             MRS, MORGAN:  This is from unexpended funds?

                I              MR. VAN WINKLE: Yes, ma 'am, it is.  And they took

                17   total amount of this and put into operational activities.

                18             MRS. SILSBEE: Mr. Ogden, did  you  have  any  coixaent?

                1!)            MR. OGDEN:  Yes.  My comment in reviewing the materials

                20   that have been sent to me was program  really  appeared  to  have

                21,  suffered from complete phaseout plan followed by scramble to

                221  keep the ship afloat,, with a result these projects,, at  least,,
                211  appeared to me to 'lack A,-programmic adhesion.  They are the
                24   more traditional support programs we have seen before and thej
                25   are aimed, a great many of them, at  health  manpower  And  there

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                I    are a lot ct, little ones.

                2              Nevertheless, I think there is som recognition of

                3    theEM and PSRO needs,

                4              I would encourage funding to let them move ahead,

                5    but I would urge this RAG renew their efforts to channel

                6    into more meaningful substantive proposals.

                7              MRS. SIIZBEE:  I think that will be very helpful

                8    advice to come from Council.

                9              MR. VAN WINKLE:  Yes.

                10             MRS. SILSBEE:  Do we have a motion?

                11             MR. OGDEN:  I will move that it be approved,

                121            MR.MILLIKEN:  Second.

                13                 SILSBEE-. Motion has been made  and  seconded
                14   the North Carolina application for $586,504 be approved  with the

                15   kidney condition, and advice to the region with  regard  to

                i(i  Councills concerns about the apparent lack of  program  co-

                17   hesion and responsibility of the RAG in  regionalizing  the

                18   important aspects of the program,

                19             Does that state your views?
                20             Is there any further discussion?

                21             AII:LN favor?
                22             (Chorus of "ayes.")
                23             NRS. SIISBEE:  Opposed?
                24             (No response. )
                25             MRS. SIWBEE:  North Carolinals application is

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                 1  approved.

                 2             MR. VAN WINKLE: We covered Northiatids  yesterday.

                 3                  MORGAN:  Yes.

                 4             NRS. SILSBEE:  How about Ohio Valley?

                 5             MR. VAN WINKLE-.  Ohio Vallev.

                 6i            This has always been one of our  stand  out  programs

                    under the  leadership of Dr. William McBeatia,

                 8             As you are aware, probably,, Dr. McBeeth left this

                 9  program to become Executive Director of the American Public

               10   Health Assocation.  One of his staff, Mrs. Hebbeler,, who is a

               11   former program development specialist and a member of the

               12,  staff since 1969,, has been appointed as Dr. McBeath's s .uccesscr,

               13              This program and staff have maintained their working

               14   relationships with all the key health  agencies  in  the  region

               15   and the present staff is changed somewhat; they cert  ainly have

               1(;  been reduced in number, but I knoiq that Mrs, Hebbeler has been

               17   recruiting and she has hired som new staff,

               18              The RAG in Ohio Valley is as active as any Iknow.

               if)  They do provide the leadership for the Ohio Valley RMP.

               20   Extremely strong, extremely active.  Well indoctrinated RAG

               21   people. And I think that the process  that  the  staff  has  set

               22   up for indoctrination of new RAG members is one that any

               23   region could well follow,

               24              The staff feel that we need to provide  them  with

               25   some staff assistance in the very near future on a continuation

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                  1   basis, particularly in the  areas  of  fiscal  management..  and

                  2   in the administrative management of the program.

                  3              Mrs, Hebbeler is new.  We feel she needs some assis-

                  4   tance, and we certainly intend to provide that.

                  5              They have requested $497,201 for the support of a
                  fill program st'aff component,, 16  operational   activities.   There
                   i

                  7   is a request in here for   support of a kidney activity.

                  8              This request, as near as we can determine,, through

                  9   telephone conversations, it is to be basically Utilized for

                10    region-wide followup and  data  system  that  relates  to  their

                11    transplant effort in the area.

                12               So here, again, we intend to alert the region as to

                13    the interim regulations, so that they are aware of this, and

                14    so can alert  the applicant agency.

                15               We do recommend approval of this application as

                iti   submitted.

                17               DR. SCHREIOR:  When they talk about regional organic

                18    sharing networks,, is this to plug Into an ongoing network

                      or are they trying to create--

                20               MR. VAN WINKLE:  It is plugging into a total system.

                21    They are not trying to create anything new.

                22               Dr. Schreiner,, you may recall that they had come in

                2t!   for kidney activities in the past, which had been approved by

                24    Councilo and those are ongoing.

                25               1 think one that was turned down that you might

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                   recall was trying to put a Belther unit in a  mobile  unit  and

                2  haul it all around the state, and they did take advice of

                3  Council, they did get their unit but stationed it  at  the  place

                4  where the transplant was to be effected. So far  as  I  can  re-

                5  call, they do have a very active program in  Louisville  and  in
                6ii
                   Cincinnati, and also there at Lexington.  But it is a tri-

                7  partite effort.

                8            They are working quite  effectively  together.  So  if

                9  they don't have the duplication of effort--

               10            DR. SCHREINER:   I was wondering what they  were  plug-

               11  ging in in southeastern--

               12            MR. VAN WINKLF,:  Erwin.  And with Arkansas and otherc

               13  yes.

               14            MRS. SILSBEE: Mr. Hiroto, did  you  have  any  comment?

               15            MR. HIROTO:   Only it seemed to me the  program  cost

               ](; as compared to the total was running something  like  40  percent

               17  I was wondering if there was a reason for that or  if  that  is

               18  considered too high?

               19            MR. VAN WINKLE: With program staff,  there  is  s  il

               20  a lot of staff activities that are being carried out, operat'loll-

               21  al activities if you will,

               2@)           Are you speaking only of personnel?

               23            'MR. HI--ROTO: It was just the numbers really.

               ?,4           @. MORGAN:     185 staff,

               25            MR* VAN WINKLE: If we had a  total  breakout  for  you
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                1  in terms of staff versus activities that they are supporting

                2  out of staff, you could see the difference.

                3           It is a difficulty we also have in trying to lden-

                4  tify what is listed in here as core.

                5           MR. MILLIKEN:  This is also very complicated in a
                6 Istate program where they have to keep constant relationships
                7 @with medical schools and state governments and voluntary

                8 and professional organizations in three states.

                9           MR. VAN WINKLE:  And four at sometimes when they get

               lo over on the West Virginia border.

               11           MR. MILLIKENS:  It absorbs a great deal of staff,

               12.          MR. VAN WINKLE:  They have been tremendously effec-

               13 tive, you know, in utilizing their resources of the-- what is

               14 ithe group, Appalachia program?

                            DR. VAN HCEK:  Regional program.
               15

               i(i          MR. VAN WINKLE:  Yes, quite effective in using that.

               17           They have been the starting tLgent'.. People who got the

               18 seed money in there,  And Appalachia has picked up almost all
               I!) lof those programs without their help.
               20           MR. OGDEN:  I appreciate the comments of Mr. Milliken@

               21 who,,I would remind you,is Chief of the Office of Comprehensive
               22 IHealth Planning, State of Ohio.
               23 i         I think he is more familiar with this program than
               24 the rest of us.

                            MR. HIROTO:  And I move f or a
               25                                        p P"rpyl@.,,@

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                                1                          MRS. MORGAN:  Second.

                                2                          (Laughter)

                                3                          MRS. SI@LSBEE:  Motion has been                                       and  seco       Inded

                                4      that  the         Ohio  Valley  Regional  Medical  Program applicati                                        on

                                5      be  approved  at  the  requested  level  of  $497,201,  with  the

                                6            ney  condition.,  and  the  advice  that  the  management  program l@e
                                11     followed  rather  carefully.

                                8                          Is  there  further  discussion?

                                9                          MRS.  MARS:    Question.

                             10                            MRS.  SI@'-BEE:    All  in  favor?

                             11                            (Chorus  of  "ayes.")

                             12!                           MRS.  SILSBEE:    Opposed?

                             13                            (No  response.

                             14                            MRS.  SILSBEE:    Motion  is  carried.

                             15                            Let's  do  South  Carolina,  Tennessee,,  Mid-South  and

                             1(;       Wisconsin,  and  then  have  coffee.

                             17                            MR.  VAN WINKLE:    South  Carolina.

                             18                            This  region  has  presented  an  excellent  application,

                             I!)       It  was  a  bit  lengthy,  but  if  you  can  wade  through  it,  I  think

                             20        they  covered  all  contingencies.

                             21                            MRS.  MARS:    I  certainly  do.

                             22                            MR.  VAN WINKLE:    Any  questions  we  might  raise,

                             23                            (Laughter)

                             24                            Quite  thoroughly  I might  add.

                             25                            They  still  have  a  13-member  staff  with  7  professionals

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                1  out of that.

                2            It has been a very active program,  They@have,an

                3  extremely active RAG.

                4            I might say that they represent a very  conservative

                5  consti tue ncy.

                6            We feel that their staff down there does an out-
                7'1 standing job of keeping the RAG informed, and thatthe  members
                 1,
                 ii
                8  of this RAG come to meetings with a level of knowledge con-

                9  cerning agenda items far above most of the counterpart  regions
               10  we deal with.

               11            We do feel, however, that this traditional  conserva-

                   tism still tends to produce certain programmic confinements
               121

               13  and I think you can see that reflected in the work that they
               14  are carrying out.

               15            I would point out to anyone the RAG chairman's report

                   in this particular application as one of-- I just think it  is

               17  excellent and I wish we could get other RAG chairmen@to  report
               18  as this one has,

               J!)           It is an excellent report and prov ided us with a

               20  great deal of information in term of what is happening in

               21  South Carolina region.
               2';)          This application does have a kidney component in  it.
               2t3 Again, we intend to alert the region as to the interim  guide-
                   lines,, or rules and regulations.
               24
               25            I wanted to point out that 15 dew activities approvei

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                    by the RAG at its November meeting assigned priorities per-

                 2  mitted proposed funds for only 10; 4 of these in quality of

                 3  care,, 2 in renal dialysis,, 2 in hypertension, I strengthening

                 4  local planning and 1 concerning EMS.

                 5            In addition, this  application  proposes  continued
                 6  support for 8 activities that were begun under the October 1

                 7  allotment.

                 8            We think the geographic distribution of the activi-

                 9  ties are very good, and that their sponsorship represents tte

               10   satisfactory spread when one considers it,  MUSC is the

               11   single medical school in the state.

               12             They have very close ties with tte CHPB  agencies

               13   and they are requesting their full allocation of  $516o5lO,

               14   and we would recommend approval of this application

               115            MRS. MOR  N:  I have a question on this;  608 pro-

               I(;  gram,, screening hypertension in children, and 78, uropathies
               17   and hypertension screening in children., is there an overlapping

               18   or are these in the same areas, or were they in different parts

               1!)  of the state?

               20             MR. VAN WINKLE:  Mrs. Kyttle?

               21                . KYTTIE: 608 has been traditionally  called,,
               '-)2 and I don't know why it is coming up in this sheet as "screen-
                  j ing hypertension.," it has traditionally been their pediatric
               2t3

               24   pulmonary activity.
               25             (Laughter)

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                1             I haven't tracked that down yet.

                2             MRS. MORGAN: It sounds like they  have  overlapping

                3  programs from just looking at the green sheet.

                4             MRS. KYTTLE:  Yes, because they are both out of

                5  MUSC.  But I think the misnomer is on 60 rather than 70.

                6  I think 60  is their pediatric pulmonary and the other is

                7  a different department.  But they are both out of MUSC.

                8             MRS. SILSBEE: Dr. Chreiner or Mrs. Mars., did you  ha

                9  any conunent?

               10             DR. SCHREINER:  Yes,, I was very happy to see-- they

               11  have some areas-outside of Charleston with extraordinarily

               12, high instances of hypertension.   I think it is good to see they

               13  turned some of their priorities in this direction,  because  the

               14  patients are there, studies could-- I think their mix of pri-

               15  orities looks pretty good to me.

               I (;           MRS. SILSBEE:  Mrs. Mars.

               17             MRS. MARS: One interesting program I thought  that  I

                   picked up was the fact, well it is not RMp's but they  are  con-
               18
               1!) tinuing with it.  The governor of the state has created a

               20  Health Policy and Planning Council which is viewed ul ima e y
               21  as being the clearing house for health dollars in  the  state.
               22             Dr. Mosley, the coordinator, doesserve on the  steer-
               23  ing committee of the task forces of this, and this is certainly
               24  a very useful health process.
               25             I really have noth ng to say except that would  not

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                                1      be  complimentary  to  it,  because  it  is  a  good  program.  I  think

                                2      they are  very  optimistic  but--

                                3                          MR.  VAN WINKLE:  Yes.

                                4                                                But  apart  from  that,,  why,,  I  certainly

                                5      move  for        its  approval.,

                                6                          I  think  the  RAG  possibly  is  a  little                            overzealous

                                71     in  its  knowledge@  because  at  times  it  does  hinder  --  seems

                                       to  hinder  some  of  the  programs,

                                9                          MR.  VAN WINKLF,:    Yes,, we  were  there  for  one  oL'  the

                              10       RAG  meetings  and  at  five  o'clock  in  the  morning  we  began  to

                              11       think  they were  a  little  overzealous  too,  and  it  did  go  that

                              12@      long.

                              13                           (Laughter)

                              14                           MRS.  MARS:    I  still  don't  think  it  is  too  much  of  a

                              15       fault.

                              I                            MR.  MILLIMN:               Secohd,,,,@,

                              17                           MRS.  SILSBEE:              The  motion  has  been  made  and  second-

                              18       ed  that  the  South  Carolina  application  be  approved  at

                              I!)      the  requested  amount  of  '@'516,510 with  the  kidney  condition.

                              20                           Is  there  any  further  discussion?

                              21                           All  in  favor?
                              22                           (Chorus  of  "ayes.")

                                                           MRS*  SILSBEE:    Opposed?
                              23
                              24                           (No  response.)

                                                           MRS.  SILQ-BEE:    How  about                       nnessee.
                              25

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                             Tennessee Mid-So:uth has experienced a tremendous
                2ii reduction in staff. This was a region that we  have  been  work-

                3  ing with quite intensively over the past several years  in  try-

                4  ing to bi@eak them away a bit from the grantee institution,

                5  Vanderbilt.

                6            In this process.. during the last year, the  coordina-

                   toy our Dr. Teschan, was-- let's say he resigned as coordina-

                8  tor and accepted another position in the grantee institution.

                9            Dr. Richard Cannon was appointed as  coordinator,  and

               10  at that time he came in and spent a full day with staff,

               11  @turned to Nashville and within the next 48 hours had  met  with

               12  his RAG and totally accomplished everything that we  had  been
               13  requesting in terms of revising their bylaws and having certair

               14  things affected.
               15            We were quite impressed with his performance and
               I   there is a new dean at the school, a Dr. Chapman, and  he  and
               17  Dr. Cannon seem to have a very effective working  relationship.
               18            We are still concerned, though., about -- perhaps  a
                   lack of financial expertise within his particular staff.  Dr.

                   Cannon is aware of this. Staff is working with  him  kn  terms
               20
               21  of suggesting staff from other RMI"s who can come in and
               2@) assist them with their fiscal management.
                             So we feel that this program does have a restruc-
               23
               24  tured RAG as a result of the bylaw changes.  They certainly
               25  will have turnover of that RAG in proper manner.  They have a

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                                1     new coordinator. They have a very small staff. Ard they

                                2     have a lot of funds coming. So we do have some concerns

                                3     about rebuilding the central capability.

                                4                        But we are basing our recommendation I think on Dr.

                                5     Cannon's success in the na.st, in meeting some very thorny
                                6@    issues and getting them                       resolved in a very short period of

                                7     time.

                                8                        The  application  requests  the  full  remaining  alloca-

                                9     tion of @658,912. These activities are spread among 18
                              10      components, 13 new activities, 2 proposals, fortifying and

                              11      continuing  activities  generated  on  October  1,  and  there  is  a

                              12      kidney  component  in  this  application,

                              13                         Here.,  again,,  we  will  see  that  the  region  is  alerted  es

                              14      to  the  interim  regulations,
                              15                         We  would  recommend  that  the  application  be  approved

                              I       as  requested.

                              17                         NM.  SILSBEE:               Mr.  Ogden.

                                                         MR.  OGDEN:    Yes.  Mk  reaction  at  the  moment  is  not
                              18
                                      to  be  overly  critical  of  programs  which  have  been  torn  apart  when
                              20      they appear  to  be  less  cohesive  in  approach  than  previously,
                              21,     but  I  am constrained  here  to  suggest  this  regional  medical

                                      program would  appear  to  need  good  RAG  review  and  staff  coor"
                              22
                              23      dination  to  pull  a  program  together,  particularly  in  view  of  th

                                      fact  that  the  coordinator  is  new.
                              24
                                                         The  emphasis  on  this  program,  as  I  read  the  material
                              25

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                                1      sent to me, is on quality assurance or individual projects.

                                2                          I am pleased to see many of them have considerable
                                31     impact in rural areas. Partly because of the way in which

                                4      Dr.  Teschan  was  removedr-  And  I  am going  to  use  the  word  precise-

                                5      ly  in  that  way--and  the  Vanderbilt  influence,  and  also

                                6      because  it  is  new,,  I would  urge  this  coordinator  seek  the

                                7      advice  and  assistance  of  his  experienced  peers  around  the

                                81     country and  I  think  this  should  be  a  direct  suggestion  to  him

                                9      from Council.

                             10                           Now,  there  are  two  things  in  this  application  that

                             11        I would  like  to  ask  the  Council  consideration  on  and  staff

                             12,       consideration,,  because  I  am somewhat  confused  as  to what  we

                             13        are  permitted  to  do.

                             14                           There  is  included  in  this  proposal  the  purchase  of
                             15        equipment  for  renal  dialysis  for  the  University  of  Tennessee

                                       Hospital,  and  a  proposal  to  establish  a  Georgia-Tennessee  Region-

                             17        al  Medical  CommunicationsSystem by  purchasing  and  installation

                             18        of  standardized  equipment  in  11  hospitals,,  and  a  microwave

                                       relay  station.    I  am  concerned  about  the  propriety  of  buying
                             20        hardware  and  installing  it  in  particular  locations?

                             21                           I  need  advice  as  to whether  this  is  still  --  well,  the
                             22   1    propriety  of  doing  this.

                             23                                    MARS:    I  thought  we  weren't  permitted  to  buy

                             24        hardware,
                             25                          MR.  VAN WINKLE:    Certai n ly  you  can I t  very we I I

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                1  create a new dialysis unit without providing some equipment to

                2  get it under way.

                3            This is located at the eastern part of the state.
   0            4            MR. OGDEN:  I recognize that.
   0            5            MR. VAN WINKLF,-.  Where there are no services.
                6            MR. OGDEN:  Yes.  Well, in a way it is similar to

                7  what we did with high voltage radiation for Anchorage,, Alaska;

                8 !
                 i people either died or went to Seattle if they had the money to
                9  do it.

               10            But I just raise the question about these things

               11  because I think it is something that shouldn't go by without

               12@ at least being mentioned, being brought up to talk about

               13  directly.

               14            MR. VAN WINKLE:  Could I ask Mr, Gardell if there

               15  is any restriction on the purchase of such equipment?

                                 GARDELL:  I think we have been discouraged from

               17  doing nothing,, but supplying equipment for any activity.

               18  But I am assuming here we have,more@of,an.interest than in

               I!) just putting equipment into a location or an activity.

               20            MR. OGDEN:  I think this may be true with renal

               21  dialys is. I am not really questioning that one.

               22            I am, however, concerned about this systems emergency

               23  medical communication system which seems to encompass equipment

               24  in eleven hospitals and microwave relay station.
               25            DR. SCHREINER:  Television?

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                 1             MR. OGDEN:  Radio.  Emergency  ambulance  call  and
                 21, so forth.
                 3             Perhaps staff personnel who can follow this    region,

                 4  give us some advice as to what this is all about and some

                 5  guidance as to what we can do.

                 6             MRS. SILSEEE:  Was Tennessee Mid-South one of the

                 I  regions visited on EIC projects this summer?

                 81
                               MR. POSTA:  Not ENS.

                 9             @. SILSEEE:  Mrs. Kyttle?

