i tu | 10 11 12 13 14 15 16 17 18 19 20 21 22 CONTENTS Opening by Dr. Pahl ’ | Remarks by Mr. C. Robert Ogden Ogden Resolution Comments of Members of the Public: Dr. Donald Sparkman Response of Dr. Richard Janeway to Remarks of Dr. Sparkman Arthritis Report of Mr. Matthew Spear Comments by Members of the Public: . Mr. John Sergeant (Maryland) Dr. Lawrence Scherr (Nassau-Suffolk) Review of Applications for Regional Medical Programs: Alabama (Mrs. Gordon) Albany (Dr..Watkins) Arkansas (Dr. -Komaroff) Bi-State (Dr. Watkins) California (Dr. Janeway) Central New York (Mrs. Martinez) Central Wyoming (Mrs. Martinez) Block Action Arizona (Dr. Gramlich) Connecticut (Mr. Hiroto) Inter-Mountain (Dr. Komaroff) Louisiana (Dr. Janeway) iw 10 13 20 36 ~ 48 72 74 79 83 90 102 106 15 120 122 (128 132 10 11 12 13 14 15 16 17 18 19 20 21 22 Contents (Continued) Maryland (Dr. Wammock) Nassau-Suf folk (Mr. MIlliken) South Carolina (Mr. Haber) Texas (Mrs. Morgan) Virginia (Mr. Hiroto) Northern Pennsylvania (Mrs. Martinez) 139 142 152 153 163 pes oy mt STD Ji FO NATIONAL ADY LTA fe) Wee oa APEMENT OF PPATTH, FPUCATION AND WELPART SOPY COUNCTL ON REGIONAL MYODICAL Conference Room G-P Parklawcr Puilding 5€oo rs Lane Thurscav, Aucqust &, GEPALD GARDELL, Acting Deputy Director, SARA Development, D KENN EDIT DR. MARI SEWA DHE PROGPAMS DPMP. H J. SILSBEF, Acting Chief, Onerations and RMP, ETH FAUM, Executive Secretary. HOM, KLEIN, Boise, Idaho. HOKE WAMMOCK, La Grance, Georgia. FE. FLOOD, Fl Paso, Texas. LL O, MILLIKEN, Columbus, Ohio. DRM. MARTINT?, Salem, Orecon. JOFN PB. GRAMLICH, Chevenne, Wvorince. CEORGE F. SCHEREINER, tashineton, D. PAUL A. HAPEP, Washington, D. ¢. PRI CTO RTT woo Pain L (continued): DR. PENGAMIN WL ATK danse yw "| Mew York, New York. C, ROPERY OCDEN, Spokane, Washington. DR, ANTHONY L. KOMAPOFPF, Boston, Massachusetts. DP. RICHARD JANEWAY, Winston-Salem, North Carolina. WYHOMA R. GORDON, Creat Bend, Kansas. FPWIN C. HTROTO, Los Angeles, California. MARIEL S. MORGAN, Albucueraque, New Mexico. And Others. 10 11 13 14 15 i6 17 18 20 Bo oy Aad PPpgocRE BYR G J pp, PAHL: Will the meeting please come to order? t Se are now all nlucged in, wo at the head table, and I think we can proceed with this meeting of the ational Advisory Council. Nost of you were here yesterday for the meeting of the ad hoc RMP Review Committee, but I do wish to welcome to the table Mrs. Gordon, and Dr. Haber, and Hr. Milliken. We are very pleased that you can re-arrange your Summer schedules and be here with us. As you know, this will be, or is expected to be, the final meeting of the National Advisory Committee, called to disperse the remaining fiscal 73 funds, which have been release¢ as a result of the court order. All of the 1974 fiscal funds | were obligated prior to the close of the fiscal year, June 39th. And as of this state, we have approximately 28 to 39 million dollars for making our awards following this August Council meeting. Now, we will be discussing more of that in 3 a few minutes, because we had a rather lengthy open session . yesterday. And many of the topics were discussed with both the Council members sitting as observers, and the review com- -mittee. I hesitate to go over all of the material again, anc perhaps it might be better as we go into the closed session to take up some specific points. If there are questions that bear ~ on the points we discussed yesterday, but I think I should make > we one of two dqeneral comments. Q rh ii Sueeifically for the benefit of the three who could i onot be wit. us yesterday, because I think it is important for the day's “seedings. First of all, Mr. Rubel did make a presentat. . and go over the current status of the legislation, and we did provide, I believe, a hand-out, did we not, Gerry, bow bo 14 15 16 17 18 19 29 . esterday? Mp. BAUM: Yes. DR. WAMMOCK: No. DR, PAHL: Well, it was intended to give a hand-out out. Can we make sure that we cet those now, today. the House I won't go into all of that now. Because, really, I believe that we still have rany steps to go before we have legislation; and by giving you our summary statement, I believe, you will MR. BAUM: All right. DR. PAHNL: Which summarizes the basic elements of understand what the main features are very quickly. certainly make provisions for a transition period, and we full anticipate that the local regional medical procrar” together It is a long bill, some one hundred pages. It does bill that has been reported out by the full committee 5 with these CHP agencies and experimental health s. ..ces delive systems, and Hill-Burton organizations will be given the prope ‘ opportunity to become incorporated into the proposed organiza- tions. i } ! ' | ! It i 1 mt co 14 pea cA pent cf 17 fo pond NM ho 3 no we a uw no wnt oy Ne w, what ig proposed is not certainly in any way a to perpetuate the PIP program as we mow it. And those of you who have been cllowing the lecislation closel: ‘ill certainly floor bill we will try o 0 rs @ iD w < o Q {y h- @ Yn oO rh ct a to get them out to you, because I do believe that it will be faily close to what may be passed. And of course, the time : table for enactment of legislation is unknown for good and sufficient reasons. But it may well be passed later this fall. MR. BARROWS: You have just given me a note saying the summary of the bill is attacned te the Council agenda. i i ! i MR, BAUM: It's the last item stapled. DR. PAHL: Oh, I thought it was a seperate hand-out. | Iosee it. It's the next to the last item. There is a National Council for Healzh Policy established within DHEW. We do not. know at this time what relationship such council will have with this council, or to the other legislatively mandated councils, of the constituent procrams. M2, OGDEN: Would it be appropriate for me to speak ‘.te this }- ‘ation at this point? iA. PAL: Yes, I believe it would be a good time. MP. OGDEN: In reviewing Mr. Rubel's summary yesterday and in thinking about the matter overn fo ght, wnile I have not a vet had an opportunity to read the ummary fully it is here. da co 17 18 feet mm 2D SD eo be eo a RO 2 -in this complicated undertaking damanéing the skills of persons G roam ereatly coneerned that HR 16204, as we heared 1t + dascribeda seems to ignore the role that RMP has played in the health > environment in recent yo 5%. two otd like to read % -s council and to those ps ne at t session, the open seusion a letter from Senator Magnusen who is chairman of the Subcommittee on Labor, Health, Education and Welfare, d to Senator Kennedy. addresse And I am quoting. bear Senator Kennedy. It has been reported to me that the proposed legislative revision of the Public Health Service Act in effect eliminates the Regional | Medical Programs. And would divert the appropriation that has aen used for RMP purposes, to local planning agencies, as I understand the present proposal. Planning agencies would then be expected to develop services in the same manner that RHP has been doing in recent years. I am somewhat concerned whetner planning agencies are the appropriate bodies to be engaged in the Gcvelopment of services. From my experience with the Washinaton-Alaska Regiona Medical Program it seems to me that the development of services rot i { n the delivery of cars, and contract planning de-) fae experienced te , ~. . » < i pends almost entirsly on the determination of health care | eds. ® n By an agency ane staff which can attempt to match ' ! | ' q } t i ' 1 | i | | pe 17 18 19 the local demand for services against rCcsOuUurces, and hopefully 4 7 n “ ah Dy orghasen ayer oe we im a develop a community consensus aS to Ac to me It seems that few if anv planning agencies a bre spectrum of pe.sons wit oo knowledge & xperience necessary for the actual creatic « new services. Nor does | it seem practical for the planning agencies to do so, since it would create an unnecessarily large and cumbersum-organiza- tion. (pb I would think that a planning board should be capabl of expressing the communities will and the board of a cevelop- 1 3 ment agency should be capable of making sound technical judg- | ents about the best way to develop services at the paticnt i | | : : : | level to meet the needs outlined by the planning agency. | These are two distinct activities which require the | | | involvenent of boards and staff with the >ir efforts and different =-t i i ms w skills. This is the way the successful RMP such as the RMP are now working. JI am concerned that if we attempt to a | both activities into the same structure, one of the activities! will suffer, and it may very well be the quality of the service: developed in the function. The medic-l school facult a < the medical specialists, : the medical admin’ © ators and others who are basically inter- ested in the way care is delivered at the patient level may | withdraw or not be well utilized if both functions are assioqne< to a’ planning agency. co oe 10 il 12 17 18 19 Tt 3 @ nercsons, Who wiht P leadership, can expang the pr . health care system in orenaration for a national he oA insurance. Tae Pecional Medical vrogram to date has -ived the talents of most of th «+ mest capable- 'm sorry _ of those most able to develop . ‘vices. Their record for gaining the cooperation of all parts of the delivery system and-improving the quality anc accessibdili of care is unequaled among the public health service act prom grams. It does not seem reasonable to assume that the capabii- ities RMP organizations are ceveloping are transferrable to ther organizations, especially «here the new organizations have few of the talent orientations of the predec-:ssors. Certainly I recognize that all RMP organizations like planning agencies and otner nealth programs have not been uniformly successful throuchout the nation. But any lack of success is more attributable to lack of consistent leadership direction at the federal level than it is tes fault of the RiP> approach. And undoubtedly are we coing to need to make some « effort sometime in the development of health care resources. Hope tly this task be assioned to agencies whose expertise and fAence can mace the ontimum contribution. RMP orcaniza- tior. ight need to be changed and strencthened in some parts of the nation. But in my opinion they orobably represent the best a se 10 il eo it 24 20 “” means of increasing the quality and accessibility of care for | the average citizen, In summar’. I am hopeful that the new legislation will be able to rec ‘ge both the ccnsumer and provider relationships needeu to make the health system work properly. There should be some way the new legislation can insure the continuation of healti services, development agencies similar to RP in structure and experience, thereby not dissipate the national resources that we have developed. It might well be advantageous if the new legislation were to establish a formal mechanism to assure that the efforts € of the planning agencies and the PMP are coordinated, i.e., that RMP's are in fact developing delivery systems to meet Oo vs Qu the health needs identified by the planning acencies, a such mechanisms. could certainly bebe established without scrapping the present programs. Creating entirely new bureaucratic structures in the. future, and in the process, using what would remain we have j achieved for existing RMP systems, such as the Washington- Alaska program have been highly successful. Thank you for your consideration. Sincerely, Warren ©. Magnusen. Now, I would like to suggest that it is the sensé of this Council that HR 16204 as we have heard it described, is inadequate as it is now drafted. In that it fails to recog- eo 2 ai b-2 bo bo OO SNe ic nize sufficiently th development efforts. ane efforts which simply cannot be limited to the localized geographic areas within a state would seam to be encompassed in the concept of the local health service area within a state which the governor would Gesignate under th: ey pLiil. And further, that this proposec 75,900 a year two ear limit for a project is grossly inacequate in our exper-_ moly will not attract maan ningful or usetu Le te fo. jience since it s applications. Therefore I would like to propose a resolu ie IL along these lines. ; Re it resolved that the Congress in adopting HR i62 statutory ana fina cf ca or similar legislation give eacn state al support to maintain a separate health ‘systems development sasis or independent commission appoin en) @ agency on a State-wi in a publicly accountavle way and devoted exclusively to such ork, and be it further resolved that the comments preceeding this resolution, and the resolution itself be transmitted to se Interstate and Foreign Commerce Com- uI Q ct a tot eet Oo car { the member mittee, and the Senate Labor anc Public Welfare Committee for ‘their consideration. DP. PAIL: Thank you Tir. Cgden. A motion has been made, to have the Council adopt this resolution. Is there > irmortant role of edequate healtna services In Gt pot fen Rea ce bent oh pet 3 13 a Ri I second it. Seconded, Is there discussion? x ° qden, would you read that resolute Be it resolved that the Congress in adopting HR 16204 or similar legislation give each state the statutory and financial support to maintain a separate health + systems development agency on a state-wide basis or indepencent commission appointed in a publicly accountable way anc cevotec exclusively to such work. And be it further resolved that the comments pre- ceeding this resolution, and the resolution itself be trans- mitted to the members of the louse Interstate and Foreign Cconr- mierce Committee, and the Senate Labor and Public Welfare Committee for their consideration. DR. DR. PAHL: Discussion? Dr. Schreiner? SCHREINER: Yes. I just wanted to ask a questicn. You would favor the dissolution of the regional process? MR. OGDEN: Yes, I am. Because I think this piece of legislation is directed toward the state-wide activity. I scognize that many cf our regional and medical proearams flow ‘ar state boundarics but if we are to have an incapsulated program which is state that we can accomodate DR, WAMMOCK : boundary oriented, it seems. to me that to that through our existing RMP's., Your point was a specific statement of sh on 11 12 13 he pile 15 17 18 19 20° ho Cu he en & overated plan? mie, OGDEN: Yes, at this warticular piece of legisla- Legislation Me 0 gq o ° Kh TH pee . +3 me yes “ s4 DR. WAMHOCK: This particular pb loesn't overc ft oO Q, BK 3 LO £ y cr c yo 0 os because the RMP as we have been flow into other states and so fortn. MR. OGDEN: That's correct. I understand it -- I was gy ul DR. WAMMOCK: Pegions, told them could be no larger than this room, or they could be. the whole United States. Thet's what called a regional area. So we are seeing some of these things, this is some of the things that I was putting to my mind all Gay yesterday, and earlier this morning. 00 I dia€n't get wo and write it on a sheet of paper. MR. OGDEN: C£ course, we have some states, for example, California, where we nave one RMP for the whole state. For the state of New York, we have at least four. DR. WAMMOCK: Four, that's right. MR. OGDEN: And under this new piece of legislation, rm these four RMP's would become ons. DR. WAMMOCK: Yes. MR, OGDEN: Which incidentally : omething I have suggested to this Council previously. DR. WAMMOCK: Well, vou've been on it longer than I Gr oo 16 il tes) es pent fs pet Qi pent oo 7 18 18 RO to 23 iwe will defer voting on this rotion until later when we have % ee x wd tt . PA Lely DR. PAHL: is there furtner chscussion. Cr. Komaroft? on ‘ 2 fy — tN 1 ht i DR. KOMAPOPT: Yes, IT find rvself in syrpathy wit : 7 | ’ sya? an ey ye dee 2 Lee ate ee - ; My, O¢den's provosal. IT woncer tnroucs, i2 ve cousa os a | . : : ae x . sate Kael oa Ay 3 Whe vote on it until some of us have na ssnance to read tne summary of the Bill, wnien I, at le. . haven't nad a chance that a planning agency is not typically a body constituted ‘ to represent the providers or to implement service activities. I think it is a very real concern, but I snare -- DR, PANL: I am sure others perhaps nave not had the opportunity also to read this, ang thus, with Council's sense ‘had an opvnortunity werbens following at least the morning coffe I asking whether any members of the public, because I know that several people are here from RMP's and also Dr. Sparkman, who is the Chairman of the Steering Committee of the National Coordinators, might wish to add a corment at this point in the proceedings, and if not, there will & MD ‘ during the formal public session omments, on this tt o Kt Qu 3 : cr Dr. Sparkman, would vou care this point? On the topic uncer consiceration? another opportunity | i i \ ! i | 1 ' i O MAKE some comments at, pend Ro B Ly DR. SPAPKUAY: You mean speaking for this motion, or just in general. | 2 | DR. PAUL: Iwas thinking of commenting on the motion, s | if you will. ‘The topic of substance of lr. | en's comments. | 5 DP. SPAPKMAN: Well, thank you. I « reciate the 6 | chance of appearing before you again. And representing the 71 || coordinators, and I support the motion as read by Mr. Ogden. 8 | t think the two important factors in the bill as I understand 94 4t -- I, too, have not seen the entire bill, although I have 10 | seen the summary that has been distributed to you. And I have looked with some care on 13995 which is gr 12 | it's predecessor, which I think has not been modified very much, ig | but sink there are two important factors. 14 | One ig the subdivision of existing state-wide or 5 15 | regional RMP's into smaller area-wide Regional Medical Programs. 16/6 ft think the subdivision into multiple smaller areas is appropri- 7 | ate for planning, as has been domonstrated by the action of 18 | those CHPB or area-wide agencies which can identify health 19 | problems in their areas and deal with them. 29 But this is, I think, a totally inappropriate way | #i | from Regional Medical Programs to func. ™ since on a state- | 2 | Wide basis we can acquire staff and: mo ‘or and a bread 93 | of different kinds of disciplines and deal wi oroblems which! 94 | we do on a state-wide basis with the medical association, the voluntary health association, health departments, and otherwise BD oH 19 11 jos “3 18 19 20 & hD site ke or deal with health as state-wide matters. rade i think it would just virtually terminate an etfeotive + PMP in the ereas which t am familiar with. And as 4@ matter of fact, in blue sheet which is one of the raports on Washington § «th matters, which IT am sure some of you are familiar with, last week reported that the bill as written would be the last rites for RMP. I think this in effect is true, that any health resource development activity kind of things RMP is doing, i look to me to be added as an afterthought and in a totally inadequate manner. I would like to mention just a couple of other things, Herb, if I night. DR. PAHL: Pleas 0 DR. SPAPKMAN: Relative to the orientation I hav 4 ¢ to regional medical program I know that some of you have served on regional advisory groups, or other committees or in etherways have been involved with the regional medical programs. I reccgnize that some of the others of you have oy some are new. Some of your predecessors have had the opportunity ¢ having to site visits to regional medical programs, and those ‘t have talked to have indicated that this was a very helpful experience in understanding what RMP's do. I recognize that you all carefully read the written material we submit to you, the applications for programs or projects. + oy be TAM = li ek 2 ‘ga te Cao 1? 18 19 iN? i ha 8 re) Be 2 ey oe We arg grateful to you for the time it takes to ravi all of these, but IT think that ths paver Goesn'n quite tell the story that I think you would have an opportunity to under- ond L£ you were actually had had an on-site visit, or had little more contact with a coordinator. I know you have an orientation session for Dr. Pahl and his staff the details of which I don't know. But since | I have thought about this I belatedly recognized that as. a ( group, the coordinators of PMP's have done a poor job in expressing to what they feel the way RMP 's function. And I have written to Dr. Pahl asking whether there | are strengths that would prevent us from communicating freely with you, and I haves not had an opportunity to have a response! to him on this, but 2 intend to follow up on it, unless you : f E 4 want to speak to it at the moment. DR. PANL: I believe not, right at this time, but we will be discussing this with some other matters individually and with the Steering Committee. DR. SPARKMAN: As an example, I don't know whether all members of the National Advisory Council receivedthis which is a report of a program accountability report that was submitt: that was released about a month ego. Which is this a familiar document to you? MR. BAUM: It's been mailed. DR. SPARKMAN: How many of you had a chance to see it? 17 DPR. PAHL: It was mailed -- 2 | MR. BAU: Tt was mailed out as soon as we got it. . Su DR. PAUL: Well at the time of our phone call it 4 | should have been received by you. | 5 MR. OGDEN: I did not receive it. 6 DR. SPARKMAN: Not very many. | 7 DR. PAUL: We shall make other copies available to ! 