B&B INFORMATION & IMAGE MANAGEMENT 300 Pence Srorer'’s BourizrvargDd UPPER MARLEDRD, MaRYLaAND 20772 ° UBA * (301) 249-D1 10 en en ee 10 11 12 13 14 15 16 17 18 19 20 21 22 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) og 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) fae ¢ r 19 13, 20 36 48 57 72 74 79 83 90 102 106 115 120 122 128 132 Be N) 10 11 12 13 14 ° 15 16 17 18° 19 20 21 22 x Contents (Continued) Maryland (Dr. Wammock) Nassau-Suffolk (Mr. MIlliken) South Carolina (Mr. Haber) Texas (Mrs. Morgan) Virginia (Mr. Hiroto) Northern Pennsylvania (Mrs. Martinez) 153 . 163 166 ~a Go cin t POUCRTTION AND Mprrapr NATIONAL ADVISORY COUNCIL ON REGIONAL MEDICAL PROCRAMS Conference Room G-P | Parklawn Fuilding - 5600 Fishers Lane Rockville, Marvland 20852 Thursday, August 8, 1974, 4 s o 3 o oO. cr ao M wo Q. 3 < @ oS o Qs . ct wo a mo or 3 \ 9 ,o.- mn) = ie o 0 ih + tg Pahl, Acting Director, Division of Regional Medical Programs, | presiding. == - | PRESENT: “GERALD GARDELL, Acting heputy Director, DRMP. 7 SARAH J. SILSBER, Acting Chief, Operations and Development, DRMP , | | . ENNETH BAU, Executive secretary. EDITH M, KLRIN, Boise, Idaho. DR. HOKE WAMMOCK, La Grange, Georgia. MARIF E. FLOOD, Fl Paso, Texas. , SEWALL O. MITLIKEN, Columbus, Nhio. FSi. M. MARTINEZ, Salem, 0. 9n. HS "DR. JOFN B. GRAMLICH, Cheyenne,. Pvomina, - DR. GEORGE F. SCHREINER, Washinatom, D. Cc, . DR. PAUL A. HAFER, Washington, D. Cc. aa I | I oy = oO. : . n SRT TAME RT OT ~~ Te ss : : - a we . DR, PERGAMIN WO. WATKINS, New York, New York. i 7 3 |i =.C. ROPERT OCDEN, Spokane, Washincton, 4 DR. ANTHONY L. ‘ARC? Rostcn, Massa atts. 5" DR. RICHARD JANLOAY, Wausten-Saler, Norv ° Carolina.: 2 | | 8 i, WYNONA R. GORDON, Creat Bend, Fansas. 7 EDWIN C. HIROTO, Los Angeles, California. g | MARIEL-S. MORGAN, Albuauercue, New Mexico. it h ~ _ - i - : gi And Others. ij = . i to | i ta ed ' is: a0 if i tt ~ ~ ite " bes an dont om 7: it ti . — 18 | 19 | - Ht u 23h ~ : ‘ 21 i; i wy 7 wea y ont 23 it _ 24 {I ford tw C1 10 ll 12 13 15 16 17 18 19 20 2l Opening by Dr. Pahl Remarks by Mr. Cc. Robert Ogden Ogden Resolution Comments of Members of the Public: Dr. Donald Sparkman “s 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 (Na&ssau-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) é Block Action ' Arizona (Dr. Gramlich) Connecticut (Mr. Hiroto) Inter-Mountain (Dr. Komaroff) Louisiana (Dr. Janeway) ad 19 13. 20 36 "h, ir i te See 3 Tones to 10 “i 13 14 15 16 7 18 19 20 to b & £ 8 Contents (Continued) ‘arvland (Br. Wammock)- Nassau-Sutfolk (ir. MILLiken) South Carolina (Mr. Haber) Texas (firs. Morqan) Virginia (Hr. Hiroto) Northern Pennsylvania (Mrs. Martinez) 153 163 ‘166 ta 1 | PRecuu Pines 7 3 |! DR. PAUL: WL1Ll the nesting please come to order?- 3 We are now all olugged in, up at the head table, and I think : 4 | we can proceed with this neStTne of the _ Qnal Advisory 5 Council. 6 Most of you were Hare yesterda, vor the meeting of 7 the ad hoc RMP Review Committee, but I do wish to welcome to 8 the table Mrs. Gordon, and Dr. Haber, and Mr. Milliken. We - | 9 are very pleased that you can re~arrange your summer schedules | 10 and be here with us. *] As you know, this will be, or is expected to be, the 12 final meeting of the National Advisory Committee, called to 13 disperse the remaining fiscal 73 funds, wnich have been release 4 28 @ result of the court order. ‘All of the 1974 fiscal funds 15 were obligated prior to the close of the.fiscal vear, June 39th. wi” And as of this state, we have anoroxinately 28 to | YW 39 million dollars for making our awards fcllowing this August . ; ; cas ; . | 18 Council meeting. How, we will be Giscussing more of that in | ; . 19 a few minutes, because we had a-‘rather lencthy open session | t . | 20 yesterday. And many of the topics were discussed with both a1 the Council members sitting as observers, and the review com- smittee. 22 I hesitate to go over all of the material again, and, 23 perhaps it might be better as we go into the closed session to! 24 take up some specific points. If there are questions that bear; 25 ° on the points we discussed yesterday, but I think I should mak 2 —_ i bed 15 16 i7 18 19 20 Lee] tn 8 ta wn mR cneé of two general comments. bh Specifically for the benefit c t+ the three who could not be with us yesterday, because I think it is imp ctant for the day's proceedings. First of all, tir. Rubel @ic a. a presentation and go over the current status of tne 1 ~§latioz. and we did provide, I believe, a hand-out, did we not, Gerry,’ { 1 yesterday? MR. BAUM: Yes. DR. WAMMOCK: No. DR. PAHL: Well, it was intended to give a hand-out out. Can we make Sure that we get those now, today. MR. BAUM: All right. DR. PAHL: Which summarizes the basic elements of the House bill that has been reported out by the full committee I won't go into all of that now. Because, really, I zalieve that we still have mny steps to go before we have legislation; and by giving you our Summary statement, I believe, you will — understand what the main features are very quickly. It. is a long bill, some one hundred pages. It does t certainly make provisions for a transition period, and we fully anticipate that the local regional : sical programs together | ! t with these CHP agencies and experin .l health services deliver : | systems, and Hill-Burton Organizations will be given the proper { ~ I opportunity to become incorporated into the Proposed organiza-!_ tions. . | | t oh 8 RO ae Wow, Wheat is propos ed any way to perpetuate we imow it.. And those of you the RMP program as who have been following the lecislation closely will certainly When we have copies of the floor bill we will try to get them out to you, because I do believe that it will be And of course, the tim @ faily close to what may be passed. table for enactment of legislation is unknown for good and sufficient reasons. But it may well be passed later this fall. HR. BARROWS: You have just given me a note Sayine the Summary of the bill is attached to the Council agenda. MR. BAUM: the Te! 8 @ 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 Health 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 programs. MR. OGDEN: Would it be appropriate for me to speak -to this legislation at this point? - DR. PAML: Yes, I believe it would be a good time. MR. OGDEN: In reviewing Mr. Rubel's summary yesteréav, one nh % an thinking about the matter overnight, while I have not yet had an opportunity to read the summary fully it is here, Ga ‘o 10 fore Ga 18 19 addressed to Senator “Kennedy. | T understand the present proposal. tes bf am greatly concernéd that Hf 14294, as we eee a Ha i described seems t6 ignore the role that f(r has played in the "nea ith care environment in “recent years. Ioweoold like to rea a to this council and to those present ac t “session, the open session a istter from Senator Nagnusen who is ‘chairman. of the ‘Subcommi tee on Labor y Health, Caéucation and Welfare, And I am quoting. Dear Senator Nennedy. It has ! bee Oo n reported to me that the proposed ie islative revision of | the Public He alth Service Act in effect “eliminates the Regional Medical Programs._ And would divert the » appropriation that has been used for RMP purposes, to local planning agencies, as | Planning agencies would then be expected to develop | services in the same manner that PMP has »een doine in recent . years. I am somewhat concerned whether planning agencies are ' the ‘appropriate bodies to be engaged in tne cevelopment of services. — ~ oo ~ From my experience with the Washington-Alaska Regiona: 3 1 teGical Program it seems to me th rat the cevelopment of services aad n this complicated undertaking demanéing the skills of persons perienced in the delivery of care, and contract planning ée- &2 pends almost entirely on the determination of health care _ t needs. By an agency and staff which can attempt to match oe cr 16 17 18 19 20 Boe OS bo oe & the local damand for services against resources, and hopefully develop a community consensus as to how to meet the needs. 4 It seems that few if any planning agencies have : a broa. spectrum of persons with the knowlc and cmoerience . noces ' for the actual creation c new ser ss. Nor does | it seem practical for the planning agencies to do so, since | b. it would create an unnecessarily large and cumbersum organiza- tion. I would think that a planning board should be capable i of expressing the communities will and the board of a develop- ment agency should be capable of making sound technical judg- | ments about the best way to develop services at the patient level to meet the needs outlined by the planning acency. These are two distinct activities which recuire the involvement of boards and staff with their efforts and @ifferent skills. This is the way the successful RMP such as the WA RMP are now working. I am concerned that if we atte: = to throw { . . | both activities into the same structure, one of the - -vities! a . will suffer, and it may very well be the quality of .ne services developed in the function. : | The medical school faculty, the medical o>ecialists: arene the ' administrators and others who are bas: iy inter- ested in the way care is delivered at the patient vel may withdraw or not be well utilized if both functions are assigned © to a planning agency. - 3 ~3 17 - 18 19 It is these persons, who with Pup leadership, expand the present health care system in preparation fe 4. national health insurance. The Regional Medical Procr to dat t { has involved the talents of most of those mest ¢ I'm sorry -- of those most able to develop services. Their. record for gaining the cooperation of all Purts of the delivery system and improving the quality and accessibi:- of care is unequaled among the public health service act pro- grams. It doses not seem reasonable to assume that the capabil- ities RMP organizations are developing are transferrable to other organizations, especially where the new organizations have few of the talent orientations of the predec:ssors, : Certainly I recognize that all RMP organizations Zt like planning agencies and other health programs have not been: uniformly successful throughout the nation. But any lack of a success is more attributable to lack of consistent leadership Girection at the federal level than it is the fault of the RP. —- - | approach. | And undoubtedly. are we going to need to make some effort sometime in the development of health care resources. Hopefully this task can be assigned to agencies whose expertise and experience can make the optimum contribution. RMP organiza- tions might need to be changed and strengthened in some parts of the nation. _ . But in my opinion they probably represent the best bed no ~~] 10 11 13 i4 15 16 i7 18 19 20 _ continuation of healti services, development agencies similar | .YOu: vonsideration. ao means of increasing the quality and accessibility of care for: the average citizen, In summary , Iam hopeful that the new legislation jj will. . able to recognize both the ccnsumer and provider Q: relationships needed to make the health systeni vork properly. - There should be some way the new legislation can insure the | to RMP in structure and experience, thereby not dissipate the national resources that we have developed. It might well be advantageous if the new legislation i were to establish a formal mechanism to assure that the efforts of the planning agencies and the PMP are coordinated, i.e 2., that RMP's are in fact developing delivery systems to meet the health needs identified by the planning agencies, and such mechanisms could certainly bele established without scrapping the present programs. Creating entirely new bureaucratic structures in the future, and in the process, using what would remain we have achieved for existing RMP systems, such as the Washington- -¢ t Alaska prooram have been highly successful. Thank you for Sincerely, Warren G. Magnusen. wow, I would like to suggest that it is the sense 3 f i 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- fa > 1} ne sufficiently the important role of adequate hAcalti services ~opment efforts. ho Qa a 3 And efforts which Simply cannot be limited to the 4 |} localized geographic areas within a state would seem to be 5 encompassed in the concept of the local health service areca § | within a state which the governor: would designate under this 7 || bill. 8 | And further, that this proposed 75,900 a year two | g | year limit for a project is grossly inadequate in cur exper- 10 +} ience since it simply will not attract meaninaful or useful li | applications. ‘Therefore I would like to propose a resolution 12 | along these lines. 13 Be it resolved that the Congress in adopting HR 16204 j 14 or similar legislation give each state the statutory and financi: '15 || al support to maintain a separate health systems development | 16 | agency on a state-wide basis or independent commission appointed i7-]| in a publicly accountable way and devoted exclusively to such “18 | work, and be it further resolved that the comments prececding 19 | this resolution, and the resolution itself be transmitted to 20 || the members of the House Interstate and Foreign Commerce Com- g1 || mittee, and the Senate Labor and Public Welfare Committee for 3 | their consideration. 23 DR. PAHL: Thank you Mr. Ogden. A motion has been 24 made, to have the Council adopt this resolution. Is there a5 || 2 second to this motion? tf 74 1 zt “ ae food ve bet ve & . RS MORGAN: I second it. is there discussion? £ DE. PIL: Seconded. Is 3 DR. WAMMOCK: Mr, Ogden, would “Ou read that resolutcc. 4 | again, please, © 5 |i HR. OGDEN: Pe it rescived thay ae Congress in | 6 adopting HR 16204 or similar legislation give each state the 7 statutory and financial support to maintain a separate health i t . 8 : systems development agency on a state-wide basis or independent 4 3 commission appointed ina publicly accountable way and devoted 10 exclusively to such work. ' ll And be it further resolved that the comments pre- pet eo ; . ; ‘ ae ; eeding this resolution, and the resolution itself be trans- mitted to the members of the House Interstate and Foreign Ccm- y mierce Committee, and the Senate Labor and Public Welfare bead ran 15 Committee for their consideration. x 16 , DR. PAHL: Discussion? Dr. Schreiner? t i 17 DR. SCHRDOINER: Yes. I just wanted to ask a question. 18 You would favor the dissolution of the regional process? 19 MR. OGDEN: Yes, I am. Because I think this Piece of i ag legislation is directed toward the state-wide activity. I 21 | Fecognize that many of our regional and medical programs flow over state boundaries but if we are to have an incapsulat ed 23 | Program which is state boundary oriented, it seems to me that 24 that we can accomodate to that through our existing RMP's. , DR. WAMMOCK: Your point was a specific statement of ij aa 10 ii 12 18 14 16 7 18 20 21 22 + because the RMP as we have been looking at them doesn't over-' flow into other states and so forth. MR. OGDEN: That's correct. DR. WAMMOCK: Regions, as I understand it -- I was S0 we are seeing some of these things, this is some of the things that I was putting to my nind all day yeaterday, and earlier this morning. I didn't get up and write it on a sheet of paper. MR. OGDEN: Of course, we have some states, for 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, these four RMP's would become one. DR. WAMMOCK: Yes. HR. OGDEN: Which incidentally is something I have Suggested to this Council previously. DR. WAMMOCK: Well, you've been on it longer than I have. DR. WAMMOCK: This particular piece of legislation | told them could be no larger than this room, or they could .be i the whole United States. That's what called a regional area. example, California, where we have one RMP for the who, state HR. OGDEN: Yes, at this particular piece of legisla- 1 | | i ! i i i t 10 ll 12 13 15 16 17 “18 18 20 alk ‘during the formal public session for any comments, on this __ | point. oO ie n° a a HW a cr by Q MW (D th G K a he fo RR Ou we ‘ +e) Q G i) a bP 9 3 2 " = rs at h QO Fy DR. KOMAROIT: Yes. =I Fine mysel= in sempathy with ir, Ogden's proposal, IT wonder though, if wea Ld defer a | vote on it until some of us have ha@ “Hance read the i Summary of the Bill, which I, at leas aaven't had a chance to do yet. To take action on it, because the basic apprehension: , 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 share -- DR. PAUL: I am sure others perhaps have not had the Opportunity also to read this, anc thus, with Council's sense We will defer voting on this motion until later when we have had an opportunity perhaps followine at least the morning coffée break. I believe I would like to take the unusual step of 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 comment at this point in the proceedings, and if not, there will be another opportunity | Dr. Sparkman, would you care to make_some comments at this point? On the topic under consideration? bo mw 10 li 15 16 17 18 ‘19 20 ts fs & DR. SPANNMAN: You mean speaking for this motion, 7+ DR. PAYL: I was thinking of commenting on the mow _sn. you will. © “topic of substance of . Ogden's comments. DR. . .RKMAN: Nell, thank you ZX appre:iate the... wD chance of appearing before you again. And representing t: 3 Coordinators, and I support the motion as read by Iir. Ocde I think the two important factors in the bill as I understand it -- I, too, have not seen the entire bill, although I have seen the summary that has been distributed to you. And I have looked with some care on 13995 which is £ it's predecessor, which I think has not been modified very much but I think there are two important factors. One is the subdivisicn of existing state-wide or regional RIP's into smaller area-wide Regional Medical Prograzs t- ; IT think the subdivision into multiple smaller areas i5 appropr ate for planning, as has been demonstrated by the action of those CHPB or area-wide agencies which can identify health problems in their areas and Geal with them. But this is, I think, a totally inappropriate way x =: Regional Medical Programs to fune’ ‘~ since on a state- Oy . basis we can acquire staff and ' caliber and a breadth £ different kinds of disciplines and cal with problems which oO t we do on a state-wide basis with the medical association, the voluntary health association, health departments, and otherwise peed CF on 18 19 29 al gO wat & RO aban H cr BR ‘3 ty be ct 3 0 fa a) Cu Lad Ca ut ct < pee tt ct G ps bt pH MS ct QO a’ 3 fa 3 oy ct () c aid be, th Q Q cr t- RMP in the areas which I am familiar with. And as a matter of fact, in the blue sheet which is one of the reports cn Washington Health matters, which I am sure some of you are familiar with, last week reported that the bill as written F co + ; would be the last rites for PMP. I think this in effect is true, that any healt: vd | resource development activity kind of things RNP is doing, 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 might. DR. PAHL: Please. DR. SPRRKMAYMI: Relative to the orientation I hav (ip 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 coat programs. I reccgnize that some of the others of you have not, some are new. : Some of your predecessors have had the opportunity of having to site visits to regional medic 1 programs, and those I have talked to vé indicated that t . 