               10              MRS. KYTTLE: The State of  Tennessee  in  which  we

               11   have two regional medical programs has passed state legisla-

               12   tion regarding emergency  medical  systems,  And  because  its

               13   requirement Called for training of X number of EMT's by X date,

               14   the Memphis program concentrated  on  that  aspect  statewide.

               15              It is not Western,, Tennessee.

                               Some of these efforts were done collaboratively

               17   with Nashville.

               18              Nashville out of staff efforts,, and I  don't  know

               l@)  a great deal about its past efforts., Mr, Ogden, because I am

               20   comparatively new in this regional assignment, have been work-

               21   ing with EM councilg which the state legislation also requires.

               22   And in working with these councils,, particularly in the eastern

               2t3  part of the states which has a rugged  terrain  and  more  rugged

               24   than the west, the need for the communication link was     viewed

               25   in the Regional Advisory Group at that time as a staff     effort

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                      to  build  on.    -And  it  wasn't  ready  for  the  October  application

                 2    but the RAG meeting that I attended at which these were discus-
                 31   sed brought these efforts forward that with the DOT, Department
                 4 1
                      of Transportation supports the state support under its legis-
                 5    lation, and with RMP, RAG was told  the  circle  would  be  com-
                 6    plete.
                 7              MR. OGDEN:   Let me just read Council the opera-

                 811  tional activity summary that appears on this,, for what it is

                 9    worth:

                10             "First to develop an emergency disaster system...

                11         by June 30, 1974, including purchase and Installation

                i2
                           Of standardized equipment in  11  hospitals  by  April  30,

                13         1974; training of personnel in  the  11  hospitals  In  the

                14         proper use of communication  equipment  by  may  31,  1974;

                15         purchase and  installation  of  microwave  relay  equipment

                I(;        on Lookout Mountain by April  30,  1974,  to  overcome  the

                17         effect of possible terrain on communication capabilities

                18         and to assure the proper functioning and usage of equip-

                I!)        ment by June 30, 1974.11

                20              MR. VAN WINKLE:  Could we suggest perhaps a restric-

                21    tion on these funds until we have an opportunity to--

                22              MR. OGDEN:   I think we ought to restrict this until

                2t'3  we have some  idea whether the State of Tennessee    could pay

                24    for this,, or maybe somebody else.

                25              It  troubles me we are getting Into the installation

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                 1   of something that is not demonstration. This is sorwthing that

                 2   is going to be there permanently.

                 3             MRS. MARS:  Right.

                 4             MR. OGDEN:  We are setting it up.

                 5             MR. MILLIKEN: This  timetable  is  not  realistic.

                 6   We just set one of these up in southeastern  Ohio;  it  took

                     2-1/2 years.
                 8i            MR. OGDEN:  Thank you.  That Is something to know.
                 91            Let me go on just half a second,, Judy,, because I

               10    would like to have Dr. Schreiner's thoughts on this.

               11              Renal dialysis unit, it says "to approve the

               12.   purchase of equipment not presently in  the  unit,  weighing

               13    pad;, cardiac monitor, and reverse osmosis  water  treatment

               14    machine."

               15             "This unit is designed for ... short-term  dialysis

                          until kidneys recover... ;function as a team."

               17              That is what they are urging us to spend these

               18    funds  for.

               1!)             This would go into the  University  of  Tennessee,

               20              MR. VAN WINKLE:  At Knoxville., is it?

               21              MR. OGDEN:  I assume it is at Knoxville.

               2 LI            NRS. KYTTLE:  Yes,

               2!')            DR. SCHREINER:  They probably have a bad water

               24    problem from the sound of things., and that is one way of
               25    solving it -- not necessarily the only way.  Not necessarily

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                 1  the best way.  But there are about five different ways of

                 2 approaching bad water and that is one of them.  That is accep-

                 3 table at least.

                 4            MR. OGDEN: Would you rather have  someone  look  into

                 5 that a little more carefully before you funded it up?

                 6            Do you think maybe it isn't the best way?

                 7            DR. SCHREINER: It probably would be  cheaper  to  use

                 8 constitutional dialysis,, something like that, where you are nol;

                 9 so troubled by the water.

               10             MR. OGDEN:  I would think I would like to ask re-

               ii  striction of both of these things until they can be reviewed

               12  further.

               ]@3            MRS. SI@BEE:   It seem to me,, Mr. Ogden,  this  also

               14  reLates to your initial concern, which was the RAG and the

               15  way in which it is-- as we know, this is in a tender stage

               l(i right now,, but this might help to put a little teeth in it.

               17             MR. OGDEN:  I hate to suggest it,, but it sounds to

               18  me like somebody who wants hardware is sneaking it into a

               1!) new director before he has things nailed down.

               20             I don It want to suggest that is the case, because  I

               21  don't know,  But these are brand new and these are somewhat

                   unusual programs
               221,                    I really would suggest we hesitate on
                   these and look into them a little more carefully to see vhethe@
               23
               24  the State of Tennessee can fund the hardware  on  the  emergency
               25  system,, and have someone    ---Dr. Schreiner or someone who

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                                                                              134

                1   knows this situation in kidney look at It pretty thoroughly.

                2             DR. SCHREINER:  Good role for a technical consul-

                3   tant, because lots of people approach these kinds of problems,,
                4   you know, with a fixed idea in mind and there may be a less

                5   costly solution to the situation.
                61            M.RS. SILSBEE:  Also with the condition that will be
                711 put on an expenditure of those funds until exception approval,
                81!11 we have two ways of getting at it.

                9             MR. OGDEN:  Okay.
               10             MRS. SIISBEE:  Dr. Foye, did you have any further

               11   c onune n ts ?

               12             DR. FOYE:  Not on this.

               13             MRS. SILSBEE:  Could I have a motion?

               14             MR. OGDEN:  I will move it with the amendments that

               15   I have made, restrictions.

                              MRS. SILSBEE:  Thanks.

               17                 ,MARS:  Second.

               18             MRS. SILSBEE:  The motion has been made that the

               if)  Tennessee Mid-South application be approved at the requested

                    amount of $658,912 with the following conditions:
               20

               21             One, that the general kidney condition be put on

               22   with regard to Social Security Administration,

                              Twop that the amounts proposed for the purchase of t@e
               23
               24   EM communications equipment and the kidney dialysis equipment

               25   be restricted pending technical review.

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                                                                              135

                1             MR. VAN WINKLE:  For the record., the renal project

                2   is number 76, in the amount of $13,200.  The EM is project

                3   81, in the amount of $50,.000.

                4             I do believe that you had further advice to the

                5   region.

                6                  SI:IBBEE:  And number three., that the staff

                    carefully monitor and the Regional Advisory Group review

                8   process,

                9             And four, that the coordinator be urged to--

               10             MR. OGDEN:  Urged to seek the advice and assistance

               11   from his experienced peers around the country in getting his
               12!  RAG and his Regional Medical Program well organized, so that
               13   he is not directly listening to them at the university.

               14             MRS. SILQ-BEE:  Motion has been made and seconded.

                              Is there any further discussion?

                              MRS. WRS:  Question.

               17             MRS. SILQ-BEE:  All in favor?

               18             (Chorus of "ayes.")

               1!)            MRS4. SILGBEE:  Opposed?
               20             (No response.)

               21             MRS. SILI--BEE:  Tennessee Mid-South application has

                    been approved,
               22
   4k
               2 '3           DR. SCHREINER:  I might just comment, I think the

                    education of the people to run the communications network
               24
               25   would be an enormously important function of R&D.  A lot of

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                                                                              136

                 1  these things are bought and don't have--

                 2;           MR. OGDEN: Educating the people so they can continue.

                 3            We might suggest, take a Look at what has been done

                 4  in Ohio Hills on this type of thing before they get involved

                 5  in this themselves.

                 6            MRS. SILQ-BEE:  The last one in  South Central is

                 7  Wisconsin.

                              Mr. Van Winkle says he can do it in short order.

                 9            M. VAN WINKLE:    I understand we have a coffee break,,

               10@ so  I  will hurry.

               11             MRS. MORGAN:  -All right.

               12             MR. VAN WINKLE-.  Wisconsin is an excellent program.

               13   They  have retained most of their key staff.  During the phase-
               14   outp  they closed their Milwaukee office and moved their

               15   entire operation to Madison.

               it;            Dr. Hirschboeck has resigned,, been replaced by Dr.

               17   Tracy, who has been a member of the staff for sometime,

                              We have no difficulties with this program.

                    have                  6, which represents their full remaining

               20   allotment for FY-74.

               21@            I could sing sorae praises about this region,, but I

               22   will not due to the lack of time and we will recommend that

               23i  the application be approved as submitted.

               24             @q. SIIBBEE:  Mr, Milliken.
               25             MR. MILLIKEN:  So move.  Agree.

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                                1                          MRS. MORGAN: Aren't we here, though, doing the same

                                2      thing,,  purchasing  equipment  for microwave  EIC  in  this  area?

                                3                          M.  SILSBEE:    This  particular  region  has  an  El&

                                4      planning  effort  of  which  this  is  a  big--  there  has  been  a  lot

                                5      of  attention  made  in  the  planning  and  this  may  very well  be

                                6@     a  natural  corollary  of  it.

                                7                          NR.  VAN WINKLE:    They were  awarded  a  two-year EMS

                                81     activity         that  was  carefully  reviewed  by  a  special EbE  committee,
                                 i
                                9      and  this        is  a  portion  of  that  two-year  program.

                                10                         MRS.    I                        heard  a  mo  ion,    u                      i  n'       hear

                                11     a  second.

                                12@                        DR.  FOYE:    Second.

                                13                         MS.  SI@BEE:                 Motion  has  been  made  and  seconded  the

                                14     Wisconsin.application  be                        approved  as  requested,  at  $540,646.

                                15                         Any discussion?
                                i(i                        All  in  favor?
                                17                         (Chorus  of  "aye@")

                                18                         MRS.  SILSBEE:    Opposed?
                                lo                         (No  response.
                                20                         MRS.  SILSBEE:    Okay,  Wisconsin  application  is
                                21     approved.
                                2                          Could  we  be  back,  please,  at  eleven  o'clock.
                                2t3                        (Whereupon.,  a  short  recess  was  taken.)
                                2,4                        @  SILSBEE:    Could  we  get  started,,  please.
                                25                         we  are  going  to  take  up  the Western  Operations

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                                1      Branch regions, the remainder. There are four of them, and

                                2      that is in the gray book,

                                3                         The first one is California.

                                4                         NR, RUSSELL: The California RMP, as noted on the

                                5      yellow sheets, went through an HEW audit, which raised a num-

                                6@     ber  of  issues,.

                                7                         MRS. SILSBEE: Excuse me,

                                8                         Mr. Hiroto, you have to go,

                                9                         MR. HIROTO: Bye-bye,

                             10                           MRS.  SILSBEE:    Yes.
                             11                           (At  this  point  Mr.  Hiroto withdrew  from  the  room.)

                             12                           MR,,  RTJSSELL:    The  issues  raised  by  the  audit,  many

                             13        of  them were  resolved  by  the  phase-out  of  RMPS,  the  notice.

                             14                           California  has  closed  down  all  of  its,area  offices,

                             15        There  were  nine.
                                                          The  staff  has  been  centr@a@6d  out  of  the  Oakland  are%,
                             17        with  staff  in  the  northern  and  southern  parts of California,

                             is        field  staff.

                             1!)                          To quickly bring you up to date where the program is

                             20        now,,  and  the  problems  as  we  see  it,  is  that,  one,  the  staff

                             21        is  very,,  very short  as  of  right  now,    This  was  a  concern,  Mrs.
                             2'?       Sadin  called  the  director  of  the  program  just  this  past, week
                             23        and  he  assured  us  that  they have  more  applicants  available  than
                             24        there  are  vacancies  on  the  CCRC  staff.    So  we  don't  believe  thELt
                             25        is  going  to be  a  problem,,

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                                1                          California continues to be innovative.                                         Its health

                                2       services educational activities are noteworthy. Its EMJS'
                                3       activities have been very successful. And as indicated by
                                4       their budget, they have programmed in all of the option areas
                                5                          One thing that we are concerned about is that the
                                        Deputy Director., in all probability, will be leaving the
                                7       CCRIV. We see this as leaving a very big gap in the manage-

                                        ment aspects in the Central Office.

                                9                         There are a number of kidney activities. Most of

                             10         these  are  ongoing.  But  we  would  want  to  recommend  to  the

                             11         CCRMP  that  they  check  everything  they have  got  going  in  the

                             12,        kidney area  to make  sure  it  does  comply with  the  appropriate

                             13         policies.

                             14                           The  CCRW  RAG  is  in  tact.     It  has  been  expanded  since
                             15         the  last  review,  from all  indications.    We  believe  the  program,,
                             I (i       is  still  viable  with  those  concerns, that  we  have  already  noted

                             17         those  do  need  to  be  addressed.

                             18                           With  that,  I would  like  to  ask  the  Council  if  they
                             1!)        have  any questions  raised  on  the  information  they  have  avail-
                             20         able?
      io                     21,                          MRS.  SILSBEE:    Mr.   Ogden.
                             221                         MR.   OGDEN:    The  California  RMF  application  material
      is
                             2@3        was  sent       to me.  I  thought  it  was  quite  good.

                             24                           It  appears  they are  approaching  their  continued
                             25         function  in  the  state  almost  on  a  be  ter  programmic  basis  than

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                                                                                  140

                 1  beforei with the elimination of  these  area  offices,,  except

                 2  for the Northern-Southern California field offices.

                 3             They had a proliferation of projects in the past,

                 4  with these area offices,  almost  made  some  nine  independent

                 5  RMP's in that state,

                               Now, it seems to me that what is resulting here is

                    going to be a great  increased  administrative  burden  on  the
                 7

                    central core staff and I would suspect that the central core

                 9  staff ought to be augmented to handle some of the work done by

               10   some of these area  offices,  That  would  necessitate  a  good

               11   deputy being on board.  Manpower assessment, development

               12!  patient care quality control structures ... I am impressed

               13   with the EM program as well as continuation of emphasis on
               14   the coordinated kidney disease program.

               15              I suspect that this is the  largest  bloc  of  money

                    we will be dealing with,, $2,645,305.

               17              California has always  been  a  vigorous  innovative

               18   program,   I think what they are doing here continues that

                    tradition  and I recommend that this be fully funded.

               20              MRS. SILSBEE-,  Mrs. Morgan.

               21                   MOR  q:  I thidchere again there is some-- whe-
               221  ther they  have complete technical review processes going$ I

                    think they need to be reminded of that.  And, of course,, the

               24   kidney components.  And is there still not the quality
               25   assurance that EMS has been approved by--

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                              MR. RUSSELL: The situation here, Mrs. Morgan.,  is

                2   that the Regional Advisory Group has allocated specific amounts

                3   of money to go in each of the various program elements.

                4             The technical reviews will be conducted,, reviews

                5   will be conducted the first part of December.

                              We have assurance, we have a List of the consultants
                71  they are using from out of state.  They are all recognized con-

                8i  soltants in their respective fields.

                9             We built this recommendation In to make sure  that

               10   they did follow, which we think they will,

               11             We would like to just clarify the recommendation say-

               12   ing that the CCRNP not fund those activities until they  have

               13   gone through a complete review process.

               14             We did not mean to imply RN:PS should withhold any

                    money for those,
               15

               I(;            mFq. MORGAN:  Right.

               17             MR. RTJSSELL:  Yes, sir.

               18             DR. SCHRELMR-.  I listened to a presentation from a

                    young lady from there who was spending this year I think  she

               20   said something like $180,000 on quality investigation for

               21   the kidney program,  She said It was funded partially by RMP.

               22   And she said the statement in public, that they had  received
                    assurances that as of July, this would be'ltaken over by the

               ?,4  state health office.
               25             I notice this is in here for continuation.  I think

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                                                                                                  142

                         this  brings up@an  interesting       question as to whether some        of

                         these programs we may not actually be deterring the  takeover
                    2

                         if  they   have   already   made   these   contract   arrangements,   and   do
                    3

                         we ilant  to do that9   I don't know         I    don't know   that@out    in
                    4,

                    5,   a   perjarative    way    but  I   wonder   if we are  deterring    some

                         of the      takeovers?
                    6

                                     MRS    MORGAN;      This domin   Jul   they   were going to
                    7                                               9     y

                         take@'it    over as of  when    this program would    be  ended

                                     DR.,SCHREINER:      Yes,       Because after    all.,   the

                         California Medical spent         $85 Jul 1 lion' on!   kidney    disease a  nd
                    0

                         they  obviously      have a    stake in quaitty  assurance     on the.

                   12    basis of     that kind of expenditures       They,   according   to her

                         were  quite   prepa'    d to   take o er their   aff6rts@    The    qestion
                   13@                       re              v

                         is   do@ve   want   to delay   that by giving   theia another   six@@onths

                         of@ RW      money?
                   15

                   16                MR*     RUSSELL:   Is t'his:project   lis   ted as   145?

                   i7                DR,.SCI-EREINER:'@- I  don't    know,@ I  listened: @to@     r
                   18    presentation    at    the    National Kidney,Fdundation:meeting and she,,

                   @ig   made  the   statement   they   had    received RMP money..   'Was 'Very

                            oessful,    and   the   State   Heal                va            o     ake
                   20    SUO                                   th     Department   s  @going t'   t

                   21    it over,

                                                                que    tion what,                 g  ti
                                     I  asked  the  specific                       are  you' go.
                   22

                         do aft  r  the phaseing    out  of  oneness.      She  said     "No@@ay4!1
                   23
                           he @said. "We@are     bing@to   co   I n'ue' on@
                   24                          9

                                     I  was  wondering   if  It  is@ the  same  project?
                   @25


                                                                               143

                I             DR. PAHL: Dr. Schreiner,, I think  we  have  certainly

                2   seen  that in the phaseout, we have asked regions to give us

                3   commitments from other organizations, state or nongovernmental,,

                4   for continuation ciCthe projects.  And many of the regions

                5   gave us very fine statements which represented true commitments,

                6   and then when the program started up, I am  sure  we  could ind in

                7   a number of regions where we are  continuing  the  proj@cto

                8             I don't believe there Is anything basically wrong

                9   with that, because there is still the overriding policy that

                10  we provide funds up to a certain point in Its development

                11  and then turn on over, and I think the regions are doing that.

                12  That was the emergency measure.  So I don't think we should

                1,3 hold them to what was an emergency situation as long as we

                14  have the standard policy,

                15            MRS. SADIN:   In three years they would be over, say.

                16  they@were approved running for three years.

                17            DR, SCHREIW,,R-* This is just the past year,,  quality

                18  assurance program, going in actually  putting  on  computer
                19  the  coded records of patients and doing  cost  control,  running

                20  through the whole thing,   It is a very  detailed  program.

                21            MRS. MORGAN:  I think as long as you give RM.P credit

                22  for having funded them,, it is in our favor,

                23            MS. SILSBEE: Also staff can  follow  up  to  see  what

                24  happened to that and investigate whether--

                25            DR. FOYE-,  'Who is the residing deputy director?


                                                                        14 4

                I          MR. RUSSELL-.  Dr. Jack Mitchell..

                2          MRS. 8ADIII:  We will know next week, this week or

                3  next week how the negotiations are coming.

                4          DR. FOYE:  I see,

                5          MRS. MORGAN:  Did you move?

                6          MR. OGDEN:  I Vill move the approval.

                7          MRS. MARS   econd.

                8               SILSBEE-.  The motion has been made that the

                9 Calil'ornia RM? application be funded as requested ctt

               10 @2,645,305, with the following proviso, that the kidney appli-

               11 cations be reviewed and funded in accordance with the Social

               12 Security regulations; that the CCRMP withhold funding of those

               13 activities pending a full.'tedhnical review.; and that advice

               14 be given to the region that the central staff needs augmenta-

               15 tion, and that good management is a must.
               16          Is there any further discussion?

               17               MARS:  Question,

               18          MRS. SILQ-BEE:  All in favor?

               19          (Chorus of "aye.-,.'@)

               20          MRS. SIL.9BEE: Oppc>sed?

               21          (No response.)

               22          MRS. SILSBEE: The California application ig approved.

               23          Would someone call Mr. Hiroto in?

               24          (At this point Mr, Hiroto returned to the room.)

               25          14RS. SILSBEE:  Mountain c)tates Is the next one.