8 you. | 9 DR. SPAPKMAN: Well, this is of no value in measuring 10 individual RMP's., But it is a measure of the aggregate impact ll of RMP's in helping to train health professionals and actually 12 serving people. And in implementing community activities, | 13 and while I wouldn't expect you to read every word of it, it | id | is reasonably well done. : 15 And it is the kind of thing that I would hope you | is had had a chance to look at. In order to better understand | 17 what we are trying to do. I would like to, then, after I have 18 had a chance to talk to Dr. Pahl, follow-up with ways in f 19 || Which we may communicate with you. | 20 Without burdening you. I Know that you all have 4 more than enough to read. The second item I would like to ey | mention briefly is the goal of the National Advisory Council ba cat i 95 and I am pleased that in the motion that Mr. Ogden that was seconded that you all looking at the policies of RMP that vou all, I think, then beginning to take steps to provide the me an 10 11 1Z -13 14 15 16 17 18 19 18 leadership that the National Advisory Council has provided for RMP in the past. I recognize that in your last two meetings in the previous year things have been pret* sll upset, first as a result of the phase out directed by the administration, and» then the rather abrupt release of impounded funds so you were kind of overwhelmed with applications. But I would like to remind you that you are a very respected group, on the health care ' scene. You represent | a group of distinguished and dedicated people and that your i word relative to regional medical programs part in health care is important and I think that you should take time to deliver | to consider health policy from the stand point of the National Advisory Council. | And I hope that you will have time to do this. At 1 I your last meeting, as an example, two resolutions came to you from the National Review Committee, and one of them recom! mended that CHP's turn to RMP's when appropriate for technical and professional assistance regarding health care changes. And the second one encouraged RMP's and CHP's at | the state and local levels to work together closely to explore ways in which better programs would be carried on regardless of the exact language that is in the legislation. These, I thought, were both good ideas. Mr. Rubel spoke against both, and after what I though 10 11 12 1B 14 15. 16 17 18 19. 20 21 22 = 2 to get married to the director of the Anchorage CHP agency. 19 was very brief consideration and discussion by you, both of them were rejected. on June 20, immediately after the meeting I wrote to Mr. Rubel and said Iwas disappointed in his dis- | approval of them, and it seems to mee is is inconsistent with his previous statement relative to on-going positive relations between RMP and CHP. Which I whole-heartedly support. And I said that I hope that there will be some tangible evidence from him on action relative to this positive relationship. He hasn't responded to me, nor have I seen any evidence of this action | on his part. To support what he said at the meeting last time. Let me add an anecdote regarding this. At the Washington- Alaska area we have two particular grants where we have task forces looking at these kinds of alternative arrangements 4 ; between RMP and CHP with the best people we can find in both RMP and CHP and other health care activities in both states. Meeting and trying to shed their vested interests - as much as possible, to see what kind of program should emerge and lastly, that in Alaska, our coordinator, who is now a very! able young lady announced ‘to me last week that she ‘was, about I saia I was all for this kind of exploration, but it seemed to : this was carrying it a little to far. Thank you, very much. KR 10 11 12 13 14 “15 16 17 18 19 . a9 DR. PAHL: Thank you very much, Dr. Sparkman. We | will have a formal open session a little later, and others present should feel free to comment upon the matters that were discussed and Dr. Sparkman, should you wish to make additional comments. But we shall table the motion until the Council has | had the opportunity to review the summary. | | DR. JANEWAY: At some time in the agenda, I would / like to respond to Dr. Sparkman's comments about the deliber- ations of the Council relative to the resolutions. DR. PAHL: Perhaps this might be an appropriate time, then, Dr. Janeway. Our agenda is flexible this morning, : and perhaps this would be a good time. DR. JANEWAY: tI would like Dr. Sparkman, I would 2 not like the impression to go unanswered, that the Council did not deliberate appropriately upon the substance of the resolution brought by the Technical Review Committee. In particularly that the wording of it is such that it implies a necessary conflict between CHP and PMP. The concern of the Council, or at least the sense of it as I recall it, was that there was some concern over the planning in control function being amalgamated into the same agency. The implication is there, we felt, and I think, quite correctly that the advisory council for RMP -- it would be inadvisable for this Council to be making dictatorial ! 19 11 12 13 14 —b 16 17 “18 19 20. 21 22 I believe it is necessary for me to repeat these remarks of wet a Co L statement from an adversary position relative to the actions of an agency over which we have no control. And I would hope to reassure you that there was adequate discussion, at least in the minds of the people who are around this table. DR. PAUL: Thank you. Is there further discussion 2 on this point? If not, I would like to return to my brief report to you. There are several points and items of business we should consider this morning. First, I would like to, with the indulgence of the Council members who were here yesterday | to repeat very briefly for the benefit of those who were not i i i here yesterday, our current status with respect to two applica~ tions that the Council had considered last time. Let me take this opportunity to do this, because we have representatives from both of those regions here this : morning, and they will be speaking with us, very shortly. And in order to provide the proper background and understanding yesterday. As you will recall, at our last Council meeting, “two of the recommendations made with regard to SEC: . applica tions -- the applications from Maryland and Nassau~Sulfolk — were of the following nature: that is, that funds should not) be awarded for those particular applications and also that the eo 17 18 ‘19 20 “the June Council to either the Nassau-Suffolk or the Marvland | ne) two programs in question should be terminated in an orderly The recommendations were accerted by the Girector |: and we were on our way to implementing se in good faith when it was called to our attention thai again, as a result, I am afraid, of a dismal ignorance of the law, that we were | not able, as a matter of fact, to implement what had been the Council recommendation. And the second part of that, the orderly termination of the two programs, that is, we had only the opportunity to | implement the first part of the recommendations and that is | not to provide funds for those s#ecific applications that were reviewed at that time. In fact that was the case. No awards were made at | programs. However, we were in error in believing that vour | recommendation could be implemented and when we were advised i | of this error by our office of general counsel, we imrediately | got in touch with the regions, and pointed out that there had . | been an error, on our part, and that what we wished to do was inform ther that they did have a right, and we hope thev would: exercise right, to resubmit applications for the review by the review committee yesterday, and by this Council. The reason that that action was taken was that the applications in question, the applications tnat we reviewed 1 in both the dune Council and applications under consideration at this Council technically are supplements to existing grants. bo 3 The budget period for all regional medical programs: fore 4 extends from February 1, 1974, through June 30, 1975, and those applications reviewed at the Last Council meeting, as Cat 6 well as the ones before you today technically are supplements! 7 to existing awards. 8 Therefore it is not appropriate for the Council to Mw 9 make a recommendation beyond funding for the specific applic: 40 tions in question. Having gotten over that psychological lL hurdle and shocked everyone we as a headquarters staff, togethe 19 with the staffs of the two regiomts in question try to work 13 effectively within the time constraints that were on all of 14 us = “a: And we extended the deadline from July 1 to July 9 16 to those two specific regions to amend, to revise and to 17 amplify those applications. And our staff met with the staffs “18 of the two regions and you may imagine that there were both jg | several trips involved, and many telephone calls, and as a sg || result of this we believe that the regions in question under- “o stand fully the concerns that the review committee and the ‘Council had and haya spoken to these concerns in the application 22. 23 Also, we have made two, made know to these regions fe | | | 7 | a 24 the fact that during the open session both the review committee 98 and‘the Council there was the opportunity to speak on behalf 19 11 12 13 lé “15 16 17 18 138 20 ai ag 23 24 25 of these matters. and when we get to the open session, this merning, we will have statements from representatives of both regions.’ ‘Now, apart from that matter I will indicate to the Council you will recall at the June meeting you approved 88 million : dollars recommended for approval. TS Te ions of dollars. We actually made awards of 84 millions of dollars, and the reason we did not implement fully your recommendations was because it was felt to be bette Management to reserve the different, four million dollars, so that we would have a total of 28 millions of dollars for support of the recommendations at, this meeting, because we had anticipated at that time to have approximately 43 million dollars in requests. And we felt we needed the 28 million in order to provide appropriate implementation of the recommendations from this Council. As a result of the actions just taken that I recited with Maryland, and Nassau-Suffolk, those two applica- | i tions have increased the requested figure so that the review i committee yesterday had in the 53 applications before it, a total request of 46 million dollars. Our total dollars that are available for support of Regional Medical Programs included not only the 28 million dollars, but some unexpended balances of approximately one and a half to no more than two million dollars, from prior budget ¥ RD oe 19 11 12 15 16 17 18 19 20 21 a2 So that the total monies that we have, and we will know exactly as we receive the report and expenditures forms ‘this Wee “sea total amount that we will have Jllowing this Council - -ing for support of Regional Medica. Programs will be approximately 29.5 million dollars, to 30 million dollars. The committee acted yesterday in our closed session. So we will be going over the specific recommendations. We have a point, however, which does require your consideration. And as I discuss what the point is, I would like to pass this - statement out to you. And indicate to you what our problem is; under ths court order which was signed and thus the litigation is ended, five millions of dollars were given to the defendants, Lf you” will, for purposes other than the direct support of regional medical programs. This was the negotiation that occurred during the settlement, and those purposes were described very completely by Mr. Rubel. Now, the condition in the court order is that eg AUT TEIT:. if Mr. Rubel and staff are unable to obligate the five million dollars within °0 days, 90 days from the signing of the final | court order, © remaining funds of that five million then [reverts to the support of the regional medical programs. Thus, wa may be faced in late October with the possiz: ity of distributing a very small or medium size, or although unlikely a large size sum to the regional medical programs. 15 16 17 18 “19 3 > -, . . & , . _. Up to five million Collar’. We will believe that there wilt ollars remaining, because obviously there is 2 ao. be very few Q a great interast on the part of the administration to utiliza those fur effectively for the purposes they were usec eurins the negot:.. lions. But we do not wish to call this Council back should 4 it be required for us to distribute the small sum. Thus, we have drafted a statement which perhaps I can explain to you rather than go over the formalities, which would, I think, accomodate the situation very well. And not require your further attention on matters which I believe are not of sufficient importance to have anothe meeting. What we will propose to do with the close to 30 geting, million dollars that we have available, is after this ™ first pay up to 100 percent of your recommendations, for each of the PELs —— Should there still be funds available to us after we have awarded 100 percent levels of your recommendations today, we would then return to your recommended levels followins at the June council meeting. Because I just indicated to vou that although you recommended that we support programs at a ‘total level of 88 million, we reduced that to 84 million, so we would then take any remaining funds and pay appropriate amounts, up to the June council recommended levels. In the event, and these are a lot of if's, but this 10 il i2 13 14 “15 16 17 18 19 20 21 22 24 the way this program must view things. Should there still he wa 52 monies available, either from what we now have available we s to us or what may become available to us in October, aS 4 result of the situation I have just indicated to yo. ‘(th the five million dollars, we would then proposed to make distri-' bution by formula, and the formula is given at the bottom of this page, and it would merely state that we would take the actual award that we made, from this August council meeting, and the actual award 3 made following the June council meeting: and ‘apply that percentaca to whatever remaining funds we have. And distribute those funds to each region. We feel i 4 1 that this is equitable and in keeping with your recommendations . and of the June and August council meetings/have been unusual, in that all programs, basically have been reviewed, simultaneously rather than at quarterly periods of the year. Secondly, the competi tt ony the appli cation have come perpetuated “rank standings of regions for 1972. So “what sa feel is at the last two council meetings, this one and the June council meeting, are our best indication of the latest considerr i } i 4 ation of merit of each region. ™ ‘ Therefore the formula that we have devised we believe o fi oa «i to be fair. what is complicated. I hope I have made it clear, ode 4 and I would like to have either a discussion or endorsement, or, if you would, like to cons ider it later, discussion or endorsement of either this proposal or a modification because | once this council meeting ends we still may be faced with a distribution of funds. | An@ I do not have that authority unless we reconvene. At some future date, so I would like to open it now for general discussion or clarification if I have not made it clear. DR. WAMMOCK: That's only a minor sum of money, you say about four million Aollars. Or a million and a half dollar: is that correct? First you will take the sum we allocated for eighty eighty million dollars, —~ DR. PAHL: Well, let me try, first I will use the funds that were available to us to pay up to 190 percent of what i we recommend today. DR. WAMMOCK: Right. DR. PAHL: The funds remaining I will then return your June council recommendations and pay up to. 100 percent of those recommendations. If funds still remain, either what | ‘we have currently available, to us this summer, or any that may become available to us in October, I would then employ the formula that I have given which would represent a percentag determined for each region based on the June and August Counc#! 10 il 12 13 14 1B 16 17 18 19 20 21 awards. . | Actual awards to that region, which will be at the 100 jsrcent June and August Council recommended levels and apply that whatever balance remains. DR. WAMMOCK: I would like to move that that be en- dorsed, or approved that -- MR. OGDEN: Can I ask a question? DR. PAHL: Yes. MR. OGDEN: I am unclear as to what this five million would be used for andthe manner in which that will be done. DR. PAHL: I can speak more fully. to the second part then to the first point. ‘ MR. OGDEN: I think it is the first point that I am more interested in. DR. PAHL: I can get you material for the first point. ot me speak to the second point, however, Mr. Ogden. The negotiations on the settlement of this litigation have been conducted primarily on behalf of the defendants by, ef course, eur office of caneral counsel and the person of Mr. Rubel. And to the purposes, needs, and challenges that will be represented by having five millions of dollars available to the administration thus have been our most and under his direct personal consideration. “He handed to us, yesterday,.a rather lengthy statemen which frankly I had not seen until yesterday, because it is a te ee 5 10. 11 12 13 14 15 17 18 ‘19 20 wa separate activity within this bill. So that the sest [Toca Go is refer you to the same do ment that I have, that T hopec jet My. Rubel to speak to it more directly, becduse we Qu really do not have information beyond what he distribut _asterday. Now, the manner in which ..e2 money will be spent I understand is fully through contract process. And the purposes: generally designed to look toward the new legisiation and to have organized, defined, cleared, and publish those kinds of studies which are concerned with health planning method- Oligies, evaluation studies, and to development of manuals | and procedures which will be of assistance to the organizations which we expect to be developing and supporting as a result | of thrproposed legislation. | I. am not sure that that says much more or even as well as what he said yesterday, but I cannot amplify that. DR. SCHUREINER: It's kind of anticipatory ~- as I DR. PAHL: It's kind of anticipatory -- let's go off the record for a moment ‘please. ee Fathi RATION MY OE Ue, ™ ieee ‘meted, hi Repeat tiscus :sion off the record.) —“™.. RFR. en . DR. PAHL: We can go back on the record acain. I woulc Ku Bet be har » if Mr. Bettcwere here today, to try and get him to come ad speak to this point. It is kind of imporant, but it has en quite peripheral to my activities. Unless there is poet 10 ll 12 13 14 15 16 17 18 19 20 21 | | | -standing that an expenditure of grant funds must come before, | funds, and I don't know what ~~ whether it is custom or law someone here. : MR. OCDEN: The reason I raise the point is that I think it is the statutory responsibility of this Council to ‘approve the expenditure for RMP money and this is five million ri | dollars of RMP money. And I think unless we improve the manner and purpose of Mr. Rubel's expenditures the money may not be appropriately spent. DR. PAHL: Yes, well that does bear on how the money is spent. It is the responsibility of this Council to approve all grant funds. MR. OGDEN: Unless we say to Mr. Rubel's resolution | that you have the authority to expend that money and we delegats 1 to you the right to spend it in the manner in which you spend.; it, how you choose to spend it, and then I question whether he is spending it under authority. MRL HIRTTO: Isn't this the result of the cour order, Bob, rather than a MR. PAHL: It's the result of the court order but Iam in a very poor position to take issue with Mr. Odden. MR. HIROTO: Okay. DR. PAUL: What I would say, is that it is my under- and be recommended for approval by this council, but contract frankl but certainly to the best of my knowledge no contract ' ¥ y o i i a 1 funds are required to come ~~ that is proposed contract expen ' I Aitures are required to come before or be approved by this © io , i} council. , : te gz oO 4 and in foct, have not been ~- so that as long as thak 5 | five million doli,. is awarded in contract I believe technica. 6 it must not come betore, but I believe it would be wise for q you to have a better understanding. 8 MR. OGDEN: Was it designatedin the court order 9 as contract funds? 40 DR. PANL: I turn to my -- quasi-lawyers. 11 MR. GARDELL: We both have a little information. I 12 think one of the things the court order did was to release s 13 impounded funds and those funds then were allocated to us. New eo | 5 . ‘a4: © 14 the amendment to the court order takes away five million dellar “45 of the released impounded funds to us, andmakes it available S 2c. TIE 16 | to nénesEGh contracts that HRP, and that's what really it is 17 So, then, wa have five million less to allocate to our RMP's. 18 MR. OGDEN: If that is the case and it goes in that 19 route, then my question is out of order. 20 MR. GARDELL: Yes. 21 DR. PAUL: Is it actually spelled out as contract? 99 ||" MR. GARDELL: That's right. They don't have to be | 23 made aS contracts. They are not made available to us to alloc: a4 to our RMP's. | 25 ‘ MR. OGDEN: Okay. 10 Li 12 13 15 16 17 18 19 20 21 69 oe at 23 PAs) . DR, SCUMMINER: i mit thins -- I con't see any ct oract.. 