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, “oth ora — wD id pes bee fet co ro oe) Ro pene t2 Rm Ga “NO are grateful to you for the time it takes to revi @ all of these, but I think that the vaver doesn't cuite tell the story that I think you would have an opportunitv to under stand if y: ‘ere actually had had an on-site visit, or had a little mo... contact with a coordinator, I know you have an orientation session for br. Pah* anc his staff the details of which I Gon't know. But since I have thought about this I belatedly recocnized that as. a group, the coordinators of RMP's have done a poor job in expressing to what they feel the way RNP's function. And I have written to Dr. Pahl asking whether there ake are strencths ‘£ would prevent us from communicating freely, with you, and i nave not had an opportunity to have a resp: ze to him on this, but I intend to follow up on it, unless yc want to spsak to it at the moment. DR. PAHL: I believe not, right at this time, but we j oa WAL be discussing this with some other matters individually and with the Steering Committee. DR. SPARKMAN: AS an axample, I don't know whether "3 a report of a program accountability report th - was submit: 2t was released about a month ago. Which ist’ a Familiar Gocument to you? MR. BAUM: It's been mailed. DR. SPARKMAN: How many of yu had a chance to see it? 10 li pot ce ed iw 17 18 19 MR. BAUM: It was mailed out as soon as we aot it. DR. PANT: Well at the time of our rsone call it Should have been received by you. MR. OGPEN; I did not receive it. DR. SPARKMAN: Not very many. ' DR. PAHL: We shall make other copies available to you. DR. SPARKMAN: Well, this is of no va? in measurin individual RMP's. But it is a measure of the <¢ . regate-impe of RMP's in helping to train health professionals and actually serving people. And in imolementing communit. activities, and while I wouldn't expect you to read every word of it, it is reasonably well done. And it is the kind of thing that I would hope vou had had a chance to look at. In order to better understand 4 what we are trying to do. I would like to, then, after I have had a chance to talk to Dr. Pahl, follow-up with ways in which we may communicate with you. Without burdening you. I know that you all have more than enough to read. The second item I would like to mention briefly is the goal of the National Advisory Council and I am pleased that in the motion that Mr. Ocden that was seconded that you all looking at the policies of RMP that you all, I think, then beginning to take steps to provide the no the 25 leadership that the National Advisory Council has provided icrz RMP in the past. Bo I recognize that in vour last two meetings in the s previous year things have been pretty well upset, first as f a result ocr the phase out directed by the administration, ar 9 "3 i D ; then the rather abrupt release of impounded funds so vou.wer Kind of overwhelmed with applications. But I would like to remind you that you are a very réspected group, on the health care ‘scene. You represent a group of distinguished and dedicated people and that your word relative to regional medical programs part in health care iar wi important and I think that you should take time to Celiver 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 your last meeting, as an example, two resolutions came to you from the National Review Committee, and one of them recon- 4 mended that CHP's turn to RMP's when appropriate for technical and professional assistance regarding health care chan--:. And the second one encouraged RNP's and CIP‘ < t. the state and local levels to work together closely to .xplore > 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 thouch? ro wo, Cr prot «3 7 16 ND than was very brie: .onsideration and discussion by vou, roth of them ware rej ted. Cn June 20, immediately after the meetine i wrote to llr. .2bel and said I was disappointed in his dis- appreval of t> to me this is inconsistent with his previous <« between RMP and CHP. Which I whole-heartedly support. Ané I saic that I hope that there will be some tangible evidence from him on action relative to this positive relationship. Fe hasn't (D responced to me, nor have I seen any evidence of this action h - oO are. rs Ss re To support what he said at the meeting last time. Let me add an anecdote regarding this. At the Vashington- Alaska area we have two particular Grants where wea have task forces looking at these kinds of alternative arrangements between RMP and CHP with the best people we can find in both | Rp and CHP and other health care activities in both states. © Meeting and trying to shed their vested intcrests a: ‘ch 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 - 2k that she -was about to get married to the director of thc cnorage CHP acency. pet] I said I was all for this kind of exploration, but it seemed to me this was Carrying it a little ts far. Thank you,. very much. bo qn 1¢ 15 16 17) 18 19 m2 BO | be inadvisable for this Council to be making dictatorial ¢ - DR. PAWL: Thank you very much, Dr. Sparkman. Ue will have a formal open session a little later, and cthers -present should feel free to comment upon the matters shat were discussed and Dr. Sparkman; should you wish to 3wélise additior. comments. oy ts ut we shall table the motion until the Ccunctio a . had the opportunity to review the summary. DR. JANEWAY: At some time in the agenda, I --culd like to resvond to Dr. Sparkman's comments ebout tne Jsliber- ations of the Council relative to the resolutions. DR. PAHL: Perhaps this might be an ap: then, Dr. Janeway. Our agenda is flexible this rornins, and perhaps this would be a good time. DR. JANEWAY: Iwould like Dr. Svarknan, I creuld not like the impression to go unanswered, that the Counei t- Gia not deliberate appropriately upon the substance of the resolution brought by the Technical Review Committe¢s. In particularly that the wording of it is such that it ir-plies 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 concer: OVE, same agency. The implication is there, we felt, and I cnink, quite correctly that the advisory council for RHP -- it woule fo aS 5 a ~J Vt 16 19 20 = - mo statement fron an adversary position relative tr ocho scticnys of an agency over which we have no control. And I would hese to r2assure au that there was adequate discussion, at least in the me of the peop | no are around this table. DR. PAIL: Thank y we Is there further discussicn 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 indulsence of the Council members who were here yesterday : to repeat very bricfly for the benefit of those who were not 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, becavse 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 I believe it is necessary. for mé to repeat these remarks of yesterday. : As you will recall, at our last Council meeting, oplica- ey) le rh tw . the recommendations made with rega: <0 spéci tics -- the applications from Maryland and Nassau-Suffolk were of the following nature: that is, that funds should not be awarded for those particular applications and also that the - 2 @ 10 li 17 18 £a 1 gS | | | | | | » ;@pplications in question, the applications that we reviewed | two programs in question should be terminated in an orderly Q The recommendations wera accepted by the CGirector . and we were on our we 3 implementing these in qooc faith when it was called to FY attention that again, as a result, tam afraid, of a dismal ignorance of the lav, that we were | not able, as a matter of fact, to implement what had been tha: Council recommendation. . t 1 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 specific applications that wer reviewed at that time. 7 | t in fact that was the case. No awards were made at | | the June Council to either the Nassau-Suffolk or the Maryland | programs. However, we were in error in believing that vour | recommendation could be implemented and when we were advised we of this error by our office of general counsel, the recions, and pointed out that there had , | been an error, on our part, and that what we wished to do was got in touch with inform them that they Gid have a right, and we hope thay would, () xercise that 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 i in both the June Council an@ applications under consideration’ id a = ~ at this Council technically are supplements to existing crantc. \ / oa a . = - 3 |i The budget pericd for all reqicnal medical programs. extends from February 1, 1974, through dune 30, 1975, and those applications reviewed at the last Council mesting, as § well as the ones before you today technically are supplements, 7 to existing awards. , i g Therefore it is not appropriate for the Council te 9 make a recommendation beyond funding for the specific applica- 10 tions in question. Having gotten over that psychological 1} hurdle and shocked everyone we as a headquarters staff, togethe: 40 | with the staffs of the two regions in question try to work 13 effectively within the time constraints that were on all of i4 l us. | 15 And we extended the deadline from July 1 to July 9 : 16 to those two specific regions to amend, to revise and to i7 + amplify those applications. And our staff met with the staffs 4g || of the two regions and you may imagine that there were both ! | 19 several trips involved, and many telephones calls, and as a . : 89 result of this we believe that the regions in question under-! at stand fully the concerns that the review committce and the- ! 59 Council had and hay spoken to those concerns in the application 23 Also, we have made two, made know to these regions ! b bo cn and the Council there was the opportunity to speak on behalf 4% \ bo And when we cet to the open session, this morning, we will have statements from representatives of both regions.: a 4 Now, apart from that matter I will indicate to the Council 5 you will recall at the June me eting you approved $8 millien 6 dollars recommended for approval. 7 88 millicns of dollars. We actually made awards of | 8 84 millions of dollars, and the reason we did not implement. : i ' 9 fully your recommendations was because it was felt to be better 10 management to reserve the different, four million dollars, il so that we would have a total of 28 millions of dollars for 13 Support of the recommendations at this meeting, because we had 13 anticipated at that time to have approximately 43 million | dollars in requests. 15 , And we felt we needed the 28 million in order to 16 provide appropriate implementation of the recommendations from 17. this Council. AS a result of the actions just taken that I "4g |) recited with Maryland, and Nassaw-Suffolk, those two applica- 19 tions have increased the requested figure so that the review 20 committee yesterday had in the 53 applications before it, ai || 2 total request of 46 million dollars. Our total dollars that are available for support of Regional Medical Programs included not only the 28 million a half to no more than two million dollars, from prior budget i i I { ! | 2 dollars, but some unexpended balances of approximately one an i bo Cl Sam an ~ eo 18 il 12 “45 16 eee af. Lo) Gt ig i) Hy kee 0 en 4 So that the total monies that we have, and wa will know exactly as we receive the report ana expenditures forms ‘this week, the total amount that we will have following this j Council meeting for support of Regional ttedical Prearens will The committee acted yesterday in our closed sessia- So we will be going over the specific recommendations, We. maMe @ point, however, which does require your consideraticn. And as I discuss what the point is, I would like to pass this statement out to you. a And indicate to you whet our problem is; under ¢> will, for purposes other than the Girect-+support of regicna? medical programs. This was the negotiation that occurred curing the settlement, and those purposes were described very complete): by Hx. Rubel. Mow, the condition in the court order is that 4 t | | if Mr. Rubel and staff are unable to obligate the five millic | | dollars within 90 days, 90 days from the Signing of the fina? ae ee court order, the remaining funds of that five million then reverts to the support of the regional medical programs. ity of distributing a very small or medium size, or altho ouch unlikely a large size sum to the regional medical programs. Thus, we may be faced in late October with the voss: | court order which was signed and thus the litigation is eniseé, i U ' * . + : five millions of dollars were given to the defendants, if won _ we oe C2 ~~ 10 Ll 12 i7 18 18 20 2i { ' i i r} ay Up co five million collars. We will halieve that there will be very few dollars remaining, because obviously there ic 3 great interest on the part of the administration to utilize thos: 'ds,.cftfectively for the purposes they were used éurinc the nr ciations. But we do not wish to call this Council back shoulé 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, ccorodate 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 co with the close to 30 hon Gollars that we have available, is after this meeting, first pay up to 100 percent of your recoiumendations, for eac: cf the RPM's, Should there still be funds available to us aft oO x we have awarded 100 percent levels of your recommendations today, we would then return to your recommended levels followin at the dune council meeting. Because I just indicated to vou that although you recommended that we support programs at a aap ~~ "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 tevels. . In the event, and these are a lot of if's, but this ro mE hy a i . : 27 ok f i i, : - - . "is the way this program must view things. Should there still : i oon ‘ ee) monies .availabic, either fr om wha w2 now have available @ to us or what may become available to us in October, as a ‘ i | I i t i | } i | no I result of the situation I “have just indicated to you with the , five million dollars, we would then proposed to make a distri-' bution by formula, and the formula is given at the bottom | | | | |of this page, and it would merely state that we would take i (the actual award that we made, from this August council meetiné, | ' i and the actual award made following the June council meeting, i and find out what percent of those two awards are of the total: ( $ baad Ou n 4 a Ou 2 1) cr ct om @ an o 5 a g 3} mu i cg Q c a ct Q Qo G 4 Q be f- os tr @ tt Pr a 1 | | Tat 2 i And apply that pe cantage to whatever remaini ng funds .wé hava. And distribute those funds to each region. We fee | e : | j that this is Squitable and in keeping with your recommendations ‘ and | | of the June and August council meetings/have been unusual, in | i | that all programs, basically have been reviewed, simultaneously | rather than at quarterly periods of the year. Seer a ac a rs ne RL TE TG EE NE NE ONO Be NE OT ‘Secondly, the competition, the applications have come | in under a competitive system, whereas during the earlier part vA /& We were making. distribution on a formula basis, which é 0 Kh be Oo perpetuated ray: standings of regions for 1972. So what we at th: St two council meetings, this one and the June rh Q @ fo he icouncil meeting, are our best indication of the latest consider> | | ation of merit of. each region. _ Therefore the formula that we have devised we believe! bed i. . les tbe fair. gop ; That is cemplicated. I hope I have made it clear, i ; 4 ° : “and IT would like to have either a discussion or endorsement, ay a) would, like to consider it later, disc ussion or or néors:. ..c of sither this proposal or a rodificaticn because - il onea this council meeting ends we still may be faced with a+ 7 | @istribution of funds. discussion or Clarification if I have not made it ar. | 8 | And I ado not have that authority unless ws reconvene. 9 |} at some future date, so I would like to open it nr oy oanera. : 10 | ¢ i t LL | DR. HIRMMOCK : what's only a minor sum of money, you iz | say about four million dollars. Or a million and a half dollars i is that correct? First you will take the sum we allocated for 18 | ig | eighty eighty million dollars, -- ~ 5 DR. PAHL: Well, let me try, first I will use the fungs i ig i that were available to us to pay up to 199 percent of what wt we recommend today. 18 DR. WAMMOCK: Right. “ 19 ! DR. PAHL: The funds rémaining I will then return 20 your June council recommendations and pay yup to 190 percent 21 of those recommendations. If funds still reamain,.either wnat ae ye have currently available, to us this summer, or any that 3 | may become available to us in October, I would then employ 24 the formula that I have given which would represent a percentacé. c2termined for each region based on the June and August Council bo oN C2 2. ; awards. | Actual awards to that region, which will be at thea that to whatever balance remains. DR. WAMMOCK: I would like to move ..at that be en- dorsed, or approved that -- MR. OGDEN: Can I ask a question? DR. PAHL: Yes. : IR. OGDEN: I am unclear as to what this five million j i would be used for andthe manner in which that will be done. | | i then to the first point. y MR. OGDEN: I think it is the first point that I am .more interestcd in. i DR. PAHL: I can get you material for the first point [Let me speak to the second point, however, Mr. Ogden. The negotiations on the settlement of this litigation have been | . - i conducted primarily on behalf of the Gefendants by, of course, our office of ¢aneral coumsel and the person of Tir. Rubel. And to the purposes, needs, and challenges that will ,b@ repr. ented by having five millions of dollars available to the .cimistration thus have been our most and under his direct personal consideration. (which frankly I had not seen until yesterday, because it is a 100 rercent Junc and August Council recommended levels and appl» DR. PAHL: I can speak more fully to the second part i i He handed to us, yesterday, a rather lengthy statement | | L. - : | 34 #e0 separate activity within this bill. So that the best I can _ » | do is refer you te the same document that I have, that I hope: 4 | to get Mr. Rubel to speak to it more directly, because we : 4 | really do not have information bayond what he distributed 5 | yesterday. 6 Wow, the manner in which the money will be spent 7 Iounderstand is fully through contract process. And the purpose: 8 generally designed to look toward the new legislation and to 9 have organized, defined, cleared, ana publish: those kinds 10 of studies which are concerned with health planning method-~ li Oligies, evaluation studies, and to development of manuals | 18 and procedures which will be of assistance to the organizations 13 which we expect to be Geveloping and supporting as a result ! te | cf thrproposed legislation. 