                 1            MR. RUSSELL:  The Mountain States Regional Medical

                 2  Program is one that most of you will, remember covers parts of

                 3  Idaho, t         On  n    n   Yom ng.

                 4            This  program t@s one of theprogra= that while re-

                 5  sponding to the phaseout instructions, continued very bptimis-

                 6  tically and retained most of its staff.

                 7            There are positions in each state for directors-

                 8  two of these directors have resigned since phaseout, one in

                 9  Nevada, one in Idaho.

               10             It is anticipated  that the Nevada director might be

               11   replaced by a nonphysician,  depending upon the results of tht@,)

               12   application,end the length that RMP's my stay, alive, this

               13   will influence the ability to recruit a physician for the Stau-e

               14   of Idaho.

               15             This program really doesn't come alive on paper
               16   very well and even staff had som concerns unti!  we  did  make
               17   an EMS visit to the@ Mountain States down at the local  level,
               18   and we were impressed with the amounts of activity and re-
               19   sults of that activity of the program staff in  these  various

               20   states

               21             The one concern that we have now has also been

               22   reflected by the regional health director., I believe this  is

               23   one in Denver, over the lack of minorities  involved on pro-

               24   gram staff and in project activities.

               25@            This was a concern of Councills during the last


                                                                                  146

                     review, and this  should  be  noted,

                                This- is one of the RMP's that we will be going back
                 2

                     to to take a@dloser look at the review process.  We never
                 3

                     reat@ly  ot that clarified,
                            9
                 4
                 5              One of the problenls here,, as noted in the review

                     of some of the programs yesterday, is the turf territory'
                 6

                     problem.
                 7
                 8              We have indications that Mountain States has attemp;ed
                 9   to make effective the document with the long title where
                 10  everybody gets together--

                                MR. POSTA:  Interregional?
                 11

                                MR. RUSSELL:  Interregional,, but have not been
                 12
                 13  effective  in getting one of the ottier progra,xas to respond.
                 14             MRS. SIIBBEE-,  Mrs. Morgan,
                 15              S. MORGAN:  I believe,, I move that   we fund  them

                     as requested, $470,652, with the   fact there will be RNP site
                 16

                 17  visit to review their  review-             a
                                                      and also re     these I  think

                 18  Mountain States tried  to coordinate with Inter-Mountain

                     and the rest of them and  commend  them to continue to put   an
                 19

                 20  interrelationship between them.

                 21             Because I believe this has been the region that.has

                     attempted to keep it ongoing and they  have  had  trouble  from
                 22
                 23  some of the other regions,
                 24             MS. SILSBEE.,  Did you also want to put that in aboLt
                 25  the minorities?


                                                                              147
                              MRS. MORGAN:  Yes.  I lived in Idaho for many years
                 2  You have got the Indians.  You don't have any other minorities;
                 3  in but you do have the Indian group there.

                 4            MR.- RUSSELL:  That is part of staff Is recommenda-

                 5  tion.

                 6            MRS. MORGAN:  Right.

                 7            MRS. SILSBEE:  Is there a second?

                 8           MRS. MAP.S:  Second,

                 9           DR. WATKINS: Second.
                 10          MRS. SILSBEE:   AnV dis.ousqi-.On?

                 11          All in favor?

                 i2          (Chor   of "ayes.

                 13          MRS. SILSBEI,;,-  Opposed?
                 14          (No response.)
                 15          MRS. SILSBEE:  The Mountain States application
                 16 is approved as requested,

                 17          Oregon.
                 18          MR. RUSSELL:  The Oregon Regional Medical Progra@m
                 19  is in our opinion probably one of the strongest we have had
                 20 the pleasure to work with,
                 21         The coordinator continues to provide outstanding
                  leadership,  The Regional Advisory Board has remained inttLv,@@,
                 22

                 2,3 extremely active,  Although the program took phase-Out
                 24 extreme ly seriously,, it was down to really about three staff
                 25  members at one time,  When the good news came,, they responded,


                                                                             148

                1   have hired back, restored their staff with experienced staff

                2   members, and it continues to function extremely effectively.

                3                       N:  -It is a very short presentation as

                4   far as the green, but if you read through the program, they

                              vor   very active and it is amazing they are clear
                                 y

                6,  back up to the strength they were in--- as a matter of fact,

                7   over what they were professionally a year ago, 12/72.

                8   And I move that we fully fund the Oregon program with no

                9   restrictions at all.

               10             DR. WATKINS.-  Second,

               11                  SILSBEE-* Kidney?  Is the-re kidney in it?

               12                  MORGAN.,  They do have a renaL disease program.
               13   We probably should flag that.

               14             MR. RUSSELL:  We did not point this out, it

               15   appears  to be purely planning.

               16             We thought since all regional medical programs will
               17   be given the interim regulations, that this would cover that.

               18   But we will call it to their attention.

               19             DR. WATKIN,-,:  If we are going to strengthen the

               20   CHP'S, perhaps we should ask them to submit their information,,

               21   to submit from CHP and not telephone call.

               22             1 think from all I have looked over, we found a rub-

               23   ber stamp thinking in the CHP.

                              if we want to spoof it up, we might ask for this all
               24

               25   the time.


                                                                                 14 9

                 1              IvM. RUSSELL:  Dr. B,einclapper, coordinator, offere@

                 2   to submit this last week.  I said I didn't, think It was

                 3   necessary.   I take the full blame for this,  But the fact

                     they do,@.--have a standing committee, Cli@.,,
                 4@                                              as part of the
                     Regional Advisory Board, this Is just the continuing evidenc
                     of' the involvement of CHP
                 6

                                Some of the activities you will notice are with
                 7

                 8   CHP,S,

                 9              DR. WATKINS:  Before the vote, the group purchasing

                to   program of plO.000 seems to have the same Ox,iorltya6, the

                11   cancer program Of $10,000.

                12              How did you see the group purchasing orogram?

                13              MR. RUSSELL:  Well, in trying to relate this to the

                     cancer program; the $1
                14                          0,000 for the cancer activity is to

                15   support the other activities which have been approved by the

                16   National Cancer Institute.

                17              So I don't reall,, you knows see any problems
                18              DR. WATKINS.  Okayi  Thanks

                19              MRS. SIL3BEE:  The motion has been made and second-

                20   ed.

                21              DR. WATKINS:  It was seconded.

                22              mrs. silsbee-  That the Oregon Regional Medi-cal

                23   Program application be approved at; the requested amount of

                24   @289,,56o.

                25@             Is there any further discussion?


                                                                                150

                 1            All In favor?

                 2            (Chor us of "ayes.

                 3            MRS . S I LC) BEE Opposed?

                 4            (No response.)

                 5            MRS. S@IT.SBEE:
                                             Motion is carried,

                 6            Washington-Alaska and Mr. Ogden will leave.

                 7            @(At this point, Mr. Ogden withdrew from  the  room.)

                 8            MR. RUSSELL-* Here, again,  the  Washington-Alaska

                 9  program is another program, which has continued to be

               10   extremely strong during the phaseout period,

               11             Please ignore the yellow sheet  figures  on  personne

               12   We had them up to 75 support staff,  That was wrong; it should

               13   have been 25,

               14             AZ indicated on the green  sheet,  the  Washl%ton-

               15   Alaska program staff was reduced. It is now back  Up  to  88

               16   percent, where it was before phaseout.

               17             During phaseout the Washington-Alaska program

               18   continued to work with the community groups,  monitor  their

               19i            and this is one of the regions where the Regional
                    programs

               20   Advisory Board insisted that it be deeply involved in the

               21   managementand monitoring of the program  through  the  phaseout

               22   period,

               23             The program has continued to respond to advice

               24   given from the last Council review and staff has  no  pro)  ems

               25   with this applica tion.  But Council may have some,


                                                                                151

                 1             MRS. SILSBEE:  Mrs, a)rs.

                 2             ICS. MARS:   I didn't actually -- they have site

                 3   'visits on there, I didn't site visit the RYE-,.  What I site

                 4   visited was the Hutchinson Cancer Center.

                 5             But at:the time I had a great deal  of  contact,  of

                     course, with the programs because they were very heavily
                 6

                 7   involved in the establishment of this Canoer Hospital Center.

                     @And I@ ot to know Dr  S arkmn very well during those few
                 8         9                 p

                 9   days since we were together practicdiilly 24 hours a day, and

                @:io we were,srtowed in also, so that was--

                11             (Laughter)

                12             So I think it is the only time In years that it

                13   snoed in Seattleo but It certainly, did snow,

                14             He., as you all know,, is an exceptionally fine  and

                15   intelligentoaid I suppose one of the  most  progressive  cdor-

                16   dinators that we have In the country. It  has  taken  a  great

                     deal of imagination and ability to steer  this  program,  par-

                18   ti cularLy when he is being involved with Alc),ska and has had s

                19   muck' territory to cover geographically.  So with all differen,

                20   types of people,, ethnic groups ranging from the Indians to th@

                21   Eskimos,, and I think that lie has -just done a remarkable job.

                22             He certainly from what I read  in  all  my  reviews,

                23   proceeded with the most orderly@ phaseout that I have seen in

                24   any of these program that I have to do with, and he has

                25   developed a concept of functional program activities     I believe


                                                                                152

                    it is here on this green sheet, to give the staff a vehicle

                 2  to catalyze activities that could be productively completed

                 3  by December 31st., 1973.

                 4             The program is Just a  reat one and I certainly
                    recommend  the acceptance of the funding for it at its full
                 5

                 6  requested  amount.

                 7             ,MRS., MORG-AN:  Are they doing anything with kidney

                 8  disease?   @@It'@doesn't say on the green sheet, but they have

                 9  several   op erational projects that could be included in this.

               10              MS. MARS:  They have in Seattle,, they- have-- I
               11   do It'know' just how much the l@'iMP is connected with it,  They

               12   have a remarkable dialysis home dialysis prograia of teaching

               13   for home dialysis,, and it is quite a setup.   In fact, I think

               14   people come from all over to learn home, dialysis there if I

               15   remember correctly,

               16              I am not too sure what else they carry on in their

               17   kidney program.

               18              M. RUSSELL:   I don't know but they have been deeply

               19   involved in the kidney program,

               20                  MA PoOi In this home dialysis teaching program

               21   I know that is true.

                               MRS. SILBBEE:  This is one of the regions that

                    CoQncil took a look at about twice before they approved their

               24   overall kidney plan,and it was funded for awhile.

               25              MRS. MARS-. Yes.


                                                                                 153

                 1             ICS. SIIZBEE: Dr. Watkins, did you have a comment

                 2   you would like to make?

                 3             DR. WATKINS:  No, I endorse this,  It is a beauti-

                 4   ful program.

                 5                  SILSBEE:  Would someone make a motion?

                 6             DR. SCIIREINER,,  Mrs. Mars made a motion,

                 7             DR. WATKINS:  I will second it.

                 8             MRS. SIL-BEE.  The motion has been made and seconde@i

                 9   that Washington-Alaska RMP  application should be approved at

                10   the requested level of $5145,473.

                11             Any discussion

                12             All in favor?

                13             (Chorus of "ayes.

                14             MRS. SILSBEE-*  Opposed?

                15             (No response,)

                16             @q. SIUBEE-,  The motion Is carried,

                17             Would someone please ask Mr. Ogden to come in.
                18             (At this point,, Mr. Ogden returned to the room.)

                19             MS. SI@qBEE-.  Now,  that finishes the-Kqstern

                20   Operations.

                21             Now we can move to the East,

                22             MR. NASH:  With the Orange book,

                23                  SIISBEE:  With the orange book, and Mr.,Frank

                24   Nash is the Eastern Operations Division Chief.

                25             MR. M@qH:  We have 18 left In the Eastern Branch to


                                                                                  154

                  1  discuss,   I think we will just take them in alphabetical or  e-.,,,

                  2  as they appear in the book, the first being Albany.

                  3             This is a request for
    315@ 836                                            '325s836.

                  4             Dr. Girard Craft replaced Dr.  Woolsey  in this

                  5  region as  coordinator,

                  6             The region was site visited in August   1972.  Mr.

                  7  Ogden participated in that site visit.  Went to    Council In

                  8  October 1972.

                  9             The  rogram was approved for three years, including
                                    p

                10   t)le, developmental components, and reviewers were pleased with

                11   the maturity and  it pain" by the region at that particular

                12
                     time.

                13              Staffing has decreased in this region from 40 to
                14   11 positions.  However., all It are very competent people and

                15   we feel they are certainly capable of carrying on this
                16   program,

                17
                                The RAG has  40  members.  It  has@remained  very  active

                     and interested in the program* at  times  in  the  past  year,  Th(@

                19   committee has also remained very active in participating in

                20   the program.

                21              As far as this proposal Is concerned, all the acti-

                22   vities fall within the option areas.

                23              There is a kidney project in here which probably

                24   will have  to have approval,  This particular region sen

                25   their application to the  regional  director  In  the  HEW  RegionaL


                                                                               1 5
                     Office, and we received a phone call from the region saying
                2    that they approved and endorsed this program,
                3             The review process originally was given conditional
                     approval.  The region responded to the conditions,- RMP did
   ip           4
                5    not follow upo did not phase out, otaf:r has no concerns about

                6    this and recommended approval,

                7             MRS. SILSBEE:  Mr. Ogden,

                              MR. OGDEN: I  articipated in the last site visit
                8             @ , Tq @'i, 41@-j @ @!I
                     that was done in August 1972.  I was very impressed at that
                9
               10    time.with Dr. Craft;, who 'was then the deputy, and is now the
                     coordinator Of
                                   this program,  HiO is a, very ample administra-

               12    t6r, has a good touch with this region.
                              This RMP serves an enormous geographical area, in,,
               14    Upper New York State, has good regional balance on the RAG,
               15    and good attendance. People come substantial distances,, over
               16    substantial terrain to get down to these meetings.
               17             The program when we saw it was well balanced,  It
               18    still is,, even though it has been reduced., greatly, in fori%
               19             I think it appears to me to still have good touch
               20    with the local needs in the various areas in which they are

               21    working.
               22             I would say the program looks to have the capability
                     for perhaps rehabilitation and continued progress and I certe,in-
               23
               24    ly second Bland's recommendation this be funded fully*
               25            MRS. MORGA N.- Second.


                                                                                    156

                  1             MRS. SIL'--BEE-,  Dr. @latk@l.ns.

                  2             DR. WATKIN,-:  Question again, I question CHP

                  3   re lationship.

                  4             Did anYO@ discuss this CH,'p relationship?
                  5             MR# NASH:     They sent this application for the estal)-

                  6   lishraent of assistance in establishment of the agency, did go

                  7   to the CHP agency in the state and also went to the CHPB

                  8   people In @l Regional Office.  One or both of those agencies
                  9   placed some conditions on this and these conditions are now

                10    being addressed by all the parties concerned.

                11              DR. WATKINS:  You will follow up?      Is this how it Jr

                12    @done?

                13              MR. NASH:  Yes.  Right.

                .14             DR.. WATKINQ:  I second the motion.

                15                   SIL'q-BEE: The motion has been made and seconded

                16    that the Albany appli,c@ i n be..appro, eo,,,,,at the requested level
                17    of $3250836, with the   kidney condition

                18              Is there further di@,3c@,-sion?

                19              i@vIR. MILLIKEN: Question.

                20              @o-.  SIL9  E,. If not, all in favor say "aye."
                21              (Chorus of "ayes,")

                22              mRS,  SILSBEE-. Opposed?
                23              (No   response.

                24              MRS. SILSBEE:  The motion is carried,
                                                  N q
                25              Frank, Dr. Schreiner stepped out for a. moment.  I


                                                                                 157

                 1   wonder if we could skip Central New York?  And go to

                 2   Greater Delaware Valley.

                 3             MR. UASH:   Nop I believe the next; is Connecticut.

                 4             MRS. SILSBEE-.  Excuse me.

                 5             MR. NASII:  Connecticut's request is $482,,7200

                 6   Mr. Ed Morrisey went in as coordinator May  1973,  and  replaced,

                 7   of' courses Dr. Clark.

                 8             This region has had triennial status,, was never

                 9   approved for components.    Had site visit just pri.or to
               10    February 1973 Advisory Council,  Due  to  the  phaseout  howevexo

               11    the findings and recommendations of Council at that time were

               12    never transmitted to the region.

               113             council will recall many of the letters did not--

               14    advice letters were not sent to the i,egi.on after February

               15    Counc,,,L 1.

               16              The Regional Advisory Group in this region remains

               17    intact, and very active4  They reviewed and approved the en-

                     tire application.

               19              This region I think you will recall has  an  extensiv@-

               20    review and evaluation progrg.in and they are still quite  active.

               21              The application was sent to the CHPA  and  B  agencies,

               22    one B agency responded and their co nE,,nts were discussed

               23    and considered by the board.  The other comments were not

               24    received in time for IIAG consideration.

               25              This program continues to be primarily a supporting


                                                                                      0
                                                                                   1:)C)

                 I   community study, staff at 'Ylil@, arid Urliversity@ of' Connecticut,

                 2   and un@'L.versity-based regiot@ial, faculty at Yale and UCon.

                 3              There are some EkV@, kidneys 3.rid state-wide health

                 4   @Inpower development  activities  and  this  particular  applica-

                 5   tioh, they had some activity in kiypertension.

                 6              This region has always had a very small staff,

                 7   Eight professionals I think is the most they kiave ever had

                 8   at one time.  They are down to f IVe now; however,,,th@y Ire con-

                 9   sidered by staff to be adequate to carry out the activates

                10   proposed,

                11              We have no real concerns about this re@ on a.
                                                                              nd

                12   re c omrae nd aooroval,

                                -MRS. SILI-BEE- 'Frank,, It do
                13                                          es have a. kidney compo-

                14   nent, dbesn't@it?

                15              MR. NA@H:  Yes.

                16              MRS. SILSBEE:@  Mr. Hiroto.

                17              MR. HIROTO:  Yes#  As a member of the site visit,
                @18  team$ there were certain concerns that seemed very real to

                19   the visitors and,, as you indicated, these  concerns  other  than

                20   verbally were never given to  the  Connecticut  Regional  Medical

                21   Program.   However -- and still continues that a large per-
                22   centage of the funding of RMPS money goes directly through

                23   Yale and University of Connecticut.

                24              Now, in as much as we ay-e at the stage we are at,

                25   I guess I recommend approval.


                                                                              159
                1             MRS. MA      Its grantee is who?

                2             M. NASH:    Ya le.

                3                  SILSBL@'E-0  YaLe.

                4             MRS. MARS: Yale.
                5             YLRSO SIISBEE:  The other aspect of that, you re-
                6   membero the third faculty with tile full-time chiefs of staff,
                7   that part has been eliminated from the budget.
                8             MRS. IMRS:  What percentage are they taking?

                              @l. SILQBEE-
                9                         .  The hospital support,
               10            MR. HIROTO:   Iwas glad tosee that,
               11            MM. @Roo:  What percentage of their fee Is--
               12            MR. NASH:   Indirect cost rate?  It is high.  I d6n'
               13  have the figure in front of me.
               14            Spencer, do you know what the indirect cost rate
                   is?

                             M.  COLBURN:  I am looking on the form 16 now,,
               16

               17            MRS. 14ARS: $75oOOO?  $'7OoOOO?
               18            @66@percent@

               19            DR. SCHREINER:  That is close.
               20            M.  COLBURN:  Based on salary and wages,, study
                   personnel --yes
               21

                            MRS. MARS:  That just kill$ me,  Abs@olutely.
               22
               23           MR. NASH:  Of course, one of the things staff hopes
                  Vill: happen in this particular region,, since we for years
               24
               25 have been supporting these full-time chiefs, which certainly


                1   should improve the quality of' care in the hospital,, but one

                2   facet of their program was that these full-time (@'hiefs were

                3   also supposed to get out into the community and do some activ

                4   ties there.  I would hope they will. continue with that part

                5   of their original proposal,, but we can't be sure of that,

                6             NRS. bMRS:  So far they haven't done It,

                7             MR. NASH:  Well, not very noticeably$ no.

                8             MRS. SILSBEE:  Mr. Ogde@

                9             MR. OGDEN-.  Well, I would just comment., the. CRMP

               10   has really, during its existericence,, aimed to establish this

                    for purpose of improving--
               11

               12                  Sl@0,BEE:  Could you speak up?

               13             MR. OGDEN.- Their application continues to stress

               14   this structure at the university, make program development

               15   assistance in local planning.