1’ feasible way of ‘ng care of the overage, It sally would be msaningles > have a council meeting for that i purpose. I don't really s¢e@ any reason for spending any time! on it. I move the motion. DR. PAHL: All in favor af the proposed resolution? Relative to the formula for distributing ~-- MRS. KLEIN: We didn't get a second. MRS. MORGAN: Yes we did. JI seconded it. DR. PAHL: I'm sorry, it‘has been moved and seconded. All in favor, please say ayé. VOICES: Ava. DR. PAHL: Opposed. (No response) DR. PAHL: The motion is carried. MR, OGDEN: As a matter of editorial comment, should the bottom line read -- June? Peet MR. GARDELL: The words will be dated in August. They will be effective September 1. You're being terribly technical pr. PAUL: All right. Now that we have gotten that, I next wanted to move over to the arthritis, but I see that both Dr. Gramlich and Mr. Spear just left the room. So, first I would just like to have the minutes of the last meeting con- 43 3 10 il 12 13 14 “15 16 17 18 19 20 21 -were just about gettingip you at this point. 4 T believe they are attached. Again, if you have not had an opportunity to read these, pernaps we could defer action on them. MR, OGDEN: These haven't been malled out. I see no reason not to suggest a motion that they be approved. MR. WAMMOCK: Second the motion. DR. PAHL: The motion has been made to accept the Minutes as submitted. Any discussion? No response.) DR. PAUL: All in favor of the motion? VOICES: Aye. ‘ DR. PAHL: Opposed? (lo response.) DR. PAHL: The motion is carried. MPS, MORGAN: As a matter of fact, it would be illegal and still is part of the minutes. DR. PAHL: We walk a tight rope here. We will be, you up to date on the status of the arthritis program. As 1 | | in just a moment, having a report from ir. Matt Spear to bring | | you will xzecall, at the last council meeting, Matt, I believe | E MR. SPEAR: Pine. DR. PAHL: If that is sufficient. As you recall at | the ,last Council meeting, you did listen to a presentation by 5 10 il 12 13 18 19 29 ai BS bo ta &> 5 we fe oe ops both Dr. Gramlich and Mr. Spear relative to the pilot artnr: program. And the activities, considerations and formal recommendat. 3 of the ad hoc Arthritis Review Committee; subsequent (. that time, wa have made awards and I would like to call on Mr. Spear to describe the current status of the program, and our activities since the last Council meeting. ae en tN te hee ne aE 1 MR. SPEAPs It will be just as convenient, I might | 9 just recapitulate so everyone is on the same starting point. © 3 i We received in 1974.an appropriate for RMP an allocation ear- 4 || marke< and a half million dollars for the development of a 5 || pilot chritis center. . | : 6 When the request for applications went out we receivec q applications from 43 regions, totalling almost 16 million g | dollars. So it was a highly competitive situation in the re- 9 || view. Policies were established which took out of the running 19 | those kinds of activities which did not seem to be directly il did not seem to directly bear on patient services and the 19 | development of things for patient, and the extension of care 13 to patients. @ 14 | In the outcome, then, as recommended by ths ad hoc “45 arthritis review committse and the Council at it's last séssion 16 | 31 of the RUP applications for pilot arthritis funds were 17 | approved. The approval exceeded the earmarked funds by. some 18 || small amount. | 19 I shouldn't say small amount, that's editorial. BY og || an amount of almost a half a million dollars. With’ the appro 94 |i val of the Council we funded, or approved, tended to approve oo |'the allocation of the fund to all of the programs that car fall det 23 within the earmarked amounts available to the program. | And that is 27 of those approved programs, and the remaining four who were approved, but for which there were not: 17 18 19 20 21 22 24 25 within the approvals has been necessary, and those cn a ar ct tot a) 2 Hi ps. I y CQ + fea g) ry pa ct % i my te available earmarked funds, are beinc or utilized are in discretionary funds up to the amount program approved by the Council. The award letter s to this effect that a recion is or is not approved for earmarked funds or is or is not approved for the utilization of discretionary funcs was issued on June 29. The letter also requested that each of the regions receiving approvals for pilot arthritis activity respond in writing as to its acceptance of the award, where an award is involved, and or in all cases the conditions of the avard, which was the statement embodied. in the approvals as to the kinds of activities that should be undertaken. | And the limits of the funds that could be exoended for those activities. Today we have acceptances 21 of those RMP 's and we are waiting for an additional ten. To round it up. Eight of those have been contacted as of yesterday, and they are working as rapidly as they can to get their accept- ances in. As you can imagine, going from a request of sixteen | million to something in the order of less than five millions some drastic cuts were made, and some restructuring of activitie 9) noes are being negotiated. It appears at this moment, that only one or two of the 31 approved regions may turn down the funds. One apparent]. bo 10 11 12 13 14 15 16 wT | 18 ‘19 20 is having some difficulty in deciding what the overhead shou be used or not. Now, the. review committee and the Council both two ocher actions, both at the same time, they recommend that ther pe some centralized follow-up from the Division of Regional ledical Programs. — The major part. of that I think the most important aspect is a desire that there be a methoa and an approach to coordinating like kinds of programs that nevertheless are dispersed the 31 RMP's. We are also in the advice letter of June 29 asked the RMP's to give it some thought, and to give us the wisdom of their exnerience and thoughts. However, they did not nave the full information needed by then to give a proper reseons o in our estimation. And we are presently preparing a letter to foll that up and give them more concrete information such as who are the ball players, who got the awards, and for what kinds of purposes and what are the nature of the programs that have been approved for funding. And just in conclusion, to these remarks, let me ead you the draft part of the letter that purports to summer it the approved programs. The emphasis of the approved pilot programs is the extension of present knowledge in arthritis diagnosis, treatment and care to coordinated services which demonstrated improved patient acess to care, and extension of beh 10 il 12 18 19 20 no ha BO oo “nters, community hospitals, and other community heaith -ailities. Educational programs in hospitals and through visiting multi-disciplinary teams will increase the arthritig handling capabilities of hospitals and private physicians and will equip larger numbers of medical and health personnel as support services in hospital clinics and -~- increased patient care will be increased through the development of patient training activities. Seminars and workshops will be conducted at many sites for improved utilization of community resources for arthritis services, including home care, guidance and surveil- lence. Existing health department personnel and facilities, and health groups, such as the Visiting Nurses Association local councils on aging, and operating community health trains programs are cooperating and demonstrations of approved arthritis health care deliveries. Several modest studies to develop criteria for qualitiative care through provided performance standards are béing conducted, and industry survey is planned in one region. And an employes, employer educational program will be developed in concert with better organized occupational health services. Another region will investigate the utiliza~ Ll ye nm: 10 11 12 13 14 15 16 i7 18 19 20 21 22: 23 Ag of solar workshops to support patient restoration to procuctiv: activities. A nunber' of programs are focusing on the problems of low income groups, rural groups, and others are focusing on the development of care deliveries in economic disadvantacec inner-city residents. Pediatric arthritis services will be \ developed in a variety of settings, and one program is demon~ strating improved services to the geriatric population. Localities which presently have little or no rheume~ tological resources are being supported by the initiation or the expansion of medical, new medical institution teaching capabilities. Across the country, chapters of the arthritis foundation are providing program coordination to -- sublicatic. and increased numbers of volunteer © workers in supportive ‘services. And increased agent referrals to local services and resources. That completes my report, Dr. Pahl, unless there are questions. DR. PAHL: Thank you very much, Matt. Dr. Haber? DR.UABER: What is, where is that program with the geriatric services? MR. SPEAR: In Michigan. University of Michigan. * DR.PAHL: Thank you, Matt. Dr. Gramlich? oO DR. GRAMLICH: As I indicated to you, I apologiz to you for not having been able to get with you a Little bit 10 11 12 2B 14 15 16 18 19 20 21 22 23 24 this morning due to the road construction which delayed my getting here. I wondered, however, if you have a statement to make generally or I think to add and the information whic! I did pass to you I thought I would like to make an explanatic and statement to council, rather than a formal resolution. But perhaps you would like to make some comments, as a result; I would have-a great desl, Dr. Pahl, except to say that this is a great example of the flexibility of the RMP process, in the administrative organization that is able to fet accept the task, early on, accomplish it rapidly, and apparent bring it to reasponably successful solution. Matt's report is superb and I have nothing to add | DR. PAHL: Thank you. Let me just take one or two minutes, and indicate to you. We are attempting, should there be further funding coming to us this year than anything | we have spoken about to date, or will there be special arthriti: { funds made available to this program we would attempt to engage in those activities which the committee recommended to you, and you endorse, that is to provide centralized audio-visual | resources, the development of certain training films, viceo- tapes and so forth. But this requires a reasonable investment, and we do not have the dollars at the moment. We do intend as Tir. Hi 5 we Spear indicated to try to pull together the existing approved | ] 9 activities into a cohesive program through the good offices wt + i © 3 of Mr. Spear. And beyond minimal funds needed for some conflictive 4 5 meetings, and so forth, I believe we can accomplish that. 6 So we do hope to be able to report back to you at some future | q time 2 Ee program is not an assemblage (of disjointed 8 projects but does represent a total national program. Now, facing us yesterday and ‘today there are a 10 limited number of arthritis applications in the July 1 RMP ll applications. I believe five regions saw fit to include 12 arthritis requests in the current applications. Which is to 13 say that most regions clearly understood that the pilot 6 44 arthritis program was related to the fiscal 74 funding anc 15 the activities of the specially established ad hoc arthritis 1g | review committee which met for one time and was disbanded. 17 Thus, we have a situation in whichI administratively 2 1g || and indicate to those regions that basically their applications 19 have submitt inappropriately, although I think in 20 Some cases there have been honest misunderstandings, so that perhaps this news would not be taken lightly. 21 99 I feel that, however, it is important to reopen | ; with you very briefly the fact that we believe the pilot o4 arthritis center program was established and is no longer / open. That is, regions should not be permitted to spend 10 11 12 13 14 15 16 17 18 19 20 21 23 24 4 currently available funds or whatever funds come to them distributions we have been discussing oO in the year, -- th this morning to support additional activities. ye ty We are trying to build a national cohesive procram oe and as a result of that I have prepared a statement which I would like to read to you, and if you feel you need to study it we can distribute it. The timing is perfect, Ken, thank | you. . | But I believe it would provide you with the sense of what he 1 || program. Those programs that have started have been picked up © 9 in some aspect by other organizations emergency services by 4 | county health departments, renal programs, by some institutions, and by community medicine, and by hopefully the institution 5 || by which that is developed, and so on. Tt is our intention from the very beginning to use the regional program as a stimulus to start developing g || each programs, ultimately to be picked up on a more permanent g || basis by other means. DR. PAHL: Thank you. Is there further discussion 11 | Of questions of Dr. Scherr? 12 (No response.) : 13 DR.PAHL:Mr. Prasad, would you have anything to © te ~ add? 45 | | " MR. PRASAD: No. I spoke yesterday. 18 DR. PAHL: Would you use the microphone, please, if 17 you care to make a comment? f i 18 MR. PRASAD: No. I spoke yesterday before the Review i9 || Committee, and most of the Council members who were present, 20 and I have no comments to make. Uniess you have some questions i i ‘ 21 to ask. DR.PAHL: Thank you. Miss McCarthy? 22 93 MISS MCCARTHY: No. Thank you. os DR. PAHL: Well, then, if there is no further dis- | i cussion on Nassau-Suffolk, I want to thank you for returning i i | i ag * here today, and submitting your statement through Mr. Prasad © yesterday. mo Are there any members of the public who wish to i we make a statement to comment upon the proceedings so far? arin ses the Council have anything further to discuss in the open session. Dr. Sparkman? q DR. SPARKMAN: Can I make one more point, Herb? 8 DR. PAHL; Yes. 8 DR. SPARKMAN: I think you are all familiar with 10 | the National Association RMP, which instituted the lawsuit i which released the impounded funds. When this was set up 2 ae ae our view that this would serve not only this lawsuit ig purpose, but also some organization like the American Public M ! Yealth Association and others to provide staff education ane’ is training. 6 And in fact we do have such a meeting planned in 17) penver for September 3rd, and 4th, I believe. At which I * think a very good program has been developed. Which so far. 29 has been oversubscribed by the various RMPs. | 20 And which will deal with the variovsparts of RMP al | programs: project development. Management, and I am sure 28 via be of considerable part, and we see that as the logical i + ! extension of the National Association. | a4 | Actually, all of you are invited to attend, and @ a #9 | we will see that information is given to you about it. | 1 I nl i || DR. PAHL: Thank you. Dr. Gramlich? DR. GRAMLICH: Would it be appropriate to ask Dr. ba ao : . Sparkman to give us a one-minute explanation of what the 4: NRMA is? i) DR. SPAREMAN: Yes. I had hoped that Dr. Jack 6 Enale from the Lakes Area PMP was going to be here, since i 7 he is the president of the board. 8 This is an organization, Dr. Gramlich, set up 9 aside from the steering committee in the regular coordinating! 10 with the coordinators committee, funded by personal and | Li private sources quite aside from anv grant funds and initiated 12 | originally around September of last year when it became | © 4g apparent that without the release of impounded funds the | | 14 RMP future looked pretty bad. | 7 15 | But it has continued with meetings of the board, 16 | the board being made up of some representatives of the | 17 coordinators, some have come from the steering committee. ! : ae 18 | We think there is a real need. for the kind of staff training 19 that such an organization can provide. 20 We hope that this is going to ke the ultimate 21 future. Obviously we should be out of the legislative --. I mean, the legal problem. As Dr. Pahl has said and ag you. know, this, I believe, has been handled and, as I hope, done with shortly. There has been auestion as to whether RMP grant — nN Ge 10 il 12 13 14 15 16 17 18 19 20 21 65 -funds could be used for this purpose. So far they have not been used. And I have spoken vigorously to this point. I _am told that legally it may be appropriate to use grant funds. Put I think until we are beyond the legal problem, until we have clearly established that this is an educational, activities, that these should not be used. So far they have not been used. The membership is made up of a wide variety of i 4 { i ! i \ 1 i people -- RMP staff, advisory group people, other indivianals. with whom we have worked. There are some institutional memberships, people like medical assocations, hospitals, volunteer organizations who wish to join in that fashion. DR. PAHL: Dr. Haber? Thank you, Dr. Sparkman. DR. HABER: Dr. Sparkman, I hope you will indulge me to the extent that I will probably ask you about matters that have concerned me deeply for a long «period of time. But it strikes me that with the imminent emergence of a national health insurance strategy, certainly the organiza- tional and substantive efforts demonstrated by RMP have a role to play, particularly in the transitional years. My question goes to this point: If indeed, as this booklet indicates, there are some 21 million people who can begin to be beneficiaries of a ~national medical n3 he 10 li 12 13 14 ‘15 16 17 18 1g 20 21 effort has gone into the providers in terms of popularizing 66 program, what has been done to bring home to the people -- the clients, if you will -- the benefits accruing to the program? Tt strikes me that I am unfamiliar -- much of the or informing. What has been done or what could be done to bring this home to the people that are the potential natural | beneficiaries? . | : DR. SPARKMAN: I think not enough has been done, : Dr. Haber. If I understand the intent of vour question, | one of the woblems that I see as a coordinator of an PMP | is that in order to function most effectively you do some very low-key way to bring people together and make as | relatively little evidence of your existence, And I find that this is the way you can get dif- ferent groups together. And sometimes they hardly recognize that the regional medical program is accomplishing this. But in order to demonstrate to Congress, the public and others that you are accomplishing something, this is not a very effective order of operation. And so we find ourselves caught between these two. ! I think that in general regional medical programs have done | a ‘poor job of demonstrating to beneficiaries that they have,.. in fact; served a useful purpose. I find continually ‘as I move around our two-State region, Washington.and Alaska, n4 br 10 il 12 13 14 16 17 18 19 20 21 22 23 24 -and guests for appearing and speaking with the Council and 67 that there are unexpected and surprising numbers of neople who have been touched in some way by ovr regional medical program who volunteer the fact that their appreciation and their hope that something like this will be continued because’ they have been unable to find any kind of assistance to bring together activities to accomplish needs, to respond to needs that they have. DR. HABER: I would hazard a guess that probably 90 to 95 per cent of the beneficiaries, while they may be aware of the local clinic or school operation or outreach operation, are not aware of the fact that this is served by the regional medical program in terms of coordinating, plan- ning and executing of it. And that is a critical step, it seems -- to bring . that realization home. DR. SPARKMAN: -I would agree. And I would welcome any’ thoughts here any of the members of the National Advisory Council have about this. I think we have done a poor job in this respect. DR. PAHL: I think in view of the time I will. close this open portion of the meeting and again thank our visitors being available for discussion, and ask at this time that all | individuals in the room other than those who are part of our Council or Federal emplovees please leave at this time. n5 10 il 12 13 14 15 16 17 7 19 20 &g Let's take a two-minute stretch, and then we will enter our review of applications. (A short- recess was taken.) DR. PAHL: May we come to order again, please? Will Council come to order, please. TY would like to recon- vene the Council for now the closed session and the review of individual applications and, just as is our custom, call to your attention the statement on conflict of interest and , confidentiality of meetings which you will find immediately behind your agenda. And I would like now to turn the meeting over to Mrs. Silsbee who will guide us throuch the applications. Most of you were here vesterday and heard the discussion. We hope that that was a mutually rewarding and satisfying experience. I have heard some favorable comments from the Review Committee members. And I certainly hope that you found it of interest. Let me state even somewhat below the Committee recommendation. The current request is for $5,592,000. It is my opinion in reviewing this -~ and I concur with the technical review committee -- that the request is overly ambitious for the time frame of accomplishment. And the amount can be effectively reduced to an amount of 3 million dollars. I would express only one administrative concern: Although there seems to be a reasonably good relationship between the RMP activity and the various CEP agencies, there are some areas of clearly unresolved conflict. And I think that with what I see as somewhat more dispersion of activity in this State tending to get back to the way it was before * reorganization, that the coordinator should be cautioned in this regard. The recommendation for funding is at the level of 3 million dollars. And I so move. n28 | 1 MRS. SILSBEE: Mr. Ogden? © | 9 MR. OGDEN: I disagree with Dr. Janeway on the 3 level of funding. “And I would like to spend a few moments 4 ‘on this particular application, inasmuch as I think it is 5 ‘the largest before us today. 