15 I am not sure that that says much more or even as | 16 well as what he said yesterday, but I cannot amplify that. | 17 DR. SCHUREINER: It's kind of anticipatory -- as I 18 get it. . 19 DR. PAHL: It's kind of anticipatory ~- let's go off 20 the record for a moment please. 7 (Discussion - ° the re cea, | ea i DR. PAHL: Wo m go kb _ he reeo gain, I vould | be happy if Mr. Bell were here toa: , to try ard get him to ! “oI = i .. | come and speak to this point. It is kind of imporant, but it | & : ~ has been quite perinpheral to my activities. Unless there is gre ~q *y at 13 15 1g 17 ig mesy 89 ya) £ SF Choncone > Womeone here. MR. OGDEN: The reason I raise the point is thnt I think it is the statutory responsibility of this Council to expenditure for REP money and this is five million Sih oO prove th dollars of RUP money. And I think unless we improve the manner and purpose of Mr. Rubel's expenditures the money may not. . | i be appropriately spent. mo - | DR. PAIL: Yes, well that does bear on how the money | ~ is spent. It is the responsibility of this Council te approve all grant funds. HR. OGDEN: Unless we say to Mr. Rubel's resolution that you have the authority to expend that money and we delegate | to you the right to spend it in the manner in which you spend. it, hew you choose to spend it, and then I question whether hel is spending it under authority. MR. HIRITO: Isn't this the result of the cour order, Bob, rather than -- MR. PAHL: It's the result of the court order but I am in a very poor position to take issue with Mr. Ogden. MR. HIROTO: Okay. - . t DR. PANL: What I would say, is that it is my under- 1 | ‘standing that an expenditure of qrant funds must come before, | and be recommended for approval by this council, but contract funds, and I don't know what -- whether it is custom or Law frankly, but certainly to the best of my knowledge no contract ~ Cam Coe Cr oJ GS 10 i} bok ho eed > 17 18 19 20 ah unds are required to come -- that is weraposaed contrace omren Qituras are reeuired to come belore o: be appre vid Ly this council ret Come ete nm -_-— dela wad na 4 se hun find in fact, have not been SO tnat as Lone as trex five million Golicrs awarced Ant rant Wed TR FA RRR IA AV MaLicon -~iGYS 15S aWwarced in contract I bcliave tacnnicr. LE must not come before, but i believe it would be wise fer you to have a better understanding. be HR. OGDEN: Was it designatedin the court order MR. GARDTLL: We both hava a little information. I things the count order did was to release ct He} f y Oo "3 0 Oo Hh ct om ® impounded funds and those funds then ware allocated to us. “Now + the amendment to the court order takes away five mil or the released impounded funds to us, andmakes it available i to nine, ten contracts that HPP, and that's what really it is. So, then, wa have five million less to allocate to our FIP's.: MR. OGDEN: If that is. the case and it goes in that: route, then my question is out cf order. MR, GAPDELL: Yes. tg yg a i WH Yu be ct 0 t G 9 t+ be Ln uy 'g Q te fa c() jen QO a ct +03] 169] Q 9 7 n cr LN] D made as contracts. They are not made available to us to alloce to our RMP's. a oi 19 il i) the ped cn 17 18 19 DR. PAL: Dre. Senrainer? DR. SCHUPEETURR: = dontt think -- I con't os really would be meaningless to have a council mesti Io move the motion, ts practical ‘feasibis way of taking care oi the overage. ct purpose. I don't really s2¢e any reason for spendi eee cr ' m (oD cr fe DR. PAHL: All in favor af the proposed resoluticn? iy Oo iy ed G fee fy Fh oO iy Qs w . n ct in} fa. Co G ct HM 3 wW ‘ i Relative to the HRS. KLEIN: We didn't gat a second. HRS. MORGAN: Yes we did. I seconded it. DR. PANL: I'm sorry, it‘thas pean moved and All in favor, please say ave. VOICES: Aya, DR. PAHL: Opposed. (No response) DR. PAHL: The motion is carried. ~AA seconded. +i MR. OGDEN: As a matter-of editorial comment, shoulé the bottom line read ~- June? - MR. GARDELL: The words will be dated in August. Will be effective September L. You're being terribly technical. DR. PAHL: 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-: Ct {9 16 il “15 16 AT 18 18 29 21 ‘ware just about gettingivou at this point. sidered. Eo bolieve they are attached. Again, if you have “ had an opportunity .to read these, p a rhans we could defer \ action on them, HR. OGDEN: These haven't been mailed ous. 2 “a no reason not to suggest a motion that they be approved. MR. WAMMOCK: Second the moticn. DR. PAHL: The motion has been made to accept the . ‘minutes as submitted. Anv discussion? (No response.) DR.-PAUL: All in favor of the motion? VOICES: Aye. an a DR. PAHL: Opposed? {No response. DR. PAWL: The motion is carried. MRS. MORGAN: As a matter of fact, it would be illegal and still is part of the minutes. DR. PANL: We walk a tight rope here. We will se in just a moment, having a report from iir. Matt Spear to bring you up to date on the status of the arthritis program. As you will xvecall, at the last council meeting, Matt, believe MR. SPEAR: Pine. DR. PAHL: If that is sufficient. As you recall at the ,last Council meeting, you did listen to a presentation by nO Go both Dr. Gramlich and Mr. Spear relative to tr -lot a 2FOGLam, a And the activities, consideraticns and .ormal ~e ~2 18 BO Oo fh) pet ae Keene bo Oo See ee Steen recommendations eo: © ad hoc Arthritis Review Corr “a subsequent to tha. .ma, wae have made awards and I like to call on Mr. he program, and our activities since the meeting. spear to describe the last Council xen on os sd bord a bes bo bed Lord t2 ee Darl i] i | | dust Necapitulate so cvaryone is on the same star “s received in 1974.an anpropriate for RMP an allo ‘2d 4 and a half million dollars for thea applications from 43 regions, totalling almost 16 miil dollars. Gid not develo arthri 31 of approv arthritis center. When the request for applications . So it was highly competitive Policies were established which took out of es which did not seam scem to directly bear on patient servicas prent of things for patient. outcome, then, as tis committse and the Council the RMP applications for pilot arthritis epproval exces - ed. The - led the earmarked I shouldn't say small -amount, that's ’ Liab le to the hed amounts ava ct a a @ fu K uw is te oe And that is 27 of those app Situation to be recommended by ths at it's Funa roved programs, tines meinct. ae ~ ne cation ¢ar went out ve ’ ana th and the extension ci Last Funds war editorial. an amount of almost a half a million dollars. With: the - t val cf the Council we funded, or approved, tended to &Or ithe allocation of the fund to all of thea programs that ioc program. 5 anc Cevelovront of a receiv m eo ke 20n ca wa ae By aopron- Sn - remaining four who were approved, but for which there were not 2 or utilized arcwin Ciserctionary funds up +6 the amount 3 program approved by the Council. 4 |i The award letters to this effect that a reaion ‘ 5 | is or is not approved for earmarked funés or is or is not i ! tae : . . : . | 6, approved for the utilization of discretionary funds was issue: | | mo , | 7] On June 29. The letter also requestee that each of the regiers i | } t ° a . . * . . 4 * 8 | ecéiving approvals for pilot arthritis activity respond in_ H ' | | § | writing as to its acceptance of the award, where an award is ; i@ | involved, and or in all cases the conditions of the award, li | which was the Stutement embodied in the approvals as to the i Vo ae : ig: hinds of activities that should be uncertaken, 1g 4 And the limits of the funds that coulé be expendes j : id | ror those activities, Today we have acceptances 21 of those i , 4 15 RMP 's and we are waiting for an additional ten. To round it 16 up. Eight of those have been contacted as of yesterday, and AT they are working aS rapidiy as thev can to get their accept- 18 ances in, - 18 AS you can imagine, going from a request of Sixteen 20 | million to something in the order of less then five millions 21) Some drastic cuts were made, and some restructuring of activi TV gg i-within the approvals hes been necessary, and those hanges are ! “ t og | being negotiated. an) i | . - 24 | It appears at this moment, that cnly ons or two of as | the 31 approved regions may turn down the funds. One apparently co on 2 prt a teat vt 16 is i7 ag aa as 23 Eipeinecinshsecsmnsoroasmiss re. is having some difl. .ty in deciding what the overhead sheou_- bie . ne az be used cr not. . Now, the review committee and the Council both two other actions, both at the same tire, ~*~ recommend that there be some centralized fcllow-up from t... bivision o% re Regional Iiedical Programs, ‘he major part. of that I think, the most important aspect is a desire that there be a method and an approach to coordinating like kinds of programs that ‘névertheless are dispersed the 31 RMP's, We are also in the advice letter of June 29 asked che EMP's to give it some thought, and to give us the wisdom of their experience and thoughts. However, they did not have the full information needed by then to give a proper responses in our estimation. ° And we ere presently preparing a letter to follow shat up and give them more concrete information such as who are the ball players, who cot 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 t 1 ) 0 read you the draft part of the letter that purports to sweraric 4 che approved programs, The emphasis of the aoproved pvilcet programs is the extension of present knowledce in arthritis ciagnosis, treatment and care to coordinated_services which demonstrated improved patient acess to care, and extension of on a . & oH [ee] bed C2 peek Cock 82 pea on BO ohn to a Dies se eceene at eerie cnrrmnncnennmnamnnnin sonnet eee “7 i . — . . mT , . t "Arthritis clinics will be established in medical | centers, community hespitals, ar: cher community health facilities. Educational procsram: a hospitals and throuch visiting multi-disciplinary teams will increase the arthritis handling capabilities of hospitals and vorivate physicians and will eouinp larger numbers of medical and health personnel ‘aS support services in hospital clinics and -- increased 3: patient care will be increased through the development of patient training activities. Seminars and workshops will be conducted ct many e : ns sites for improved utilization of community resources ; arthritis services, including home care, guidance and surveil - lence. Exist ing. health cepa rtment nersonnel and fachiitiss, | and health groups, such as the Visiting Nurses Association | local councils on aging, and operating community health trairi: programs are cooperating and Cemonstrations of approved + arthritis health care celiveries. Several modest studies t 4 to Gevslop criteria for gualitiative care through provided t performance standards are b&ing conducted, and industry And an emplovee, employer educational. program will be developed in. concert with better organined occupational \ health services. Another region will investigate the utiliza- Co fr a pew Bee eS an of solar workshops ta support patient restoration to procyuctie: oa CA LL 7 A number: of prograns are focusing on the problems o K @ F oO Q & mn } $ y WQ £ low income groups, rural groups, and others on the development of care celiveries in economic disadvantage: inner-city rasidents. Pediatric arthritis services will he developed in a variety of settings, and one procran is Ceven- strating improved services to the geriatric population. . Localities which presently have little or no vrneumi- tological resources are being supported by the initiation oz the expansion’ of medical, new medical institution tere thing cudabillities. Across the country, chapters of the arthritis foundation are providing program coordination to -- publicatic: Q Ry and increased numbers volunteer workers in supportive ser services, And increased agent referrals to local and resources, That completes my report, Dr. Pahl, unless there are questions. ~ H DR. PAHL: Thank you very much, Matt. Dr, Habe t DR.HABDR: What is, where is that procran with the geriatric services? MR. SPEAR: In Michigan. University cof liichigan. DR.PAHL: Thank you, Matt. Dr. Gramiich:? ja> . DR. GRAMLICH: As I indicated to vou, I apolocize to you for. not having been able to get with you a little bit 10 11 13 14 15 16 17 18 19 20 21 22 24 resources, the development of certain training films, vidceo- a1 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 which : r 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 deal, 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 accept the task, early on, accomplish it rapidly, and apparentl: bring it to reasponably successful solution. Matt's report is superb and I have nothing to add to it. 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 arthritis 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 tapes and so forth. But this requires a reasonable investment, and we do not have the dollars at the moment. We do intend as Mr.’ 10 il 13 14 / 415 16 17 18 19 20 i i, 1% tet ' ‘ . “Kaas a : ee 5 verse] | Spear indicated to try to pull together the existing approved | activities into a cohesive procram through the goca offices | . of Mr. Spear. i And beyond minimal funds needed for some conflictiv2 meetings, and so forth, I believe we can accomplish that. So we do hope to he able to report back to you at some future time that the program is not an assemblage of disjointed projects but does represent a total national progran. Now, facing us yesterday and teday there are a limited number of arthritis applications in the July 1 RMP applications. . I believe five regions saw fit to include arthritis requests in the current applications. Which is to Say that most regions clearly understoode that the pilot arthritis program was related to the fiscal 74 funding and the activities of the specially established ad hoc arthritis review committee which met for one time and was disbanded. Thus, we have a situation in whicht administratively and indicate to those regions that basically their application have been submitted inappropriately, although I think in some cases there have been honest misunderstandings, so that perhaps this news would not be taken lightly. I feel © at, however, it is important to reopen with you very bristly the fact that we believe the pilot arthritis center program was established and is no longer open. That is, regions should not be permitted to spend i b LS to 10 il 13 14 15 16 17 18 19 20 2 43 currently available funds or whatever funds come to them in the year, ~- the distributions we have been discussing this morning to support additional activities. We are trying to build a national cohesive program M and as a result of that I have prepared a statement which ‘ t 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 I believe is necessary in order to be fair to all regional medical programs and to try to build a cohesive pro- gram .from those activities that were reviewed and approved by the Technical Board of Experts. The statement that I would like therefore, for you to read to you and ask for your endorsement is the following, the underlying authority for the 1974 initiative in arthritis was pilot in scope and intent. And heterogeneous activities ‘beyond this level would not be appropriate employment of current grant funds. The full development and delivery of services for t arthritis is an enormous undertaking, and requires a continuing ‘well organized attack such as could be initiated under presen pending legislation. Thus, .while Council is fully aware of the urgent | al needs in the arthritis field, it does not consider expenditures 10 11 12 13 14 15 16 ‘17. 18 ‘19 20 21 22 24 additional thrusts in arthritis in the event of appropriate _ i*not reviewed by that special arthritis review group. for arthritis, other than for approvals and recommendaticns made at the June council meeting to be anproprizte in ths present environment. And the allocation or expenditure by individual regional medical programs of funds for arthritis in addition to approvals provided at the June 13-14, 1974 Council meeting t t : are not approved. The Council will entertain approval of * authority and new grant or other funds become available to 1 the RMP's, Dr. Gramlich? DR. GRAMLIGH: I heard therefore in the periodization process at the June meeting there were four applications that were approved by not funded. Those were outside the acepe of this -- DR.PAHL: Those four are outside and they have been given specific permission following that Council discussion to utilize their funds to support. Because those applications | : went to and through the review process by the arthritis review committee, t This pertains only to those activities that were cm nee a acme + eeneenneteetnenettentmenenementee DR. GRAMLICH:Okay. DR. PAHL: Because regions are permitted to rebudget,} and anybody can rebudget into arthritis inthe coming year. | Oa 10 ll 12 13 14 15 16 17 18 19 21 ta ta & £ 8 “ actions, including the form which we did not have funés to I don't know how we can establish a national prearam if wea basically leave it open ended. The applications in arthritis that have come before» you today have not been reviewed by the arthritis panel, and cannot be because we have no possibility, have no vossibility of calling them together again. What we are saying, therefore, is that your June 7 pay, but were given permission by that closes the arthritis | program effort unless special arthritis funds were made avails able to us, or. unless additional RMP funds, and then it would | come back to this Council in full measure. That is the statement, the intent of the statement. DR. GRAMLICH: It seems reasonable and perfectly clean to me. I move that it is adopted. Unless Council wishes -- DR. WAMMOCK: Second it. DR. PAHL: It's been moved and seconded. Is there a discussion? - Pree iy DR. JANEWAY: Isn't the intent of that also to exclu those grants which on technical grounds were disapproved? DR. PAUL: Yes. DR. JANEWAY: I think this will be clear in the sense of it. DR. PAHL: This then will be incorporated. This : i | | | | | 4 nh ~1 15 16 ‘18 19 ay to ne 23 24 17 ii ee sre ce i says that “Saly approved activity -- activities in the June a 1 set of meetings can utilize Fi uncs, disapproved activities. » Cannot utilize then, any activities cannot be started with currently available :or expected to be available of the | actions we have taken to date, this morning. DR. KOMAROFF: Do vou know off hand those five regions that we can consider that in making funding? . , ; DR. PAHL: The specific four regions? “Mr. Snear? .