                              I think    gn area like Connecticut will, develop th(@ir
               16

               17   health care system and pretty evenly distribute the system.

               18             The way they have gone at this in the past seem

               19   to have.hod the desired effect of producing advances in

               20   assurance of quality of care and especially manpower coordina.-

               21   tion development.

                              You may recall In the past I have criticized Con-
               22

               23   necticut's program institutionally based personnel, but under

               24   the current circumstances,, this does appear to have produced

                    responsive, statewide structure and program In this


                     application.

                2              I think it is resulting In a fair balance, and it
                3    ought to be continued and fully funded.

                                    MOliGA N. Is that a motion?

                5              MR. OGDEN-*  I will so move.
                6              MRS. SILSBEE-.  Is there a second?

                                    MORGAN:   I will second it.
                7
                8              MRS.  SILSBEE:  The motion has been made and second-
                9    ed that the applicatiohl-flrcm Connecticut Regional Medical
                10   Program be approved at the requested amount of $482,720,

                11   with the  kidney condition.

                12             Frank, is there any further condition?

                                   NASH:  No, I think we, of course, want  o
                13

                   1  visit this regio4 certainly will take another look at their
                14

                15   process,  Although they have an extensive review and evalua-

                16   tion procedure there, when we mde bur initial review process

                17   verification visit  we found there were some problems so far

                @18  as being in compliance with the 11,MPS standards fox- review and

                19   verification and we, of course,, will be following through oh

                20   that.@

                21             M.RS SILSBEE:   Is there. further discussion?

                               All in  favor?
                22
                23             (Chorus of  ayes,

                               MRS.  SILSBEE:  Opposed'@

                               (No response.)
                25


                                                                                    162

                  1                S. SILSBEE-.  The application is approved as re-

                  2   quested.

                  3              We will go back to Central New York now.

                  4              MR. NASH:  All right.  If you will back up one appli-

                  5   cation    to Central New York, this is a request for $200,686.

                  6              Mr. John Murphy continues as coordinator, with

                  7   Dr.    Clark Case as the RAG chairman.  He has been the RAG

                  8   chairman there for at least three years that I know of, and

                  9   certainly has been active and extremely interested and sup-

                10    portive of this program, although the program does appear to

                11    have a few problems.

                12               This region was last reviewed by Council in Octbber

                13    1972. That review was preceded  by  a  site  visit  in  August,

                14               Dr. Schreiner from  Council  participated  in  that.

                15               There were some  problems  and  Council  recommended
                16    a    reduced funding level, $889,,ooO versus the request of one

                17    full million that had been submitted by the region,

                18               The problems noted at tha@t timewe'r@ea need for larg r

                19  @@S'taff w-ith additional competencies and a need to strengthen

                20    planning and fiscalraanagement.

                21               @We still find the same [)x,6'blen)s with this region

                22    today in   staff Is opinion,

                                 -At the maximum                           staff of 22
                                                 this region had a total
                23

                24    people.    They are now down to 9 peoples 2 of whom were

                25,   part time,  And we feel that there isa little concern about


                                                                                 i63

                     staff because some of these 9 are recent graduates of the

                 2   Maxwell School in that area, two or three of them did

                     participate as interns with the Centx@al New Yox,k, Regional
                 3
                 4   Medical Program.  However* this probably doesn't necessarily
                 5   give them the depth and background that a competent RMP

                 6   staff would be expected to have.
                 7             This particular proposa4 I  think  we  should  describe

                 8   how It came about.    They sent out zl,,500 letters of  solici-

                     tation to all the hospitals,  physicians,  nursing  homes,  and
                 9
                10   other groups involved in the health  care  delivery  system  in

                11   the region,  From that ailing they received 40 projedt pro-

                12   posals.  These vereglven a technical review, review by the

                     Regional Advisory Group- 12 were approved  and  6  were  selected
                13
                14   to be included in this  application. Those 6  do  appear  to  fal

                15   within the RMP options.

                16             @q. SILSBEE-.  Excuse me, staff--

                17             MR. NASH: Staff did  note  one  of  their  proposals'

                18   pediatric hypertension activity, 'which appears to be  part  of

                19   ten-year research Effort,, the Regional, @dd.cal Program is

                     asking to support this for the  first  one-half  year.  The  rest
                @20

                21   of'the activity then will 'be picked up for 9-1/2 years by Etoti

                     Laboratories,o. So the questionstaff  raised  a  little  question
                22
                     about that,
                23

                                    SILSBEE:  What number is that,, Frank?
                24
                25             MR. NASH-.  Jerry, what is the nLunber?


                                                                              164

                1             MR. OGDEN:  47.
                2             MR. GARDELL,:  4-(.
                3             MR. NASli: I think the red application is one other
                4   thing.  This region did submit as a part of their review com-
                    ments of all of their technical. review committees and the RAG

                6   and the executive board. So someone pointed out to  me  that

                7   there is a little confusion about one of the comments on one
                    of the projects$ C.PR training activity.  It 9,ppears that
                8

                9   we were recommending from here that this not be approved due
               10   to some technical or 'technicalities, 'but that was not our

               11   recommendation, This was a reconuric4tidetion of one of their

               12   own technical review committee people.
                             Apparently that particular person was overruled
               13
               14   and the  G did approve the activity and it is part of this

                    application.
               15

               16            The review process for this region was given con-
               17   ditional approval.  The region responded to the conditions

               18   that we had placed and we did not follow up due to phase out.
               19            Staff concerns here, then, are the program  manage-
               20   ment and direction certainly appears to need strengthening,

               21   The program qtaffo as I pointed out earlierp appears to lack
                T   depth@arid experience. Add we have some  recommendations,  but
               22

                    I will save those until you people discuss It.
               23

                                 @SIISBEE:  Dr. Schreiner,
               24

                            ,DR. SCHREINER-.  Yes, I was at the site visit there.


                                                                                  165

                1               It is an interesting region,  goes  from  Canada  down
                2    to Penn ylvania, and ,altliough in a :rich  eastern  metropolitan

                3    state by image, the density is actually- lower than most of

                4    our western states that we  talk  about  being  sparcely  inhabi-
                5    ted.

                6              They do have a tremendous number of problems, in-

                7    eludes one Indian reservation which is totally mishandled

                8    because it apparently didn't sign a treaty with the United

                9    State s Bureau of Indian AffaJ.rs and is  a  state  responsibility

                10   and It is really falling through the  cracks.  They,  had  dental

                11   equipment there that had never been unwrapped and all kinds

                12   of wasted sorts of things that  weren't  very  well  coordinated,

                13             One whole county, Rs I recall,,  without  any  doctors.

                14             So they do have lots of problems, even though, as

                15   1 say, your image of the center part of Connecticut doesdt

                16   carry those kinds of things In your thinking,,  but  this  fellow

                17   Murphy Is a very, very energetic, vivacious man and I was,

                i8   I will admit,, a little prejudiced against this kind of wide

                19   network of projects, what he calls mini projects; however,

                20   it did result in some very, very innovative kinds of ideas being

                21   brought into the widely cast net,@one of  which  was  a  combined

                22   well'baby and venereal disease clinic, which I don't think

                23   any doctor would have thought of.

                               (Laughter)
                24

                25            We  recommended that ki(., get some professional


                                                                                166

                    assistance, although I felt he was sort of a spark, and this

                 2  fellow who is chairman of the RAG Is an excellent, remarkable

                 3  person, really, for the amount of' time he devoted.

                 4            The morning I got there, he operated in the morning

                 5  and rose at five o'clock, in the morning to get there.  He

                 6  really knocks himself out.

                 7            He is an exceptionally well-trained mano trained

                 8  at@ @s General as a matter of fact.

                 9            So I think that they are trying.   I have a  few

               10   minor quibbles.  I think their video tape projects on home

               11   dialysis, they don't really have that good a home training

               12   program that is worth video taping. They  probably  could  buy

               13   It commercially cheaper than to develop their own  video  tape

               14   capability.

               15             But they were working and their  outline  thing,

               16   the things up in the north country I found particularly

               17   exciting. I thought they were trying, to get into  a  very

               18   difficult area.  So I would overall move for approval.

               19             MR. NASH:  Dr. Schreiner, I think you recall Dr.

               20   Carl Hart, who was with the university part time and with

               21   RNP part time,, andhis primary assignment over the past year

               22   has been In what they call their thrust north,  trying  to
               23   improve the medical care delivery system in the northern part

               ?A   of the region,

               25             I notice,, I believe in the cover letter, that  came


                                                                             1 167

                1  with this application that he Is being pulled OtAt@ of that areE
                2   and assigned to the southern area,  I'hatalso has a lack of
                3   health personnel,  The reason being he has attracted or
  4p            4   recruited 35 out of a desired 45 physicians to practice in

                5   the north country,  I think this is remarkable.
                6              DR. SCHREINER-.  Yes;, lie was a real shirt-sleeved
                7   fellow, rolled them up and went out in his old car and really

                8   moved around the field, He was a very Impressive man.
                9              MRS. SILSBEE-.  Dr. Foye, did you have anything to

                10  9,dd?

                11             DR. FOYE:  No.  I would agree with staff's rea@om-

                12
                    mendation.
                13             MRS. MARS:  Why can't this region,, if It Is such a

                14  weak oneo  be divided up and put intopart of It into the
                15  Lakes area, and so on, even into Maine?  Wouldn' t It Ibe more

                16
                    constructive to do  that?  Instead of leaving this as--

                17             MRS. SILSBEE-. Your geography is a little bit off.
                18             (Laughter)
                19             @9. MARS:  That Is what I am wondering -- well,

                20  Dr. Schreiner said -- I would like to see a map,  Dr. Sc rein(.@r

                21  said it coms from; Maine on down to--

                22             DR. SCHREINER:  From Canada,.

                23             MRS. MARS:  Must touch the Lake regions,

                24             MR. NASH:  It is up between Rochester gnd Albany

                25  regions,,, covers 15 counties.


                                                                               168
                               DR. SCHREINER:  Goes L4) the Saint Lawx,ence River,
                     up In the Indian reservation. M ny of the houses are on the
                 2
                 3   border and when the women get pregnant', they move in the bacl,L
                 4   of the house so they can go in the Canadian Health Service,.,
                 5             (Laughter)

                 6             MR49. MARS:  Wonderful Idea.

                 7             MR. NASH.- I thi.nic the regional boundaries were
                 8  around the Medical Center in Syracuse, medical training
                 9  area involved.
               10              I don't believe the people of Syracuse would really
                    prefer to be put in either Albany or Rochester.
               12             MRS. SILSBEE:  As an old New York Stater, the
               13   boundaries of this region reflect regional plan that was
                    developed by the state  oh, must have been 25-30 years ago
               14

               15             DRv4SCIfREINER:  The only thing that might be split
               16   off would be the Bradford-,Susque)aanna area In Pennsylvania.
               17   But all the people we talked to from there relate to Syracuse
               18             MRS. SILSBEE.  That is the Syra Clinic, I think the,r

               19   call it6

               20             DR. SCHREINER:  Yes.

               21             MRS. MARS: Yes,, I see.

               22            MRS. SI@l-BEE:  Frank,
                             MR. NASH:  Yes, staff has some recommendations,
               23
                   One is the approval of the re(4uest and two,, certainly the
               24
                   transmittal of the concerns that have been expressed to the
               25


                                                                                      i6g

                     region*

                  2             A little  more)  better  ooncertc@d  monitoring  of  this
                  3  program   by   PS staff,  and  the  provision  of  technical  assis-
                  4  tance when and where indicate(].

                                We also recommend this be given a rather high priority
                  @5

                     for management assessment visit.
                  7               S. SILSBEE-,   In the  discussion  of  the  RMPS  staff
                  8  the concern about the  management  of  theprogra,rn  and,  you  know,
                  9  the 4,500 letters of  intent$  and  so  forth,  and  the  fact  that

                 10  thLs has been sort of a perennial problem, we were hoping

                 11  in addition to these recommendations here that perhaps Council
                 12  might consider asking for  a,  report  on  how  they  are  overcoming
                 13  some of  these  management  deficiencies  and  that  that  might  put

                     a little more muz@le into what staff has to do.
                 14

                 15             DR. FOYE:  So recommend.

                 16             MRS. MORGAN:  Second.

                 17             MRS. SILSBEE:  The motion has been nia           secon   e

                 18   that the Southern New   York application be approved at the

                 19  level requested, $20o,,686,   and that  the  concerns  of  the  staff

                 20  and Council be transmitted    to the region; and that there be

                 21  more concerted monitoring of' the program by RMPS staff,
                 22  technical assistance, and the i-egiotibe given priority to
                 23  PS@assessment visits  and  there  be  a,report  to  Council  on  the
                 24  progresses made in solving  some;,  of  these  per:renial  management

                 25  pr ob le=


                                                                              1'7 0

                I                there any discussion?

                2            All in favor?
                3             (Chorus of "ay@es.tl)
                4            MRS. SILSBEE-.  Opposed?
                5            (No response.)

                6            MRS. SIL.9BEE: Motion is carri.E@d,
                7            MR. MILLIKEN:  I am wondering if it is possible to
                8  entertain a motion to keep going?  Some of us have to leave for
                9  the airports at twos two-thJ,rty@ or three.  I am wondering if
               10  our rate of speed is going to

               11            MR-'-. SILSBEE:  I am giad you brought that
               12  Mr. Milliken.

               13            MRS. MORGAN-.  There are a lot of the,m'that have to
               14  go*
               15           MRS. SILQBEE.-  What are t@.e plans?  How do you want to
               16  proceed here?

               17           We can concentrate on those that we think need some
               18  special action and we still have quite a. few in, unfortunately
               19  the Eastern operations, and we have one In the Mid-Continent
               20  thaIt we feel does need discussion. The rest of them In a way
               21  we feel could be handled rather quickly.
               22@          MR. NASH:  Actually I have three left in the Eastern
               23  Branch@ that staff expressed som concerns about, end perhaps
               24  Council would want to have some discussion on. The rest Of then
               25  staff feels pretty well satisfied with the application, view


                 1    those in the books;we did recommend approval of them,

                 2              Mrs. Morga,n

                 3              MRS. MORGAN:    I move we go through the three that

                 4    Mt. Nash has a problem with as a group of three, and the

                 5    rest of them that he has no questions with, that we take

                 6    them en bloc.

                 7              MRS. WRS.-  You can't do problem areas with a group

                 8    of three,

                 9              MRS.  MORGAN4.  I mean this group of three that he

                10    has a problem,  that we go through, and then the rest of

                11    them we go through as an entire --. if this is possible.

                12              MRS. SILSBEE:  How do the rest of you feel about

                13    that?

                14                    MARS:  Yes,

                15              MR. HIROTO-.  Second.

                16              MR. MILLIKEN.-  You have a seconder.

                17              MRS, SILSBEE:  Okay,, motion has been made and

                18    seconded, as far as the Eastern Operations Branch is concerned

                19    that there will be three -- do you want to identify those?

                20              MR. NASH-,  The ones I have here are Greater Delawar(

                21    Valley, Maryland, and Puex-to Rico,

                22              MS. SILSBEE:  Not New York Me@tro?

                23              MR. NASH:  Excuse me, yes, New York Metro.

                24                    SILSBEE-.  Could we amend your motion to    four?

                25              t@q. MORGAN:  Yes,,


                                                                                 172

                               MRS. SILSBEE-  And these be discussed and acted

                 2   upon by Council, and that the additional regions be looked at

                 3   in terms of bloc action.

                 4             Further discussion?

                 5             All in favor?

                 6             (Chorus of "ayes.")

                 7               S. SILSBEE:   Opposed'?

                               (No response.)

                 9             @S   S IISBEE:  Mr. Nash.

                               MR. NASH:  Greater Delaware VaLley.

                11             Hurricane,.Agnes'did a tremendous amount of damage

                12   up there floodwise, but there 4'16 another reason that that  is

                13   known as flood territory also,

                14             This is a reqtAest for $591,332, which is the re-

                15   mainder of this region's F'Y-74 allotment.

                16             Dr. Dean Roberts, from 1.@lanahan, is currently servinir

                17   as executive director,  He replaced Dr. Ingraham,@,vhol...@f!eplace(i

                18   Dr.. W61hman, who left in June.

                19             The regio was Last site  visited  in  December  1971.

                20   Dr. Watkins, from Council, participated in that site visit,

                21             It was reviewed by Council in February 1972.

                22   At that tLme Council recommended denial  of  triennial  status,

                23   no developmental components,, and reduced funding,  Council

                24   recommended two-year funding and site visit at the end of the

                25   old full year.


                                                                                173

                               Throw  his in just to give you the idea that the

                 2   region hasn,lt always been what we would like to see it be.

                 3             The principal issues at that time were needed re-

                     fidement of the regional planning operational
                 @4                                                 objectives and

                 5   priorities, and two, that the policy and decision-making process

                     was cumbersome and in conflict with the spirit of RMP intent.
                 6,

                 7             There was limited Involvement of allied health pro-
                 8   fessions,, and consumers.  And further, that the policies on

                 9   continued support not be developed by the region.

               10              The staffing in this particular region dropped from
               11    a total of 49 to a current 35.

               12              Historically this region has maintained a rather

               13    complex structure consisting of the central core staff, five

               14    subregional offices., and an RMP staff unit at each of the

               15@   five medical schools,.

               16              In the past this region has been slow to respond to

               17    new initiatives,  This appeared to be primarily the result

               18    of the progrant early involvement with continuing education

               19    activities in the medical schools,,

               20              Now, in the past year the RAG has undergone rather

               21    extensive reorganization which we certainly were glad to see.

               22    This was needed in order to 'bring the program into compliance
               23    with the RMPS policy statement on liAG grantee relationships.

               24              This particular application was sent to CHP for re-

               25    view, but comments were not received in time for consideration


                                                                                  174

                  1  by t@ie,RAG.

                  2            This particular proposal,, the staff that reviewed

                  3@ it, thought that -it was a good  application  one  of  the  better

                  4  ones to come out of this particular region:.  However, the

                  5     plex orga national structure with the large ataff compo-
                     com          n

                  6  nent leaves no funds  for  project  type  activities.  Soo  there-

                  7  fore, this region at the direction of the Regional Advisory

                  8  Gy-oup, revised the current program along task force lines,

                  9  and these are all within the RMI-IS options.

                10             The application does contain a kidney pi,oposalo

                11   which I am sure needs to be flagged.

                12             One positive feature of  this  application  is  that  the

                13@  staff supporting the medical boliools  are  now  assigned  specific

                14   responsibilities which we hope will be monitored by the manage-

                15   ment of the program., so that we can see  whether  we  are  gettin
                                                                                      8
                16   anything out of the dollars that  are  going  into  those  schools.
                17             MRS. SILSBEE-.  Dr, 'Watkins,
                18             DR, WATKINS: I  noted  you  have  a  revised  application

                19,
                     that the money was revised downward.
                20                 NASH:   Yes, the initial  application  that  came  in
                21   apparently during this change of coordinators up there that went

                22   oh through the summer, they  misread  som  signals  from  here  and

                23   included in their initial request the remainder-- not remainder,

                24   but the Impounded -- it 'wasn't even impounded -- restricted

                25   portion of the $6.9 "73 dollars, so the application was over


                                                                               175

                 i and above their remaining allotment for FY-74,

                 2           I think I should point out also that  when  they  cam

                 3 in for their first quarterly allotment, RNFS put a restriction

                 4 on $100,000 of that. lboause at that time they had  task  force

                 5 working to determine the organizational structure and the

                   direction of the program, So since they had no  good  plan  for
                 @6

                 7 a program, RPMS did restrict $100,000., and t@iey, were asked.,

                 8 when they@decided what their program was going to be, what

                 9 their staffing and organizational structure was going  to  be,

               10  they could apply to us for release of those fundi.

               11            So the release of those funds I believe is con-

               12  tained in this request for the release is in this 9,pplication.

                             MRS. SIESBFE:   Put in the same blocks,

               14            DR. WATKINS:  I have a quick overview,  That is;,,

               15 the pro ram at five medical schools certainly  has  some  poten-
                          9

               16  tial, but we discovered further that there was a o-ituation

               17  of the tail wagging the dog,, and I think we have to monitor it

               18 for several reasons.- The fact that Dr. Dean Roberts  is  6  new

               19 executive'. the fact that there was some -- I have. to use  the

               20  word "suspicion" we might be assisting 'with the staffing..