6 Those of you who were here yesterday and listened 7 to the discussion will recognize that Dr. Heustis, who was 8 the primary reviewer yesterday, recommended this be funded 9 in full, $5,592,000. Dr. Hirschboeck, who was the secondary 10 reviewer, suggested it be reduced to 2 million dollars. 11 After considerable discussion among the people 12 around the Review Committee table about the projects and a r ) 13 group of other things, the final decision came down to a bit 14 of dickering. Now, at the risk of going over things that 15 you "j;gtened to yesterday, there was a show of hands on how 16 many would prefer 3 million. 17 Dr. Heustis said, how about 4 or 5? 18 Then Mrs. Silsbee said, well the motion has been 19 | made at 2 million, how many in favor. That was voted down. 20 That motion was defeated. 21 And Mr. Barrows said, well, then I will move it at 92 -3 million. And they finally got an acceptance at 3 million 23 without any discussion of whether these were valwble projects, 24 whether the RMP was being cut too far or particular discussion © , 95 with respect to the quality of the this program. n29 10 11, 12 13 14 15 16 17 18 19 20 21 22 . program staff, which includes existing projects as well as ‘In looking across, I see that there may be some cutback on 92 i Now, you don't have available to you, t don't think, the yellow printout sheets on this. Do you have this in your books? If you would look for a moment with me at the yellow printout sheets on the California Regional Medical ‘Program, there are some things here that I think are of considerable interest to us. MR, MILLIKEN: These are numbered. Which one do you want to look at? | MR. OGDEN: Let's begin with the cover sheet for just a moment. There are 83 projects here; 61 of them are new, and 22 are requests for continued support -- 1.3 million of continued support. And if you look at the next page, you will see that continued projects, is 1.6 million. Now, if you add up the continued support and program staff, you are at 2.9 million, which is the 3 million dollars that we are talking about. Admittedly program staff may be possibly reduced in the event they do nothing on new projects. But the 3 million, I «suggest, may only continue the projects that they have and cover programs. That does not cover new projects. program staff if there are no new projects. DR. JANEWAY: May I make a point of clarification? It was my impression, as I was primary reviewer, that none 93 n30 1 of this was for program staff. That was all funded in the © a, May-June application. 3 _ MRS. SILSBEE: Is that not correct, Mr. Russell? 4 . MR. RUSSELL: That is correct. 5 DR. JANEWAY: That 1.6 million has already been 6 funded, 7 MR. OGDEN: All right. If you come down to the 8 request for September of '74,to June of '75 which is in the 9 third column, that is under the heading of five in here, 10 you will begin to see the programs that they are proposing 11 are those to which they propose to add some additional 12 funds. @ 13 These include a series of kidney programs, some 14 of which were funded at very small amounts in the July '74. 15 to June of '75 request and for which they are now reauesting 16 additional funds. 17 And when you come over, come several pages along, 18 don't you have a printout, now beginning on page 7: you begin 19 to pick up new projects which they are talking about beginning 20 with about 147T. And you will find some that are added to. 21 But beginning on page 8 they are all new projects that. they i ‘are talking about funding for the period of September '74 to June of '75., 23 24 Now, I find some of these to be of considerable © 25 interest and also of value. There are projects here concerning n3l 10 11 12 13 14 15 16 17 18 19 20 21 22 24 _ness project here. 94 : t the health care network in the Imperial Valley which involves migrant workers. There is an American Indian clinic aware- There are upgrading of free clinics, ambulatory care facilities -- a whole series of things that I feel were simply ignored in the discussions yesterday. And I came away from yesterday's discussion somewhat dismayed with the manner in which the California application was handled. I recognize that this is a big program and it is an expensive program. It is a lot of money. But my reaction to it is that the cut from 5.5 million, nearly 5.6 million to 3 million was done almost on a bargaining basis, without much consideration of the actuality of the needs of this program. And I think or feel that we should add back money into this application. I haven't totaled up the requests that appear on pages 8, 9 and 10 at all. But I would sug- gest: that if we added back upwards of a half million dollars, maybe-even a million, we would be finding money well spent in a superior program that has always had exceptional manage- ment and has done a great deal of good in what is now the largest State in this nation. MR, WAMMOCK: You would take it back to 5 million? Is that what you are saying? MR. OGDEN: I would take it back at least to 4. n32 10 11 12 13 14 ‘15 16 17 18 19 20 21 22 95 DR. JANEWAY: Let me respond to that. Perhaps I am speaking not as a member of the National Advisory Council . and a little bit too much from a technical standpoint. But if you are going to put 1.5 million dollars into a hyperten- ‘sion screening program in 10 months, you had better be pretty well prepared as a physician population to have some reasonable idea as to what you are going to do with the people who you identify. And that is where my comments saying that they are being overly ambitious: If there are indeed 23 unidentified | hypertensives in the United States, and probably more than | that, you can set up programs which build up people's expec- | “tations to a level which you cannot possibly meet within the | Limits of the delivery system or within the cost barriers that would be imposed by defining that population. | I think it is an admirable program. And I am not making a comment there. I am just saying that as to the quality of it I think it is overambitious. And that was my | interpretation of the technical review that was also given. I would agree that on the surface there would appear to have been some bargaining as to the level of funding, at the -outset of which one would get the impression that it was not being done on the merits of the proposal. But I thnk ultimately that it was and that the technical expectation was the one that cast the deciding n33 10 Il 12 13 14 15 16 17 18 19 20 21 22 well spent in that as it would if it were distributed dif- *‘ technical reviewer on this, but when you have a very high 96 factor. And I would say that Ir agree with your comments to a point, but I certainly agree with the recommendations of the Review Committee. That is just too much money. It would not be as ferently throughout the regions. MRS. SILSBEE: Dr. Gramlich? DR. GRAMLICH: Dr. Janeway raises a criticism of a million dollars for a hypertension screening progrem, And I would observe that the same Review Committee recommended a million dollars for a hypertension screening program and treatment program in the State of Mississippi. DR. JANEWAY: They cut is by $840,000 specifically. DR. GRAMLICH: Yes, but from a2 million dollar level, leavin- them with a million dollars. DR. JANEWAY: The incidence of hypertension in the State of Mississippi or prevalence, whatever you want | to use, based upon the racial distribution and the character- istics of people living in that area, I think you will find a striking difference from California. As I said, I don't want to get into being a percentage black population,and in the entire Southeastern United States, if you look at the prevalence of hypertension, . coronary, arterial disease -- you are dealing with a different n34 10 11 12 13 14 “1 16 17 18 19 20 21 22 24 97 type of population and a different health care need, MR. OGDEN: Let me make one brief comment here. I think since the time we started the Regional Medical’ Programs in 1966, we have witnessed in America::probably the greatest migration of people in history. And I speak about the migration of the black peoples of this country from the South to the North and the West. We may not all be aware of this, but as recently as probably 1946, right after the war, some 77 per cent of the black population in this country lived in the South and was thought of as the rural Southern problem. Today 65 per cent of the black people in this country live in the North and the West and are really thought of as an urban problem. The black population in this nation has settled in California, New York State, Michigan, New Jersey. And I think we sometimes are not aware of these things that have been affecting our regional medical programs. And I would suggest that if hypertension exists in Mississippi it also exists in California. There is a tremendous black population in California. And it has been a very rapidly growing population. Dick, may I just comment, too, then I will close this off: Many of these projects I asked you to look at on pages 8, 9 and 10 of this computer printout are not hyper- tension projects; these are projects spread among a great n35 10 11 12 13 14 15 16 17 18 ‘19 20 21 22 24 not from California. But I simply feel that this is a pro- yesterday. ’ to be superior or above average that -- just that is another 98 many other things. | I plead no particular case for California. I am gram that deserves better consideration than it received MRS. SILSBEE: Dr. Schreiner? DR. SCHREINER: ‘I justvwant to point out that both the reviewers have made some excellent specific points. I do think, however, we should put in perspective that-7 million dotlars plus 3 or something over that is roughly 10 per cent of the entire nation's RMP funds. I don't think we should view California as being a deprived State. MRS. SILSBEE: Dr. Komaroff? DR. KOMAROFF: Another was to look at the perspec~ tive is that California has 10 per cent of the population of the country. And we had available about 64 per cent of the funds that were requested in this cycle. 3 million put of a request of 5 is about 60 per cent. | | i i t So an average region ought to get around 3 million. But I would think that if this region is, in fact, regarded context within which one might look at the 3 million. MRS. SILSBEE: Dr. Janeway has made a motion that the application be approved at the 3 million dollar level. 10 11 12 13 14 “15 16 17 - 18 19 20 21 to -- 99 I didn't hear a second. | | - MR. WAMMOCK: I will second that motion. MRS. SILSBEE: All right. The motion has been | made and seconded that the California application be approved: at the level of 3 million dollars. Is there further discussion? ‘(No response.) MRS. SILSBEE: All in favor say aye? VOICES: ‘Aye. MRS. SILSBEE: Could you put your hands up, please?: That is one, two, three, four, five, six, seven say aye. Nay? Seven. | MRS. MORGAN: Maybe we should set it aside and go MRS. SILSBEE: Dr. Wammock? DR. WAMMOCK: You talk about the new projects over | here. I have just been looking at that hypertension. And if you look at on page 9,I thought I had it, California, it. seems to have gotten away. But it looks to me that there are lots of hypertension projects over here ~- 159C, 159D, 159E, 159F, 159G, community hypertension awareness project, 159H, | ‘thigh blood pressure control in Berrett County, 159 -- there's | about 10 or 15 down there that go right on to the hyperten- sion. So I think there is a tremendous amount of money n37 10 11 12 13 14 15 16 17 18 ‘19 20 21 22 24 100 being put in that program there. MRS. SILSBEF: Well, I think that was brought out a little earlier. DR. WAMMOCK: It was brought out a little earlier. But this is in the new projects in which they are requesting this. MR. OGDEN: Can -I make a new motion that we put California at 4 million dollars? MRS. SILSBFE: Is there a second to that? DR. GRAMLICH: Second. MRS. SILSBEE: The motion has been made and seconded that California application be approved at the level of 4 million dollars. Is there further discussion? MR, MILLIKEN: I think 3 and a half. Try 3 and a half. DR. JANEWAY: How about 3 million €40? MRS. SILSBEE: I might add that the Council doesn't seem to be any more deliberate in its setting the fund levels than the Committee seemed to be yesterday. All in favor of the motion to approve the applica- ’ tion at 4 million raise their hands? Four. Opposed? Eight, nine. The motion is defeated. MR. ODGEN: Dick, you want to move it? n38 10 11 12 13 14 15 16 17 18 19 20 21 22 24 101 DR. JANEWAY: JI move approval of the California application at $3,640,000. MRS. FLOOD: I will second that motion. ( MRS. SILSBEE: $3,640,000. The motion has been ‘made and seconded that the California application be approved) at the level of $3,640,000. MRS. GORDON: I would like to ask for a short explanation of the magic mathematical formula used to arrive at that? DR. JANEWAY: It is 65 per cent of 5.6 million. MRS. SILSBEE: Does that answer your question? Is there further discussion? (No response.) MRS. SILSBEE: All in favor of the motion say aye? VOICES: Aye. MRS. SILSBEF: Opposed? (No response.) MRS. SILSBEE: The motion is carried. Would someone ask Mr. Hiroto to come back? n39 10 ll 12 13 14 15 16 17 18 19 20 21 22 24 level of $450,000. I was not quite so generous. I found 102 CENTRAL NEW YORK MRS. SILSBEE: The next application is Central New York, and Miss-Martinez is the primary reviewer. MISS MARTINE?: The Committee recommended a funding' that at least two sets of projects duplicated or extended each other in that they were two that were, number 77 and 78 were really building of facilities, which I don't think is feasible for one year projects. Two more were really sort of education projects. The end result is that I ended up with a funding recommenda- tion of 381,372. MRS. SILSBEE: Dr. Schreiner? “DR. SCHREINER: Yes. I had perhaps the advantage of site visiting this area. And there are a number of developments from the previous time. I agree with Miss Martinez on those two particular projects. I would also like to point out, however, that in. the region's own priority list they are in the low priority groups, so that they have insight into the problem which she mentioned. We helped them actually set up a very democratic method for determining the priorities in the various places. And I think it has worked extremely well there. There are a high number of inputs, and they have a very good type of 10 11 12 13 14 715 16 17 18 19 20 21 22 193 rating system for establishing priorities. - Now, in previous sessions the kidney programs were % toned down because’ they did have some problems in getting areawide agreement on a number of the projects. I do think that they made a lot of progress in that particular area since our last funding. And the kidney projects have been asked for at a level of 111,000. The second area that I would give very high priority to, and I can find in their priority list reasonably highly rated as well, are those relating to the north country, which is an extremely desolate area. Even though it is in New York State, within easy driving distance of New York City, it has one of the lowest population densities in the United States. And there are a number of very unique minority circumstances up there, including an Indian reservation which never signed a treaty with the United States and therefore doesn't come under the Bureau of Indian Affairs and it is entirely dependent upon this kind of activity. I can identify about another $135,000 worth of projects relating to the north country area. So I am afraid ‘that my recommendation would be a little bit higher. If I assumed the program staff figure is correct -- and I would agree it is possible it could be cut a little bit and put two the emphasis in these/areas -- I could come up with a figure n4l 10 11 12 13 14 15 16 17 18 ‘19 20 21 22 24 194 of $562,000. So then I am a little far away from Miss Martinez. MRS, SILSBEE: Well, I don't have a motion. DR. SCHREINER: I would like, obviously, to move the higher figure and she would like to move the lower figure. MRS. SILSBEE: We've got three figures before us now. MR. OGDEN: What are those, please? MRS. SILSBFE: But we don't have a motion. DR. SCHRFINER: I would like to move 562. MISS MARTINEZ: 562 ? DR. SCHREINER: Yes. MRS. SILSBEE: $562,000. Is there a second? (No response.) MRS. SILSBFE: Is there another motion? MISS MARTINEZ: Yes. I would like to make a motion for 382,000. MRS. SILSBEE: 383,000? MISS MARTINEZ: 82. MRS, SILSBEF: 382,000. .Is there a second? (No response.) MRS. SILSBFE: Is there another motion? DR. KOMAROFF: I move the Committee's recommenda- tion of $450,000. DR. JANEWAY: Seconded. 105 n42 1 MRS. SILSBEF: The motion has been made and seconded © 2 that the Central New York application be approved at the | 3 | level of $450,000... : 4 Is there further discussion? | 5 a (No response.) 6 MRS. SILSBEE: All in favor? 7 VOICES: Aye. 8 MRS. SILSBEE: Opposed? 9 (No response.) 10 MRS. SILSBEE: The motion is carried. 11 | 12 e : 14 15 16 17 | 18 19 20 21 22 | | n43 10 ll 12 13 14 15 16 17 18 19 20 21 22 C n COLORADD/WYOMING MRS. SILSBEE: The next region to be reviewed is _Colorado/tyoming. And let the record show that Dr. Gramlich is out of the room. Miss Martinez? MISS MARTINEZ: I am waiting. All right. I believe the Committee's recommendation was for $200,000. Again I am a little low in that I recom- mend 146,959. I have a comment to make on one of the projects in particular -- well, two, all right. One, number 59, seems to me to be primarily an education project. And I was wondering vhether/Staff person could tell me if this was developed in cooperation with the educational commission of Colorado? MRS. SILSBEE: Miss Murphv, did you hear the aues- tion? MRS. MURPHY: Yes. I have to check it. MRS. SILSBEE: Could you get over to the microphone, _ please? MRS. MURPBY: I really know no more about the project than what is on page 15. MISS MARTINEZ: Well, if it is the information that I read last night, then I just make the observation that the educational commission or agencies in the State were not consulted and that the project description was extremely n44 10 11 12 13 14 15 16 17 18 ‘19 20 21 22 Lui hazy in my mind. So I have severe questions about that one. But the one that I really object to is number 64, which is entitled, health promotion service, primarily a project to reach senior, Spanish-speaking senior citizens, sort of an education project. And at one point the comment is made that the money is going to be given to the public health department to hire nurses who will go out and try to overcome social barriers. That doesn't explain how it is going to be done, it doesn't explain who, you know, what criteria is going to be used inthe selection of staff to do this. To me, this is an example of a lot of poor planning that goes into pro- jects which are supposed to reach minority people and don't. In other words, it is an ewmple of the use of a minority population for funding. And I would suggest that either that project proposal be developed so that it is under community control and hires community persons to do the out- reach or that they be requested to not fund it. MRS. SILSBEE: Dr. Haber? DR. HABER: I have a serious question about project “number 61. Could Staff enlighten us about what is intended with the $17,000? You can't buy band-aids for $17,900. MRS. MURPHY: That proposal has been called into EMS for consideration. We will not fund it until it gets | { i { i { i 1 n45 10 11 12 13 14 15 16 17 18 19 20 21 22 108 approval. | DR. HABER: Very well. MRS. SILSBEE: It has not been referred to EMS. That was one we wanted to get the Committee's views on, because it doesn't conflict with the legislation. DR. HABER: I would like to point out that a burn center is an extremely expensive operation, requiring heavy staffing by very skilled people. And I think that we sadly or badly need the development of such burn centers. But unless this is some kind of exploratory project -- I can't tell here -- I would say that the scope appears to be hope- lessly inadequate. The demands of these burn centers are such that you should deploy these with the greatest precision and in, —— where they are likely to be well utilized, and concen- trate the rest on developing transportation svstems to get people to where the burn centers are. I don't know what this, but $17,000 seems to be so inadequate that it is ludicrous, I would think. MRS. SILSBEE: Mrs. Morgan? MRS. MORGAN: I