~ NR. SPEAR:. Florida, Memphis, Mississippi, ar Gri- State. DR. FLOOD: Tri-State brought up -- ti DR. PFHL: There is a motion on the floor and seconded, All in favor of the motion, please say aye. VOICES: Aye. | DR. PAHL: All opposed? (No response.) DR. PANL: Motion carried. That concludes the formal business, except for, I think thé very important public session, and I would like to ask Council whether you would like a brief break and then bring some coffee back to the table and have your open meeting with the representatives, Or whether you would like to continue on, and then have a nreax? DR. MILLIKEN: Coffee now. _ DR. PANL: All right. I think that is fair to our {2 10 ll 12 13 14 ‘15 16 17. 18 19 20 21 24 25 have had a chance to get some refreshment, I would think we .- :mit a statement, and then following any discussion will you 47 visitors too. Why con't we try to reconvene in, oh, ten cr twelve minutes, aS soon ae ue can bring some coffee or doughnuts ! back to the table. And then we will be refreshed for hearing ! from our guests. (Whereupon, a short recess was taken.) DR. PAIL: May we come toader please? Now that we are in better position to consider the remarks of our guests. I would like to welcome both Mr. Bacon and Mr. Sargeant from the Maryland RMP, Mrs. McCarthy, Dr. Scherl, Mr. Prasad, from Nassau- Suffolk RMP, and of course, Dr. Sparkman has already spoken with us this morning. If there are other guests, I do not have their names|- here. We would certainly invite you to participate in the open session. I have been asked because of other commitments to if we could call on Mr. Sargeant,“from the Maryland RMP first, and I would do so now. - ~ And I would ask to have you identify yourself, if you will, for the record. And give us your statement, or sub- please ~-- we'll hear also from Mr. Bacon. If you care to speak and then if that is satisfactory, we will come to Dr. Scherl, and others from the Nassau-Suffolk RMP, 10 li 12 13 14 ‘15 16 17 18 18 to no nO rt = OB y ithat is made up of 2.7 million, in Maryland. MR. SARGEANT: Thank you. T do have a 12:00 appoint-: ' i ment in Baltimore, and that is what you get when you try to schedule things so tight. I am a member of the Executive Committee of the Regiona ' Advisory Group and the Maryland Regional Medical Program. Like you I am a volunteer and give my time for -- towards hopefully operating an. efficient and effective regional medical program. I do have a statement which has been distributed to_ you, but in the interest of your time, I am going to summarize it if I can. When we. received the news referred to earlier this morning in ‘Maryland we did discuss it at some length, land felt it important that perhaps«people coming from all over tthe country are not as@gnizant of the city of Baltimore, and the state of Maryland, as they might be, and we felt it would be important that you understand our case; and our philosophies|, rand therefore that is part of the reason that I am here today. | The gentleman from VA is probably close to Maryland so understands the geographic situation perhaps better than most of you and I am sure Dr. Schreiner does, from Washington. Maryland has a fairly large population but, our Regional Medical population only serves about three million of that population And 300,000 in York, Pennsylvania. I’. think it was referred to earlier this morning, that regional medical programs. do cress state bounJaries and ours indeed does. As all of 49 the Regional Programs we have been involved in changing prior~ _ I 2 ities, and a change in the effectiveness of funding, and so 3 || forth. ~ 4 So we have been somewhat perplexed at times, and i 5 somewhat harried at times in order to cet in our applications | 6 for money. And I am sure that you have experienced the same | 7 situation that we have. | - i 8 Now, of the three million people that we serve in- | 1 i 9 the Maryland Regional Medical Program approximately two 10 million of that total is included in the metropolitan Baltimore } { 11 area. That comprises the five standing counties as well as 12 || Baltimore city itself which is a separate and distinct politic: 13 subdivision, not part of a county. id ; And in western Maryland there are approximately 15 300,000. These figures are on the statement which was 16 given to you, I am rounding it off; on the Eastern Shore of i7 || Haryland, which I guess is referred to as Chesapeake country, | ‘18 there are approximately 250,000, and in the southern part 19 | of Maryland is 115,000. - 20 Then we have an additional 390,000 in York, Pennsyl- 21 i vania. Interestingly enough,-of the pooulation, and that is | be ‘ 29 two million in the Baltimore area, 75.6 percant of that pop- | are 23 II ulation/in the low income area, in fact, 25.6 parcent of the 24 people in metropolitan Baltimere city alone are Medicaid recipients. 3 415 16 17 18 19 20 ' services to neighborhood corporations and we have also assiste: In fact, 54 percent of all the people in the ste... of Maryland, the entire population of Maryland who are medi- caid recipients réside in Baltimore city. Hence, I think ; what I am trying to point out to you is that many of our obliyations have been centered on Baltimore city, which has ; been onethe criticisms that we have had, And we have tried to expand our services in areas | outside Baltimore, but primarily the greater part of our efor: vand concentration has been toward improving methods of the people in Baltimore city to receive medical care. And so, while it may seem out of proportion to the members of the group, and the members of the technical advisory group, indeda, it hasn't when you look upon the geographic and the economic distribution that exists in the state of Maryland. Now, we have adopted many approaches in our efforts to submit grant applications. We have -- amongst those include Support of planning, for Health Maintenance Organizations we have been a great deal of patient education in hyper-tension | i i for the low-income black. families, particularly in Baltimore | city. ' | We have pioneered in the areas of home health care in the training of pediatric nurse practitioners who today in maryland are serving not only Baltimore city, but they are serving in the rural poverty areas as well. 10 11 12 13 14 15 16 ‘U7: 18 19 20 tw te = 8 ' ‘rounded off for a three vear closed chest cardio-pulmonary un bh I would like to point out secre of the very important effects of the RMP has had on activities in the health field in the state of Maryland. In Baltimore -- I am sure that those of you associated with medical schools in the city. There is always great rivalry between the medical schools, — wno is going to be the first with what. In Baltimore when we developed our mechanism for -- let me get the correct title here. Kidney Transplantation ° - Program. We were funding part of this several years ago. “we were able to bring together the state's two medical scheols the state Health Department, a kidney foundation, and two or three of the community hospitals which ha@ their own pro- grams, to bring them together. So now we have one unit working in a cooperative - manner to accomplish the objectives that four or five units were working towards before. We think that this is a very positive accomplishment that has been made in the city of Baltimore, particularly when as I said earlier, there have al- ways been rivairy, 7“ And I see some smiles on some Doctors faces here. We also back in 1969 asked for and received a grant of $115,090 resuccitation training program. And this has been taken over Since that time by the Heart Association of Maryland who has | trained some 13,000 individuals in the life saving technique. cF 10 ll 12 13 14 15 16 17 18 19 20 21 22 ‘services where few if any previously existed. 52 Materials into Dutch. And is using them in connection with its patient education programs in Durope. So, again, w2 think that this is a very important ‘for us. Now, these three things that I have just mentioned to you. We feel they demonstrate the vital role that the Maryland Regional Medical Program has played in the development of new and effective nethods of providing critically needed You have before you today, or you will have before | you today two projects which applied for in our July applicaticn two of them applied directly to the Western part of Maryland. | Where three hundred thousand of Our population reside. They : are part of the second application program. They involve health education in one case, health education for teachers and professionals in school systen, | | | ! | a joint effort to educate the teachers so that we can communicat 1 ' this information to the Students, and the school system in Western Maryland, which is part of the Appalachia Poverty Region. area. Over on the Eastern: shore we have, which is 250,000 population, we are funding a clinical cancer program -- a -hospital discharge planning program and continuing educational | program in general, in Tivert County. All three.of these are 4 now being continued under private enterprise and private funding } i York, Pennsylvania which we serve, with a population: | | \ 10 ll 12 13 "18 19 20 21 continued, and today is serving an areas with a population with a population of 300,000, approximately we have given continucus attention to this area. We have an acute intermediate and long term scope care program begun in 1969 with a grant of $561,000. This established a special hospital unit for the total care and rehab of stroke patients. And since the termination of the funding for that program, in 1972, the entire program has been: of 300,000. We are very proud of these accomplishments. Which we think are positive things which perhaps in the rush of all the other applications and information coming to you may be overlooked. I would just like to make one last comment, to point out that each of the eight projects that we have pro- posed for funding which will be before you today, at least, we anticipate is aimed at achieving a specific objective spell out in the latest, I said latest -interpretation because as I have indicated earlier, there have been continuous changes of Federal guidelines, and that is developed cooperative relationships in the improvement of care in uncerserved areas Developing innovative approaches to medical care. All of these projects received full review by the Technical Review Committee of our Regional Medical program by the compl¢ regional advisory group and by the Maryland Comprehensive = 7 ur 1 Nealth: Plan agency. 2 Io thank you vary much for your time. I have been i 3 as brief as [I could. We do have complete details on the 4 || material that has already been distributed. I am glad to answer 5 | your questions. 6 DR. PAHL: Thank you very much, Mr. Sargeant. Dr. | 7 || Gramlich? 8 DR. GRAMLICH: Mr. Sargeant, I am sure we all very | 9 much appreciate your lucid comprehensive remarks. May I ask 10 4 your occupation? 11 MR. SARGEANT: I happen to be the Executive Director 12 | of the State Medical Society. 13 DR. GRAMLICH: For the state of Maryland? }é | MR. SARGEANT: Yes. 15 DR. PAHL: Dr. Wammock? 16 DR. WAMMOCK: What did you say about the medical 17 schools competing together. What? 18 7 MR. SARGEANT: We did gef them into a kidney transplant 19 || program. It has been very effective and we have very active 20 |, recruitment for kidney transplantation that. are ~~ 91 DR. WAMMOCK: But that is the only program they get oy | together on, 23 MR. SARGEANT: They have gotten together in many o4 || Others. The university medical service program is working & very closely with them, as is the Medical Society. We have a close relationship that we try to bring them together. Try fi ) 55 & _—_ , . | 1 to get them to see each other's view points. We think com! - : 2 petition is good. However, we don't think that is entirely : 3 bad. : 4 DR. PAHL: Is there any other discussion or comments . 5 Thank you very much, Mr. Sargeant. We hope you make your ! 6 appointment in Baltimore without breaking the speed limits. | 7 Mr. Bacon, do you have anything to add? | 8 . MR. BACON: No, in view of the time pressures, Dr. 9 ‘Pahl, it has been a pleasure to be invited. And if there 10 are questions I would stay around. But I also want to get 11 Mr. Sargeant back to his meeting. So I won't interfere with 12 that. 13 DR. PAHL: Yes, Dr. Janeway. 7 DR. JANEWAY: Could I ask one question of Mr. Sargeant “45 When you say you got them together, does that mean in the : 16 ‘kidney transplantation and dialysis. are being done in only | 17 one of the universities? : | : 18 : MR. SARGEANT: We have-in Maryland, perhaps, a unique 19 Situation. Two years ago the state legislature passed a 20 statute which set up a Maryland Kidney Commission. That 21 Maryland Kidney Commission has jurisdicticn working with the 29 CHBA to designate only certain areas for kidney transplants 23 and dialysis. 24 In answer directly to your question, no. That does 25 not mean that there is only one university in Baltimore doing 10 il 12 13 17 -18 19 20 gm £ & i { from Nassau-Suffolk has a statement, and Dr. Scherr, if you that. Obviously there would have to be some interchange back and forth. There aré many dialysis centers. But I think I belic to my understanding there are only two units, two transplanta- tion units in the City. DR. PAWL: Thank you very much. We certainly“ under-j stand as you dash off to another appointment, perhaps we may now turn our attention to -- I believe Dr. Larry Scherr, will identify yourself for the record we will be pleased to hear from you. DR. SCHERR: Dr. Pahl, members of the Council, I'm Dr. Lawrence Scherr, Charman of the Nassau-Suffolk regional advisory group. And I am a member of the area's medical community. I appreciate the fact that I can appear before you. The purpose of my visit here is to express the strong support of the regional advisory group for our program and to answer any questions that yu may have. We recognize very well the critique: of this Council and the organization t cf. our RAG group. And actually to that end I visited the division of the regional medical program with another member of RAG to speak with the staff, to work out means to put into effect what was necessarily to present this grant before you. 10 11 12 13 14 15 16 ‘V7. 18 19 20 21 22 24 62 oO Yesterday I unfortunately could not be here, but many of you did hear our ccordinator, Mr. Prasad co over the contents of our program. . You also have a prepared statement from me and I Will not go over that again. The content of the program and any questions referrable to that I will explain -- they are explained in that statement. I just would like to clarify one or two points, . that are not in that statement itself. To begin with, our: region, Long Island, the two counties as in Maryland has a comperable population of 2.6 million people. The distribution of the popilation is in a rather hetero ceneous fashion. Half being in an established suburban community, the other in. a rural community fast becoming a suburban community. Secondly, there is a rather unique geographic position of our region. It is penninsular in origin, and finds itself admirably to regionalization. And it is that end that we have developed our pro- gram. It is a community based’ regional medical program whic has been in actual operation for the past four *. years and has been recognized by the community as an appropriate agency - for the implementation of certain health procrams. Now, earlier this year, the Regional Advisory Grou: through it's committee had established the geals and priorities of ambulatory care. The actual development of delivery ser- to 10 ll 12 13 14 15 16 7 18 19 20 2l 22 23 | 1 | 5a? vices and diagnostic services of preventive care and this fortunately confermed to our areas, the goals and prioritiss : of Nassau-Suffolk Comprehensive Nealth Planning Council and i was actually the start of good effective cooperation between | the two agencies. How, the grant before you is really a revitalized. : ; . approach for our Nassau-Suffolk regional medical program. | “We are proud of the stated objective and the methods of achiev- ing these objectives. To go into details it does have fourteen directing ambulatory care projects. It has two emergency services projects which are in essence ambulatory care projects. And it has two renal programs which have ambulatory care components to them. Thereby meeting our goals and priorities. Now, some of the programs, despite the current limitation on RMPs future course do require two years for realistic completion. Our grant contains provision for this as well as the means for continuing staff support. 7 That is, not only for the monitorirg those particular programs that are carried forward, but for monitoring what _ - has gone on before, what is going on this year in the programs. that have been started in previous years. And we believe that is a rather vital and important role, ~_ Just three other very brief items. One is the go 10 il 12 13 14 15 16 17 18 ‘19 20 21 22 RIP staff. The advisory group believes thet our newly rececanizes staff under the direction of Mr. Prasad has the strencth and the wisdom and the ‘leadership to help us carry this progran. Through to it's successful " completion. The grant before you will, I think, not oniy reflects their dedication, but I think it reflects their expertise in their field, and I point out again, that their technical competence and their cooperation with regard to our area-wide | comprehensive health planning council. : Secondly the RAG itself has corrected some of its -- most of its prior ordanizational difficulties. That is, +f i the separation of tha.functions of the grantee organizations from the regional advisory group itself. The by-laws have been revised and completely conform, now, to RMP directives. 7 i And I think they have sustained a continuing interest, by the way, in it's objectives by this representative community group. And we believe that it is a major and a viable organiza-— tion to serve the health needs, On Long Island. . 4 Secondly, a word about:the grantee organizations. | OUr grantee organiztion .is independently incorporated specific: ly to deal with RHuP functions. I would just likd to point out that in a recent fiscal audit, covering three to five months on a rather intensive basis, really on a daily basis, the grantee organization was commended for its' expert handlizne of the fiscal matters. 