               21  meaning the salaries
                                         of the medical schools.

               22            I was up there at the time of the secession of'

               23  Delaware, as you recall,, and what I am saying is we ma@ have ti)

               24  cuddle it, monitor it,, closely, including their  bookkeeping,

               25  to be sure they are distributing the money in the  right  way,


                                                                                     176

                     And 9.lso if we are going  to  continue  or  increase  f'unding,

                  2 1if a new grant is given, then it should be revisited or

                  3  'visited by either staff or perhaps a member of' the Council.

                  4             1,4R. NASH  Staff  recommendation  on  this  for  this

                     particular region   was  to  require  periodic  progress  reports
                  5

                  6 for the medical   school and subparagraph staff for measuremnt cf

                  7  the  degree of goal attainment

                                DR. @tATKINS:  I move it be accepted.

                                MRS. SILSBEE:  Is there a second?

                 10             DR. FOYE-.  See i

                 11             MRS. SI@'-BEE:   Motion has  been  made  and  seconded

                 12  that the Greater D@-laware Valley   application   be   approved at

                     the requested level of  591o-')320  with the kidrie  condition and
                 13                                                      y

                 14  the condition  that written progress reports be submitted to

                 15  RMPS, indicating the progress that has been made by the atsk

                 16  forces and the utilization of the staff in the medical schools,

                 17  and that in the event that additional money is forthcoming, thEt

                 18  a Council site visit be held.

                 19             DR. WATKINS:   Thank you.

                 20             YIRS. SI LSBEE:  Is  there  any  further  discussionI?

                 21             MRS. IAARS-. How long has  this  program  been  in  o
                                                                                   ,pera-

                 22  tion?

                 23             MRS. SILSBEE:    Practically

                 24             MRS. MA@'Q:  From the beginp@ng?

                 25             MRS. SILSBEE:  Yes. It has had problems.


                                                                                    177

                 1              MRS. MARS:  One was divided up in that area,  I

                 2   can t--
                 3              MRS. SILQBEE:  DE@l,aware broke off.

                 4              MRS. YIARS-.  Delaware 'broke off.
                 5              DR. WATKINS:  First state to secede.

                 6              MRS. SILSBEE-&  It is a  complex  region,  It  has  the

                 7   City of Philadelphia and  covers  quite  a  wide  area  of  Pennsyl-

                 8   vania.  And@it has rural problems over into New Jersey--

                 9   and then the  five medical  schools  have  been  a  real  problem,

                10   They have  tried to develop this, they have responded in VarriOU3

                11   ways. @At  one point they put  a  superstructure  on  top  of  all

                12   of this thinking that would help and all that did was have

                     almost twice the staff that was needed.
                13

                14              Now, they have gotten rid of    the  superstructure  a,nd

                15'  in the view of  the  staff,  looking  at  this  particular  applica-

                16   tion, for the first time the  money  that  Is  going  in  the  medi-

                17   cal schools at least has an  objective  to  it  and  some  way  to

                18   monitor it.

                19              The question Is whether one   of the medical     school

                20   heads can  manage the others,, and that  is the question.

                21              DR. WATKINS:  Dean is head of Hanahan.@@@Can he manag(!

                22   Templeton?

                                MRS. @SILOBEE:  Yes, that Is right,
                23

                24                   @RS:    Is Delaware doing  all  right  on  its  own?

                25              MRS. SILSBEE:  Delaware is out of the picture entirely.


                                                                                178

                 1             They were phased out because we thought perhaps there

                 2  might be an application for this Council, but-.-

                 3             @.IlARS-0  They were phased out entirely.

                 4             MR. NASH: Spencer, Dr. Roberts,, didn't fie  go  off

                 5  the Hana@han. payroll and  now    100 percent time on  the  RMP

                 6  payroll?

                 7             So it is a matter whether the other medical schools

                 8  will consider him as still favoring Hanahan or not,, or

                 9- whether he@can serve as  executive  director  impartially  with

               lo   all five medical schools.

               11              NRS. SILSBEE:  Did we have a motion?

               12              DR. WATKINS:    Yes.

               13                  SILS   E:   The motion has been made and seconded.

               14   Is there further   discussion?

               15              All in favor?

               16              (Chorus of "ayes.

               17              MRS. SILSBEE:  Thear)olication  has  been  approved.

               18
                                     nd.

               19              MR. NASH:  Maryland is the next one we will consider.

               20   This is a  request for $226,878.

               21              Dr, Davins continues as coordinator of this program,

               22   and,,surprisingly enough, this is one of the regions in the

               @23  Ea8tern.Branch that did have their review process certified,

               24   although the region is known to have had some problems in the

               25   past.


                                                                               @179

                              This program was last reviewed by  Council  in  Feb-

                2   ruary 1973, which was preceded by a site visit.  At that

                3   time Council reco=ended a reduced level of support, $1 million

                4   versus their request of $1.29 million,, and that  this  program

                5   be considered on probation.

                6             The key issues were the continued support of the

                7   epidemiologic and statistical staffs which had a  staff  of  14

                8   people, and these were carried for several years  as  part  of

                9   the program staff;in Maryland,  And:also the absence-- apparent

               10   absence of leadership by the Regional Advisory  Group  and  the

               11   fact that this program was almost totally Baltimore based.

                              I think in the past that this region has been
               12

               13   characterized as one which continually tried to anticipate

               14   fe deral help initiatives and to move in that direction, rather

               15   than assessed Maryland's health needs and  trying  to  develop

               16   a program to meet those needs.

               17             This I think was evidenced by the  prograials  prema-

               18   ture and heavy involvement in HMO activity.

               19             The staff has bee reduced from a total of 26 dow  n to

               20   4-1/P- people.  This is primarily brought about by the removal

               21   of the-- and no further support of the 14 people  on  the  EMS

               22   staff which certainly was a move in the  right  direction,  and

               23   one that has been recommended by this Council for two or three

               24   years.

               25             We feel that the present staff is p
                                                              I   robably adequate


                                                                                    180
                 1   to manage the program herein,@proposed.  However, if additional

                 2   RMPS dollars are made availableo, then  certain  more  staff  woul(

                 3   be ne   eded.

                 4              Now, the Regional Advisory  Group,  if  you  recall  my

                 5   prior statement'. there was concern by Council and by site

                 6   visitors that the RAG was  not  giving  leadership  to  this  pro-

                 7   gram,

                 8              Mr. George Hinkel, of our staff, recently visited

                 9   up there within the past  two  weeks  and  @  documented  the  fact

                10   that the RAG, technical review comittees,, are very active

                     in development ofthis oarticular application. As a matter

                12   of fact)  the Regional Advisory- Group for  the  first  time  used

                13   a priorit           I
                              'y eva@Luat on form in Its review process,

                14              And another consideration was  the  fact  that  all  of

                15   thIe proposals which were presented  to  RAG  were  not  approved,

                16
                     They actually  disapproved some projects,  iSo that Is a good

                17   indication anyway.

                18              Maryland,      as far as their relationships with

                19   CHPA and B agenci 4 seem to be excellent.

                20              All the projects In thi,s particular application

                21   were reviewed by the  agencies  involved  and  the  total  applica-

                22   tlons reviewed by the agency and we have    copies of their

                23   letters on file.

                                This particular proposal contains requEsts for  sup-

                25   port of three projects and one staff activity. Three  of  the


                 1  four activities are stren then@Lng of local planning -- under

                 2  strengthening of local planning option; other in kidney,

                 3  kidney thing will probably have to be flagged.

                 4            One project that they have which is a pediatric-

                 5  nurse-practitioner project, is a continuation of activity
                 6  they were carrying on last year.

                 7            The kidney activity, which is an organ procurement

                    and preservation project, was approved by this Council in its

                 9  meeting February 1973, and met the complete RMPS review re-

               10   quirements prior to Council approval.

               11             We are Pleased to see, as I mentioned before, they

                    have :taken their funds out of support of the EMS activates
               12
                    and a re @ho7 16n
               13                 ger in the HMO business.  The staff's,primary

                    concern with this region is the lack of adequate staff to
               14
               15   r)lan, develop and monitor larger program as funds become

               16   available,

                              ifR@q. SILSBEE:  Mr. Milliken.
               17

               18             MR.MILLIKEN.-  I have nothing to add.

               19             I think the staff recommendations are adequate.   I

               20   move it be accepted.

                              MR. HT-ROTO:  Second.
               2 1

                              DR. WATKINS:  Second.
               22

               23             MRS. SILSBEE:  The motion has been made and seconde@
               24   that the Maryland application be approved at the requested

                    level of $226,,878,, with the kidney condition.
               25


                                                                                182

                 1             Any discussion?
                 2             MR. MILLIKEN-6  Question.
                 3             MRS. SI@IBEE:  All In favor,?
                 4             (Chorus of flayes, if
                 5             MS. SI@0,BFE: Opposed?
                 6             (No response.)

                 7             @0. SILSBEE-.  The application has been approv6d.

                               14R. NASH:  New York@ Metro.

                 9             MRS, SILSBEE:  Dr. Watkins,
                               @(At th  "poin@ Dr. @iatk-,ins withdrew from the room.)
                                      SI
                10

                               ICq. SI@QBEE:  Thf,, record will ref'l(@dt he 1.6 out
                11
                12  of' the room.
                               MR. NASH.-  This Is request for $458,584.
                13

                               Dr. Aronson, who is a former deputy coox,di.nator,
                14@

                15  replaced Dr. I. J. Brightman, who resigned last Deceniber.

                16             We have a little concern about  the  management  of

                17  this particular program due to health condition of Dr.

                18  Aronson.   He recently had a second heart attack and has been

                19  out for sometime.  However,,, we learned last F'x,i.day that- he is

                20  now back on boar4 at least on a half-time basis,

                21             This particular region was last reviewed by Counci 1

                    FebrQary 1973,  That was preceded by site visit in December.
                22
                23             CounciL recommended at that time one-year funding
                24  at about $2 million level.  The key Issue then was primarily

                25  administrative problems and their relationships between the


                                                                                     183

                     grantee and Regional Advisory Group, program director pro-

                     gra.m  staff  I think  Council  will  recall  that  the  former  gran-
                  2             .0
                  3  tee tias the Association of Medicq.]. Schools of Greater  New

                  4  York, and the key problem  was  the  grantee  was  not  willing  to

                  5  turn  over  decision-making  authority  to  the  Regional.  dvisory

                  6  Group*

                  7             This has been changed.  The New York  eademy of
                  8  Medicine is the  new  grantee.  The  13AG  remains  active  and  there
                  9  has never been any question about the technical consulting pan@ls

                10   for this region. They are certainly considered excellent.

                11              From the total staff of  214,  as  of  last  December,  the

                @12  region's now down  to  5  people.  This  certainly  gives  us  some

                13   concern.

                                This application requests support fcr four projects
                14

                15@  a:nd one staff activit    which all appear to be within the optii)n
                                            yp

                16   areas and all  were, previously approved by this Council in     its

                17   February 1973,.meeting due to phaseout they were unable to

                18   initiate any  of these activities  and  are  proposing  to  do  so  in

                19   thisIapplication.

                20              The proposals fall on  three  within  the  local  p  an-

                21   ning:  One in quality assurance,, one in hypertension.

                                The  Regional  Advi.soryGroup  in  considering  these  pro-
                22
                23   posals disapproved two projects and two staff activities,        So
                     the four that we  have  plus  the  staff  actiIvity  were  all  approvec
                24

                25   by the RAG.


                                                                                184

                 1             There is no request for kidney in  this  particular
                 2   application. However, some, further support was  provided  to
                 3   the New York Regional Transplant Program out of  the  region-
                 4   alls first quarter allotment,, so that probably should be

                 5   flagged,
                 6             I am not real sure 'whether they put that money  in
                 7   the New York Blood Bank or not.  Council may recall.
                 8            Council will recall there was a 9-1.0 application
                 9   involving Nassau/Suffol . New York, New Jersey RMP.  That
               10    ran into quite a few problems here., fallen by the wayside,
               11    I do know New Jersey has pulled out and is requesting
               12    to support their own activities apart from Metro New York.
               13             This application was sent to the proper CIIP agencies
               14    but co@ nts were not received in time for  Regional  Advisory
               15    Group consideration.  Review process of this region has not
               16    been certified.

               17
                              Key staff concerns then are lack of  adequate  staff
               18    to monitor-evaluate the program, particularly if i ore RNP
               19    dollars are made available.
               20             We have some concern about program direction in the

               21
                     event of further setback of Dr. Aronson'6 health.
               22             ICS. SILSBEE:  Mrs. Morgan.
               23             MRS. MORGAN: In going through this,, this  seems  to
               24    be the biggest problem,, although Dr, Aaronson replaced a
               25    gentleman which the Council at the time was very willing to


                                                                                 L85

                 1  have replaced, or felt it wise he be replaced,

                 2             It is unfortunate that his health has failed him

                 3  in taking care of this program, whether he will be able to

                 4  maintain will be something we will have to see, but I recom-

                 5  mend we do fund the program but that we do highly recommend
                 6  that Dr* Aronson get very competent help to assist him in

                 7  performing this program, so that he does have good, strong
                 8  technical people onboar(I in case he should have to be relieved.

                 9             MRS. SI@'-BEE:  Does anyone else have any comments?

                10             This region is one that gives me problems because

                11  of the staffing,

                12             I think they have gone overboard on getting rid of

                13  people,

                               MR. NASH:  Dr. Brightracin was an excellent recruiter
                14

                15  but his retention rate wasdt too good.

                16             (Laughter)

                17             MR. OGDEN:  How long have you had the grantee?

                18             MR. NASH:  Since I believe it was, wasn't it,

                ig  Jerry?

                20             MR. GARDELL-.  Yes.

                21             IC. OGDEN-. I thirkthis has been a,good deal.  My re-
                    action to  it is certainly to fund the thing.  I agree with
                22

                23  Mariet, with the new grantee some of these things may improve,

                24             There was a very tense situation there before,,

                    this RNPO  and I am sure Dr. tironson has been one of the great
                25


                                                                              186

                 1  diffi-CuLt-lest disappointments of t;l-iis Council.

                 2            bM. SIIBME-  Actually I think the fact they
                 3  went ahead during the phaseout and proceeded to change the,
                 4  grantee is an indication of strength in the RAG.

                 5            MR. OGDEN:  Probably the most welcome sign we have @,ad
                 6  for sometime.

                 7            (Laughter)

                 8            @q. SILSBEE-*  Did you have--

                 9           MRS . MORGA N: In the form of a motion,, we do fund
               10  them with  the recommendation that they look for strong

               11  staff addition.

               12            MS. SILSBEE.-   Is there a second to that?

               13            MR, OGDEN: I will second it,

               14            MRS. SILSBEE:  The recommendation has been made that
               15  the region be approved at the requested level of $458,5
               16  that there be kidney condition not on this application but
               17  on the activities that are ongo@Lng, and that the coor inator
               18  be advised that Council make strong recommendations that he
                   get additional staff who are competent in the areas of program
               @20 concerned,
               21            MRS. MORGAN:  I think particularly due to his health,

               22  tila tthis@ is our main concern,

               23            D-R. SCHREINER:  Where is the transplant registry
               24  based?

               25            14EO-. SILSBEE: The transplant registry?


                                                                               187

                               MR. NP@SH:  Jerry, do you know anything about this

                2   transpla t registry

                3              las - 14ORGN: it was :in their first quarter.

                4              MR. GARDE LL: I thought it was at the New York plac

                5   1 thought  they were the original. recipient, that is  orne  --

                6   next door  to Cornell; it is riot Cornell, it is Independent.

                7              DR. SCHREINER:  It is going to be very interesting

                8   a problem  for Social Security.  There are 17 transplant

                9   program in the New York area and four different typing tech-

               10   niques.

               11              MR. HIROTO:  Seventeeia,

               12              (Laughter)

               13              MRS. SILSBEE:  Any further discussion about

               14   New York Metro?

               15              MR. OGDEN:  Question.

               16              MRS, SILSBEE:  All in favor of' the raotion to approv(@

               17   the glpplication with the conditions listed say 'la,ye.

               18              (Chorus of "ayes.")

               19              MRS, SIIBBEE.- Opposed?

               20              (No response.)

               21              MRS. IOJI,LSBFE:  Motion is carried.

                               Could someone bring Dr. Wetkinz in,'please.

               23              (At this point Dr. Watkiris reentered the room.)

               24             'MRS, SIIZ-BEE: And Iluerto Rico,

               25              MR* N-4SH:  PuE,,,rto Rico, Yes.  This is a request


                                                                             188

                    for '@3040113o which is the remainder of their      allotment.

                2   There, has been a fairly recent change in coordinators of this

                3   program.  Dr. Ri vera-Castanoo who was former deputyo is now th-@@

                4   coordinator.  Dr. Fernandez., who was the former coordinator$
                5   is now part-time deputy coordinator.  8o they had a little

                6   switch 9,round there,

                7             Dr. Fernandez apparently was barred 'by Dr. Negag ion!

                8   to participate in some health services development projects

                9   in the western part of the

               10             This particular program was last reviewed by Council

               111  in June of 1972, that review was not preceded by a site visit

               12   but was made on the recommendation of staff ,inniversary

               13   review pa@nells comments and comments from the review committee.

               14             The recommendation at that time was for increased SLP-

               15   port for 'this region,

               16
                              The review Process of this region was not fully

               17   certif iedi  They were given conditional approval.
               18             The region responded to the issues 'which were raise@

               19
                    With the@,te6Lm, but we did not follow up due to phaseout.

               20             The staffing in this region, this is about the

               21   third time around really for Puerto Rico.   It seem every

               22   time there is a black cloud on the federal funding picture,,

               23   the whole staff down there resign.--,,

               24             (Laughter)

               25             And we have had two or three of these.   The latest


                                                                                     189
                      one   being phase out, they were down to about two or three
                  2   people,  Since that time they have boosted the Staff back up
                  3   to a, total of 21,, or at least it will be 21 if this applica-
                  4   tion is approved and if they are able to recruit the people
                  5   they request.
                  6             In this  region's  request  for  the  first  quarterly
                  7   allotment of the FY-74 dollars  --  this  region,  by  the  way,
                  8   just about went out of business   in June and were sort of
                      resurrected at the last minute,

                                Anyway,,    their first quarterly allotment was
                10
                11    used primarily for staff' to  support  three  projects,  in  the,
                      health manpower development.  They budgeted part of their
                12
                      fourth quarter allotment, in project evaluation,  The regio    6
                13
                      stated they wanted to do some in-depth evaluations with previous-
                14

                      ly funded activities,
                15
                               The other one  was in the health plannin  assis
                16,                                                        9
                17    tance.

                18             This  particular  application  requests  funds  to  add
                      motelstaff and to refund  two  previous  projects,  and  add  one

                      new one.
                20
                               Staff sort of questions  why  they  would  have  to  go
                21

                      back and resurrect two categori
                                                      cal projects for funding.
                22
                               There has been a  recent  change  in  the  chairman  of
                @23
                      'the Regional Advisory Group. There was no transmittal letter
                24
                      with this application, no  report  from  the  Regional  Advisory
                25


                                                                                 190

                 1   Group.

                 2             Staff here suffers from a lack of current information

                 3   on this particular region,  So we are not real sure what is

                 4   going on down there or what the status of the Regional

                 5   Advisory Group is at th is time*  And their participation in

                 6   the direction of the program,

                 7             Staff has some concerns, one is the potential for

                 8   fulfilling budget vacancies with qualified personnel.

                 9             We wonder about the intactness and degree of the

               10    Regional Advisory Group involvement.

               11              We question the need for reinstatement of two

               12    previously supported categorical projects,

               13              There needs to be some evaluation of' Puerto Rico
               14    RMP Staff acti vities since Joly 19'730

               15              DR. SCHREINER:  What is the progress?  In the greei
               16    sheet there is nothing in the BD&F. colunins.
               17              MR. NASH:  They are all under multi or other,

               18    or under A.