don't believe Colorado has a burn -center or such at the present time. They have applied to the legislature and were turned down last spring for money to build a burn center. This $17,000, I believe, mainly is to take a nurse n46 10 11 12 13 14 15 16 17 art 19 20 21 22 24 199 who has been working in, quote, unauote, what they call their burn center where which is a $12,000, add they treat their burn patients, to it travel about the State, and I think really to urge passage of a legislature bill where it witl be taken care of by the State at’ the Colorado General. DR. HABER: Well, if it is preparatory or educa- tional -- MRS. MORGAN: I think it is really a study to get information to develop one. DR. HABER: Well, O.K. Under those circumstances I will be mollified.. MRS. SILSBEE: | Wyoming. MISS MARTINEZ we fund at the level of MRS. SILSBEE: DR. KOMAROFF: MRS. SILSBEE: I haven't had a motion on Colorado/ | i Yes. I would to make a motion that: 146,959. Is there a second? Second. A motion has been made and seconded : that the Colorado/Wyoming application be approved at the level of $146,959. DR. KOMAROFF: Including that caveat that she mentioned about theSpanish-speaking -- MRS. SILSBEE: MISS MARTINEZ: That is project 54. Yes, either it be developed with n47 10 11 12 13 ‘15 16 17 18 19 20 21 {-! } > the safeguards I mentioned or that it not be done. MRS. SILSBFE: All right. Is there further discus- sion? DR. JANEWAY: Does that mean, Miss Martinez, that if it is developed in a manner satisfactory to Staff and EMP that the allocation is increased by $€5,000? DR. KOMAROFF: Or $41,000. DR. JANEWAY: $41,000, whatever it is, so it would come out 187,000. MISS MARTINEZ: Yes, I would be willing to go along with that idea. MRS. SILSBEE: That requires a motion, amendment. MISS MARTINEZ: I would like to make a motion to that effect. MRS. SILSBEE: We.still have one on the floor now. “MISS MARTINEZ: I see. MRS. SILSBEE: The motion was not that. MISS MARTINE%: Can I withdraw the original motion? MRS. SILSBEE: Yes. Does the second want to withdraw? DR. KOMAROFF: Yes. MRS. SILSBEF: All right. Start again. MISS MARTINEZ: All right. I move that Coloradco/ Wyoming be funded at the level 146,959 and -- how should I put it -- which would include the elimination of project 10 11 12 13 14 - 15 16 17 18 19 20 21 22 24 lll number 64, unless that project can be developed to include a community control policy board and outreach workers who are from and sensitive to the needs of the particular popu- lation being served and that if such conditions are met that the funding level be increased -- MRS. SILSBEE: No, you have to go the other way to get a motion like that. MISS MARTINEZ: $41, 000. DR. KOMAROFF: 187, 188, but restrict the $41,000 unless they do it right. MISS MARTINEZ: O.K. Does it come out exactly 187? MR. HIROTO: 188. MISS MARTINEZ: All wight. Let's try this once again. I move that Colorado/Wyoming be funded at 188,182 with the condition that project 64 is to be developed to include a community policy board and community outreach workers sensitive to the population in question, and that if such conditions are not met that the funding level be reduced to 146,959. MRS. SILSBFE: You have heard the motion. Is there “a second? DR. WAMMOCK: Second. MRS. SILSBFE:: Any further discussion? (No response.) 149 10 11 12 13 14 15 16 17 18 19 20 21 2e 24 112 MRS. SILSBEF: All in favor? VOICES: Ave. MRS. SILSBEF: Opposed? DR. JANEWAY: No. MRS. MORGAN: No. MRS. SILSBFE: Let's see. Let's have the ayes raise their hands. O.K. Let's have the nays raise their hands. The ayes have it. The motion is carried. Dr. Janeway? DR. JANEWAY: It seems to me that there must be a reasonable balance between fulfilling all the responsibilities and carrying out the policies and statutes of the RMP versus the selective identification of particular projects. The technical review has been done. And there are only two Council members who have had the opportunity even to read the forms 15. I would just hope that we don't get like the fellow who went down into the swamp and he saw an alligator down there, and he beat that alligator over the head and he killed them. And he just kept running into more alligators and ‘killing alligators and forgot after he was down there with all those alligators around that somebody sent him down to clean out the swamp. DR. WAMMOCK: Common, Sam Ervin. n50 10 11 12 13 14 15 16 17 18 19 20 21 22 24 _ 113 MR, MILLIKEN: You mean he is up to his elbows in alligators? MRS. MORGAN: He's not quite that far. DR. JANEWAY: I have to abridge the story a little bit. MRS. FLOOD: As a matter of comment -~ and again, as Dr. Janeway occasionally says, gratuitously -- I do think though that we have some responsibility. If the technical reviewers or the Regional Advisory Group itself does not take into consideration the problems of dealing with minority groups and using terminology such as overcome cultural barriers rather than to address cultural barriers in a manner that can be adapted to the health delivery system. And we do face the responsibility of questioning the development of individual projects when they a re serving | i | i } 1 { a population that many times is not articulate in expressing | its own needs. DR. JANEWAY: I don't disagree with that one bit. MRS. SILSBEF: Thank you. The transcript for Arizona has arrived, and have you had a chance to look at it, Mr. Hiroto, or would you rather go ahead? We can come back later? MR. HIROTO: All right. I will take Connecticut. MRS. SILSBFE: You'll take Connecticut. Do you have that one? n51 a 10 11 ‘12 13 14 15 16 17 18 19 20 21 22 23 24 MR. HIROTO: No, MRS. SILSBEE: We have to hold for just a few here. (Whereupon, at 12:30, a luncheon recess was taken until 1:00 p.m.) minutes while there is a switch -- the changing of the guard | 10 1 12 13 14 15 16 17 18 19 20 21 22 _ing proposals and ask if objection is raised on the part of : 115 AFTERNOON SESSION MS. SILSBEE: The meeting will come to order. In the break that we have had, I've had about three or four requests of individuals in regions who have to leave early and I'm prepared to accomodate them as much as possible, but) we're going to have to move along. Hr. Hiroto. MR. HIROTO: Ms. Chairman, would you entertain a motion that should the primary reviewer and the secondary reviewer have no problems or difficulties with the result of the Review Committee, that we vote in block on those and | go along the table and list those states that we feel secure |; with and only review those or discuss those that some people! may have questions about. I | MS. SILSBEE: I will entertain the motion. | MR. MILLIKEN: Second. | 4 DR. HABER: One mechanism for accomplishing that might be if you were to read down the entire list of remain- primary or secondary reviewer with the committee’s recommen=| dation. A negative answer would seem to indicate that it | would then be part of a block to vote on. | MS. SILSBEE: Richt. DR. WAMMOCK: You said you would read down the list? DR. HABER: Yes. There are several ways to 10 -il 12 13 14 15 16 17 18 19 20 21 22 tion from the Block Vote. 116 accomplish this, but the most expeditious would be for Mrs. Silsbee to read down the list and if anyone feels that he doesn't ao along with the committee's report, he so states and it is then removed for individual considera- MS. SILSBEE: I think the record should show that the entire council has before them the composite recommenda- tions of the review committee showing the requested level and the committee approved recommendation. I also think that the record should show that this is in view of the fact that you participated as observors in discussions of the committee's deliberations yasterday. MS. GORDON: Was there any problem with the con- flict of interest? MS. SILSBEE: Not on block action. All right, the motion has been made and seconded that we go through this. I'll go down the list and if anyone has any objec- tion to the committee recommendation, we will take that particular application out for discussion, otherwise there will be a motion about the block action. All in favor. MS. SILSBEE: Opposed. Motion carried. I will not only read the list, but I will read into the record what the recommendation was as far as the funding level. 10 11 12 13 14 15 16 17 18 ‘19 20 21 22 MS. MR. MS. DR. MS. Greater Delaware Valley - $684,512. SILSBEE: HIROTO: SILSBEE: GRAMLICH: SILSBEE: . 117 Arizona - $150,000. Object. Connecticut - $750,000. Object. $600,000 - Florida. Hawaii - $486,750. Illinois - $750,000. Indiana - $240,000. Intermountain - DR. MS. DR. MS. DR. MS. KOMAROFF: Object. SILSBEE: JANEWAY: SILSBEE: WAMMOCK: SILSBEE: Iowa - $173,929 Kansas - $363,545 Lakes Area - $150,000 Louisiana Object. Maryland - $650,000. I think we had better go over that. Memphis - $950,000 Metro-D.C. - $250,000 Michigan - $500,000 Mississippi - $2,000,000 Missouri - $540,000 Mountain States - $300,000 Nassau/Suffolk 10 11 12 13 “4 "15 16 17 18 19 20 21 22 118 DR. KOMAROFF: I think we had better discuss that. MS. SILSBEE: * MRS. GORDON: MS. SILSBEE : MS. SILSBEE: Nebraska - $95,000 ‘New Jersey - $1,100,000 New York Metro - $950,000 North Carolina - $120,000 Northern New England - $600,000 Northlands ~- $300,000 Oklahoma - $250,000 Oregon - $148,693 Puerto Rico - $131,335 Rochester - $1,000,000 South Carolina ‘Objection. South Dakota - $88,850 Susquehanna Valley - $500,000 Tennessee/Mid-South - $570,000 Tri-State - $610,000 We'll come back to Texas. Tri-State $610,000. Virginia - $960,860. MS. MARTINEZ: MRS. FLOOD: _ Object. They have an arthritis program. It's not essential, it's automatically taken care of. MS. SILSBEE: From the previous recommendation. Washington/Alaska - $530,000 West Virginia - $1,000,000 10 11 12 13 14 15 16 17 18 19 20 21 22 119 MS. SILSBEE: Western Pennsylvania - $450,000. DR. HABER: Objection. MS. SILSBEE: Wisconsin - $200,000. We'll review Arizona, Connectucut, Intermountain, Louisiana, Maryland, Nassau-Suffolk, South Carolina, Virginia, Western Pennsylvania with Texas. MRS. MORGAN: I move that we accept the Review Committee's recommendations for funding of the regions not specified to be taken care of separately. DR. KOMAROFF: Second. MS. SILSBEE: Is there further discussion? . (No response) MS. SILSBEE: All in favor. Opposed. MS. SILSBEE: Motion is carried. We'll now go to Arizona. MRS. KLEIN: This is just a minor thing, but we had taken some this morning and the way the motion was worded, all those other than the ones that were recently enumerated, so I think the motion should show, except for those already discussed and approved. MS. SILSBRE: I think that was the consensus of the discussion beforehand. 10 11 12 13 14 15 16 17 18 19 20 21 22 120 ARIZONA MS. SILSBEE: Arizona - Dr. Gramlich. DR, GRAMLICH: As a matter of principle, Arizona has had difficulty with the organization, the leadership and had had some other difficulties that were technical with the DRMP and counsel said to clear it up, so Arizona cleared them up and the Technical Review Committee rewarded this function by cutting their allocation---their recommenda- tion. The question is one of principal. Do you reward virtue in a negative fashion or a positive fashion? There's not much question about the technical capabilities of the region to accomplish the project it had ordered. That was a minor element, but the concern on the part of the technical review committee was, if you haven't been good up to now, that you've changed everything we said you should do, so we're going to reward you by cutting your grant. MR. HIROTO: I echo that. I was going to request the council to consider changing the amount of the award to $240,000--~-$240,718 because at least it meets the three component projects in the upper three projects that have the highest oriority. DR. GRAMLICH: If that's a motion, I second it. MS. SILSBEE: The motion has been made and seconded that the Arizona application be approved atthe level of $240,718. Is there further discussion? t 4 { 10 11 12 13 14 15 16 17 18 19 20 21 22 (No response) MS. SILSBEE: All in favor. Opposed. MS. SILSBEE: The motion is carried. 121 10 11 12 13 4 ‘1 16 17 18 19 20 21 22 24 122 CONNECTICUT MS. SILSBEE: We will now go to Sonnecticut. ’ Mr. Hiroto. MR. HIROTO: I can appreciate the problem that probably we all face with Connecticut and that Connecticut's program has continued as it was designed until just the last 10 months. The technical reviewers, one recommended a a level of $250,000; the other recommended a level of $1,400,000, which reflects, I think, the difficulties we all have in reviewing Connecticut. Dr. Gramlich, if you have any comment that you would like to make. DR. GRAMLICH: Yes. Again, these are general comments and more philosophical then technical. Here, apparently and I don't know the region well at all. I may be in error, but it appears this is an RMP set up with a different kind of program from the pattern throughout the rest of the States, throughout the rest of the nation and therefore, our last Technical Review Committee said, well, since it doesn't conform, we shouldn't give them any money. Now, maybe this is an entirely wrong interpretation. I would appreciate staff input on the assessment of the justification for dropping the funding because of the fact of the different kind of program, one from the other. MR. HIROTO: Dr. Gramlich, I don't think that is a primary consideration. The problem seems to be that all 10 11 12 13 14 ‘15 16 17 18 19 20 21 22 123 of the RMP funding or most of it has gone into the institutional area, rather than into other areas and despite staff efforts to spread the program a little more fully throughout the state and throughout other institutions, this was not accomplished. At the last council meeting, council agreed to reduce funding dramatically because this was the only way that Connecticut would get the message, so to speak. They have gotten the message to a degree and so the $750,000 level seemed reasonable to rhe review committee. DR. GRAMLICH: Rebuttal time. MS. SISLBEE: Dr. Gramlich. DR. GRAMLICH: To begin with the May request for funding was not large. It was something in the order of $636,000 dollars. The major request is’ what we have in front of us now. Therefore, since the timing again with Connecticut, was differnt, we are penalizing them even further by not killing their program by refusing to accept their major funding request. MS. SILSBEE: Dr.Janeway. DR. JANEWAY: It is my recollection, Dr. Gramlich that one of the things that was taken into consideration was considerable amount of their funding was going through into 1976. ‘ ‘DR. GRAMLICH: Correct. be 10 11 12 13 14 15 16 17 18 19 20 21 22 124 DR. JANEWAY: And the way I recall the technical discussions, there was a general sense of that group that 2 felt they should not fund projects through '76. MS. SILSBEE: There were several considerations, Dr. Janeway in terms of the level. One of them was the | two year funding request. The other was a contract that would have enabled the monitoring capacity to go beyond June 30th, but in addition, there were the two university resources that were funded at a fairly sizable amount. Other portions of the program that would have been of con- cern was the third faculty. There were no funds requested for that. The Connecticut application in May, Dr. Gramlich was requesting support for staff plus two months of continuay tion projects. This amplification asks for 10 to 22 months for some activities and 10 months for others, so it is complicated by that factor. DR. GRAMLICH: Right, but neverthelsss, if you take all the two year projects and this iscrude arithmatic but nevertheless if you take the two year projects and cut each of them in half and award them one half of the two year total, you're in effect awarding them for one year. They ’" still wind up with a figure $1,430,000. The way I visualized this, it was incorrect, that since Connecticut came in for | | a small grant request last May, if we cut them way down this | time, we're in effect, killing their total program. x 10 11 12 13 14 15 16 17 18 19 20 21 22 125 MR. HIROTO: There was something like $240,000 more or less requested just for the monitoring by Yale University of the second year program, so we might sub- tract further your total by that much. I may be wrong. DR. GRAMLICH: The principal involved is do we want to kill Connecticut or not. MS. SILSBEE: There is no motion on the floor. DR. GRAMLICH: Since I have done most of the screaming and hollering, I will therefore move that Connecticut be awarded a grant in the amount of $1,435,500. MS. SILSBEE: Is There a second? DR. HABER: I will second it. MS. SILSBEE: © Dr. Gramlich, what was the total? DR. GRAMLICH: $1,435,500. This is arrived at by very crude arithmatic, by taking each two year project and dividing it in half and totalling it with the ones of the one year projects. It's the only way I could really figure it. MS. SILSBEE: The motion has been made and seconded that the Connecticut application be approved at the level of $1,435,500. | MRS. GORDON: I'm just wondering, there's really no way probably that we have of knowing whether dividing the two year project in half leaves you a viable project. MS. SILSBEF: I think in this particular instance, 10 11 12 13, 14 15 16 lq 18 19 20 21 22 126 we have--- MRS. GORDON: --~it's not a matter of a new activi; so much. | MS. SILSBEE: I think we may need some help here from Mr. Nash. The two year projects, are they all new or are they continuations? MR. NASH: I think some of them.are new. The onces, I think, that concern the review committee, the four projects going to Yale and Yukon are for over $800,000 for the two year period. MS. SILSBEE: Mrs. Gordon, because you were not here yesterday, there was considerable discussion with the committee and Dr. Pahl about the two year request. The region recieved its money and has the option of putting some money away for some activities, if they feel they shoudl go longer than two years, if they can work. out some kind of a contractural arrangement, so this is just a way of arriving at a level and I don't think that should be a major worry for you. The Regional Advisory Group will make that decision. Mr. Milliken. MR. MILLIKEN: My understanding is that you have-- my understanding is that Yale was just awarded one of the few large cancer centers---cancer development research. Are they going to be able to spend all of this with the limited staff they have there? tr } ; ' 10 11 12 13 14 15 16 17 18 ‘19 20 21 22 DR. GRAMLICH: The money that goes into the Regional Medical Program aspect of this program would not---this is their community outreach part of the university budget. They won't---I don't think they will have much of a problem spending money. MS. SILSBEE: They have had experience in this. The motion has been made and seconded that the Connecticut application be approved at $1,430,500. All in favor. Could: I see a show of hands? Five. Opposed - the opposed have it. The motion is not carried. I will entertain another motion. | /MR. HIROTO: I move the review committee's recommendation of $750,000 be approved. MS. SILSBEE: Is there a second? MR. OGDEN: Second. MS. SILSBEE: The motion has been made and seconded that the Connecticut application be approved at the level of $750,000. Is there further discussion? (No response) MS. SILSBEE? All in favor? Opposed. The ayes have it. 10 1t 12 13 14 15 16 17 18 19 20 21 22 128 _ INTERMOUNTAIN MS. STLSBEE: the next application to be reviewed is Intermountain and the record shows that Mrs. Klein and Dr. Gramlich are out of the room. Dr. Komaroff was the reviewer. DR. KOMAROFF: Intermountain was rated by the June Council as an above ‘average region. They were awarded 2.23 million dollars, as a result of last council's session. They now request a supplement of $481,000 for 19 new project activities. The last council expressed several concerns which appear---most of which appear to have been resolved and let me summarize them briefly. There has always been a turf problem with the Intermountain regions, the mountain states and Colorado and Wyoming regions. This appears to have been resolved by some interlocking membership of the advisory groups and frequent regular meetings of the members of the advisory group---of the members of each of the three | advisory groups as well as by some joint funding of projects which have a geographical overlap with these three RMP's,. A second concern has been the relationship of this RMP its CHPH agency and apparently, according to the staff review and the CHP letters in the application, there is now a serious review by CHP under consideration by the RAG of CHP. The third concern that the council expressed last i t 10 11 12 13 14 “15 16 17 18 19 20 21 22 129 time involved the role of the RAG in developing and monitcr- ing projects. The region has developed what they call a drag advocate program whereby individual members of the RAG are responsbile for shepherding a project proposal through it's passage and subsequently monitoring that project after it has been funded. It seems like a worth- while idea. There was a question of conflict of interest in the establishment of a health development services corporation. Dr. Pahl mentioned yesterday that through action by the State Attorney General and through meetings with the RMP staff members, this conflict of interest ques- tion has been resolved. There was concern that council epxressed regardingthe university domination of past projects. In this cycle, 18 of the 19 projects were sponsored by outside agencies which may have created a problem, but has solved at least the concern of council from the last time. The directorship of the program and the capabilities of the four staff are deemed to be good by those people who know the region best. I have not visited there. The project proposal, however, seemed to me to be exceedingly non specific and hard to evaluate. They have some very uninspiring continuing education pro- jects and they propose to develope their own audio visual materials. Many of them give the impression of duplicating kinds of activities which have gone on in other regions with- 10 11 12 13 4 - 15 16. 