10 i 12 13 14 15 16 17 18 _19 to bo & gO *supposed last year of funding, and that is to seek a way to - ol This, I understand, is unusual to have a commendaticn. On an exit conference. Finally, in cicsina, I would .just like to reaffirm my.. support of our program in the support of the regional advisory group. We believe that the program is well designed and it is well coordinated to meet the needs of the people of | Long Island. We have asked for an amount which exceeds slight! two million dollars for this next period. We do ask and do 7 ‘ request and do request that you favorably consider this, and thank you very much. DR.PAHL: Thank you very much, Doctor. I am sure you would be very responsive to any questions that may come up. Is there a discussion question? Mr. Milliken? MR. MILLIKEN: With regard to past budgets, in regard to the projects that you are proposing, or recommending, within this, what has been built in to see that these projects are inter-related with other sources of funding. And what is the potential for their continuation in case the RMP money is not available after this grant period. DR. SCHEDRR: That of course has always been a major consideration of the Regional Advisory Group. Despite the stimulate the project to begin with. And encourage the project office or other provider organizations to pick up the program provided it is demonstrated its worthiness. Now, I think that therein is the strength of our to ca 18 ‘19 20 al ms ‘aa program. Those programs that have started have been picked ur in some aspect by other organizations emercency services by county health dspartments, renal programs, by some institutions, and by community medicine, and by hopefully the institution by which that is developed, and so on. It is our intention from the very beginning to use the regional program as a stimulus to start developing’ each programs, ultimately to be picked up on a more permanent - basis by other means. DR. PAHL: Thank you. Is there further discussion of questions of Dr. Scherr? | (Jo response.) DR.PAHL:Mr. Prasad, would you have anything to MiR. PRASAD: No. I spoke yesterday. DR. PAHL: Would you use the microphone, please, if you care to make a comment? | MR. PRASAD: No. I spoke yesterday before the Review Committee, and most of the Counéil members who were present, and I have no comments to make. Unless you have some questioas to ask. | DR.PAHL: Thank you. Miss McCarthy? MISS MCCARTHY: No. Thank you. DR. PAHL: Well, then, if there is no further dis- cussion on Nassau-Suffolk, I want to thank you for returning a aa x. ar ~- a a4 {59 here today, and submitting your statement threuch Mr. Prasad yesterday. Are thers any members of the public who wish to make a Statement to comment upon the proceedings so far? Does the Council have anything further to discuss in the open session. Dr. Sparkman? | DR. SPARKMAN: Can I make one more point, Herb? DR. PAH; Yes. - DR. SPARKMAN: I think you are all familiar with the National Association RMP, which instituted the lawsuit which released the impounded funds. When this was set up it was our view that this would serve not only this lawsuit purpose, but also some organization like the American Public wealth Association and others to provide staff education and training. And in fact we do have such a meeting planned in Lenver for September 3rd, and 4th, I believe. At which I think a very good program has been developed. Which sa far has been oversubscribed by the various RMPs. And which will.deal with the variouw parts of RMP pregrams: project development. Management, and I am sure ‘will be of consiéerable part, and we see that as the logical extension of the National Association. Actually, all of you are invited tO attend, and we will see that information is given to you about it. Labatt ttt ee eee etneee een Fann ew se cn mene ni— 10 Il 12 13 15 16 17 18 19 20 21 22 64 DR. PAPFL: Thank vou. Dr. Gramlich? DR. GRAMLICF: Would it be appropriate to ask Dr. - Sparkman to give us a one-minute explanation of what the NRMA is? DR. SPARKMAN: Yes. I had hoped that Dr. Jack. Engle from the Lakes Area PMP was going to he here, since he is the president of the board. This is an organization, Dr. Gramlich, set up aside from the steering committee in the regular coordinating: with the coordinators committee, funded by personal and private sources quite aside from any grant funds and initiated originally around September of last year when it became apparent that without the release of impounded funds the RMP future looked pretty bad. ‘But it has continued with meetings of the board, the board being made up of some representatives of the coordinators, some have come from the steering committee. oa We think there is a real need for the kind of staff training that such an organization can provide. We hope that this is going to he the ultimate . future. Obviously we should be out of the legislative -~ I mean, the leqal problem. As Dr. Pahl has said and as you know, this, I believe, has Leen handled and, as I hope, done _— with shortly. There has been question as to whether RMP grant i t t * Lo G> an ~2 10 il 12 13 15 16 17 18 19 20 €5 funds could be used for this purpose. So far they have not been used. And I have svoken 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 people -- RMP staff, advisory group people, other indiviauals. with whom we have worked. There are some institutional meee nein memberships, people like medical assocations, hospitals, volunteer organizations who wish to join in that fashion. DR. PAHL: Dr. Haher? 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 id 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 demonstratea 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 «pational medical n3 mo te 10 1i 12 13 14 15 16 17: 18 19 20 66 program, what has been done to bring home to the reople -- the clients, if you will -- the benefits accruing to the program? ” It strikes me that I am unfamiliar -- much of the effort has qone into the providers in terms of popularizing 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 your question, one of the roblems 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 reqional 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 10 li 12 13 14 15 16 i. and guests for appearing and speaking with the Council and 67 that there are unexpected and surprising numbers of people a who have been touched in some way by our 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 Advisorv Council have about this. I think we have done a poor job in this respect. . oo 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 employees please leave at this time. n5 Eg 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. I 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 vould like now to turn the meeting over to Mrs. Silsbee who will guide us through the applications. Most of you were here yesterday 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 “f6r the record that this was an unusual proceeding and that it was through a comedy, a set of highly unusual circumstances, but that the members of the Council were sitting as official visitors and not in any -Way.. aS participants. And so your discussion, review and recommendations today are now as Council members and may be in support of or guite divergent from whatever discussion, recommendations i { : i i | 3 =m _ were made yesterday. 7 o And with those few comments, Judy, would you 5 i please lead us through? i MRS. SILSEEE: There are a counle of background 5 items that I think are important here. The committee did 3 express after the meeting yesterday some concern about the ” speed with which they had to move, but they never had a g || choice. . 9 - They had the Council meeting today. And it may 19 not have been apparent’ to all, but at the get-together in ll July the individual reviewers did talk with one another and, 12 | in most cases, where they were not able to, they tried to 13 i communicate by phone. So there was a good deal more back- wl ground in terms of their Celiberations than appeared in 15 public in the record. 16 The other thing is that we put on your desks this 17 || morning -- I mean, in front of you -- this is supposed to - 18 be pink. And this is the Staff's -- yesterday as the Commit- 19 tee was deliberating we were trying to write these up so 20 that you would have something in front of vou, 21 This is the gist of the recommendations of the t ant "Committee, and they are alvhabetically arranged. Also, just now we have -- I feel like, yes, Virginia, there is a way of doing this -- we did get the transcript for yesterday morning's session back in time. mee n7 10 11 12 13 i¢ 15 16 17 3 18 19 20 21 70 This is the first ~- we have been asking for this for some time, but it finally came about. That is only those regions that-were reviewed in the morning. The after- noon session is still heing typed. So we have asked the Staff to take apart the transcrivts and give you the verbatim transcript of those regions that we now have the transcript available on... coe With that backaround, I think this morning we will | try to go alphabetically. | 7 ! Dr. Schreiner? | DR. SCHREINER: Refore you do that, I would find : it helpful. in perspective to know if vou added up all these, what did it come to? MRS. SILSBEFE: A very good point. DR. PAHL: Well, I have the figure. MRS. MORGAN: It was on the board. MRS. SILSPEE: I erased it from the board this morning because it didn't seem to be a thing to be public knowledge. : | DR. PAHL: The figure is $26,557,154, which is, from a management point of view, a very nice level. But you * should not be bound to it in either an upward or downward | direction, particularly in view of the action you tpo,. this ,; morning which gives us that kind of flexibility to manage our affairs, ner Ae eeemnemetmanee egtserinpat eyecare aetnti® Suen eee he cys 1 né at li 12 13 14 15 16 17 18 19 71 DR. SCHREINER: That gives us a feel for where we are, MRS. SILSBEE: I am asking Mrs. Leventhal to dis- tribute the kind of running summary we keev that puts toge- ther as much information as you have at this point. This is the summary data on the recommendations vesterday. DR. JANEWAY: Mrs. Silsbee, can I make a gratuitous " comment? MRS. SILSBEE: Yes, sir. DR. JANEWAY: I think it is an extraordinary accomplishment, to be able to get the transcripts on the table this morning. You must have had people chained to the walls all night. I don't know how that was done. MRS. SILSBEE: Well, this gentleman to my right and his peers are the ones that are responsible for that. But also, a push, I think, from the Director's . office helped, DR. PAHL: We found that once the rumor that I relayed yesterday didn't materialize there was a free evening | for everyone, | ng bo 10 li: 12 15 16 17 18 19 20 2i day. Do you have anything to add? ALABAMA MRS. SILSBRE: O.K. Could we start with Alahama? I think the best way to proceed today is to ask the primary reviewer to make whatever comments and make recommendations and then if the secondary reviewer has anything different I will ask for that. ‘But it may not be necessary at this _ point, ' Alabama. Mrs. Gordon? MRS. GORDON: I was pleasantly surprised this Morning when I read the various and sundry things we have | received, since I wasn't here yesterday. I agree primarily with the comments made yesterday, The only addition that I would have is that Alabama does have a couple of their projects that nearly all of the money is for equipment. And that I do question. ‘That is 126 and 125. | MRS. SILSBEE: Mr. Ogden, you were present yester- MR. OGDEN: No. I would agree with the comments that were made yesterday, particularly those which appear in the transcript from Dr. Vaun. Project number 134 does . indeed appear to be the same project that appeared here in the previous application and was rejected. And it is unlikely -- I felt in reading the material that was sent to me -- that it could be completed in a a 10 11 12 13 14 ‘15 16 V7 18 1g 20 73 reasonable period of time. And some of their other projects | perhaps are not terribly feasible within the periodof one year. The matter of the eauipment doesn't bother me that : much. And I would agree with the allocation made by the | Review Committee vesterday. that? tion. Mrs. Gordon, do you have anv other feeling on MRS. GORDON: No. MRS. SILSBEE: MR. OGDEN: second it. MRS. GORDON: All right. MRS. SILSPREE: I would agree with the alloca- Could I have a motion, please? If Mrs. Gotdon will move it, I will The motion has been made and seconded that the Review Committee recommendationof a approved. MRS. SILSBEE: “ Discussion? (No response.) All in favor? MRS. SILSBEE: VOICES: Aye, Opposed? (No response.) MRS. SILSBEF: The motion is .funding level for the Alabama application for $680,000 be carried. nil ta 18 19 20 ’ 74 ALBANY MRS. SILSPEL: The next region is Albany. Dr. Yatkins is the primary reviewer. DR. WATKINS: Albany has a history as a superior region. In the May funding which Council recommended in June it almost got 100 per cent of the request. In other | words, it was 1 million 66 hundred thousand, and they got “1 million 12 thousand. They are asking this time for 541,437. Mr. Barrows recommended 487,000. Based on Albany's superiority and community involvement, 1 make a motion that they get 487,000, which was recommended : yesterday by the Review Committee. MRS. SILSBEE: Dr. Haber? DR. HABER: I have nothing to add, except that I would ask Dr. Watkins if we could amend his motion to make it $500,000, $13,000 more than he has suggested. MR. MILLIKEN: For what reason? DR. HABER: I think that these projects are well | conceived. I think that the a I am particularly interested in is the one commented on in terms of evaluation of the medicaid screening program. I think that there seemed to * be some disparity between some of the reviewers about what the level of funding should be. Since both of them are a little bit below what they asked, I think we can be slightly more generous and give ' | 1 + to, 10 i 13 ig ‘15 16 17 18 19 20 21 Se accept it. coming applications. I think if we could use specifics the * Committee feel were not worthy. then some more, MRS. SILSBFE: Does thatconstitute a second, Pr. laber? a i DR. HARPER: Yes, it does, if Dr. Watkins will DR. WATKINS: I accept it. MRS. SILSBFE: The motion has been made and seconded that the Albany application be approved at a $500,000 level. Additional comments ? Dr. Milliken -- I mean, Mr. Milliken? MR. MILLIKEN: I am concerned about the precedent for the future applications. ‘ MRS. SILSBEE: Could you use a microphone, please, sir? MR. MILLIKEN: I am a little concerned about the precedent of this amendment for consideration for the forth- | Dr. gave in terms of a specific project that the increase be allocated specifically to that for the reasons that he gave rather than leaving it to the judgment of heaven, they might spend it on projects that this Council and the And I notice a departure from our usual routine. I am not against it. But I believe there ought to be more specific instructions. n13 10 11 12 13 14 15 16 17 . 18 19 20 21 22 76 MRS. SILSPEF: Mrs. Morgan? MRS. MORGAN: Can we give specific instructions to the regions as to how they are to spend the money? MRS. SILSBEE: We can strongly recommend that the basis of the funding decision was based on that aspect. DR. PAHL: We can give advice, but we do not really earmark it for one specific project. And in that ee in adding additional funds we would just have to rely upon - whether they chose to follow our advice or not. So your reasons should be very ‘well spelled out. | But we can't guarantee the results. We do our best to transmit that advice. DR. GRAMLICH: Dr. Pahl, Mr. Milliken's remarks have crystalized a growing concern that has wormed its way into my mind. This sounds a little bit like -- I want to apologize and make it very brief. The mechanism that is used is illustrated by this particular request, especially where yesterday you will recall that one reviewer said, Iet's make it this figure, | the second” reviewer said, let's make that, and they said, well, let's just split it. And I like the approach that Dr. Haber has suggested that they be more specific. And this points up to me the urgency of the problem which is only existing-in this parti- cular session, ‘‘because if this is the last session it will nl4 10 hh 12 13 14 LB 16 17 18 19 20 21 22 77 never be up again. But here is a situation in which the whole structure * is a reverse pyramid. The primary reviewer, who is the only one who has really had the time and the ability to go over the grant request in detail is the one who starts at the bottom of the apex of the pyramid on which the total funcing process is accomplished. The secondary reviewer says, well, yes, I think - ‘it is probably all right, or maybe we ought to do this or that. But then the Review Committee accepts that, and if we accept it, in turn, the Review Committee's recommendation ex pro facto without any really serious consideration we are just compounding that pyramid, on which some very important decisions at the regional level might well take place. So my plea is simply that I think yesterday's review session, which wasinteresting, very interesting, Wa. probably unique in that it was pressured timewise, and mav have reached the right decision -- probably in most instances it did. | : ; But I would agree. I think the Council shoulé " subject that to ample scrutiny before accepting it. MRS. SILSBEF: The motion has been made and seconded that the Albany application be approved at $500,000 with advice to the region about the one project involving nl6 10 ll 12 13 14 15 16 ‘VW 18 19 20 21 22 a supplement of $816,000. 79 ARKANSAS . MRS. SILSBEE: We will go to Arkansas. I'm sorry, I can't remember which ones came up, so if you all will point this out it would be most helpful. Dr. Komaroff is the primary reviewer of the Arkansas application. | DR. KOMAROFF: The June Council rated this region as average. Its funding level on the basis of the June - Council recommendation is currently 1.425 million. They seek: t The main concern of the June Council centered around the stability of the core staff and the uncertainty: about a new coordinator to replace Dr. Silverbladt. According to Mr. Posta and the Staff of DRMP, that problem is | being resolved. Virtually all the vacant staff positions have been filled. And the current acting coordinator very likely will become the permanent coordinator. The project proposals in this supplement are somewhat disappointing to a And I think Dr. Carpenter's review yesterday summarizes my impres- sions. The application sconsists of a great variety of unrelated projects. Many seem designed to further the goals of a single institution within the region rather than to accomplish regionalization. I agree with that. There are cena ae ceria coer ee nls 10 11 12 13 14 - 15 16 17 | ‘18 19 to te mR F B ' make these recommendations tangible, agree with the level of * this prior to the meeting. I concur with the technical 81 I think there are similar prototype for this king of a rape crisis center around the country.that apparently are quite effective. But the concern I have is whether RMP funds under Section 900 -of the law really allow for this kind of a categorical activity to be supported. It is not noncategorical: it is categorical. “And it does not fall, in my estimation, within the language of the law. | | - DR. PAHL:. It is also discriminatory. MR. KOMAROFF: I suppose rape can be. I would, to $400,000 the Review Committee recommended yesterday, but with two restrictions: one, that there be no dollars expended for the rape project and, second, thatno more than $30,000 be expended for the digestive disease proposal. DR. WAMMOCK: Which would be for education? DR. KOMAROFF: Yes. DR. PAHL: Dr. Komaroff, I think we would feel comfortable with that recommendation as a program. MRS, SILSBEE: Dr. Janeway? t DR. JANEWAY: Dr. Komaroff and I have discussed review and with Dr. Komaroff's comments, and second the proposal. . ~_ MRS. SILSBEE: A motion has been made and seconded 82 ni9 1 that the Arkansas application be approved at a $400,000 7 . 