               19              DR. SCHREINER:  I don't see any point in building
               20    up staff if you have no program,

               21              MRS. @RS:  Theyhaven't,  That is the whole trouble.

               22              MRS. SI@'BEE.-  Mrs, 14ars.

               23              MRS. MARS:  This is one of the weakest applications

               24    I have ever read.  I really don't see any future for the

               25    program  the way it is set up at the moment*


                                                                              191

                 1            I have little to add to what  Mr.  Nash  said.  I  thinc

                 2  he said it all for me, which is what I had in my own notes,,

                 3            There is only one program on here really which  s@-em,,,

                 4  to me that if it could be implemented, it might be of help

                 5  and that is.the number 18 projects Ahich is"the integration

                 6  of health between the public and private health sectors has

                 7  been a continually expressed concern at all federal levels of

                 8  review,

                 9            If that could be implemented,, that certainly

               10   would@be worth while.

               11             Most of their programs are being partially supported,

               12   being state supported in any@even@ and could  certainly  be  car-.

               13   ried on by the State Health I)epartment to say the lEast.

               14             1 really cannot recommend funding as far  as  for  con..

               15   tinuation of the program,

               16             I think It should literally have adequate funds to

               17   phase it out gracefully and then that is it.

               18             I Just can't see any future to it, without com-

               19   plete@@.reorizanization and establishment of it.

               20             I think Mr4 Nash and I more or less would agree @on

               21   that, except perhaps he won't go as far as I have,

               22             MR. NASH:  In discussing this with other staff

               23   that reviewed the application, I tliirk there is consensus

               24   that there is a lot about this region we dori It know. and I

               25   think before recommending complete phaseout of the program,


                                                                                 192

                 i   perhaps there should be a visit down  there  to  really  assess

                 2   what is going on and what potential is.

                 3                   MARS.- We have had quite a few 'visits.,  haven't

                 4   we,  down  there?

                 5             MR. NASH:   I don't think we have  had  one  down,there

                 6   in the last two years really.  There have been a couple of

                 7   fast visits.

                 8                   MARS-,  Then we are the ones that are being

                 9   negligent.

                10                 NASH-.  This Is part of the problem,, yes.

                11             MRS. SI@'-BEE-, That is true.  As  I  recall,  Puerto

                12   Rico -- 'yoQ know; before the phaseout. @it@ was )working@ on',

                13   its triennial ar)olication.

                14             MRS. MARS:  That's right.

                15             IVES. SILq-BEE-* I think it was due  and  then  theremas

                16   going to be a site visit,

                17             MR. NASH:  Then we got the phaseout,

                18                   SIL'--BEE-. It phased out.  The  recommendation

                19   was that it be phased out and therj,,at Frank mentioned,, there

                20   was a resurrection, And I had occasion  to  talk  to  Dr.  Merril

                @21  who was the other reviewer, and he  expressed  the  same  feeling

                22   of frustration  that you dQo Mrs* I&,irs; he said there  wasn't

                23   anything to the application.

                24             MRS. MARS:  No, there Just isn't.    So why is it so

                25   worth saving?  Why not start all over again?


                                                                              193

                              I can't see the logic.

                                S. SILSBFE:  Welto I think Mr. Nash is right, that
                 2
                 3  we do not have adequate information one way bi, the other.
                 4            MRS. YAA@'--.  But in the mantime, we are going to
                    give them a considerable amount of money to put down the
                 5
                 6  drain,
                 7            1,4RS. SI@qBEE-. I haven't heard a motion to that ef-
                 8 ff-, c t .
                 9            @o NASH:   One consideration might be, perhaps,
               10   restricting some of these funds until a look-see could be tak(,Nn
               11   of' the region.  That is a possibility,
               12             ICS. MARS   I would restrict @9,11 of them until such

               13   a time,
               14             (Laughter)

                              MRS. SI@'BEE.- I thiri@,c ttit is a very difficult thin@.;.
               15
               16             MRS. iMA P.9 Give them enough for Continued operatiori-

               17   al expenses and I thin  a very, very imminent visit is indi-

                    Cate

               19             MRS, SILO--BFE: Does anyone else on the Coutici'A. have

                    some suggestions?
               20

               21             DR. lil O'YE -6 I am inclined to agree wits the s,ugges-

                    tion.
               22
               23             DR. SCHREINE-R: I don't think they understand what
                    it@ is:,a-11, bout.
               24
                              I was down with the VA a, year and a-h,,Ilf ago, and
               25


                                                                                        194

                   1   we got to to@lking with  one  of  the  peoples  and  they  real  y

                   2   didn't understand the :regional project.

                                  MRS    MARS  Certainly from the application they
                   3

                   4   don't.

                   5              DR.   PAHL:  I think that Is an excellent suggestion
                   6   if you  wish  to  make a motion  along those lines,    restriction

                   7   and full Council visit.

                   8              We are as a staff I think partly responsible for
                   9   not having kept in closer touch, ,and that in turn has resulted
                   10  in phaseout and not the site visit with triennial application,

                   11             We have had a difficult time with, them,       It was our

                   12  intention  to phase them out arO, wi.sely or unwisely, they con-

                   13  v@inced us that we were in error.

                   14             14iS . YjA RS  But no one bothered to go down to see.

                   15             DR. PAHL:  Well, we didn't have the luxury,         Li ke

                   16  a, 24 hour decision,  it  was  the  close  of  fiscal  '7  and  we

                   17  had pressures from the Depirtment and pressures from other
                   18  places, and rather than make w@ t could be a, gross error, whict-L

                   19  i,t seemed to be on the surface, we proceeded to maintain the

                   20  viability  which,  by  the  way,  was  the  instruction  from  the

                   21  Assistant Secretary of Health,  So we were at least in

                   22  compliacne with the Department,
                   23             IVIRS. SILSBEE:  But with no dollars  or awh

                   24             DR. PAHL:  With, no dollars:,     Over the summer, it

                   25  was very complicated.


                                                                               I @-)

                 I            To swn it upo I think it Would be a uiistake to take

                 2  a terminal action without a visit, but I am not at all sure

                 3  we wodt arrive at the same decision after.  And perhaps the

                 4  best end kindest thing would be to start all over.

                 5            But it should be done on the basis  of  first-hand

                 6  information,  And restriction of funds pending:the outcome of

                 7  that vis it I think would be a most appropriate action.

                 8            MRS. MARS:   Very well,, I VJ.ll so mov@

                 9            MRS. SILSBEE: Are you moving  restriction  of  the

               10   total amount?

               11             MRS. WRS:  Yes.  Except for enough for continued

               12   operational expense.

                              MRS. MOR@N:  Would this depend on when a site visit;

               14   could be made?  Says a site visit couldn't be made until

               15   February. They really need something  to  operate  through--

               16             MRS.         I said for operation, exclude funds

               17   absolutely necessary for continued operational  costs  until

               18   t hat time.

               19             MR.MILLIKEN:  Second.

               20             MRS. SILSBEE:   If I could  paraphrase@our  motion
               21   then,, the motion has been made and seconded that the funding

               22   for Puerto Rico Regional Medical Program as requested in the

               23   application be restricted at an amount to be determined by

               24   staff.

               25             @c' . MAP, oO Right*


                                                                                      196

                  1              MRS. SILSBEE.-  That vould enable the region,, the

                  2   staff to keep inoperation,, but not expand the program,

                  3                    MARS:   Until such a  time until---

                  4                    SII.SBEE.- Until such time as a Council site

                  5   ,vJ,sit ,Ls made.

                  6              MRS. MARS-*  And staff definitely.

                  7              MRS. Sl@O-BEE-6  Will you delegate to the site visit,

                  8   if they say everything is fide, to release more funds, or

                  9   if    everything--

                 10              MRS. YiA RS   I think It should come before the

                 11   Council.

                 12              MR. OGDEN-  Come, back before  the Council.

                 13              MRS. IAARS    No. it must come before the Council,

                 i4              @q. MORGAN:     It is scheduled pretty soon anyway.

                 15              MRS. SI@BEE:  Report back to Cou                  ther

                 16   action.

                 17                    MORGAN:   I second it.   I secodd your statement

                 18   of her motior4

                 19              (Laughter)

                 20              @0-. SILQBEE:  All in favor?

                 21              (Chorus of "ayes.")

                 22              MRS.    SI@BEE:  Opposed?

                 23              (No res Pons e.

                 24              @0-. SILSBEE:  Motion is carried.

                 25              MR# NASH-.  May I have just one other thing.      It is


                                                                               19,T

                 1  not a region,, I won' t go through the whole discussion on it,

                 2  but in addition to one death in the Eastern Operations Branch,

                 3  we had one divorce in the last year, that being Nassau/Suffolc.

                 4            You my recall this is a region that requested and

                 5  was approvedtto sort of merge and be funded, now,
                                                                       jointly

                 6  @witti the CHPB agency in Nassau/oouffolk area.

                 7            Recently they requested to be divorced, separated.

                 8  They--moved into different quarters, that appears to be

                ,g  operating satisfactorily.

                10            I think there is one little problem as far as
                11  fiscal financial management- people from the two groups now
                12  appear not to want to talk to one another., but I think you
                13  would be able to straighten that out, Jerry.

                14            MR. GARDELL:  Yes.

                15            MR. NASH-.  Thank you.
                16            @, SILSBEE: For the remainder of the regions    in
                17  the Eastern Operations Branch, I have looked through the s taf J'
                18  recommendations,, ard the staff has recommendel,,,t at Lakes
                19  area,, Maine, Rochester, S  q  h @l  .,,Valley, Pennsylvania  be
                                                 e a
                20  approved,,,a,t, @)i uested level.
                21            DR. FOYE:  So move.

                22            MR. OGDEN:  Could l@ ask if there are any comments

                23  from those who reviewed those applications?

                24            NRS. SILSBEE:  Any comments from any of the reviewers?
                25            MRS. YJARS:  The only thing that amused me in the


                                                                                196

                 1  Lakes region, Dr. Ingalls apparently was optimistic that this

                 2  program was going to endure and lie hired more staff instead

                 3  of decreasing Lt.

                 4             MRS . S I @'BE,E It is the only one that went up over

                 5  the Interim,

                 6             MRS. ARS:   I think that was quite a point.

                 7             MRS. MORGAN:  I so move, we accept It.

                 8             1,4R. OGDEN:  Move they 'be approved.

                 9             MRS. SILSBEE-,  All in favor?

                10             (Chorus of "ayes.

                                    SIL'q-BEEO- Opposed?

                12             (No response.)

                13             MRS. SILSBEE-,  Then of the remain ng regions$

                14  Metropolitan.Was ington, Nassau/Suffolk, New Jersey', Northein

                15  New England, Virginia, West Virginia. they all have kidney

                16  condition.

                17             (Laughter)

                18             MRS. MARC--,  In more ways than one.

                19             MRS. -0-ILSBEE:  Otherwise staff recommends they be
                                                , h @ @I

                20  approved as requested,

                21             ICS. MORGAN:  I move that these be approved as

                22  requested, with the flag on the kidney condition,

                23             MR. MILLIIEN:  Second.
                               2 1
                24               S. SILSBEE., All  in favor?

                25             (Chorus of "ayes.


                                                                               199

                 1            IQRS. SILQBEE: Opposed?

                 2            (No response.)

                 3            l@-. SILSBEE:  That Is carried.

                 4            Now, we move to Mid-Continento Mr. Posta.

                 5            Do you want to have a l'i.ve-minute break?

                 6                POSTA:  Maybe they do need a kidney break,

                 7            MRS. SILSBEE:  We only have one region that has been

                 8  dentified by staff, but it rwy- require  considerable  discus-

                 9 sion, so  let's take a five.-mi-ritue break.

               @io            (whereupon, a short-) recess was taken.)

                              MRS. SIWBEE:  Could we get started.

               12             Th@ is Mr. Posta, from the Mid-Continent Operations

               13  Branch   and he has for your consideration Inter-Mountain,

               14             Of the regions that are left for  the  Mid-Continent

               15  Branch,  staff had recommended that Arkansas and OkLahoma
               16  be approved at the requested Piaounts.
               17             In addition, the @,BI-State, Iowa, Nebraska  applica-

                   tions,, staff is recommending approval at the  requested  amount

               19
                   with the kidney proviso,, and the    ndi g full RAG review  con-
               20  ditidn, because in these instances it   Is evident that they

               21
                   were doing the technical review and @-G was going  to  look  at

               22  it ln@December,

               23             Then the New Mexico one had an HFW, after  coraplying

               24  with some regulatiors with regard to a public             thing,

               25  it had kidney.


                                                                                  200

                                Missouri and North Dakota and Texas  all  had  kidney
                 2
                     projects   that had to be flagged. Otherwise  the  staff  recom-
                 3
                     mends they be approved as requested,

                                If any of the Council members  who  reviewed  these
                 5
                     have some questions about them or, would like to have them
                 6
                     considered please let us know,
                 7
                                DR. SCHREINER:  I have i, couple.
                 8
                                Arkansas has a terrific state-wide kidney  program
                 9
                     which was  set' up by Pat Fla,na,ga,ii, and they really moved out @,Lri-
                10
                     to the boondocks and set up some installations.
                11
                                @I notice. they have not had a6Ything going in
                12
                     hypertension.
                13
                                    MARS:  That Is right.
                14
                                DR. SCHREINER,  But they came up with
                                                                       one after  the
                15
                     phaseout-,  And I think the. staff ought to take. a look at
                16
                     it,
                17
                                For one thing, it seems to me that  the  geographical
                18
                     planning that went into kidney could be used  for  the  hyper-
                19
                     nnsion units.
                20
                                I hope they are not going to use this money to star;
                21
                     a whole different kind of network. It seerts to  me  it  could
                22
                     be closely coordinated.
                23
                                IC. POSTA: I would like to respond to that,
                24
                                I think 34 percent of this  particular  application
                25


                                                                              201

                 1  from Arkansas is In the area of' hypertension and they have
                 2  coordinated the planning that the 110liPB agencies that work in
                 3  harmony with the EMS proposal that is 'being funded through

                    Dr. van Hoek's shop,, and they do have extremely good coopera-
                 4
                 5  tion with the A. B. and Experli-aental Hertltti Del@lvery System

                    down there.

                              It is definitely a state-wide coordinated effort,
                 7
                 8            MRS. MARS:  Is IPlanagan still there?
                 9            MR. POSTA:  Yes.
               10                the kidney, they did get legislation passed

                    duri'ng the funding of their particular program from RMPS.

                    They do not request any additional moneys for that particular
               12

               13   pr6jebt cominiz@@ up.

                              :It is just about finished.  They did get about
               14
               15   $300,000,a year for the last three years from the state

               16   legislature, to carry on tie kidney activity'.

               17             We felt that was a real good program, good appli-

               18   cation, good management,

               19             MRS. @RS:  They have a, renal satellite program,

               20   don't they?

               21             MR. P(L-TA: Yes.

                              DR. SCHREINER:  Yes.  I was thinkin@r it would be a
               22

                    natural to heng their hypertension screening on those
               23

                      its, because they are all around.
               24   un

                              MR. POSTA:  Good suggestion.
               25


                                                                                 202

                                    SL@BEE:    Staff will follow through on that.

                    The suggestion they mor)itor-- it may indeed  be  in  their  plans,
                 2

                    but we, certainly will check on that, and advise you at the

                 4  next Council meeting.

                 5             14,R. OGDEN-.  I have a comment really concerning Kan-

                 6  sas,

                               It seemed to me that this application suffered@from @t
                 7

                 8  '@lack of cohesive quality, they, scattered stio)t among all of

                 9  these identiPied areas they have had out  there  for  along  tirie,

                10  it seems to me.. and while they have done something with

                    kidney  and hypertension screening;, I really think that

                12  somebody from the staff ought to get out there and encourage

                13  a more cohesive program,

                14             I wonder if they are Just not doling some f Qdds out

                    to the..various regions that they have without being very

                16  careful about what they are using them for.

                17             MRS. SllqBEE:  Would you like to put that in the

                @18 f 6rm of a motidn9

                19             MR. OGDEN:  Whatever motion is made here      approval,

                20  I would like to have that included in connection with    Kansas.

                21             MRS. Sl@'-BEE: All right, that it  would  be  funded  in

                22, the amount requested,, but with the condition that Staff

                               MR. OGDEN-,  Staff,
                23

                               MRS. SILSBEE-. -- work  on  developing  a  more  cohesive
                24

                25 p r ogra m.


                                                                                                      203

                                      Any further discussion?

                     2                MR. HIROTO:       Including those comments, I would like

                     3   to make a    motion these     be approved.

                     4                ICS.   MARS:   Second.

                     5                NRS.   SILS  E-6    Okay,   the   motion   has   been   made   and

                     6   seconded    that   the  applications     f rom A rka its as  Ok latioma   Bi  -

                     7   State,, Iowa, Nebraska, New Mexico, Missouri, North Dakota, and

                     8   Texas be approved with the recommendations and conditions                    that

                     9   have  @been noted before; and in addition, that ill Arkansas,

                    10   staff,will   follow   through   on   the   coordination   to   see    how    the

                    11   hypertension screening program be coordinated with the kidney

                    12   prograr4  and   in   Kansas   follow   through   to   help   on   developing   a

                    13   more cohesive program

                    14                Any further discussion?

                    15                M.RS@,@PZ: Is there anything noteworthy happening ir

                    16   Texas

                    17                MRS. MORGAN:       They have changed,  lost Dr. MoCall

                    18   there,,  their   director.   But   Dave   Fergusonp   who    has    been    his

                    19   deputy   director for sometime, took over and I think even thouL@h

                    20   he is not an M.D., is a very capable, viable person that

                    21   can   keep   the   cohesiveness   that   is   necessar   in   the   State    of
                                                                                y

                    22   Texas     They don't have a large amount and I am concerned

                    23   whether  with  that   small   amount,   how   much   they   can   do   in   that

                    24   huge state.  But I think what program they have is very good.

                    25                NR. POSTA:      I might respond,, Mrs. Mars, having


                                                                              204

                 1 followed Texas closely for the last several years, that

                                       1 ition gets services or RE? activities
                 2 this particular appl'cc

                 3 involved in both urban and the rural areas,  concentrating  on

                 4 Mexicans, Indians and blacks,  They propose to do more than

                 5 they ha,ve@in the past years,

                 6           They do have a relatively small staff,  However,,

                 7 most of the activities proposed in the project area, is  going

                 8 to be administered through the contract mechanism,

                 9           MRS. 1,40RGAN:  And they did do away with their region-

               10  al areas?

               11            MR# POQTA:  Subregional offices were closed when

               12  they got their phaseout instructions,

                             That hurt them as far as outside assistance is
               13

                   concerned  additional moneys coming in from other sources
                 4

                  and s oforth,
               15

               16                :MARS:  Thank you.

               17            MRS. SILSBEE:  Is there further discussion?

               18 FLIrther'discussion of any of these applications?

               19            All right, all in favor of the motion to approve

               20  these with the conditions noted in the staff recommendations

               21 and the additional comments made by Council.

                             (chorus of "ayes.
               22

               23                SIIBBEE:   Opposed?

                             (No response.)
               24

               25            Mo. SILSBEE: Now, that leaves one  region  and  that


                  1  is Intermountain.

                  2             MR. POSTA:    In your red bookso in introducing a little

                  3  background about this region, I would like to say that there ha,---

                  4  been quite a few  comments  by  ill  of  our  RIES  staff  concerning

                  5  this particular region.  We have also got or have received

                  6  100 12,, 15 points from  the  HFW  Regional  Office  in  Denver.

                  7             As a result,, we have invited Mr. Webster to attend

                  8  this  particular session and to feel free to bring up any

                  9  questions  once  the  Council  members  have  mde  their  proper
                 10  comments,

                 11             We would like  to  say  that  the  Interinountaih  program
                 12  is  requesting  $760,374  in  this  particular  request.  I   mention

                 13
                     that money specifically because it is     one of the highest

                 14  funded regions in   the group of Mid-Continent regions,

                 15
                                Of that  figure,  about  @165,000  is  earmarked  for

                 16
                     indirect  costs.

                                The  present application calls for ,i,botit 39.7 percent
                 18  of their  award  going  for  indirect  costs,  That  sounds  like  an

                 19
                        vful lot of money, but 'believe it or not, a year ago that

                 20
                     rate  o@n.salar es andwges was 61.4.

                 21
                               'I have heard frorii Dr, Ward StLIdt, the coordinator,

                 22   i-io has been onboard since Ja@iuary of this past',@yea,r,  re-

                 23  placing Mr. Hanklin, that he will 'be coming in this week to

                 24  talk with Mr. Gardell and others concerning the possibility of

                 25  going  to a private o
                                           rganization which, 'if that does take


                                                                                      206

                   1  place   will greatly reduce the indirect cost,

                   2                   SILSBEE:  You  mean  changing  the  grantee   to

                   3  a nonprofit organization?