17 18 19 20 21 22 out giving evidence that they plan to build on the experience of others and I have the uneasy feeling that they may be repeating the failures and not the successes of other such attempts at RMP, but it's hard to tell from these abstracts. One proposal is to establish a workshop on drug and alcohol abuse, and I just wonder why they haven't applied through the institute for drug and alcohol abuse or such an activity. It seems to me on the fringe of RMP's funding mandate. Several strong projects are listed. One of the most interesting involves a computerized agency referal for extended services in which they would try to do a better job of referring patients to apparently social service agencies. I would---I'm not concerned that the projects are over inflated as has been described by the past council and the review committee yesterday. In. fact, if anything, they appear to underestimate the cost and time needed to accomplish local objectives, but I have a feeling there is a lack of cohesion about the whole package and I take issue with the committee's decision to fund them at virtually 100 percent of their request and would reduce the request from---reduce the award from $450,000 to $350,000, out of a total request of $480. I would also convey to them again, as council did at its last meeting that the project---the corp staff, not the project staff should include more minority representation, particularly 10 11 12 13 14 (15 16 17 18 19 20 21 22 LOUISIANA MS. SILSBEE: The next region to be reviewed is Louisiana. Dr. Janeway. DR. JANEWAY: I'm the secondary reviewer---I'm the] primary reviewer. The reason why I wanted to take it out of the block was partly to get some technical advice from the staffon this. I am concerned about the application for $75,000. MS. SILSBEE: Bring Dr. Gramlich and Mrs. Klein back in. DR. JANEWAY: I'11 hold my comment until Mrs. Klein gets back. She's a lawyer and she may be able to help. (Dr. Gramlich and Mrs. Klein re-entered the hearing room.) MS. SILSBEE: Is staff ready to listen to the question Dr. Janeway has. Can theycome up to the table, please. DR. JANEWAY: My questions are technical and relates to Project C-10 in the Louisiana application which is entitled "Study of N. 0. Tax Supported Clinics Serving ~ Title 19 Recipients." It's the major request in the | Louisiana Application and I would like to know whether it is appropriate that RMP funds be used to evaluate the activities of the clinics supported by other tax funds. 10 11 12 | 13 14 15. 16 17 18 19 20 21 22 ® 133 One wonders if that shouldn't be the function of either the state, per se or the agency that provides medical funding. It's just a question that I, myself am unable to answer it. I don't have the knowledge. MS. SILSBEE: Mr. Sibloski, do you have any comments? MR. SIBLOWSI: Not really. It's a hard one to swallow. | DR. JANEWAY: I brought it up BECAUSE Nobody in Technical Review even mentioned it. MRS. GORDON: As secondary reviewer, we only figure what they were trying to do was get an impartial judgement on it and the other federal agencies weren't impartial. DR. JANEWAY: It might pay to have Blue Cross come in and do it for them. | DR. GRAMLICH: My impression of the medic-aid level is extremely low. MR. SIBLOWSKI: I can't really respond. I really had some concernwhen I was talking to Dr. Savlier as to why they decided to participate. He was basically saying that the IMP is in the only neutral position in the state to attack it. Everybody else seems to be involved and it's a non biased review assessment and if you look on Page 16, the people all involved in this---are involved with the consulting firm of Shindell and Associates. The Louisiana d 10 1) 12 13 14 15 16 17 18 19 20 21 22 134 Division of Administration and Planning; the Division of Family Services; the Division of Health Maintenance; the Charity hospital systems division and it seems reading in between the lines that many Board members in many it is a non biased type of thing where the organizations, RMP is entered in and is trying to fulfill a certain role. DR. JANEWAY: Let me ask” you---try to explain to me the comments coming out of the HPC in Lafayette, Louisiana to which is attached, at least in my copy a memorandum, the last paragraph which says, "This study is intended to in- fluence the manner in which HEW funds out patient medical services in the state and may result in increased availabili of these funds." I'm only asking this question because I don't want the people in this National Advisory Council to be put in the position of approving something which is against statutes. I'm not trying to hurt the Louisiana RMP. MR. POSTA: If I could make a brief comment. This is not related directly to your question, which I think is quite valid. The last council, if you will remember, one of the reviewers specifically requested to get them more involved with the REgional Medical Program, more involved with bringing the private institu- tions in and the private sectors into the indigent clinic or the hospital system. I'm not saying this was developed 10 ll 12 13 i4 15 16 17 18 19 20 21 22 of all thepeople. 135 totally as a result of that recommendation, but to me it sort of fits into that cline of the Regional Program-~- Regional Medical Program through some of its new leaders who are making a conscientious effort to upgrade the care DR. SCHREINER: My comment to that comment is the last time---it's a very unique system. This represents an extremely high percentage of the state budget going into the support of these hospitals which are really state hospitals and I think it's very superficial to say the private practioneers should get involved at the expense of the state hospitals. If you have essentially a Govern- ment hospital and the physicians there are on salary, there is really no practical way those kind of physicians are going to get involved and this is what they have. They have a network hospital, and a very high percentage of the state budget goes to it, a very high percentage. MS. SILSBEE: Dr. Pahl, I'm glad to see you back. DR. PAHL: I'm gearing up for Texas. MS.SILSBEE: Dr. Janeway has raised the question with regard to the Louisiana application. The project C-10 which J MP funds are going to be used to evaluate the medic-aid services for children--- MRS. GORDON: Tax supported clinic. DR. JANEWAY: Tax supported clinics for Title 19 10 11 12 13 14 ~ 45. 16 17 18 19 20 21 22 136 at least recipients and they are going to contract this out, it says in the memo here they will contract it out to Shindell Associatés. MS. SILSBEE: He is questioning the legality. DR. JANEWAY: Far be it from me to question the legality. I'm questioning whether it is legal. I want some technical input. MS. SILSBEE: That's a better way to put it. The legality of counsel taking action. DR. PAHL: As usual, I am not prepared, certainly on the spur of the moment. I think what we would like to have is your recommendation within.what the legalities are and we can determine then post counsel and act accordingly. In other words, on a technical matter like this, I'm not really prepared to give you an answer that has any force behind it. What I would prefer to do is find out whether it is the consensus of this committee that, if legal, do you recommend that we make the award which would include that or if not legal, do you recommend a funding level which encompasses those dollars, but they could use those dollars for other purposes, so we need your assent and we will determine the legality. DR. HABER: I too was concerned about this project, but in a direction somewhat different from Dr. Janeway. I thought this was a particularly apt use of funds, Regional 10 11 12 13 14 15 16 17 18 19 20 21 22 37 ww Medical Program and at a stage when winding down is in process and when one would hope that funds approvriated for the project would be susceptible to a final verdict, I think that one of the purposes of the Regional Medical Program is the development of innovated projects and certainly the evaluation of ongoing government mechanisms. I agree with Dr. Schreiner assessment that Louisiana is hard put in terms of development of medic-aid programs and I think it would be very useful to get indevendent surveys. I think it is appropriate. I'm not qualified to judgethe legality.In terms of appropriateness, I think we ought to approve it though. «+ MS. SILSBEE: Is there a motion? DR. JANEWAY: In light of the discussion, I move therefore that we accept the recommendation from the technical Committee that louisiana be funded in the amount of $168,680 dollars, pending review by the staff on the legality and appropriateness of C-10. MR. HIROTO: Second. MS. SILSBEE: Dr. Janeway, does that motion en- compass, aS a rule, if they could not spend money on that, that the region should have the money or have it taken awav. DR. JANEWAY : No. MS. SILSBEE: Is there any discussion? . _ (No response) 10 11 12 13 14 15 16 17 18 19 20 21 22 430 MS. SILSBEE: The motion has been made and seconded that the touisiana application be approved at the level of $168,680 with the condition that the funding for the amount of money for Project C-10 be contin- gent on our staff review of the legality and appropriateness All in favor. Opposed. The motion is carried. 10 11 12 13 14 ‘15 16 17 18 19 20 21 22 ' MARYLAND MS. SILSBEE: The next application to review is Maryland. Dr. Wammock, would you get the microphonebefore you start? DR. WAMMOCK: I think so. I was the primary jucce in this case and at the May-June Council meeting, there was a request of $762,000.dollars and this was denied and then they put in a new request for $724,000 dollars and 786 cents and at the meeting yesterday it was approved for $756,000 dollars. I need a little bit of information here. The total program staff. - C-0000 - is that $336,604 correct? MS. SILSBEE: Let me look at the sheet? MRS. FLYNN: That was May-June. MS. SILSBEE: Mr. Nash, could you come up to the os table please? Ms. SILSBEE: Did you hear Dr. Wammock's question? . MR. NASH: I did not. | MS. SILSBEE: Dr. Wammock wants to know what about-- was it 338---? DR. WAMMOCK: $336,467 was the original program staff---total program staff. The original grant in May and * June, the request was then $762 and the new one is for Precera> Staff of $233,000 and $724,000 for July. The Program Stafi of $233,000 with the approval yesterday of $350,000---no, $650,000---that's one-third for staff. 10 11 12 13 1“ - 415 16 17 18 19 20 21 22 MS. SILSBEE: Dr. Wammock, if you will look at the printout labeled 7-74, you will see that the total request was $724,000, of which the staff is $302,961. DR. WAMMOCK: That's right, the indirect column is right. MS. SILSBEE: There was no money provided for staff because there was no money provided from the May application, so this is it. The $650,000 as I understood the committee recommendation yesterday would allow for the . staff, about half for staff and about half for the activitie that were proposed. Is that right, Mr. Nash? MR. NASH: I thin, one of the recommendations was that $250,000 for staff and $400,000 for projects. DR. WAMMOCK: 400 for projects and 250 for staff? MR. NASH: Yes,sir. MR. OGDEN: I think we ought to be aware that a great deal of the activities that may go into this project is staff activities, so that you can't judge the total request for a particular project as being the total cost because some of that. activity is being carried out by staff people themselves. DR. WAMMOCK: I recognize that. MR. OGDEN: So, I don't. believe the action yester- day of say $250,000 for staff and $400,000 for programs is any sense out of line. UF 10 11 12 13 14 15 16 17 18 19 20 21 22 24 14] DR. WAMMOCK: You don't think that's out of line? MR. OGDEN: No, I don't. I recommend that it be accepted the way it was yesterday. DR. WAMMOCK: I just reopened it for the question of clarification in my own mind as to which way this was going because I wasn't quite sure. I went through this thins and looked at the various projects which I described and I don't know whether they're goingto be implemented or not. Perhaps it may do some good and perhaps it may not do any good. I'11 let the motion stand as it is as of yesterday, but I wanted to bring this up for clarififation in my own mind. I make a motion. ‘ MR. OGDEN: I'll second it. MS. SILSBEE: The motion has been made and seconded that the committee recommendation of $650,000 stand. Dr. Watkins, did you have anything to add to that as secondary reviewer? DR. WATKINS: No comment. i i t } MS. SILSBEE: The motion has been made and seconded that the Maryland application be approved atthe level of $650,000 dollars. Is there any further discussion? (No response) MS. SILSBEE’ All in favor? Opposed. The motion is carried. 10 ll 12 13 14 15 16 17 18 19 20 21 22 NASSAU?SUFFOLK MS. SILSBEE: The next region to review is Nassau/Suffolk and. the primary reviewer is Mr. Milliken. MR. MILLIKEN: Was this discussed yesterday? MS. SILSBEE: Yes, sir. Do you have a transcript on that? MR. MILLIKEN: Yes, I do. With the information we had this morning, it would appear that we do have to change our previous decision of no funding. I have no evidence to find fault with or change the review committee recommendation of $900,000, although I personally question if that much is necessary due to‘the situation therein. Maybe the second reviewer has something to add. I'11l make a motion later on. DR. GRAMLICH: I find this interesting. It appears we're reversing our position of June and July. They have made a strong appeal and I guess if council has no major objection to reinstating them, I would have to support that decision. So move. MS. SILSBEE: Second. MS. MORGAN: Second. MR. OGDEN: Could I ask the members of council--- MS. SILSBEE: Mr. Ogden, could you use the microphone. MR. OGDEN: Look at the page concerning Nassau/ 10 il 12 13 14 15 16 17 18 19 20 21 22 24 143 Suffolk. The program staffing here of $343,000 for what they have proposed to be slightly over a $2 million dollar program, now if we're limiting this to $900,000 dollars, obviously we cannot let the entire $343,000 for the program stay, so I think there needs to be something said if we accept the $900,000. I didn't hear the review committee yesterday. MS. SILSBEE: They made the point, Mr. Ogden, it was not in the motion, but it was in the advice to the region. MR. OGDEN: That may be in the minutes. Idon't have: that in my notes. ‘ MS. SILSBEE : The pink slip says: "Based on the funding recommendations for the attending period, it was further recommended that the Nassau/Suffolk RMP be adjusted, Staffing request to be proportionate to the forthcoming award. DR. GRAMLICH: In relationship to the presentation this morning, I was a little at a loss and wondered if the applicant was fully aware of the fact that this council felt they should be in a phase out period ‘MS. SILSBEE: Mrs. Flood. MRS. FLOOD: May I ask if staff has verified that Projects 021 and 022 of the EMS projects are appropriate to the atllowable concepts of our funding. 10 11 12 13 14 15 16 17 18 19 20 21 22 144 MS. SILSBEE: We have had a return from Mr. Reardon who is EMS Systems Chief and he doesn't see any problem with regard to their portion of the legislation and we got a telephone call this morning from the part of HRA that is administering the training part of EMS and they also do not see any problem or conflict. That is not to say they are looking at it from any other standpoint but that. MS. FLYNN: Those two line items approximate $400,000 dollars and even though we're recommending. from committee that their staff be brought into line by readjust- ment according to the award, if they're just given an award without further recommendation, other than stafé limitations, it would appear that their only endeavor would be emergency medical services and emergency medical training. MR. STOLOV: We have received the priority level on the projects and the equipment is below the $900,000 dollars, however, the EMS training is above it,but again, I feel it is expensive, but it was their determination where to put the Money once they get this $900,000. They may not put it all into that EMS training. The Nassau County which is the more populated and richer county is way down at the bottom of ‘their priority list. MR. OGDEN: Would you explain to me what this $355,000 is, how much of this would be funded out of the ~ $900,000? 10 11 12 13 14 ‘15 16 17 18 19 20 21 22 24 MR. STOLOV: I believe Dr. Pahl mentioned yesterday : that we still have not developed policy regarding what hapvoens in terms of independent RMP beyond June of '75, so we don't know HEW wide if this is allowable under grants and administra- tion practices, but I believe it would have been a contract in their own Nassau/Suffolk RMP Inc to carry this out in this. scope and amount. When the. committee looked at this, it did not consider this in their funding level. They left it out. MS. SILSBEE: The Chairman suggested the $2,000,000 request be cut down to $900,000 and that maybe a moot issue in terms of continuing the program or putting money aside. DR. SCHREINER: I was primary reviewer on the last go round. MS. SILSBEE: According to the old assignment list Mr. Milliken, you had it last year also. DR. SCHREINER: I was hoping it would be somebocy here. I'm very impressed as Dr. Scherer happens to be an old friend of mine and I was wondering if this was in line with his $900,000 speed. DR. PAHL: Mr. Milliken, right, I'm afraid you're MS. MORGAN: Mr. Milliken, you were it last time. MR. MILLIKEN: I don't recall all the details. MS, SILSBEE: In terms of making the assignments, I try to keep them as consistent as possible. f { it. : MR. MILLIKEN: On the yellow sheet, the second yellow 10 11 12 13 14 15 16 17 18 19 20 21 22 146 sheet, the second item CO-5,COG-5, Grantee Central Service. | Could somebody explain what that is? , MS. SILSBEE: That is what we were just discussing. MR. STOLOV: It's an independent RMP, therefore according to instructions, they should close by June of '75 and they have to issue contracts to extend beyond that period and they felt it would be good use of Government money if they continued to fund the grantee should over ride contracts be issued. DR. PAHL: I was about to make a statement on that when we got to Dr. Schreiner's question. We have a policy which comes out of the DHEW decisifon not to permit staff or an RMP to perpetuate itself beyond June '30 of '75. To merely state that all grantees, regardless of what they wish ta do in terms of contract activities may not engage in that kind of situation which would perpetuate the RMP or the staff beyond June 30 of '75. They may contract with groups to carry out activities past June 30 of '75, bu not in such a way to perpetuate themselves, so if Nassau/Suffolk, and I don't know the details of this, if Nassau/Suffolk or some other RMP has funds in.it which, in effect, would continue to support staff beyond that point in time, then I believe we would take appropriate administrative action with our office of manage- ment because we're applying a uniform rule in accord with departmental policy. I hope I have made that distinguishing i { q i 10 11 12 13 14 ‘AB 16 17 18 19 20 21 22 24 147 line rather clear. MR. MILLIKEN: I still go with the action of June and the report of the committee unless there is new informaticn or evidence that shows reconsideration should be made. MS. SILSBFE: Would you state that motion again and into the microphone so we can all hear it. MR. MILLIKEN: I’move the committee recommendation of a phase out award of $900,000 be awarded to this state. MS. SILSBEE: A "phase out" award, do you want that stated in the motion? MR. MILLIKEN: Yes, I do. MS, SILSBEE: Is there & second to that? MR. KOMAROFF : Point of clarification. Would you resolve your ambivolence? MR. MILLIKEN: I will remove from the motion the "phase out" words, but I would like staff to be instructed to have them understand that this $900,000 dollars is for the purpose of helping conclude their efforts and not continue . the program as they proposed. DR. PAHL: I'm not sure I'm going to clarify this situation at all. I think we do understand that in all of these recommendations, particularly where there has been some drastic cuts from requested levels and I'm sure more so in the case of this region, that it will have a very serious impact on their program development. I think it would be 10 il 12 13 14 15 16 17 18 19 20 21 really in error for us to characterize this more than some others that we have been concerned with here as phase out or terminated. I think we really should only accept the motion for a funding level recognizing that probably what you say will cause serious dislocation from what they had anticipated. MS. SILSBEE: Would you restate your motion. MR. MILLIKEN: I move that council accept the committee recommendation to fund this agency at. $900,000 dollars. MS. SILSBEE: Is there a second? MRS. MORGAN: Second. ‘ MS. SILSBEE: The motion has been made and seconded | that the Nassau/Suffolk application be approved at the level | of $900,000. Is there further discussion? | DR. WAMMOCK: I would like to ask a question about 32 family nurse practical and critical care nursing patient family nurse, that comes to $150,000. Will somebody explain | that to me? MR. STOLOV: Your addition is correct on that. MS. SILSBEE: What do you want explained, Dr. * Wammock? > DR. WAMMOCK: Are they going to train practical nurses or what? ‘ MS. SILBEE: We don't know if thev're going to do 10 ll 12 13 14 15 16 7 18 ‘19 20 21 fey anything because they have had a request of $2 million. Jerry, do you know the purpose? MR. STOLOV: They are separate projects. One is the university base and the other is a community base. One is nurse trained - nurse practioner and the other is more of a socio emotional thing to train nurses in giving support to families who have critical illnesses. They are different projects. MS. SILSBEE: The question is, where do they fall on the priority list? MR. STOLOV: I'll check that out on my paper work. DR. GRAMLICH: May I ask a question? It does not relate to the subject at hand, but it does relate to the Nassav question. In one of the other regions, we find that the regional advisory group apparently worked very well and in Nassau/Suffolk, they apparently did not. MS. SILSBEE: That has a long history. I think they actually didn't have a combined board. There was a combined grantee and we made them have ,a different regional advisory group and a different council. Thre was some overlay “but the combined grantee situation did not work out andthat was was about a year ago September or so. We had joint staffing too, Dr. Gramlich. MR. STOLOV: I have on both projects my paperwork. 