2 level, with the following conditions: that no dollars be 3 expended for the rape review project and that no more than 4 $30,000 be expended for the digestive diseases activity. 5 | _ DR. JANEWAY: ‘That is component 104. 6 MRS. SILSREE: Component 104, 7 Is there further. discussion? 8 | (No response.) ; - 9 o MRS. SILSBEE: All in favor? 10 VOICES: Aye. 11 | MRS. SILSBEE: | Opposed? 12 (No response.) ‘ 13 MRS. SILSBEE: That motion is carried. 14 15 16 17 18 “ 19 - : 20 | . , 21 22 23 24 ~ a . n20 to 10 1i 12 13 14 15 16 17 18 19 & £ 8 83 BI-STATE MRS. SILSREE: The next application to be reviewed is Bi-State. The principal reviewer there is Mr. Milliken. Mr. Milliken, Dr. Watkins was here yesterday and you weren't. I don't know whether that -- MR. MILLIKEN: I will defer to him. MRS. SILSBEE: Dr. Watkins? DR. WATKINS: Yes. The Bi-State request was for . $472,458, and the recommended funding level was for $275,000. And I agree with the Review Committee. I think that this | Bi-State critique, the projects compared to May-June were sort of around the same level -- in other words, the same level of prioritization and so forth -- except that since time is running out it is possible that they might have padded a little to get the $472, So what we are asking is that this be reduced toa more feasible figure for them at $275,000. There was a recommendation by two reviewers of 270 to 300 thousand. And I think one reviewer even suggested 335 thousand. But we are suggesting that it be 275 thousand. ! MRS. SILSBEE: Mr. Mitliken? MR. MILLIKEN: I would like to in general agree with that. However, in looking at the many projects that were recommended be dropped, there was one, number 59, evaluation and placement of long-term care patients. I don't 84 n21 . 1 know the qualitv of this program. ~ 9 However, generally there are two great needs in 3 the country which would show a need for developing and 40 ‘eontinuing such projects. One relates to cost containment ~ 5 for health care, and the other to get resources in place for 6 the impending national health insurance. q And based on this, and if this is -- I would have 8 to rely on Staff -- if this is a program that can be a . 9 quality program and make contributions to those two needs, 10 I woutd recommend that we add $30,000 specifically earmarked | 1 for funding of number 59. 12 MRS. MORGAN: I don't see where 59 was deleted, 13 | anyway. 14 MR. HIROTO: It wasn't. : ‘15 . MRS. MORGAN: We've got 57, 58, then we go to 60. | 16 MR. MILLIKEN: Oh, really? The list I have : 17 | indicates:-- : 18 : _ DR. WATKINS: Let me see if I can -- the regional 19 office made comments on 60, 57,59 and 64, which were 20 favorable. And it would be an additional $60,000. The 21 question is: Are we in agreement with this? If you are 22 “in agreement I will adithe $30,000. 23 MR. MILLIKEN: Right. 24 - MRS, SILSBEE: O.K. Mrs. Flood? _ 25 . MRS. FLOOD: The Review Committee's comments that n22 10 il 13 14 15 16 17 - 18 ‘19 20 21 22 24 little discussion was givm to his new role in plans or the ‘made about the rest of this money -- that is, $60,000 or _ 85 are listed on the pink sheet says that brief mention is made of Dr. Felix's arrival as the new coordinator. Fowever, role he might play in the development of this application. Being a little bit familiar with the past history | of the Bi-State program, I think that the power that a man of Dr. Felix's personality and capability might have in making the program develop into something stronger even in - this last phase is something we shouldn't overlook. Now, I would agree that at first glance some of these projects do not appear to be of the most outstanding quality. But I would think that Dr. Felix has the capability of holding neutral ground in a particular area where there is quite a bit of university medical school discussion, and there is impingement on Bi-State by the Illinois RMP and there has been inactivity at times by the Missouri RMP. I would like to ask if the gentlemen might consider|, in light of the cut that was given at the June Council, an. additidénal $100,000 to fund the Bi-State program at $375,000 rather than $275,000, with your specific recommendation of that project being included, that 59, but with no comment $70,000. That might be of value to Dr. Felix to accomplish something, coordination in another area. n23 10 11 12 13 14 ° 15 16 17 18 19 20 21 22 24 86 MR. MILLIKEN: You feel that he needs additional staff, do you? MRS. FLOOD: No,I don't think he needs necessarily additional staff. I think he needs a little discretionary ‘Capability there, to be responsive to these things in the so region/that he doesn't have the stigma of being ralated to the universities in that area. I think he needs a little more discretion so he. can be more able than the previous coordinator to relate to needs ‘in that region. DR. ‘WATKINS: Well, if we were to review and we were to add, I would suggest that it be based on what we just mentioned, the regional office comments. And those comments were an additional 60, not 100. So I woulé@ want to have a reason for adding to the 275, and the reason would be : strongly in favor of the regional comments which were the projects just mentioned, 59, 64, 60 and 57. That was the group eliminated by the reviewers. That is a group that is worth 60,000. So it would give me a better feeling if I said 60 rather than 100. MRS. FLOOD: Well, I would accept the 60. MR. MILLIKEN: What bothers me -~- I am not against adding another 40;000. We have the money... But: I think we need a more tangible, specific advice for so._doing, in line with my earlier comment. n24 10 11 12 13 14 15 16 17 “18 19 20 21 22 24 87 I think it puts us in a verv bad light to adda additional amounts without a very specific cause. DR. WATKINS: Can we have Staff comment on this? MRS. SILSBEE: Mr, Posta? MR. POSTA: I think the purpose of what Mrs. Floog picked up in the green sheet was primarily instigated by Staff. It was something that was not said rather than what was said. Dr. Felix did come in and talk to Dr. Pahl and ‘the proper staff here at DRMP. He did respond with a three-page letter stating some of his goals, what he would like to do during the next year in the St. Louis area. As we know, he does have a terrific reputation. And to date -- he has been on board since July lst -- has gotten together with experimental health delivery service system there in St. Louis as well as with ARCH program and the CHP agency. And one of his primary goals is to utilize the institutions already set up and yet at the same tim eo pursue some of his goals. in primary care and in manpower. Now, the other point that was mentioned in the pink sheet you have before you was the role that Dr. Felix has played ‘in establishing and preparing this particular application. And when we asked him that, the answer was com- pletely negative: He did not have a role in-preparing this particular application. So it is our strategy at least to | n25 - 1 present this to you with expectations that perhaps Dr. ! 5 Felix would have more latitude in getting into those areas ' 3} that he particular has a special talent for. : 4 . MRS. SILSBEE: But for Council's consideration, - 5 they have the application in front of them. This is sort 6 of the horns of a dilemma. And in terms of the advice that. 7 we would give to the region, as I heard the discussion, is 8 thatcertain of your activities we think are first rate, : 9 ‘some of the others we don't think are good. But we really 10 think that you ought to scrap the whole thing and look at 11 your priorities all over again and put your faith in Dr. 13 Now, this could be translated in some way or 14 another, but it does create a problem. as MR. HIROTO: Is there a motion? 16 , MRS. SILSBEE: No, there isn't. a DR. WATKINS: We move $335,000. 18 7 MR. MILLIKEN: I second it. 19 MRS. SILSBEE: “The motion has been made and seconded 20 that the Bi-State application be approved at the level of 21 || $335,000. 22 ° ' Is there further discussion? 23 (No response.) 4 - MRS. SILSBEE: In favor? ~ VOICES: Aye. n26 10 11 12 13 14 15 16 17 18 19 20 21 22 24 MRS. SILSBFE: Opposed? ‘DR. JANEWAY: No. * MRS. SILSBEE: Let the record show there was one in opposition. The motion is carried, MR. HIROTO: Am I to leave?— DR. JANEWAY: Yes. 10 11 12 13 14 ‘15 16 17. 18 19 20 21 22 24 " reorganization, that the coordinator should be cautioned CALIFORNIA MRS. SILSBEE: The next application to be reviewed * is from California: And Mr. Firoto is out of the room. Dr. Janeway is primary reviewer. DR. JANEWAY: As noted in the May-gune review, the program was above average and continues, in my opinion, to be above average to superior. The May-June request was on the order of $8,170,000, with a DRMP funding decision of almost 7 million dollars -- even somewhat below the Committee recommendation. The current request is for $5,592,000. It is rv 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 CHP’ 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 in this regard. The recommendation for funding is at the level of 3 million dollars. And I so move. n28 10 ll 12 13 14 15 16 17 18 19 20 21 22 on this particular application, inasmuch as I think it is the largest before us today. “IMade at 2 million, how many in favor. That was voted down. *3 million. And they finally got an acceptance at 3 million 91 MRS. SILSBEE: Mr. Ogden? MR. OGDEN: I disagree with Dr. Janeway on the level of funding. “And I would like to spend a few moments Those of you who were here yesterday and listened to the discussion will recognize that Dr. Heustis, who was’ the primary reviewer yesterday, recommended this be funded . in full, $5,592,000. Dr. Hirschboeck, who was the secondary reviewer, suggested it be reduced to 2 million dollars. After considerable discussion among the people _ around the Review Committee table about the projects and a group of other things, the final decision came down to a bit of dickering. Now, at the risk of going over things that you “jagtened to yesterday, there was a show of hands on how many would prefer 3 million. Dr. Heustis said, how about 4 or 5? Then Mrs. Silsbee said; well the motion has been That motion was defeated. And Mr. Barrows said, well, then I will move it at é , without any discussion of whether these were valuble projects, whether the RMP was being cut too far or particular discussion ; with respect to the quality of the this program. n29 10 Il 12 13 14 15 16 17 18 re 20 21 22 24 , 92 Now, you don't have available to you, I 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 100k 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 - program staff, which includes existing projects as well as- 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. “In looking across, I see that there may be some cuthack on 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 - ; pee 10 11 12 13 14 15 16 17 18 19 20 21 93 of this was for program staff. That was all funded in the May-June application. MRS. SILSBEE: Is that not correct, Mr. Russell? MR. RUSSELL: That is correct. DR. JANEWAY: That 1.6 million has already been funded, | MR. OGDEN: All right. If vou come down to the request for September of '74.to June of '75 which is in the. ‘third column, that is. under the heading of five in here, you will begin to see the programs that they are proposing are those to which they propose to add some additional funds. ‘ These include a series of kidney programs, some of which were funded at very small amounts in the Julv '74 to June of '75 request and for which they are now recuesting additional funds. And when you come over, come several pages along, don't you have a printout, now beginning on page 7 you begin to pick up new projects which they are talking about beginning with about 1477. And you will find some that are added to. | But beginning on page 8 they are all new projects that they ‘are talking about funding for the period of September '74 to June of '75, Now, I find some of these to be of—considerable interest and also of value. There are projects here concernine | 1 10 11 ‘12 13 14 15 16 17 18 ‘19 20 21 22 24 .ness project here. 94 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 adda back money | into this application. I haven't totaled up the requests : that appear on pages 8, 9 and 10 at all. But TI 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 ll 12 13 14 15 16 17 18 19 20 21 22 24 95 DR. JANEWAY: Let me respond to that. Perhaps tI 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 guality 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 erent cen ey cereneT cect wate oT n33 10 11 12 13 14 "15 16 17 18 ‘19 20 21 22 24 96 factor. And I would say that I 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 well spent in that as it would if it were distributed aif- ferently throughout the regions. MRS. SILSBEE: Dr. Gramlich? DR. GRAMLICH: Dr. Janeway raises a criticism of - a million dollars for a hypertension screening program. 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 a 2 million dollar level, leavin- them with a million dollars. 2 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 ‘ technical reviewer on this, but when vou have a very high 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 15 16 17 18 19 20 21 22 24 type of population and a different health care need, MR. OGDFN: 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 countrv 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 many other things. I plead no particular case for California. I am not from California. But I simply feel that this is a pro- gram that deserves better consideration than it received yesterday. MRS. SILSBEE: Dr. Schreiner? DR. SCHREINER: I justwant to point out that both the reviewers have made some excellent specific points. I . do think, however, we should put in persvective that 7 millior 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 heing 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 cvcle. 3 million bye of a request of 5 is about 60 per cent. So an average region ought to get around 3 million. But I would think that if this region is, in fact, reaqarded " to be superior or above average that -- just that is another 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. n3® 10 11 12 13 14 15 16 ; 17 18 19 20 21 22 99 ‘I didn't hear a second. MR. WAMMOCK: I will second that motion. MRS. SILSBER: 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 to -- | 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 9,1 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 -- 159¢, 159D, 1598, 159F, 159G, community hypertension awareness project, 159H, “high 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 22 100 being put in that program there, MRS. SILSBEE: 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. SILSBEE: 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: IX think 3 and a half. Try 3 and a half. | DR. JANEWAY: How about 3 million 640? 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 appvlica- “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 24 141 DR. JANEWAY: I 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 11 12 13 14 ‘15 16 17 18 19 20 21 22 = level of $450,000. I was not quite so generous. I found is feasible for one year projects. 102 CENTRAL NEW YORK MRS. SILSBFE: The next application is Central New York, and Miss-Martinez is the primarv reviewer. { MISS MARTINEZ: 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 - Two more were really sort of education projects. The end result is that I ended up with a funding recommenda- tion of 381,372. a 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. An@ I think it has worked extremely well there. There are a high number of inputs, and they have a very good type of n40 10 11 12 13 14 15 16 17 18 ‘19 20 to be ®R F 8 193 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. . i 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, tne teen ee 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. - Iocan 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 j } 104 n41 1 of $562,000. : | 2 So then I am a little far away from Miss Martinez. 3 ; _ MRS. SILSBEE: Well, I don't have a motion. 1 DR. SCHREINER: I would like, obviously, to move 5 the higher figure and she would like to move the lower figure. 6 MRS. SILSBEE: We've got three figures before us 7 now. 8 MR. OGDEN: What are those, please? . 9] | MRS. SILSBRE: But we don't have a motion. : (20 DR. SCHREINER: I would like to move 562. il MISS MARTINEZ: 562 ? 12 | DR. SCHREINER: Yes. ° | | 13 MRS. SILSBEE: £562,000. Is there a second? 14 ; (No response.) ‘15 MRS. SILSBEE: Is there another motion? 16 MISS MARTINEZ: Yes. I would like to make a motion | 17 | for 382,000. | 18 a MRS. SILSBEE: 383,000? | 19 MISS MARTINEZ: ~ 82. ; | . ' 20 MRS. SILSBEE: ~382,000. Is theré a second? | 21 . (No response.) 22 _ MRS. SILSBEE: Is there another motion? : 23 DR. KOMAROFF: I move the Committee's recommenda- . 24 || tion of $450,000. - 25 DR. JANEWAY: Seconded. Ma 105 n42 1 MRS. SILSBEE: 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 |. (No response.) | 6 MRS. SILSBEE: All in favor? | oe | 7 VOICES: Aye, 8 MRS. SILSBEE: Opposed? - 9 = (No response.) 10 MRS. SILSBEE: The motion is carried. 11 13 14 ‘15 16 17 18 | “ 19 20 21 . 22 106 n43 1 . -. .COLORADO/HYOMING 2 ' MRS. SILSBEE: The next region to be reviewed is 3 || Colorado/tyoming. And let the record show that Dr. Gramlich 4 is out of the room. 5 Miss Martinez? 6 MISS MARTINEZ: I am waiting. 7 All right. I believe the Committee's recommendation 8 || was for $200,000. Again I am a little low in that I recom- 9 ‘mend 146,959. I have a comment to make on one of the project a 10 in particular -- well, two, all right. 11 One, number 59, seems to me to be primarily an 12 education project. And I was wondering whether/stafé person 13 could tell me if this was developed in cooperation with the 1é educational commission of Colorado? 15 MRS. SILSBEE: Miss Murphy, did you hear the ques- 16 tion? 17 MRS. MURPHY: Yes. I have to check.it. 18 MRS. SILSBEE: Could you get over to the microphone 19 please? : : 20 MRS. MURPHY: -I really know no more about the 21 project than what is on page 15. 