                   4             MR. P(LQTA:  Yes,  Yes, to a private, nonprofit

                   5  organization.

                                 If that d'                               that  rate  w
                   6                       oes take place, of (,course,,              ould

                   7  go down to about 23 percent.

                   8             For  your  information,  staff  has  prepared  In  your

                   9  booklet the  legal  size  sheets  in  white  that  totally  break

                 10   down the total  staff  complement  and  all  of  the  people  working

                 11   on  the  various  proposed  activities,  whether  they  are  core

                 12   activities,,  program  staff  activities,  or  whether  they  are

                 13   projects.

                 14              One of the big  questions  that  we  have  had  in  the

                 15   past concerning this region is the total number of people on

                 16   board.   I think when the  site  visit  took  place  last  year,,

                 17   Mrs. Mars @was onbard, and I am sure that she will have some

                 @18: comments  about  that.  But  they  were  concerned  about  the  total

                 19   number of people obboard.

                 20              With  the  submission  of  this  particular   application,

                 21   we asked th@m.to  send  us  Information  so  that  we  could  tell

                 22   exactly how  many  of  these  folks  were  calling  program  staff

                 23   and how many were actually working on projects,

                 24              If you took at that particular breakdown,, you will

                 25   see breakout of time for about 69 people, which includes


                                                                                   07

                  1  everybody on all of the projects  proposed,  and  program  staff

                  2  itself

                               You will note that the coordinator, Dr. Stiidt, is

                  4  working 35 percent of his time on the program staff and he is
                  5  also involved in three or four other project activities,

                  6            When Pete gave you the breakdown yesterday, you
                  7  may nave noticed that he, DrStudt, was part time.       However,,
                  8  when you add up his time for the four  other  projects,  he  was

                  9  onboard about 87 percent of the time,

                10             if we add them all up and divide them by 100 per-

                     cent, we have about seven ful.1-time professionals on this

                12   particular staff,

                               MS. SIIBBEE'    70r,'

                14             MR. POSTA-.  70.

                15             MS. MARS-.   70.

                16             MR. P OS T-A If you add all of the percentages together.

                17   That is professional.

                .18            Of course,, they have a like number of clerical staff',

                19@  too.@

                               Needless to say,, with another big concern in con-
                20

                21   J@unc @i-on with the indirect costs with  reference  to  the  total

                22   staff,, most of the money happens to be funded  to  the  univer-
                23   sity, And we had hoped that this particular region would

                24   got more activities funded outside of the region to the extent

                25   that the dollars would be going to the other@institutions


                                                                              2 O.Qu

                 1  outside of Salt Lake. However, as you look  at  the  appliaa-
                 2  tion and indirect costs involved, most of the money is going

                     nto the university, and the services emanate from  there  in
                 3

                 4  the surrounding three or four states,

                 5           We can't say that services aren't being rendered to

                 6  those four other states, because I think of all, of the  turf

                    problems that we have and certainly Mid-Contirient seems to
                 7

                    have their share of them- this particular region has been
                 8                          lp
                 9  getting or has had more complaints, let's put it that way.
               10            We are concerned that Mid States in particular,
               11   Colorado,. Wyoming, program,,:, be more intimately, involved with
               12   the particular activities suggested in this particular appli-
               13   cation and also those requests that might come through for

               14   the unexpended funds December ist.

               15            We are concerned about the total amount  of  dollars

               16   earmarked for option A planning.  We wonder if all the CHPA

               17   agencie s have been notified in the area, and whether or not

               18   the mandate fromthe liLV Regional Of@fice not to fund any

               19   further B.agencies has been considered.

               20           We-have not talked with the  region  regarding  this.
               21   However, I do think that it would be worthwhile to pursue this

                    in@@ ur conversation this morning
               22

               23           They do have  two kidney proposals,, relatively small.,

                    in amount, and they will be receiving or alerted to the
               24

                    interim regulations where the kidney disease is concerned.
               25


                                                                                209

                 1             With that as an introduction, I turn it open for

                 2  ditouss@@on.

                 3             Mrs. Mar  would you like to continue?

                 4             MRS.   RS:  Well, when I was there on a site visit,

                 5  I believe  it was about a year ago,, isn't that rights

                 6                 POSTA:  Just about.

                 7             MRS. @RS:  They had so many problem we sort of

                 8  almost,didn't know where to begin as to what to advise to do,@

                 9             Of course,, the, coordinator, Mr. Hagland, who was

                10  in charge  at that point) was only In the capacity of  acting.

                11  And there  was great discord between the university which is

                12  the grantee,, and the Rbg which seemed to be partoy lodged in

                13  14r. HagLand.

                14             Mr. Hagland didn't seem to di,.-Like the university,,

                15  but the university seemed to dislike Mr. Hagl.and very much,

                16             I think possibly Mz,, Hagland was trying to weaken

                17  the university's control.,       we say, over the program  and

                18  perhaps this was the basis of' the dislike that was expressed

                19  for him.

                20             Since that time there seems to have been a better

                2@l relationship established.

                22             The Dean of Medicine is on RAG and the university

                2.3 is beginning to accept the decentralization concept of the RAG

                24  res pons ib I I I t ies.

                25             I believe a new president has come in since in the


                                                             210

             1  University.

             2          MRS. MORGAN-.  Gordon,

             3           S.  MAR: Yes. And this was part, the president

             4  and his assistant were both extremely, antagonistic to the

             5  fact that Rle wished to express itselfi and they did not lash

             6  RAG to really have any part in the program,

             7          From what I could discern in reading this applica-

             8  tion,, Dr. Studt is making an effort to follow the recommende.-

             9  tions.. of the site visit team.

            10          The RAG is certainly being more Involved in greater

            11  program participation and planning.

            12          The 8uoposed staff reduction is certainly one of my

            13  worri.es likewise,

            .14         I counted them up yesterday witn Posta. We

            15  arrived at 69 people on here.

            16          When we wIere out there at that time, frankly they

            17  didn't know how many people they had, They lit @ally didn't.

            18          They had so many pax-t-ti.me and bits and pieces,,

            19  the program director was a, woman who -- well., I don't

            20  knowIhow quit6 to express it; she was efficient, but she

            21  vacillated.

            22          Is that your assessment more or less?

            23          MR. POSTA: Right.

            24          @0. @RS  -And so believe she 1, as been e liminatec .

            25          MR. PO,@TA: I think so yes


                                                                                   211

                                 IVIRS , @@0- Is that; true?

                  2              Mary?

                                 MRS. MURPHY.  University
                  @3
                  4                    MARS: dan't hear you,,

                                 MRS. MURPHY:  She I,,,4 in the university.
                  5
                  6              MR.  OGDEN: She is  vacillating  to  the  university.

                                 (Laughter)
                  7

                  8                   POSTA: She doesn't happen to be on this group
                      of 69 anywk.
                  9

                10               MRS.  MARS: No.

                                 (Laughter)
                11

                12               1 note that Xr,.Hagland Is  still  100  percent  time

                137   as director of operational projects here.

                14               So I am not sure whet@iex, that is good ox, bad.  I

                15    think it is a@ 'Liit on the bad side, stiall we say.

                16               The turf problem, of course, is a very, difficult

                17    thing,  Certainly there is a need for the Intex@a,gency.Council

                18    to be reestablished and I thi.nk@ that we should have an assur-

                19    ance from the program that this -is-- a very definite effort,

                20    very serious effort is going to be made to reestablish the

                21    ra,pp6rt between the states, and that this Interagency Council

                22    be activated,

                                 Of@course@, it didn't matter while the  competition
                '23

                24    for money  wasn't there during the phaseout period,  but  with

                      the money  that@is being funded, there must be development of
                25


                                                                                  212

                     program, and we must have an assurance that- there certainly

                 2   will be no duplication of programming,

                 3              I think this is very, very important.

                 4              This region is  a  peculiar  region.  It  certainly

                 5   could, be a region that could 'be designated     4,mproving@

                 6   grounds for really an organized effort to Improve the quality

                     of life in rural America.,

                 8              It is a paradox that the@ux,ban centers really have

                 9   some of the finest equipment in  the  western  United  States.

                10   They have the manpower and  they  have  t@-teclinology  there,

                11   And I think that RYIP there has done a great deal to try

                12   and identify these.

                13              I think that one of RMPIQ efforts  should  be  made

                14   in trying  to mix these.
                15              Certainly they have too few  health  care  profesl-

                     sionals with possibly too little modern equipment in the
                17   rural areas,   It all seems to be conce                      n
                                                             ntrated  in  the  urba

                18
                     areas

                19              Thiz, :'Ls sad, really unfortunate.

                20              We also were concerned at the time  over  the  min-
                21   ority representation on RAG.   I believe that this  is  being,

                22   corrected.  And fromthe application, I gather that it is be-

                23@  ing carefully monitored and that efforts are  'being  made  to

                24   ensurp@ proper representation,

                25              The 'program was making an effort to take  care  of


                                                                                 21,3

                 1   the health needs of the ni.ig@rant worker; certainly there

                 2   was some thrust in that direction.

                 3              The migrant workers are a very large percentage of

                 4   the population at certain times of the year, and there are

                 5   many., many problems connected with theni,, and the thrust was

                 6   being made towards that.

                 7              So there are sea funded agencies in the area and some

                 8   unfunded.   Arid that I think more or less concludes what I

                 9   have to say about it.

                10              It certainly needs careful. gupervis'lon. I would

                11   like to see another site visit made there.

                12              I would like to see more or less of a site visit made,

                13   end as far as funds, I would fund ito yeso but    under great
  40

                14   supervision, shall we @gayo with restrictions,

                15              Thank you.
                16                   SILSBEE:  Dr. Schreiner.
                17              DR4 SCHREINER-*  Yes.  I find the programs,, in view
                18   of their resources, singularly unimaginative.
                19              They have got one of the ten top transplant sur-
                20   geons in the country., and virtually nothing in their programs
                21   to reflect any interdigit;ation to this.

                22              They have one of the three biggest artificial heart

                23   programs,  with Dr. Coles there, and  nothing appears anywhere

                          ,e
                24   i4n th project,

                25              ThEyhave got the first artificial eye programs,  whicli


                                                                                 214

                 1    is spending about $2 million a yea    and they are running
                 2    9, I 1over Washingtorl looking for money for thatv and it

                 3    doesn't seem to have entered into the RMP at all.

                 4              I think $1000000 you know, for  a,  little  informa-

                 5    tion@lgathering service Is a pitiful unimaginative kidney,
                 6    program for aIplace with that kind of resources,    I think to
                 7    spend 33 percent,# 37 percent on overhead and  33  percent  on
                 8    planning but of a chunk of money of this sort -- it is an aw-
                 9    ful lot of paper work and very,, very little  reality  of  what

                10    Is actually going on In the place,

                11              I would like to see  the  planning  money  choppe  in

                12    half or something like that as  a  gesture,  Notice  to  them.

                13              MRS. MARS-. Another thing that  worried  me  which  1

                14    forgot to mention is the fact they  don't  show  any  salaries

                15    anywhere* You can't find out  what  they  are  paying  anybody#

                16              MR. POSTA:  @Tell, to Just respond, you are per-

                17    fect;ly right, the   ster sheet did include salaries, but non(

                18    of the reviewers at the 13 level or regional office- that has

                19    been an administrative complaint too,

                20              In all sincerity -- I am not  putting  a  finger  on

                21    them because the salary rates don't seem to  be  out  of  line,

                22    It Is that the way they submitted  their  applications,,  they

                23    felt that was privileged communication between  liMIS  and  the

                24    region    period.  But you are exactly right,

                25              MRS. SI@BEE:  Mary,, did you have anything to


                                                                                                                 215

                                                               j., c) t') b C) Llt tki.e e f'f ort.,@7,  o:f' the
                                       ii t t @h s a p p  Ic a t          L

                              i-i        ntair@ program in  t'l).e k,'LdnE@,i@'          in the  past?

                                                                                                 h      C" ra I
                                                   m                     they c@,@,ffie on wi.t   SE@V

                             b i.g propose., is  f o - kidnc@,,y@ and      ti,i-@,.rik 'we shot tl,i,ern down a  few

                                                          'be more      O' LI t' 1. nS t C) l@ t;
                                        ;o    there    may

                                            l@s   far   as   the   salaries   are    c(,,rice,y,ned,,    apparently

                             '(-,Yify considers  this  confidential a,r@,id just; ptit  @l.t  in the  initial,,

                             application because  'I @i,!a,ve :Y,ei@@,,@(aest@,@ed many                    they

                                                 but they ju@-.,@t :r@efuse,.

                                                     a@'TA   I do knew, @'r.      "chrei.r)E@r,  that R,MPS,
                                c c@ LApic@ of years ago,            put qu,'@.te  @l@, few dollars in contract@

                             lrl(,)n y to that programs

                                                   SI    B'E@E         @"@chi,e@l.ner,  I  wer,@t@  on   two   @ite

                             v .,c,,Il,ts, not this last one 'btl@,t two PI'EVi.C)US                 and  the

                             p:r,c)bl.,:-i@@i with Monte  kidney pi,ogra,,rci, is  the saiw-, i,s  it  @L,,;  'I.ri some

                             other, @,,,reas  in Inlv-ermouritain @-.- t-,I-iere@ were  tr,a,  ir
                                                                                                 in  1.@"  projects,

                             there was another aspect of the  k.-@t.dney proj(-,.@oi;,  ,Ind  two parts

                             (@l' the University, wouild 'be  two different dE'@@partine,@nts, were

                       I!)   riot coordinating.

                                               lot of this                           i-."z,ogrci,m seems  to send

                       21         a lot     of  activity  to  the   local,   areas,   but,   tki(,,@,y,   are   all

                       2     each    centrally    from    whzitevex-    division    or    department     of     the

                       2 r@1                 that Ls in                     @Lt.

                                            MR'@, . MA,R,'-,@ 01.  c@,()ti-,r@se,  '@'. do think they,  ,re just

                             try@l,,r@g to  serve t    o large an areas,.            really r.,Io.

     l@OOVER REIIORI ING CO,


                                                                                         2

                                                        s ri l@ c i,d i.na t@c@ cl
                                        S I *S@, FE- E

                                                                                      f f ort.
                                            S   No, i..t@ just isrilt@ a co(@)rcit; e d e

                                                         -an
                                 not toc) sure  t kia t@ @l. t

                                                                    -oin the Denver
                                                        W'c! b,@, t E@:r i'x.

                       t@,egi(Dna.1 Office.

                                                                                   th c)ne
                                  12@.. WEBSTEI f-'?, I wo@A,ld 1, @k(@ to start; out w,,

                                      for the Intexm(@)t@rita@Lri liMP, an(J that -,i.s tile

                                  they have di,@(Dpp(,,zd ox, done z@@tv Ly with the r huge print-

                    11 irig plant.

                  lo              (Elaughte:r)
                                  On    St site 'Vis.Lts, 1.       we lo(-,@k,-ed, :rather askarit@
                       at       operation, doing wo@rk, f'o.-r    whole University  s
                  j2

                                its own (.,)perat@Lc)ri.

                                    would very                  to thank Dr. Patit for
                   4

                       the  opportunity  to  be  here.    don't get baci,@. to Washingtciti

                       vf:,, ,r,@r cl@'ten and it is good to see of you          and the

                                 w(:@ll., and It has been         an enj(,.)yt'bl.e experience.

                                  But in be,.'L.r.@E,@ here    J. have to look at I IVIP

                       bot@,,@ fy,om the viewpoint of' having been an 'eMI'S staff member,

                       sort(] I still are representing      in the 11(@!gl.,ona@t, (')ffice,

                       even t@i(@@ugh unfortunately (@)UT, oola,iunicatiLor@,@,@ with the BiWIs
                  21

                                                                                -iave the
                           not as ctrong ti,s they wex,e, because 'we do not    1
                  2

                       t-,r@a%?E 1, @.,@,nd sijpport raoney. I.' meritic-@@n this bec,.auTe .'L would

                       kir@)[)e Di,,. Pahl, when things get'i b(@@t"ter wYii..ch t,ki(.,,@y will @l'

                       th@t,,,kl wf,", needed this type c)f' @Regiotiil.

    HOOVE'R @-tFPORTiNti CO,  i@-@
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                                                                                                                                                  2  3@7

                                         I       o rn s h 1  p  a     '-,his            the                          'I  air@, ki@ x,(,@  r(.@present
                                                                tia

                                                     -@,egio    a ',L    a 1                                    t)ecatjs(-.,  of'  the
                                             t@ he  I

                                           I,, ()w  (@.1 o      a   t   v 1. t,                 acr...@    w,.th.             activities

                                                                from,  the                        OJ   i.c@,e'

                                                                  of    the  F)rob                              have              @,n,E-,@nt.'@l.oried

                                                                                               "tt  possibly                      ;4e      have      put
                                     h@@re     a    t   e c Lear I,y,      we

                                     t@;         r,,@  t  e  f (@@) Y,-m  of a (. He s  t  J.n  ... ... 't;h@it      there       f.@ro'bat)'y       should

                                     bE,.,  m(.)re  support  to  outside                                 and  organizations  to  help

                                              dc)  their  thing              "I,,atiliex,  than                 things  for  Items

                                                        This  has  Core  up  -@-r@  tl,).I.s  particular                       ppl,,.Lcat@l,.on       in

                                                                  it                                   d  ti@-)  the                      of  addi-

                                                        consulted                                  ii'L.th           peof,.).     ;,@i,    ?iose

                                                          have  'he  d@rect  @,i-                                     su(,@l.         in  the

                                                    nee                                                         iant"  't-@                erigtli.er,.i.@i
                                         n t              d   to   'be   s   tre   ngt;,Iae              we

                                                        But  by                     LAp ad".i",Li" '!.on-"tL  units  @4kie:r,e  there  is

                                          li(,@@p   so we  are  tol.d. of                         b(.@@i.ng     n y a d,d i t@l, i f.) n t 1, @B

                                     a,gr-@           (",x@eateci  a,@i.,,J  f unfJr.!(,i   tkiat,  f'ui;urc.,  CH"  in.@:)i'leys  will  go

                                     t(.,@  tlle  ,.@@t@rigthenirig  @Df'  e.,,..I.st;l,ng                          c)r-il@,y.   J-@t  least  as

                                                                                       That                @iE@  w  ul.(J  1-i@@E)e  that  these

                                                    and  resource,,:,,                    be                        in             dimnction,

                                                       go       help  the           @),g,   ".'.E'
                                                                                                     help  g: ve  bet;tc              cc)vci,agr-
                             @24

                                     t(-,  the    states  conec@rri(@@j,J.

       HOOVER REPORT@NG Ct),

                 D.C. 2 00fj'2


                                                                                                                                                                    2 1

                                                               (@,,A  t e  n a t L@, ra 1, I y      t t@@ e   i.@,:  c,,, ti a 1,

                                                  eei-ta,-n         things  h--                      c-tt             iii@-Ity 'b E@  d 1. f',:C ,i@,e r@, t f r om w  h,,.',L

                                                              or       S  does.               ):k.,                                                        oppoi,

                                          tt)tiit,ly.              find                                 disappointing  @i,riri  I                      eeni-  to

                                                             I th  d I f f e re ri t  f I.g LARE@           e v,,@,, ri  'b ut  'I  g @,@(e s Ic   @-i.t,).ere  are

                                   6            ,Qt   240  professional.  and                                          pey,sonr.IE,@l,  employed  rao:re  ca-

                                                                                  ho.VE?,  the  t,@'ibl@            so  I  di-(,itilt                         just

                                          @,ih,@i,t  p,.-.,@ cenGage,           But  of'  t@i.          )I(),   there  -,Ls  nt,)t-.  evi,dent:Ly
                                                                                                                                                                 from

                                                      t:)vin  application,,,                     @..n         irilr@ox,ity                      E@Illplc)y,ed      in       a

                                          p   o J'e s      o na        -,Y.,  t e - h    c       c,,. 3@  c@:1 t, y

                                                               I'  a.,a,,,  sui,c@  t@iat                 proper  s@aar,@@h,i.np@,                           must          be

                                          pe(@)@)le  of        t  o,@,e  backgrounds                            have                                    and  I  would

                                          hope  tY@i@ t        maybe  :t                                  on  m-.I..gi-it  be  made  th.at  c,:ts   the  PX-@:)..