10 11 12 13 14 ‘15 16 17 18 19 20 21 22 24 150 On both projects - family nurse practioner which was $142,000! project, it ranks number 11, which the critical care nursing i project, Number 16.: The dollars fall out, if they stick to | i 1 { the original dollars submitted, $860,000 off of projects 1 through 10 and it stops at venereal disease. These are well below the level again. MS. SILSBEE: So'they would fall out. MS. FLYNN: If I may just ask, does Project Number 29, fall out. MR. STOLOV: Project 29 does not fall out. MS. SILSBEE: That project--- MS. FLYNN: They left their priority and spending dollars the same? MS. SILSBEE: Yes. There is a motion on the floor. MR. STOLOV: Mr. Ogden raised the question, what was the title of the project. MS. FLYNN: It's a computer analysis of whether health educational materials have been written by authors in a leval that is readable by the health care consumer. $36,000 dollars to have a computer analyze all health education materials so it will be at the 4th grade reading level. "MS. SILSBEE: There's amotion on the floor to the effect that the Nassau/Suffolk applications be approved at the level of $900,000 dollars. Is there further discussion? * (No response) 10 11 12 13 14 ‘15 16 17 18 19 20 21 22 MS. SILSBEE: All in favor say "aye". Opposed. The motion is carried. McLane oe 10 11 12 13 14 ‘15 16 17 18 19 20 21 22 MRS. SILSBEE: Mrs. Flood, we will convey your concern for this complete documentation at what level health education materials: need to be prepared for consumability capability. As this discussion went on before you finally | acted, there was reluctance, but in terms of the final action | Yassau/Suffolk now has $909,990. We will be glad to work with them further on this. rm2 10 11 12 13 14 15 16 17 18 19 20 21 SOUTH CAROLINA MRS. SILSBEE: The next application to be reviewed is South Carolina, and Dr. Haber, you are the vrimarv: reviewer. DR. HABER: I must confess -- ( MRS. SILSBEE: Could you talk into the microvhone, sir? DR. HABER: I must confess to a larger decree of | confusion about this protocol than I felt on first reading it. It seems to me that it is difficult to reconcile the | reviews that we had in June with those that are submitted now.! | I wonder if staff could accommodate me to the extent of dis- | cussing one of the major issues of the concerns that we had 2 at our last meeting about the involvement of the Governor's office in the RMP. Could that be briefly clarified now? MRS. SILSBEE: Mr. Van Winkle? MRS. MORGAN: The Governor is going to resign tonight, MR. VAN WINKLE: Dr. Mosley has recently sent us,- | not a series, a whole bundle of correspondence, menos. He has been in touch with these people. I don't think it has been resolved. Negotiations are going on. I am not sure ‘there is any resolution in terms of getting them to agree to agree. MRS. SILSBEE: Would you speak into the microphone. MR, VAN WINKLE: The region originally resvonded rm3 10 11 12 13 14 "15 16 17 18 19 20 21 22 154 very vehemently because they felt that the representatives of the Governor's commission had been a part of the -- both the technical review and the regional advisory groun in which the decision had been made, and there were none of these difficulties raised, and they felt that the project had haa proper review, but we have been explained by phone, the council's condition took the consideration, but still felt there had to be a resolution locally. That has not yet occurred. DR. HABER: Well, that is unfortunate, of course. - “Nonetheless I feel, and my contention is that the funding review that some of the reviewers have recommended for this is unduly harsh. I feel that this has been a good program. “tn the face of adversity they have tried to keep it together. They have replaced their losses with admirable fortitude. I think that many of the projects are well constructed and conceived. It seems to me we are criticizing them, or at least some of the reviewers are criticizing them, for a wide “variety, apparently, of disorganized projects, and yet in the earlier criticism was that it tended to be too global and not specific enough, so we are getting them both ways, and. *I think this unfortunate. Again, I feel that many of the projects are well constructed. I feel that there is no point in our perpetuating our own indecision or worse, contrary views, rm4 10 li 12 13 14 15 16 17 18 “19 20 21 22 24 155 towards them. I think they have had the endorsement on pages 194 and following the CHP RMP annual review conference. | t think that they Have; it seems to he indicated the ultimate - phase-out of this by modest extensions of some of these activities, and I would suggest that instead of the vrovosed level, that they should be funded at a level of a million dollars for the supplemental request that they have come in, | which is some $473,000 less than they have requested. MRS. SILSBEE: ODr. Komaroff£? DR. KOMAROFF: I think a series of projects, 66 projects which are described here, can both be vague in their individual description and disconnected, without anv kind of sense of cohesiveness, and I -- well, that in fact is. ny feeling about reading this application. ‘ie have a region that is a relatively small state in terms of its population which is already funded at a level of two million dollars, and I have kind of a gut feeling that their supplement ought to be closer to $400,000 recommended by committee than an additional million dollars, bringing our level up to three million. DR. KOMAROFF: I will summarize. As an example of my edginess, I will tell you why I am edav. Yesterdav there was a question as to whether the RAG had set any priorities among these 66 projects. Now, in fact, there is a listing of priorities, but you will notice that the ranking. | i i j rm5 ao 10 11 12 13 | 14 15 16 17 18 ‘19 20 21 22 24 South Carolina in recent months. Some of the other regions ! over ambitious, in a region that was already quite well 156! of the projects within each group is in exact ordinal sequence to the numbers of the project. ‘hat I mean is | these projects which are rated one through 12 are projects | number 91, 2, 3, 4, 5, 6, 7, etc. You have the feeling that unless they numbered the projects after they set priorities, that this priority rating is simply a kind of -- a joke. whey just took blocks of projects in sequence as they appeared in their numbering and gave them, quotes, "priority rating." That may be unfair to the region, and the staff knows whether this region numbers its projects after they give them a- priority rating which would be guite unusual in my experience, then I would be mollified. MR. VAN WINKLE: I don't know when they number them. My guess would be that that is one of the last orders of business before they mail to us. I haven't been down to when thev prepare those, they prepare them by title only. MRS. SILSBEE: Thev have their own local numbering system, and then they relate it to ours. DR. KOMAROFF: It may be nothing, but I had a feeling i reading through this that it was kind of poorly connected, | funded for its size, and I would be reluctant to bring their level up to three million. MRS. SILSBEE: We don't have a motion on the floor. rm6 10 11 12 13 14 (15 16 17 18 19 20 21 22 157 DR. KOMAROFF: Could I move five hundred thousand? DR. WAMMOCK: I second that motion. MRS. SILSBEE: The motion has been made and seconded that South Carolina application be approved at the level of $500,000. Is there further discussion? (No response. ) MRS. SILSBEE: All in favor? VOICES: Aye. MRS. SILSBEE: Opposed? (No response.) MRS. SILSBEE: The motion is carried. rm? 10 11 12 13 14 ‘15 16 17 18 19 20 21 22 24 L535 TEXAS MRS. SILSBEE: If we go alphabetically, we come + to Texas. MRS. FLOOD: We are going to Texas? MRS. SILSBEE: Mrs. Flood is going out of the room. Has the Texas pink sheets, or white, been distri- buted? MRS. MORGAN: No. MRS. SILSBEE: Let's distribute them. Off the record. (Discussion off the record.) MRS. SILSBEE: On the record. You will recall that the May application from the Texas regional medical program included requests for funds for a series of contacts of which the ideas were spelled out in the May application, but the specifics regarding who was going to carry it out and what institution and the amount for each contract was missing because that was going through their local review process at the time that it was going through the national review process. Council considered this application and decided “that in general the goals and objectives of the region and the general management of the region seemed to be sufficient to enable council to delegate to the review committee which at that time had felt that it was going to meet in June or rms 10 11 12 13 14 16 16 7 18 19 20 thing in the 12 months, and they didn't want to slow them had met in August, which was yesterday, and they discussed 159- July, to delegate to the committee the authority to look at the individual project proposals and recommend whether that money should be released or not, so in effect council made a recommendation of -- well, let's see if I can find it now. They recommended that the Texas application he funded at the requested level of two million three hundred and thirty- three, five hundred and fifty-one, pending the satisfactory review of the specific contract proposals by the July review committee. This was to enable Texas to go ahead because it was a non-profit corporation that had wanted to do their down in that process. The July committee was not able to meet, and they the application. Now, Mrs. Morgan, I am going to let you pick up from there. MRS. MORGAN: Our pink sheet that has now turned white, the application for funding for the various contracts of one million four hundred thousand dollars was what was left over from our meeting in June. The review committee * recommended the use of one million dollars. The reviewers were still apprehensive regarding the monitoring capabilities ; | we have had, and I don't believe the review committee had this information, and this is that they are going to activate their rm te 10 11 12 13 14 ‘15 16 17 18 19 20 21 22 169 review committee which will consist of on this, plus members from the RAG. The concern of the review committee was health professionals reviewing these projects. If you are familiar with the Texas RAG, it is practically all health professionals. About 95 percent of them are physicians on the RAG, and these | physicians are going to be the ones, and this is from the material we have received,.who will be on the review committee. There is no question in my mind but that there will be health | professionals reviewing these area contracts. They have sent in their form, which is a six page form. It has to be filled out monthly on the various contracts and sent in; will be reviewed by their committee. & havein my mind no doubt that these will be reviewed by health professionals, and I would like to move that the level from June meeting of one million four hundred thousand be returned to the Texas RMP. | MRS. SILSBEE: Dr.Schreiner? DR. SCHREINER: I ama little bit confused about the back and forth thing and the old grant. If you could clarify that a little bit? In other words, are you -~ I didn't hear the discussion yesterday on this particularone. ‘Are they proposing any additional new money? MRS. SILSBEE: No. Well, they are. I was going to ask Mrs. Morgan if she would mind rewording her motion. We gave them an award for two million three hundred whatever t 7 rm19 10 11 12 13 14 15 16 17 “18 19 20 21 22 161 it was, and we restricted 1.4 million dollars pending the satisfactory review, so in a sense they can't spend that 1.4 million. DR. SCHREINER: It is called internment. MRS. SILSBEE: Internment for a reason. The action; of the committee yesterday would release one million dollars of that. Another four hundred thousand, presumably, would come back here, and they would not be allowed to spend it. MRS. MORGAN: May I change my motion to state that we released to Texas RMP one million four hundred thousand dollars of impounded funds to them? DR. PAHL: We remove all restrictions. MRS. MORGAN: In other words, restrictions are reroved from Texas. DR. WAMMOCK: The restricted funds is what you meant, and not impounded. MRS. MORGAN: Had this one million four hundred thousand dollars been released in June to Texas, they were not planning on coming in on this cycle four, any money at all. DR. SCHREINER: So this comes out of the 84, not ‘out of the 20. Thatis what I wanted. MPS. MORGAN: It comes out of that money. MRS. SILSBEE: The money that has already been awarded. rmil 10 li 12 13 14 15 16 17 18 "19 20 21 22 24 162 DR. SCHREINER: I will second that motion. © MRS. SILSBEE: The motion has been made and seconded that the restrictions on the contract funds in the Texas award be lifted. Is there further discussion? MR. HIROTO: Question. MRS. SILSBEE: All in favor, aye. VOICES: Aye. MRS. SILSBEE: Opposed? (No response.) MRS. SILSBEE: The motion is carried. rm12 10 11 12 13 14 ‘15 16 17 18 19 20 21 22 24 planning, for the normal planning of CHP programs, which I VIRGINIA MRS. SILSBEF: ow we go to Virginia, and Dr. Watkins. . DR. WATKINS: I have no problem with Virginia. This is Virginia, and Dr. Perez has changed the face of the whole program. Miss Martinez had a question. MRS. SILSBEE: Miss Martinez? MISS MARTINEZ: In thinking over the project descriptions, I notice that a great many of the projects are really supportive or extending grants to CHP's for am not sure is terribly wise, even if it is legal. In anv case, I think the committee recommended nine sixty-three? MRS. MORGAN: It is nine sixtv-three eight sixt’. MISS MARTINEZ: And I would like to reduce that sum somewhat to seven-oh-seven seven fifty-nine. I just went through the projects, and eliminating things like nutber . 48 which is a grant to a CHP agency for a -- MRS, SILSBEE: Miss Martinez, in terms of what vou are recommending there, have you, are you aware, that a message was sent back to the regional medical programs “concerning the need to do -- or to get geared up for health resources planning and that this should be done in collaboratio with the CHP agencies? - MISS MARTINEZ: No. rm13 10 11 12 13 14 45 16 17 18 19 20 21 22 MRS. SILSBEE: And this was a definite sugqgesticn that was given to the regional medical program back in “arcn or April, sometime like that. MISS MARTINEZ: All right. It doesn't seem to ~e that any of their projects are terriblv innovative or forvareé looking, but if that is with the RMP -- MRS. SILSBEE: No. If you don't thinkthe activities themselves, that is fine, but as far as being legal, this is something they have been sort of urged to do. MISS MARTINEZ: All right. Are you satisfied? DR. WATKINS: Yes. When we were on site, we were very hard on them, and I feel that Perez has done a good job in changing that program. He has changed the RAG, he haS& increased the minority representation, minority input in the urban areas, and I think I would like to ‘see it remain as is. MISS MARTINEZ: Okay. I will reaffirm the committee's recommendation. MRS. SILSBEE: Is there a second? MRS. MORGAN: I am seconding. MRS. SILSBEE: The motion has been made and seconcéed that the committee recommendation on the Virginia application to approve the application at the level of $963,860 be aporovec, recommended. Is there further discussion? * (No response.) rml4 10 11 12 13 14 15 16 17 18 19 20 21 22 MRS. SILSBEE: All in favor? VOICES: Aye. MRS. SILSBEE: Opposed? (No response.) MRS. SILSBEE: The motion is carried. rmi5 . 10 11 12 13 14 met) 16 17 18 19 20 21 22 166 WESTERN PENNSYLVANIA MRS. SILSBEE: Now we will go to Western Pennsyl- * vania. MISS MARTINEZ: In that case I would like to do the very same thing on ‘estern Pennsylvania because the number that I cameout with was about a hundred thousand dollars less. I had subtracted number 49 from that, so it comes out more or less the same. MRS. SILSBEE: Would you move? Would you put the Gollar in? MISS MARTINEZ: Four hundred fifty thousand. MRS. SILSBEE: Is there a second? MR. HIROTO: Second. MRS. SILSBEE: The motion has been made and seconded that the Western Pennsylvania application be approved at the level of $450,000. Is there further discussion? MRS. MORGAN: Question. MRS. SILSBEE: All in favor? VOICES: Aye. MRS. SILSBEE: .All opposed? (No response.) MRS. SILSBEE: The motion is carried, and that ends the review of the applications. rm16 10 11 12 13 14 15 16 17 18 19 20 21 22 24 resolution. 167 DR. GRAMLICH: May I open up one more small subject? DR. PAHL: We have that as well as Mr. Ogden's DR. GRAMLICH: I mean relative to this project, specifically Mississippi. MRS. SILSBEE: Yes, sir? DR. GRAMLICH: There is a very strange request and it is kind of -- the review committee didn't pay an awful lot of attention to it, a two million dollar, roughly two million dollar request for hypertension screening and treatment program including one million dollars for salaries, and included in that salary scale was 82 public health nurses who presumably are already on deck, so that the RMP funds as far as I can determine from the grant requests, be used simply to supply what is now being spent. by the state health | department. Included also is $500,000 plus or minus for - i drugs for treatment of some possible 11,9090 hypertensives. | Now, the review committee's attitude is, it is a poor state | and they have got lots of blacks and they need all of this, | but there was no particular attention paid to the construction of the budget which included apparent substitution of RMP | salaries for what are now state health department salaries. That is one item. The other item is, if the treatment to be applied to the suspect hypertensive or to discover hypertensive which rm17 to 10 11 12 13 14 “15 16 7 18 19 20 21 22 168 is to be administered to the county health officer in each county. Now, this poses a problem of practice of medicine, if you will, by RMP funds. If the council feels this is appropriate, this is fine. All I want to do is bring it to the council's attention to make sure it is considered appropriate. This has to do with Mississippi only. MRS. SILSBEE: Is there discussion on this point? DR. KOMAROFF: Can staff enlighten us as to whether this will supplement the resources of the state health department, or merely supplant them? MRS. SILSBEE: Mr. Van Winkle, there are two issues here, in case you couldn't hear. MR. VAN WINKLE: I heard. I was trying to hide. My answer is, no, I don't know. I read the application. We did ask that they include the full, when thev sent in, not the center form 15. That is all vou would have had. I presume that Dr. Vaun looked at it, being the primarv reviewer. He did not discuss that; however, as far as practice of medicine, we have been in the habit of doing it for years on demonstration projects. I do know that they proposed to take these over and continue it after this first ‘year funding. The government has put already a line out of its budget to supvort it, but I do not know if these nurses are on bid, or if they intend to hire new ones. I just don't know: rml1s8 10 1 12 13 14 15 16 17 18 19 20 21 22 24 169 MRS. SILSBEE: Dr. Komaroff? DR. KOMAROFP: I looked at that application -last night after our discussion, and I had the impression that it was an unusually well documented request, but probably what was going on was that RMP money was offsetting certain | expenditures that were part of the state department of public) health this year, but that the quid pro quo was that the government was going to take over the support of the program in future years, and that that seemed to me a reasonable bargain; consider the imoortance of this problem in that state medically. DR. GRAMLICH: I am satisfied. Thank you. DR. PAHL: I have two items of business before we adjourn. 