22 || MISS MARTINEZ: Well, if it is the information that 23 I read last night, then I just make the observation that the 24 educational commission or agencies in the State were not 25 consulted and that the project description was extremely n44 10 11 12 13 14 15 16 17 18 19 20 21 22 = 107 hazy in my mind. So I have severe questions about that one, * But the 6ne 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 exmple 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? t 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 $17,000. MRS. MURPHY: That proposal has beén called into EMS for consideration. We will not fund it until it gets n45 10 ll. 12 13 14 “15 16 17 18 19 20 21 22 = 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 heavv staffing by very skilled people. And I think that we sadlv- or badly need the development of such burn centers. But unless this is some kind of exploratory project -- I can't tell here -- IT 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 areas where they are likely to be well utilized, and eoncen- trate the rest on developing transportation svstems to cet 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 18 19 20 21 22 = 1099 who has been working in, quote, unquote, what they call their burn center where they treat their burn patients, which is a $12,000, add to it travel about the State, and I think really to urge passage of a legislature bill where it wiil 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: I haven't had a motion on Colorado/ Wyoming. MISS MARTINEZ: Yes. I would .to make a motion that! we fund at the level of 146,959, MRS. SILSBEF: Is there a second? DR. KOMAROFF: Seconds. MRS. SILSBEE: — A motion has been made and seconded that the Colorado/Wyoming application be approved at the level of $146,959, | I DR. KOMAROFF: Including that caveat that she mentioned about theSpanish-speaking -- MRS. SILSBEE: That is project 54._ . MISS MARTINEZ: Yes, either it be developed with ~ 15° 16 17 18 3 to da 3 lil 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 he reduced to 146,959... : . ‘ MRS. SILSBFE: You have heard the motion. Is there a second? DR. WAMMOCK: Second. . MRS. SILSBEE:: Any further discussion? (No response.) n49 10 11 12 13 14 15 16 17 18 19 20 21 22 24 ‘killing alligators and forgot after he was down there with 112 MRS. SILSBEE: All in favor? “VOICES: Ave. MRS. SILSBEE: Opposed? DR. JANEWAY: No. MRS. MORGAN: No. MRS. SILSBEE: 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 a 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 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 bit. ‘reviewers or the Regional Advisory Group itself does not 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 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 _ 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 are serving 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. SILSBEE: You'll take Connecticut. Do you have that one? n5l 10 11 12 13 14 15 16 17 18 19 20 21 22 24 114 MR. HIROTO: No, MRS. SILSBEE: We have to hold for just a few + minutes while there is a switch -- the changing of the guard here. (Whereupon, at 12:30, a luncheon recess was taken until 1:00 p.m.) 10 11 12 13 14 15 16 17 18 19 20 21 22 ‘reviewer have no problems or difficulties with the result _ ing proposals and ask if objection is raised on the part of 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. Mr. Hiroto. MR. HIROTO: Ms. Chairman, would you entertain a motion that should the primary reviewer and the secondary 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. MS. SILSBEE: I will entertain the motion. MR. MILLIKEN: Second. | 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 anaven would seem to indicate that it would then be part of a block to vote on. MS. SILSBEE: Right. DR. WAMMOCK: You said-you would read down the list? us ; _ DR. HABER: Yes. There are several ways to 10 il 12 13 14 15 16 17 18 19 20 21 22 24 _and the committee approved recommendation. I also think 116 accomplish this, but the most expeditious wonid be for Mrs. Silsbee to read down the list and if anyone feels that he doesn't go along with the committee's report, he so states and it is then removed for: individual considera- tion from the Block Vote. | | 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 ; 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 yesterday. 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'11 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. ene 10 11 12 13 14 15 16 17 18 19 20 21 22 = MS. MR. MS. DR. MS. Greater Delaware Valley - $684,512. SILSBEE: 117 Arizona - $150,000. HIROTO: Object. SILSBEE: GRAMLICH: SILSBEE: Connecticut - $750,000. “Object. $600,000 - Florida. Hawaii ~- $486,750. Illinois - $750,000. Indiana - $240,000. Intermountain —- DR. MS. DR. MS. DR. MS. KOMAROFF : SILSBEE: JANEWAY : SILSBEE: WAMMOCK : SILSBEE: Object. 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 14 ‘15 16 17 18 19 20 21 22 = 118 DR. KOMAROFF: I think we had better discuss that. 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 Cdrolina MRS. GORDON: ° Objection. MS. SILSBEE: South Dakota - $88,850 Susquehanna Valley - $500,000 Tennessee/Mid-South ~ $570,000 Tri-State - $610,000 MS. SILSBEE: We'll céme back to Texas. Tri-State $610,000. Virginia - $960,860. MS. MARTINEZ: Object. MRS. FLOOD: 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 - $1,000,000 119 ; 1 MS. SILSBEE: Western Pennsylvania - $450,000. - 2 | DR. HABER: Objection. 3 MS. SILSBEE: Wisconsin - $200,000. 4 We'll review Arizona, Connectucut, Intermountain, Louisiana, 5 . Maryland, Nassau-Suffolk, South Carolina, Virginia, Western : 6 Pennsylvania with Texas. ” MRS. MORGAN: I move that we accept the Review 8 Committee's recommendations for funding of the regions - 9 || not specified to be taken care of separately. 10 DR. KOMAROFF: Second. 11 MS. SILSBEE: Is there further discussion? 12 (No response) 13 MS. SILSBEE: All in favor. 14 Opposed. "45 | MS. SILSBEE: Motion is carried. 16 ' We'll now go to Arizona. 17 MRS. KLEIN: This is just a minor thing, but we 18 had taken some this morning and the way the motion was : 19 worded, all those other than the ones that were recently ! 20 enumerated, so I think the motion should show, except for 21 those already discussed and approved. 22 MS. SILSBEE: I think that was the consensus 23 of the discussion beforehand. 24 _ 25 4 a 10 11 12 13 7 15 16 17 18 19 20 21 22 tion. The question is one of principal. Do you reward 120 ARTZONA MS. SILSBEE: Arizona - Dr. Gramlich. DR. GRAMLICH: As a matter of principle, Arizona | has had difficulty with the organization, the leadership andi 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-- - 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 priority. 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? + —eantannenteblieneetiainentne nee rieetermnenttine ieee wey - : iene 10 11 12 13 14 415 16 17 18 19 20 21 22 x (No response) MS. SILSBEE: All in favor. ’ ” ‘Opposed. MS. SILSBEE: The motion is carried. 122 10 11 12 13 14 15 16 17 18 ‘19 20 2i 22 La $1,400,000, which reflects, I think, the difficulties we 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 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 il 12 13 14 15 ‘16 17 18 19 20 21 22 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_ _S0 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 pregram by refusing to accept their major funding request. MS. SILSBEE: _ Dr.Janeway. DR. JANEWAY: It is my recollection, Dr. Gramlich i i , I that one of the things that was taken into consideration was | considerable amount of their funding was going ‘through into 1976. ~ DR. GRAMLICH: Correct. 10 11 12 13 14 15 16 17 18 19 20 21 22 ‘. resources that were funded at a fairly sizable amount. * still wind up with a figure $1,430,000. ‘The way I visualized 124 DR. JANEWAY : And the way I recall the technical ! discussions, there was a general sense of that group that 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 .- 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 continuat+ 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 ~ 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. ‘N 126 1 we have--- | 7 2 MRS. GORDON: ---it's not a matter of a new activity 3 so much. . - 4 . MS. SILSBEE: I think we may need some help here 5 | from Mr. Nash. The two year projects, are they all new : 6 or are they continuations? | 7 MR. NASH: I think some of them are new. The : 8 onces, I think, that concern the review committee, the - g || . four projects going to Yale and Yukon are for over $800,000 10 for the two year period. j1 MS. SILSBEE: Mrs. Gordon, because you were not 12 here yesterday, there was considerable discussion with the . 13 committee and Dr. Pahl about the two year request. The 14 ‘region recieved its money and has the option of putting 15 Some money away for some activities, if they feel they 16 ' shoudl go longer than two years, if they can work out some 17 kind of a contractural arrangement, so this is just a way of ; ‘18 arriving at a level and I don't“ think that should be a major 19 worry for you. The Regional Advisory Group will make that 20 decision. Mr. Milliken. ' 21 MR. MILLIKEN: My understanding is that you have-- 99 " my understanding is that Yale was just awarded one of the 23 few large cancer centers---cancer development research. 24 Are they going to be able to spend all of this with the 25 limited staff they have there? 10 11 12 13 14 "15 16 17 18 19 20 21 22 = 127 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) 8 | MS. SILSBEE'! All in favor? Opposed. The ayes have it. 10 ll 12 13 14 ‘15 16 17 18 19 20 21 22 = 128 INTERMOUNTAIN MS. SILSBEE: The next application to be reviewed is Intermountain and the record shows that Mrs. Klein and Dr. Gramlich are out of the room. Dr. Komarof£ 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 séme 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 1 t 10 11 12 13 14 15 16 17 18 “19 20 21 22 ,corporation. Dr. Pahl mentioned yesterday that through action by the State Attorney General and through meetings 129 time involved the role of the RAG in developing and monitor-~' t 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 iike a worth- while idea. There was a question of conflict of interest in the establishment of a health development services with the RMP.staff members, this conflict of interest ques- tion has been resolved. There was concern that council i 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 | i i | i kinds of activities which have gone on in other regions with | | | | 10 11 12 13 14 15 16. 17 18 19 20 21 22 _ RMP's funding mandate. Several strong projects are listed. one of the most interesting involves a computerized EEE EE EDO I EO ee 130 ! out giving evidence that they plan to build on the exverience 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 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 cencerned 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. JI 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 1 12 13 14 15 16 17 18 19 20 21 22 = 132 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 ofthe 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 they come up tothe 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, funding. to answer comments? swallow. Technical what they on it and in and do per se or the agency that provides medical It's just a question that I, myself am unable it. I don't have the knowledge. MS. SILSBEE: Mr. Sibloski, do you have any MR. SIBLOWSI: Not really. It's a hard one to DR. JANEWAY: I brought it up BECAUSE Nobody in Review even mentioned it. MRS. GORDON: As secondary reviewer, we only figured were trying to do was get an impartial judgement the other federal agencies weren't impartial. DR. JANEWAY: It might pay to have Blue Cross come: 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 FMP 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 10 ll 12 13 14 ‘15 16 17 18 19 20 21 22 . to which is attached, at least in my copy a memorandum, the 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 organizations, it is a non biased type of thing where the 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 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 availabilit: i 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 ox the hospital system. I'm not saying this was developed 10 11 12 13 14 ‘15. 16 17 18 19 20 21 22 = you recommend that we make the award which would include 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 lecality. DR. JANEWAY: Far.be it from me to cuestion the legality. I'm questioning whether it is legal. I want © | some technical input. MS. SILSBEE: That's a better — 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 leaal, do 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 and I think it would be very useful to get independent 137 Medical Program and at a stage when winding down is in i process and when one would hope that funds appropriated 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 7 hard put in terms of development of medic-aid programs 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- t compass, aS a rule, if they could not spend money on that, that the region should have the money or have it taken away. ! DR. JANEWAY: No. MS..SILSBEE: Is there any discussion? (No response) 10 ‘All 12 13 14 15 16 17 18 19 20 21 22 = MS. SILSBEE: The motion has been made and seconded that the Louisiana application be approved at the level of $168,680 with the condition that the Gy oO 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 judge! 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 table please? MS. SILSBEE: Did you hear Dr. Wammock's auestion? 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 Staff of $233,000 and $724,000 for July. The Program Staff of $233,000 with the approval yesterday of $350,000---no, $650,000---that's one-third for staff. ' 4 i * June, the request was then $762 and the new one is for Program 140 1 MS. SILSBEE: Dr. Wammock, if you will look at the | J ~ 9 printout labeled 7-74, you will see that the total request | 3 was $724,000, of which the staff is $302,961. 40 | DR. WAMMOCK: That's right, the indirect column is ~ 5 right. 6 MS. SILSBEE: There was no money provided for 1 staff because there was no money provided from the May 8 application, so this is it. The $650,000 as I understood . 9 _ the committee recommendation yesterday would allow for the 10 staff, about half for staff and about half for the activities 11 that were proposed. Is that right, Mr. Nash? 12 MR. NASH: I thin, one of the recommendations was 13 that $250,000 for staff and $400,000 for projects. 14 DR. WAMMOCK: 400 for projects and 250 for staff? : 5 . MR. NASH: Yes,sir. 16 | MR. OGDEN: I think we ought to be aware that a 17 great deal of the activities that may go into this project 18 is staff activities, so that you can't judge the total 19 request for a particular project as being the total cost 20 because some of that activity is being carried out by staff 21 people themselves. | | 22 |i" - DR. WAMMOCK: I recognize that. 23 MR. OGDEN: So, I don't believe the action yester- 24 day of say $250,000 for staff and $400,000 for programs is 25 any. sense out of line. icc! tc ccch cca sctaaaaaasaaaaasaaaaasaaaaaaaaaaaaaaaasaaaaaaaaaamamaama sama saat en ee I 14] 1 DR. WAMMOCK: You don't think that's out of line? | — ~ 9 MR. OGDEN: No, I don't. I recommend that it be : 3 accepted the way it was yesterday. ! 4 i. DR. WAMMOCK: I just reopened it for the question ! 5 of clarification in my own mind as to which way this was | 6 going because I wasn't quite sure. I went through this thing 7 and looked at the various projects which I described and I | 8 don't know whether they're goingto be implemented or not. 9 _ Perhaps it may do some good and perhaps it May not do any 10 good. I'll let the motion stand as it is as of yesterday, 11 but I wanted to bring this up for clarififation in my own | 12 mind. I make a motion. 13 MR. OGDEN: I'll second it. 14 MS. SILSBEE: The motion has been made and 15 seconded that the committee recommendation of $650,000 164. stand. or. Watkins, did you have anything to add to that 17 as secondary reviewer? (18 . DR. WATKINS: No comment. 19 MS. SILSBEE: The motion has been made and seconded 20 that the Maryland application be approved atthe level of 21 $650,000 dollars. Is there any further discussion? 22 |. (No response) 23 MS. SILSBEF All in favor? 24 Opposed. _ 25 The motion is carried. 142 1 NASSAU?SUFFOLK i _ 2 MS. SILSBEE: The next region to review is 3 3 Nassau/Suffolk and. the primary reviewer is Mr. Milliken. | = ; 4 | MR. MILLIKEN: Was this discussed vesterdav? | 5 MS. SILSBEE: Yes, sir. Do you have a transcript 6 on that? 7 MR. MILLIKEN: Yes, I do. With the information 8 we had this morning, it would appear that we do have to - 9 .change our previous decision of no funding. I have no 10 evidence to find fault with or change the review committee 11 recommendation of $900,000, although I personally cuestion 12 if that much is necessary due to the situation therein. 13 Maybe the second reviewer has something to add. I'll make 14 a motion later on. 15 DR. GRAMLICH: I find this interesting. It 16 | appears we're reversing our position of June and July. 17 They have made a strong appeal and I guess if council has 18 no major objection to reinstating them, I would have to , 19 Support that decision. So mova. 20 MS. SILSBEE: “Second. ' 21 MS. MORGAN: Second. 22 " MR. OGDEN: Could I ask the members of council--- 23 MS. SILSBEE: Mr. ogden, could you use the 24 microphone. ~ 25 . MR. OGDEN: Look at the Page concerning Nassau/ i 10 11 12 13 14 15 16 17 18 ‘19 20 21 22 143 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. QGDEN: 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 allowable concepts of our funding. 10 11 12 13 14 - 15 16 | 17 18 19 20 21 22 ~ ‘their priority list. 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 staff 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 : 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 ll 12 13 14 15 16 17 18 19 20 21 22 MR. STOLOV: I believe Dr. Pahl mentioned vesterday that we still have not developed policy reaarding what happens in terms of independent RMP beyond June of '75, so we don't know HDEW wide if this is allowable under grants and administra- tion practices, but I believe it woula 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 prosyam 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 somebody here. I'm very impressed as Dr. Scherer happens to be an old friend of mine and I was wondéring if this was in line ,with his $900,000 speed. DR. PAHL: Mr. Milliken, right, Iim afraid you're it. 