                                                    e,xf)ands,,,   that                                         hiring          of          these          people.

                                                               1.t  also  is   true  that                               are                           employed  as

                                          i)@r,(@)f      i,om 1.  or  techn i,ca L,  p@.,@( pl,(@  c)t@l  ti                            rtrt@,  staff.           But
                                                                                                                         '13   prc)g@

                                          a@@@yiiay  let  me,  just  SUMffi,'Ltr'!.7E   1)@r  c@,aying  we  %,iou@L(.i   I,j..@ce  t,                            see

                                          iti,,aybe  a  more  broad  cross--,sect:"i.on  rep-rest@nt@jt-.,!.c)@i  o@l  'C,.he  staff

                                   0           well  as   on   the   T@3l@G.                 .'.r  .I,gi@-ee,   .1'.'            the  'I'@,@G  rc,,presenta-
                                      I   ti(@@n      a,-:,.approved,      @ie      w(DulCi,      I,Ik:e      to      see      more       supp@.),r,t@       being
                                   21

                                    2     given  to  agencies  and  orgo,n,,..zat":Loris                                     the                            field.

                                                               The  '@TMP  has  a                                     staff;                              we           think:
                                   2

                                          they              be  P.  little  too  courageous   In  what;  they  do.                                           Th, e  amoe t a.

                                                      to       be       constantly       changing       -in       skiipe        and        si.ze,,,and        even        :Ln

        HOOYER REPoR,r@i4G, co.,  lrii,.
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                                                                                        219

                       this application it has raised the question we couldn't get
                  211  answered, where  they  evidently  proposed  putting  in  a  poison
                  all  control satellite in  Boise,,  Idaho.  We  are  not  even  sure  the

                  4    Mountain States PM,,  which  is  headquartered  in  Boise,,  knows

                  5    about  it.

                  6               I think we have raised some questions which we woul(i

                       like to turn over to staff possibly,, some may be answered

                  8    well but I think it would be well.

                  9               MR. POSTA:  Thank you,

                                       SILSBEE:    Is there  any  further  discussion  of

                       Council?

                 12               MRS. MARS:  The other thing,, they will turn to thei3,

                 11?   green sheet here,  the  allocation  of  funds  here,  There  is  a

                 14    great deal of concentration  as  you  will  note  of  money  under

                 15    A'here, And,  of  course,  much  of  this  is  in  conjunction  with

                           A and B agencies* So  the  question  is,  of  course,,  is  this

                 17    lost money?  How much of it is lost?

                 18               M.  SIU3BEE:  For  years  Council   and   site   visitors

                 1.1)  -have been recommending what Dan alluded to, to get out of

                 20    Salt, Lake and to get out of the Salt Lake direction.

                 21               In other words,,  to  let  the  communities  decide  what

                       it is they wanted to do,
                 22
                 2@'3             MRS. MARS:  Right.
                 24               MRS. SIISBEE:  And  then  seek  the  help  from  Inter-
                 25    mountain.

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                                                                              220

                               This application is the first time that I have  seen
                211 that they were even thinking of developing advisory  groups  ou
                31@ there.  It is sort of late.

                4              (Laughter)

                5              But I think the fact that they are thinkin
                                                                         g in terms

                6   of community planning is helpful as long as they dotit  have

                7   to do it themselves.  I mean, start from scratch.

                8              If you recall, Dan,, they used to have an excellent

                9   staff member who had beon@a.former League of  Women  Voters.

                10             MR. WEBSTER:  Yes.

                11             MRS. SIWBEE:  Staff.  And she had the best

                12, sense of this kind of community  organization  But  she  did

                ),3 not stay long with the program.

                               MR. WEBSTER:  No.  No.

                               MR. OGDEN: Could I ask, what is project  number  64?

                    Regional coordinator for planning,  I am trying to get at

                    Dr* Schreiner's comment, is number 37 Boise,, Idah
                17                                                    ot  poison

                    control  program?
                18

                               MR. WEBSTER:  I would like to take a little answer

                    on that,
                20
                               There is one thing I thought from an  PMS  viewpoint
                21.
                22  was rather peculiar in this application$ and that is In most
                -9@3 Instances where they have an activity proposal, they have a
                24  separate project proposal to administer the other project or
                    cluster of projects. And I think this gets back  to  the  first
                25

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                                                                            221

                   question you have asked.
                2111         So,, forexample, the regional coordination for planning,

                31i which I dont have the figure on, but I think It is a  pretty

                4  handsome figure,, is a separate project to administer five suc-

                5  cessive projects.

                6            We wondered about this when we looked at it, why

                7  that wasn't just built into those projects,

                8            The something is true in the area of quality

                9  assurance.  They have a separate project for regional coordina-

                10 tion of three separately funding projects and they have done

                11 that even with kidney. They have in their  activity  project

                12 of expansion of kidney network, they have a paralliel project

                13 funded in about or to be funded in about the same amount of

                14 money to monitor or to operateit,  And it seem to me they

                15 should have been combined.

                I            MRS. SILSBFE:  Is number 37 the Boise project?

                17           MR. WEBSTER: Number 37, yes., I think that is  the

                18 one,,

                             MR. POSTA:  B-3.

                20           MR. WEBSTER:  Yes, In the application they did not

                21@ specify locations,, but in a meeting with one of the staff

                2'2 members,, just before coming here, we deter-mined that one  of

                2,3 the two places   this is under item 2,  develop  dialogue  at

                24 minimum of two communities in the  region,  We  learned  "dia-
                25 logue" meant subsatellite centers.

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                                                                                  222

                               while I don't know one of them where they are
                  211 proposing to put one of these satellite centers -- we even
                     possibly questioned whether there needed  to  be  an  additional
                  4i satellite -- was in Boise,  That is why we raised the question
                  5  about Mountain States was aware of this,, and had  he r con-

                  6  ourrence,
                  7            DR. SCHREINER:  Is there any legal problem about
                  8  running conferences for state legislature?

                               MR. WEBSTER:  Our own feeling on this was while the

                  10 IRMP might certainly give support to this type of activity,
                  11 I can't see any objection in that.
                  12,          We felt it was more the logical function of the
                  13 state comprehensive health planning  agency,  because  the  con-
                     ferences would be on the basis of statewide and subregional
                  14

                     health needs,
                  15
                               MM. SILSBEE: I think there is a problem,, Dr.

                     Schreiner, particularly when Mountain States, which is respon-
                  17
                     sible,, doesn't know that this kind of thing is  going ori.
                  18

                               MR. WEBSTER:   I don't know.

                               MR. O@GDEN:  I don't think the Boise@@t4 ing  ought  to
                  20

                     be approved.
                  21
                               I question this business of information assis    tance
                  22
                     to state legislature* I wonder about the business of the
                  2ti
                  ,4 regional coordinator for planning,gets,all the money involved
                  2 i
                  25 for planning.

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                                                                                  2 3

                                It looke to me like the program is unbalanced and
                 2,@ a Little incom rehensibleo And I think we, as a Council,
                                    p

                 3
                     have every right to simply decline it.

                 4              I don't know if you want to go that far,  Certainly

                     Pull parts of it but,

                 6              DR. SCHREINER: I would  be  willing  to  try  a@motion

                     to approve with deletion of the Boise   project,,   legislative

                 8   project, and withhold 50 percent  of  the  planning  money,  with

                 9   an encouragement that it be released by  the  staff  if  some  of

                10   these peripheral activities  money  can  be  put  into  program

                11                   MARS:  I will second that motion.

                12.             MRS. SILSBY:  Any discussion?

                13              MR. HIR(YTO:  May I raise a question or point? I think

                14   It has some bearing on this?

                15              I am reflecting on the five areas, categories,,

                1(;i of   concern that would be acceptable for  these  applications,,

                17   and then upon the words of Dr. Margulies and Dr. Endicott

                18   yesterday., then conversation that occurred at this table among

                     Council members relative to thrust  of  the  program,  of  course

                20   thrust of the project.  And though the Council doesn't want

                     to get into the area  of  approving  or  disapproving  specific
                21,

                22   projects unless they are beyond the scope  of  the  extent,,  I

                     wonder if th-e-Council,. if we were to make a general statemnt
                2:3

                     that should any of the RMP's desire to redesign those accepted
                24

                     dollar amounts into different projects, that fit the scope of
                25

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                                                                             224

                1   PMS-, this might not resolve some of these things.

                2             I wonder if these were thrown lim here quickly to

                3   make certain that the dollar amount met the maximum due to  th(

                4   region?  And that there wasn't too much thought given to the

                5   program itself,or the project itself.

                6
                              MR. POSTA:  I think your point is well taken, sir.

                7   That is one of the main reasons I think that we brought up this

                8   particular region for discussion specifically as a branch..  and

                9   too I think, everybody is j.n accord.

               10             The recommendation that was suggested, not  moved,  if

               11   you knock Off two cf the program . it is about $5OoOOO.

               12   I mean,,  the one on legislature and the one on Boise,, on poison

               13   control.

               14             I wasn't exactly clear whether 50 percent reduction

               I r) of planning, total budget Itself

                             DR. SCHREINER:    150,, whatever it is.

               17            MR. POSTA:  That would knock off $145,,000.  So we
                    are talking about $194,625 off the request of $160,374
               18

               19            MR. OGDEN:  $19406P5. back.

               20            MR. HIROTO:  Out of all the projects,, someone men-

               21   tioned there was a particular project they would much rather

               22   have funded here, but inasmuch as they have these constraints

               23   upon which direction their projects could direct, they had

               24   chosen one instead of another, or something of that nature,
               25            DR. PAHL: We will be  correcting  that,  hopefully,  in

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                                                                              225

                 1  a manner in which I indicated this mornings and that J3 to  get

                 2  out a written statement following its approval by Dr. Endicott's

                 3  office, to all regional medical programs, So that  we  Vill  be

                 4  able to give that information uniformly to all regions,

                 5            I would like to make the observation I think  at  this

                 6  point in the discussion that our own staff and now here at

                 7  Council table we hear a rather lengthy catalogue of problems
                 8  of this region., and I would just call to your attention the

                 9  fact that in an application earlier today'in Puerto Rico,# we
                 10 had a similar cataloguing of problems,, and an action was  taken

                    which perhaps might be a precedent, to look at in terms of thi3

                    region. I don't know whether that is further than  you  want  to
                 12.

                 13 go*
                              But I dare say we have had some experience.,at  least
                 14
                       my office, over the last few months, with Intermountain
                 15
                    face-to-face conversations with Dr. StQdt and we have  had  some

                    rather lengthy convoluted discussions concerning the space
                 17
                    requirements of the program,, and it always turns out we  don't
                 18
                    quite understand what is going on.

                              We have a number of staff here who never seem to quibe
                 20
                 21@ ,have all thelfacts and figures at their fingertips and this  is
                 22 the only reason we seem to have these difficult problems in
                 23 those regards,
                 24           I would dare say even though we rearrange a few
                 25 dollars or few projects in that particular application, that is

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                                                                              226

                1   not going to go very far toward resolving the issue.

                2             I do not know what it will take to resolve ito

                3   but I do look to that Puerto Rico type of activity as

                4   being one that may be appropriate.

                5             We do have Council meetings scheduled,. we do  have

                6   a staff that is rather knowledgeable on many of  the  issues-

                7   but perhaps again a Council staff visit with a full  report  to

                8   the Council and action at that time permitting  them sufficient

                9   funds to maintain their operation throughout  this  intervening

                10  period might provide everyone a little bit better way to

                11  approach,

                12,           I just suggest it because it does seem  that  there
                13  are a number of issues which the specific actions that are
                14  now being discussedat least @om my point of view  In  recent

                15  discussions with the region would not seem to materially

                    change,

                17            NRS. MARS:  I do@ think the university is handicapping
                18  the region. I feel that it really should separate from  it  as

                    its grantee and form its own organization. I think  that  will
                1!)
                20  be one help, and possibly 'one solution,
                21.           And certainly from there on, why the Ple could go on
                22  by itself and strengthen itself.
                23            It certainly needs to move off of the university  as
                24  far as the staff headquarters go.
                25            of course, it was all separated, I believe -- Mrs.

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                 1                                                           227

                1  Murphyo wasn't itv in four different spots when we were out

                2  there at that point?

                3            MRS4 MURPHY:  It is located in a temporary building.

                4            @, MARS:  But it is still with the university., so

                5  to speak.  And this is very necessary,, that it is moved off of

                   the university grounds.
                6

                7            MR. MILLIKEN:  I would like to amend the motion in

                8  accordance with Dr. Pahl's suggestion.

                9            MRS. SILSBEE:  Would you restat6 your amendment?

               10            @. MORGAN:  Who niacle the motion?

                             DR. SCHFIEINER: I will accept the amendment.

               12.           MR. OGDEN:  I think what you are saying is we with-

                   hold granting of these funds until there has been a thorough
               13
               14  review., bring back to Council sometime next meeting?
                                  MARS:  And be granted necessary operational
               15

                   funds.

                             MRS. SILSBEE:  So the motion is to restrict'the
               17

                   f unds--
               18
                .19          MR. OGDEN:  Right,
                             MRS. SIIBBEE-0    to Intermountain, with the  excet)ti(@n
               20

                   of operating funds to be determined by staff?
               22            MRS. MORGAN   Yes.
               23            MR. OGDEN:  Yes. I have a comment here. I wonder
               24  abou4 and I may be wrong,, but it is my recollection that
                   neither Idaho nor Montana nor Nevada nor Wyoming -- I may be
               25

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                                                                                     228'

                 1   wrong about Wyoming -- has a medical school.

                 2              MRS. MORGAN:  No.

                 3              MR. OGDEN4.  The influence of the University of

                 4   Utah Medical School is an issue here, It isn't a turf problem,

                 5   Put It this way, there is  a  turf  problem  perhaps  in  our  sense

                 6   between Colorado-Wyoming-Intermountain and--

                                NR. POSTA:  Colorado-Wyoming,
                 7

                 8              MRS. SILSBEE-.  Mountain states.

                 9              MR. OGDEN:  Mountain states.  But there is another

                 10  turf problem  that  involves  the  influence  of  the  University

                 11  of Utah Medical School and the WIND program., which is the

                 12, Washington-Montana-Idaho  program.  I  think  we   are   drifting

                 13  into an area here,, we are getting an overtone of it in this

                 14 'kind'of thing with the University of Utah sponsoring a

                 15  poison control center in Boise, Idaho,

                                People  are  sending  their  medical  school  students
                 17  to University of  Washington,  putting  them  back  in  their  local

                 18  @communities., having some medical training.

                 J!)            I think there  are  things  here,that  don't  quite  meet

                 20  the  eye In this kind of  application,  and  I  think  all  these

                     thingsneed to be assessed and considered and brought back to
                 21,

                     the Council.  So we will have a little better understanding
                 22
                 23  of all of the things involved In this.
                 24             It is a complicated picture,
                 25             MRS. MORGAN:  Having lived in Utah for many years

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                 1  myself,, you realize how come you don't have any women on  it,

                 2            (Laughter)

                 3            Because they dodt believe in women working, that is

                 4  all there is to it.

                 5            MR. OGDEN: You might also  say  there  are  religious

                 6
                    overtones.

                 7            MRS. MORGAN:  Very.  Very.

                 8            MRS. MAIL'-:  Very much so, religious overtones.

                 9            MR. OGDEN: And this has to do  with  the  fact  there

                10  are no minority employees perhaps,

                11            MRS. MORGAN:  Yes.

                12.           MR. OGDEN:  These may be things on which it is dif-

                13  ficult for us to comment, but I don't think they are things

                14  we should ignore,, nor do I think they are things we will i norE

                15  and I want that statement put in  he  record:  They  are  no  h rgs

                i(i we will ignore when this application comes,back,

                17            MRS. SILSBEE-, Along that line, some  of  those  con-

                18  cerns you are mentioning and the ties are what made the original

                iq  group of the Council committee members team to  go  out  and

                20  see why they couldn't get together  better.  At  least  keeping

                2t  one another informed in communicating with  one  another  would

                22  help,

                23            They can't, wouldn't say:  Intermountain, you can't
                241 operate over here because there were other  things,  but  at
                25  least you ought to keep the  respective  political  programs

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                     inf ormd.

                  2            MR. OGDEN:  One reason we are withholding this
                  3  thing, we might say, is to make sure they cleared it all of
                  4  the policy and procedures, or interfacing these  various  medi-
                  5  cal programs,, regional medical programs. I don't  think  that

                  6  has been done, pretty obviously.

                  7            MR. MILLIKEN-.  Question.

                  8            MRS. MORGAN:  I was going to volunteer to go out

                  9  there since I know about half the people on that staff.

                  10           MRS. SIISBEE:  Mrs. Murphy.

                  11           MRS. MURM: I would like  to  add,  they  were  worki

                  12@ to oputting minority and women on the staff. When  the  phase t
                  13 came, a lot of those women left and I think It is just a

                  14 matter of getting bodies for the staff.

                  15           DR. SCHREINER:  Question.

                               MRS. SIWBEE:  The motion has been made and   seconded

                  17 that                 for $760,374to Intermountain Regional
                  18 Medical Program -- I hate to use the term., but to  be,aoproved
                  is) with the large proportion of the funds being restricted,  the.,
                  20 exact amount to be determined by staff and oh the@@-lbasis of@
                  21 keeping the program operating at a certain level  with no  n6v@
                  22 activities.  And that a Council site visit will be made.
                  23 And to look into all of the problems that have been identified
                  24 In this discussion and to report back to Council  before  that
                  25 restriction is lifted,

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                                1                           Is  that the,sense?

                                2                           MRS.  WRS:    That  is  it.

                                3                           NRS.  SILSBEE:  Any  further  discussion?

                                4                           MM,  MARS:    Question.

                                5                           MRS.   SILSBEE:    All  in  favor?

                                6                           (Chorus  of  "ayes.

                                7                           MRS.  SILSBEE:               Opposed?
                                8                           (No  res pons e.

                                9                           MR.  MILLIKEN:    Different  subject.    I  move  Council

                              10       commends             the       staff       for       an       outstanding       job       on       these       materials.

                              11       They are             made  under  trying  conditions.

                              12                            MR.  HIROTO:    Second,

                              13                            MRS.  MARS:    Three  cheers,

                              14                            MRS.  SILSBEE:    I  certainly,,  as  Chairman  of  this

                              15       session,  want  to  thank Council  members  for  doing  their homework
                              1(')     and        reading        under        very,,        very         trying         circumstances,         We         appre-

                              17       ciate it.

                              18                            DR.      PAHL:      We      know      that       Dr.       Schreiner       is       just       itch-

                              if)      ing  to  dash  out  the  door,,  and  please  feel  free  to  do  so,
                              20                            (Laughter)

                              21.                           But  if  I may  take  one  more  minutes  Mr.   Milliken

                              22       and      Mrs.      Silsbee      just      took      two      of      my       points,,       that       is       thanking

                              2t'3     the  Council  for  full  and  productive  meeting  and  our  own  staff,,

                              24       who,  as  you have  already  recognized,,  have  worked  really  very

                              25       hard  under  trying  conditions  In  preparation  for and  during

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                                1      this meeting.  And although Dr. Foye is absent, I would                                                      like
                                2      to recognize his participation and very helpful contributions
                                3      and again I would like to note that this is the last  mee  ng
                                4      of both Dr. Watkins and Mr, Milliken, although we do hope

                                5      we will be able to call upon their services again  an  recog-

                                6      nize their very valuable assistance during the entire  period

                                7  ,   of  their  tenure.

                                8                        And  lastly,  but  really  not  again  least,,  there
                                9      have  been a  few  people  who  have  helped  with  the  preparation

                                10     of  this  meeting  and  I would  like  to  Identify again  Mrs.
                                11     Handal  and          M/S   .  Miller,,  and  Mr.  @n Baum,,who had  the  right
                                12,    materials  at  the  right  places,  and  the  only  comment  I would

                                13     like,  Ken,  is  next  time  we  need  more  Kosher  corned  beef  and

                                14   @:not  so much  turkey  right  after Thanksgiving,

                                15                        (Laughter)

                                i(i                       Meeting  stands  adjourned.

                                17                         (Whereupon,  at  1:45  o'clock,,  p.m.,  the  meeting

                                18              was  concluded,

                                20

                                21,

                                22

                                2t3

                                2,4

                                25

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