10 11 12 13 14 15 16 17 18 ‘19 20 21 22 . 170 the First is that the action which had been tazen, Gecisions made b y this Council result in a total recommended dollar level of $27,154,374 which is $597,220 above the total recommended to you by the Review Committee. te recommendations; five regions had some amount added to the committee's recommendations, and in two cases, your recommencati were to reduce the Committee's recommendations. “he second item of business I would like to come at ty a back to, unless there is Aiscussion on that -- Dr. Komaroff? FOMAROFF: Does that mean we approve less DR. money than is available to spend? How does that affect the policy we approved earlier today about pro-rating a kind of an extra supplement after the fact. DR. PANL: We are in just fine shape at these lavels. We ended the day very happily. ™he action you Q took this morning and the recommended dollar level is going to permit us to distribute all of our monies and denending on what happens over the course of the Fall, we will be able to - with the formal order that you endorsed, | be able to accommodate any change there. So, managerially evervthing is okay. DR. JRURBVAV: Eowas just checking -- at xa TTT DR, PRMT? Wi : When you frown, I am not so sure thing hape. m Ky 0 ee ° 3 M4 G Oo Q oO 3 ou n JRNEWAY: I was checking my own mathematics NP? RAN Lileharecd because I thought we had added $331,909, but it is such 40 of the regions you concurred with the Committee's 10 11 12 13 14 ry 4 1 | » a small amount of difference, only $309,999, 171 DR. PAIL: If there is a difference, we will either take it out of FPdith's salary, or give it to her. We have one of these Fantastic data -matic aides on sale, or something, and there is voltage fluctuation and during one of my afternoon telephone calls, I found maith sitting poking these keys. At the same time, doing everything in long hand because with voltage fluctuation you don't end with the same digits you should. So, I think we better go back to lead pencil and paper. I gather the correct figure is $27,349,054. ‘Another one of the rumors. re I have received information, also, again, I don't know whether it is a rumor or not,but presumably it has -been announced out of the White House that, as you know, there will be announcement either at 9:09 -- and now some people say 8:30 - and Congressman Ford is to undergo his inaugeration . een: at 6:00 p.m. tomorrow. I quess we will all learn as to go to airports whether this is rumor or direct, This was given to me as a statement. The other item of business which TI bn more firm ground ab out is to reconsider the resolution that Mr. Ogden introduced, and which we tabled until hopefully you had an opportunity to look over. The summary material pertinent to the resolution. Mr. Ogden, I think we have distributed this to each person. Perhaps, you would like to make some comments. MR. OGDEN: I hope that many of you have had an 10 ll 12 13 14 ‘15 16 17 18 19 20 21 | 172 opportunity to look at the material headed "Summary of the “ational Health Policy Planning and Mesources Development Act of 1974," , m7 Dr. FKomaroff, who is sitting next to me here, has probably gone through it a little more carefully than many of you and underlined the areas and I will call on him just in a few moments for his comments. But, in going through this piece of legislation I found no place where I could find anything that fitted the function of any existing regional medical program, save perhaps some of the programs which are in fractions of states, such as some of those perhaps in the State of New York. If the Governor of the state were to decide the health service area, for example, was Nassau/suffolk - pernarps Nassau/Suffolk RMP could become the health service systems agency in that particular area. Dut, this particular piece of legislation while it seems to encompass Hill Burton almost completely and you will find that comes up on Page 5 on the description of the health resources development ~-- the only place that I find RMP perhaps even suggested is on Page 6 under Area Health Services Development Fund. Now, remember here we are talking about a health system agency. Now, health system agency is a non-profit fee wy private operation on a local or area-wide basis. But, th is a health service area nonulation of less than half a million. It is not permitted. It can be up to about two million, as I recall lir. Rubel's comment yesterday. But, it would encompass-the health service area would encompass any te 10 11 12 13 14 15 16 17 18 19 20 21 22 173 standard metropolitan statistical area, which is entirely with a boundry - it can a over state lines, but there are literally, I understand, 190's of SMSA's in the United States. So, that what we are looking at here is an area nealth services development fund which is going to be a localized thing, and indeed we find that the grant that can be made for the development within one of those on page 2 - no single grant or contract may exceed $75,000 he made for more than two years. It simply talked about the area health services development fund. ‘This is why I have proposed this resolution. That this piece of legislation - it be suggested that this be amended to give each state the statutory and financial support to maintain a separate health systems development ‘agency on a state-wide basis, So, that at least we have sonething similiar to the RMP's we have today who can perform a state-wide mission or function. And, indeed, wo could even say, going beyond state lines. But, I suspect the kind of legislation we are se cing coming up here is. going to be limited to state boundries and national health insurance. may indeed have in it have some sort of state-wide function mechanism, So, I propose this resolution and in it, the : second part of it I have said, "The comments that proceecce and the resolution itself be transmitted to the ct tae oy OQ Ht oO wh 9 he he members of the Rouse Interstate and Foreign Commerce Committee -~- and by that I meant to encompass the cess aha nat I made Magnuson to Senator Kennedy, which in the letter from Senator t i t en} 10 11 12 13 14 “15 16 17 18 19 20 21 22 24 ‘to be able to have the continuation of somethinglike the . There was a motion introduced and seconded, I think 174 I read to you earlier and which should arpear in the transcript Bh of the minutes of this meeting. I can aive you that letter if you would like t6 Merox it. I would like to have it back. But, I will be happy to hand it to you. | tT do recommend that we do this. I am quite concerned that the kind of legislation that we see coming out simply does not recognize the place that regional medical programs have come to serve on the American scene. And, certainly many of us who worked with this program since its i énception eight years ago this Spring feel that it has accomp]3 far more than it has been given credit for and that it has the potential to accomplish a great deal that is goingto be necessary in order to make national health legislation function when it begins to deal with the very complicated undertaking of the delivery of services and the delivery of care. . . And, it seems to me that unless the providers of this Mation are given an opportunity to “axe their in put through something like RMP, that the success of national health insurance is jeopardized and I hore that we are going regional medical programs. DR. PIL: Phank you, very much “Mr. Ogden. possibly... . DR. WAMMOCK: Second. DR. PANL: Thank you, Dr. Wammock. I think there should be room for discussion by 10 11 12 13 14 “15 16 17 (18 19 20 21 22 175 Council on this important topic. Dr. Komaroff? DR. HOMAROFE As I look through this, the Bill, the thing that concerns me is that all of the various agencies which would be created by the Bill seem to relate to planning and to the monitoring of facility expansion within the region. That there is no sense or very little language that would relate to what you might think of as perational arm of such an agency, or group of agencies to actually do demonstration projects in health services. And, the funds that are alluded to 3l4a and b funds, I believe, are by title 9, Planning Funds. Not operational funds. ‘ So, as I understand your motion,Bob -- I am unclear about your first -- the first component of it. Do nee you mean that oe operational agency would . be independent of The ncengi ~ MR, OGDFN: Yes, I do. DR, HONAROFF | tree ne really the nub of the question. Who reports to who? I believe that there ought to be a separate and clearly oS and funded operational tT am bothered, though, at the ee prospect of having that agency wholly separate from the DR. WAMMOCK: I will_yield to you. DR. JANEWAY: 30 seconds? DR. WAMMOCK: 30 seconds of my time. DR. PAHL: Dr. Janeway. ! leadership, or whatever, supervision of the planning agencies.) . : 1 10 il 12 13 14 15 16 17 “18 19 20 21 22 1 DR. JANEWAY: I would support, quite frankly, the Separation of the planning function, particularly the strategic planning function, to use a managerial term, which is implied by the summary of the legislation - proposed legislation. I think that to have planning and control - when I say operational control - the implementation mode of any kind of management function in the same agency is courting) disaster and, although, I would agree with you, Tony, that there has to be a responsive inter-relationship, that there is so much to be gained by having the planning function separate from the implementation function. That, I would certainly be prepared to support a resolution of this nature. DR. KOMAROFF: Why do you feel it would be courting disaster. Are you thinking back to experience between RMP and CHP? “ £ DR. JAMEVAY: NO. I am thinking in terms of tn management function and there is room for disagreement in this a Control Syste but if you read Antho1 mS we the possibility of the planner becoming so involved in the plans that the implementation becomes impossible, or frat sia eae cee ese there is no outside requilation of it. It puts too much power in one place. a Mow, there are admittedly some managers who Gisacree sith that and say the planning control ought to he in tne same agency, ff you set planning or isolate it you develos think tanks that don't drain anywhere. But, if you put planning and control in the same vo 10 11 12 13 14 15 16 17 18 “19 20 21 22 -to come into beina. But the legislation just simply doesn't 177 acency, vou go to the opposite extreme where you think that by creating an infinite number of haystacks will give you an infinite supply of needles. Pe. EOMAROFF: It cuts both ways, but the for the reason you just cited, it seems to me that the providers would more likely be attracted to these kinds of planning agencies, and therefore, the doing of reasonable planning. If there were some - or more tangible operational components that they could be involved with. t think one of the problems with CHP has been that the providers have found it unattractive because it was so abstract and so unrelated to subsequent tangible accomplish; ments and if there could be some uniting of this operational arm and the planning arm, so that what the operational arm was doing didn't in fact thwart the rational plans of the region, then it would seem to me to make more sense. DR. JANEWAY: What I was trying tO indicate is that I would hope that the planning function would not thwart the normal operational arm. MR. OGDEN: I think that this, perhaps, could be. corrected by having the development component also report which is lth planning and development acency na NASR RCH EARLIER DEEL I ES mee ae assumed to exist under this piece of legislation. It has spell out sufficiently how that development is going to take place, except for these very local agencies. And, I would like to see drafted into this piece of legislation the provision that there be a separate health s ni! ystems development aM paeaew ae 10 11 12 13 14 15 16 17 18 19 20 21 22 24 ever you want - try to plana health program. It seems to states on the Western side or the Eastern side together to 178 agency within the state health planning development agency ‘ a ia aa re Tie EN ET agin OC al Fran structure. DR. KOMAROFF: But it would report to the state health planning agency. I would support that. MR. OGDEN: I don't see how it could do otherwise. I don't think it would report to a central body in Washington, D. C. It would have to be on a state level. DR. WAMMOCK: I have been somewhat disturbed since I have had the privilege and the opportunity to serve on this council, and in particularly in fact seeing the ministries fractured or other number of states or group, region - what me to be a rather difficult situation to put two or three wed them, in the North and South - to wed them, in one program. I don't see how this is possible to develop any worthwhile health system care delivery, or whatever you want to call it, unless vou have it ona state-wide basis and you have all the components of all the agencies that are involve in this kind of a system yorking together. Because if you are going to put it in one community or another community, or 15 different projects, unless it comes under one umbrella, they are going to be in difficulty. I base this on what little bit that I know about the operation of the regional medical program, and from the standpoint of a state-wide operation that something has come out of this. But, if te 10 11 12 13 14 15 16 17 18 “19 20 21 22 179 it gets dissolved -- and I haven't read this -- and if I read it I am guite sure I wouldn't know what I was reading. “n s - the third or the fourth time ues t kac jad I may have to read or the fifth time, and may not know what 7T was reading. My own personal feeling is that I am probably too close to the trees to see the forest, or the forest to see he the trees. Or whatever you call it. Forest-trees, trees~ MR. OGDEN: Woods. DR. WAMMOCK: I think that, as Mr. Ogden has pointed out and someone else, that people don't know about the good that the RMP has done and I think it is pretty nard to get across to people what RMP is and I am sure that there are a lot of physicians that do not understand th Nae ae the operation and the mechanism of the RIP program. Some o them feel that it has not been worthwhile, but I personally feel that it has been worthwhile and I think this resolution here drawn up by Mr. Ogden. I want to congratulate him for the foresight and the merit and the courage and the good common sense and judgment to draw this up and’ I think we need to support this resolution and somehow or another get it across. | How effective it will be as far as Congress is concerned, I don't know. . PAHL: Is there further discusSion or modificatidn n ds J e 2. KOMAROPP: I would like to add some language ive uo that makes it clear that this health svstems development agency will support demonstration health services projects. 11 10 1k 12 13 14 15 16 17 18 19 20 21 22 24 180 I don't tHink that health services is written in. i am not sure it is guite clear how this agency would be different from the planning agencies that are in the current§ bill, and secondly, I think we ought to state that this , separate agency would report to the state health planning and development agency that is described in the Bill. DR. JANEWAY: Would you read it to us? DR. KOMAROFF: Read the proposed language? I haven't written it yet, but I will. How would this be: “Resolved: That the Congress or similar legislation give to each state the statutory and financial support to maintain a in adopting HR 16204 separate health systems development agency which supports demonstration projects and health services. This agency would report to the state health planning and development agency, or similar independent -- I am sorry - agency ~~ and be devoted exclusively to such work. And be it further resolved -- DR. WAMMOCK: Dr. Komaroff, I am sorry, but you are getting too wordy there. We are going to get lost because I think the first sentence-what you say - the health systems development agency on a state-wide basis -- and I think health systems development agency is very comprehensive. TO me it is. DR. HABER: Might I suggest Health system development and-demonstration agency. MR. OGDEN: On a state-wide basis for similar ESee eTIG hy fs Free ‘fg re El je AMEND M pea bs Leal Oo wo feo be pea nn font on pet a 19 20 21 22 24 neck Lene oa development agency and devoted exclusively 181 independent commissions in a publicly accountable way in reporting to the state health and development agency % and devoted exclusively to such work. DR. KOMAROFF: All right. | | DR. WAMMOCK: I yield. DR. PAHL: May we have the final wording before we have the question? i i t ' | MR, OGDEN: The way that I have this drafted at the moment reads "Resolved: That the Congress in adopting HR 16204 or smilar legislation give to each state the statutory) and financial support to maintain a separate health systems development and demonstration agency on a state-wide basis, or similar independent commission appointed ina | i I } publicly accountable way, reporting to the state health q to such work, and be it further, Resolved: That the comments preceding this resolution and the resolution itself be transmitted to the members of the House Interstate and Foreign Commerce Committee and the Senate Labor and Public Welfare Committee for their consideration. DR. PAHL: Thank you. DR. WAMMOCK: Mr. Ogden, for clarification. Accountable way and reporting? “Pp, OGDEN: I am sorry. Appointed in a publicly | accountable way. That has to do with -- , DR, WAMMOCK: But you put another word in there. MR. OGDEN: We inserted the words "reporting to the state health and planning agency.” 13 10 11 12 13 14 15 16 17 18 “19 20 21 22 24 This was Tony's point, that separate health systems development has to report to somebody. We are going to have it report to the state health planning -- 3R, WAMMOCK: Wouldn't that be under state, or not? "Pp, OGDIN: Well, I don't think.that this damages the sense of what I am trying to accomplish. MRS. KLEIM: fir. Chairman. DR. PAHL: Yes, “rs. Klein. MRS, KLEIN: This reporting bothers: me as to whether jt shoulda be to the agency or,as in Idaho, the planning qroups report to the Governor, who is responsible for admins- tration of all programs. And, that would keep it on the state -~- As. I understand it, the purpose of that insertion is to keep it ona state-wide basis, rather than reporting to any federal agency, for example. So, I would lixe to see it made more general, rather than a specific title, because some states don't have that type of agency, or one that is titled that way. RS, MORGAN: They will have this Bill. MR, OGDEN: Under this Bill, they will have to. DR. GRAMLICH: In the resolve, what do you mean by, “in the comments preceding this resolution?" .- “Rm, OGDEN: This was the letter from Senator “tagnuson. DR. PRED: Is there further discussion by Counsel? MRS, MORGAN: Question. OGDEN: Wait just a moment. On the matter “IR of information. Tony and I have decided that this should be i 140 10 ‘ll 12 13 i¢ ‘15 16 17 18 19 20 21 22 24 183 "yoporting to the state-wide health coordinating council." Those are the people that have the 16 members. We have the wrong group to report to. We are qoing to report to the state-wide health coordinating council. Is everybody terribly confused? Can we vote on it? DR. PAHL: With that change, namely, the state-wide health coordinating council. With no further discussion, I would ask the question - all in favor ofthe resolution as last amended, please say “aye.” VOICES: Aye. DR. PAHL: opposed? (No response.) DR. PAHL: The motion is carried. In closing, I would like to thank Mrs. Silsby and the staff very much for again going through an unusually difficult period and specifically say that I am not quite certain under what circumstances this council -- we may or may not meet again. We have not set a future meeting date. I would, however, like to thank you individually and collective! as a council for your guidance and support throughout a rather difficult period, and not this particular review cycle. Since we are uncertain what does face us, I want ‘you to understand that terms of appointment continue until such time as we inform you otherwise because of the passage of legislation or other unforeseen circumstances. But, I do look forward, as I know the Staff does to working with you again in some way as we enter into 15 10 11 12 13 14 15 16 17 18 19 20 21 22 24 our new error. Unless there are Further comments, I then adjourn this meeting. Thank you. (Whereupon, at 3:15 p.m., 184 the meeting was adjourned.)