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, — MR. MILLIKEN: On the yellow sheet, the second yellow 10 11 12 13 14 15 16 17 18 ‘19 20 te to R F 8B 14€ 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 périod and they felt it would be good use of Government money if thev 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 volicy which comes-out of the DHEW decision 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 to do in terms of contract activities may not engage in that king of Situation which would perpetuate the RMP or the staff beyoné June 30 of '75, They may contract with groups to carry out perpetuate themselves, so if NasSau/Suf folk, 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 Seyond 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 activities past June 30 of '75, bu not in such a way to ; i , ; : 10 11 12 13 14 15 16 VW 18 ‘19 20 to — bw to $3 147 line rather clear. MR. MILLIKEN: I still go with the action of June and the report of the committee unless there is new informaticr. or evidence that shows reconsideration should be made. | MS. SILSBEE: 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 a 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 11 12 13 14 15 16 17 18 ‘19 20 to to gR 8 & 1492 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. NS. 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 they're going to do | " 149 | 1 anythina because they have had a request of $2 million. : 7 2 Jerry, do you know the purpose? | . 3 MR. STOLOV: They are separate projects. One is ! 4 the university base and the other isa community base. : 5 One is nurse trained - nurse practioner and the other | 6 is more of a socio emotional thing to train nurses in | 7 giving support to families who have critical illnesses. 8 They are different projects. - 9 7 MS. SILSBEE: The question is, where do they fall 10 on the priority list? 11 MR. STOLOV: I'll check that out on my paper 12 work. . 13 DR. GRAMLICH: May I ask a question? It does not 14 . relate to the subject at hand, but it does relate to the Nassau 15 question. In one of the other regions, we find that the 16 regional advisory group apparently worked very well and in 17 Nassau/Suffolk, they apparently did not. 18 MS. SILSBEE: That has a long history. I think 19 they actually didn't have -a combined board. There was a 20 combined grantee and we made them have ,a different regional 21 advisory group and a different council. Thre was some overlap 92 || butthe combined grantee situation did not work out andthat was 23 was about a year ago September or so. We had joint staffing 24 || too, Dr. Gramlich. 25 MR. STOLOV: I have on both projects my paperwork. 10 11 12 13 14 15 16 7 18 ‘19 20 21 22 * materials so it will be at the 4th grade reading level. * 150 On both projects - family nurse practioner which was $142,000 project, it ranks number 11, which the critical care nursing project, Number 16< The dollars fall out,if they stick to 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~--- HS. FLYNN: They left their priority and sovending 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 heakth education | NS. 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. fe Ww McLane rml 10 11 12 13 14 15 16 17 18 19 20 21 to b Rg F & 152 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 vou finally acted, there was reluctance, but in terms of the final action Nassau/Suffolk now has $900,990. We will be glad to work with them further on this. - rm3 10 11 12 13 14 15 16 17 18 19 20 21 22 * “I think this unfortunate. 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 had proper review, but we have been explained by phone, 1 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 mv contention is that the funding review that some of the reviewers have recommended for this | is undulv harsh. I feel that this has been a good progran. In 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 t not specific enough, SO we are getting them both ways, and 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 11 12 13 14 “15 16 7 18 19 20 21 22 = 155 towards them. I think they have had the endorsement on pages 194 and following the CHP RMP annual review conference. I think that they Have; it seems to be indicated the ultimate phase-out of this by modest extensions of some of these activities, and I would suggest that instead of the proposed 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: Dr. Komaroff? DR. KOMAROFPF: I think a series of projects, 66 projects which are described here, can both be’ vague in their individual descrivtion and disconnected, without anv kind of sense of cohesiveness, and I ~~ well, that in fact is my feeling about reading this application. We 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. i. ‘ DR. KOMAROFF: I will summarize. As an example "of my edginess, I will tell you why I am edgv. Yesterday 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 10 1l 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 $500,900. Is there further discussion? (No response.) MRS. SILSBEE: All in favor? - VOICES: Aye. MRS. SILSBEE: Opvosed? (No response.) . MRS. SILSBEE: The motitn is carried. rm7 1 10 11 12 13 14 15 16 17 ‘19 20 21 22 = 18 to Texas. buted? Texas regional medical program included requests for funds . for a series of contacts of which the ideas were svelled out in the May application, but the specifics regarding who was TEXAS MRS. SILSBEE: If we go alphabetically, we come 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-_ 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 going to carry it out and what institution and the amount for each contract was missing beGéause 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 we rae tveta pene S 16Q rm9 1 review committee which will consist of on this, plus members | g |} from the RAG. The concern of the review committee was health i * 3 professionals reviewing these projects. If you are familiar | t 4 with the Texas RAG, it is practically all health professionals. 5 About 95 percent of them are physicians on the RAG, and these! 6 physicians are going to be the ones, and this is from the 7 material we have received,.who will be on the review committee. g | there is no question in my mind but that there will be health 9 professionals reviewing these area contracts. They have 10 sent in their form, which is a six page form. It has to be 11 || filled out: monthly on the various contracts and sent in; will 12 || be reviewed by their committee. I havein my mind no doubt 13 that these will be reviewed by health professionals, and 14 || I would like to move that the level from June meeting of 15 one million four hundred thousand be returned to the Texas 16 | RMP, 17 MRS. SILSBEE: Dr.Schreiner? 18 ue DR. SCHREINER: I ama diittle bit confused about 19 the back and forth thing and the old grant. If you could a 20 || clarify that a little bit? In other words, are you -- I 21 || didn't hear the discussion yesterday on this particularone. 22 “Are they proposing any additional new money? 23 MRS. SILSBEE: No. Well, they are. I was going a4 || tO ask Mrs. Morgan if she would mind rewording her motion. 25 || We gave them an award for two million three hundred whatever rm1o0 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 removed 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. a t DR. SCHREINER: So this comes out of the 84, not ~ ‘out of the 20. Thatis what I wanted. MRS. MORGAN: It comes out of that money. MRS. SILSBEE:. The money that has already been awarded. | rm12 10 11 12. 13 14 15 16 17 18 ‘19 20 21 22 MRS. Watkins. DR. This is Virginia, and Dr. Perez has changed the face of the whole program. MRS. MISS MARTINEZ: SILSBEER : * WATKINS : Miss Martinez had a question. SILSBEE: VIRGINIA 163 ow we go to Virginia, and Dr. I have no problem with Virginia. Miss Martinez? In thinking over the project descriptions, I notice that a great manv of the projects are really supportive or extending grants to CHP's for planning, for the normal planning of CHP programs, which I am not sure is terribly wise, even if it is legal. In any case, I think the committee recommended nine sixty-three? MRS. MORGAN : It is nine sixty-three eight sixty.. MISS MARTINEZ: And I would like to reduce that sum somewhat to seven-oh-seven seven fifty-nine. went through the projects, and eliminating things like number 48 which is a grant to a CHP ageticy for a -- MRS. SILSBEE: Miss Martinez, in terms of what you I just are recommending there, have you, are you aware, that a message was sent back to the regional medical programs resources planning and that this should be done in collaboration with the CHP agencies? MISS MARTINEZ : No. “concerning the need to do -- or to get geared up for health foe cern ee ew a ee eee ewe oo meme rer wey em eee ee teresa: oe = 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, 165 rm16 10 11 12 13 14 15 16 17 18 ‘19 to to gS & 8 resolution. 167 DR. GRAHLICH: May I open up one more small subject? i i DR. PAHL: We have that as well as Mr. Ogden's DR. GRAMLICH: I mean relative to this project, specifically Mississippi. i 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 drugs for treatment of some possible 11,090 hypertensives. How, 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 L68 rm17 is to be administered to the county health officer in each 7 2 county. Now, this poses a problem of practice of medicine, 8 if you will, by RMP funds. If the council feels this is ! 4 “appropriate, this is fine. All I want to do is bring it . 5 to the council's attention to make sure it is considered : 6 appropriate. This has to do with Mississippi only. 7 MRS. SILSBEE: Is there discussion on this point? | 8 DR. KOMAROFF: Can staff enlighten us as to whether | 9 this will supplement the resources of the state health | 10 department, or merely supplant them? 11 MRS. SILSBEE: Mr. Van Winkle, there are two 12! issues here, in case you couldn't hear. 13 MR. VAN WINKLE: I heard. I was trying to hide. 14 |) My answer is, no, I don't know. I read the application. 15 We did ask that they include the full, when they sent in, 16 not the center form 15. ‘That is all you would have had. at I presume that Dr. Vaun looked at it, being the primary ® reviewer. He did not discuss that; however, as far as 19 practice of medicine, we have been in the habit of doing it 20 for years on demonstration projects. I do know that they 21 proposed to take these over and continue it after this first #2 ‘year funding. ‘The government has put already a line out of 23 | its budget to support it, but I do not know if these nurses 24 | are on bid, or if they intend to hire new ones. I just don't 25 | know. rm18 10 11 12 13 14 45 16 17 18 19 20 21 22 x bargain; consider the importance of this problem in that 169 MRS. SILSBEE:. Dr. Komaroff? DR. KOMAROFF: I looked at that application -last night after our discussion, and I had the impression t i 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 state medically. DR. GRAMLICH: I am satisfied. Thank you. DR. PAHL: I have two items of business before we adjourn. , a small amount of difference, only £309,999, 7 DR. PANL: If there is a difference, we will 3 || either take it out of Rdith's salary, or give it to her. 4 We have one of these fantastic data -matic ~ - 5 aides on sale, or something, and there is voltage fluctua? 6 and during one of my afternoon telephone calls; I found: Mdith sitting poking these keys. At the same time, doing 7 everything in long hand because with voltage fluctuation 8 ; - you don't end with the same digits vou should. So, I think 9 7 we better go back to lead pencil anda paper, 10 I gather the correct ficure is $27,349,054, Il | Another one of the rumors. 12 I have received information, also, again, I don't 13 || Know whether it is a rumor or not,but presumably it has been announced out of the White House that, as you know, there ee ne _~ 14 ; will be announcement either at 9:00 -- and now some people 45 é ! say 8:30 ~ and Congressman Ford is to uncergo his inaugeration | 16 ; , ‘at 6:00 p.m. tomorrow. TI quess we will all learn as to 17 . e . . ° go to airports whether this is rumor or. direct. This was 18 . given to me as a statement. 19 The other item of business which I think we are 20 }0n more firm ground ab out is to reconsider the resolution g1 | that lr. Ogden introduced, and which we tableé until hopefully : ‘you had an opportunity to look over. HR. OGDEN: I hope that many of you have had an 22 The summary material pertinent to the resolution. ' 23 . ‘Ir. Ogden, I think we have distributed this to each person, : 24 . ~ Perhaps, you would like to make some comments. Mad 10 ll 12 13 14 15 16 17 18 19 20 21 172 opportunity to look at the material headed "Summary of the ; “National Health Policy Plannina and Nesources Development Act of 1974," : Dr. Fomaroff, 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 - perhaps Massau/Suffolk RMP could become the health service systems agency in that particular area. But, 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 private operation on a local or area-wide basis, But, this. is a health service area population of less than half a million. It is not permitted. It can be up to about two million, as I recall ilir. Rubel's comment yesterday. But, it would encompass-the health service area would encompass any > 10 1l 12 13 14 “15 16 17 18 19 to ioe] mR F & 173. | standard metropolitan statistical area, which is entirely with a boundry - it can go over state lines, but there are literally, I understand, 1090's of SMSA's in the United States. So, that what we are looking at here is an area health services development fund which is qoing 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 be made for more than two years. | It simply talked ahout 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 havea something Similiar to the RMNP's we have today who can perform a state-wide mission or function. And, indeed, we could even say, going beyond state lines. But, I suspect the kind of legislation we are seeing 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 proceeded the resoltuion and the resolution itself be transmitted to the members of the House Interstate and Foreign Commerce Committee -- and by that I meant to encompass the comments that I made in the letter from Senator Magnuson to Senator Kennedy, which 10 11 12 13 14 15 16 7 18 ‘19 20 21 22 = 174 I read to vou earlier and which should appear in the transcrip of the minutes of this meeting. I can give vou that letter if you would like to Xerox it. I would like to have it back. But, I will be happy to hand it to you. I do recommend that we do this. I am auite concerned that the kind of legislation that we see coming - out simply does not recoaqnize 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 enception eight years ago this Spring feel that it has accompl far more than it has been given credit for and that it has the potential to accomplish a great deal that is coinsto be necessary in order to make national health lecislation function when it begins to deal with the very complicated ‘ = x uncertaking of the delivery of services and the delivery of care. And, it seems to me that unless the providers of this Nation are given an opportunity to make their in put through something like RMP, that the success of national health insurance is jeopardized and I hope that we are going to be able to have the continuation of somethinglike the regional medical programs. e DR. PAEL: Thank you, very much Mr. Qoden, . There was a motion introduced and seconded, I think possibly.. . DR. WAMMOCE: Second. DR. PAHL: Thank you, Dr. Wammock. I think there should be room for discussion by = x { + - s* ae 10 11 12 13 14 - 15 16 17 18 19 20 21 22 ~ DR. JANEWAY: I would support, quite frankly, the Separation of the plannina function, particularly the strategic planning eunction, 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 RNP and CHP? DR. JAMENAY: NO. I am thinking in terms of the management function and there is room for disagreement in this but if you read Anthony's book on Planning Control Systems, the possibility of the planner becoming so involved in the plans that the implementation becomes impossible, or that there is no outside regulation of it. It puts too much. power in one place. | Now, there are admittedly some managers who disagree with that and say the planning control ought to be in the same agency, If you set planning or isolate it you develop think tanks that don't -drain anywhere. But, if you put planning and control in the same co 10 11 12 13 14 ' 15 16 17 18 19 20 21 22 = an infinite supply of needles. agency, you go to the’ opposite extreme where you think that i by creating an infinite number of haystacks will give you MR. KOMAROFF: 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. | I 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 pane 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 to the state health planning and development agency, which is assumed to exist under this piece of legislation. It has *to come into being. But the legislation just simply doesn't 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 systems development 10 10 11 12 13 14 15 i6 17 18 19 20 21 22 “the operation and the mechanism of the RMP program. Some of -concerned, I don't know. 179 it gets dissolved ~- and I haven't read this -- and if I read it I am quite sure I wouldn't know what I was reading. I may have to read it back the third or the fourth time or the fifth time, and may not know what I 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 the trees. Or whatever you call it. Forest-trees, trees- forest. 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 hard to get across to people what RMP is and I am sure that there are a lot of physicians that do not understand 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 ltr. 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 “DR. PRHL: Is there further discus$ion or modificatig DR. KOMAROFF: I would like to add some language that makes it clear that this health systems development agency will support. demonstration health services projects. n. 4 10 11 12 13 14 1B 16 AT 18 19 20 21 22 24 1280 I don't think that health services is written in. IT am not sure it is quite 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? f haven't written it yet, but I will. How would this be: "Resolved: That the Congress in adopting HR 16204 or similar legislation give to each state the statutory and financial support to maintain a 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 10 il 12 13 14 “15 16 17 18 19 20 21 22 = 181 independent commissions in a publicly accountable way in reporting to the state health anc development agency and devoted exclusively to such work. “DR. MOMAROFF: All right. DR. WAMMOCK: I yield. DR. PAHL: May we have the final wording before we have the question? MR. OGDEN: The way that I have this drafted at the moment reads “Resolved: That the Congress in adopting HR 16204 or smilarlegislation give to each state the statutory and financial support to maintain a separate health systens development and demonstration agency on a state-wide basis, or similar independent commission appointed ina publicly accountable way, reporting to the state health accounting and development agency and devoted exclusively 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? MP. OGDIM: I am sorry. fEppointed in a publicly accountable way. That has to do with -- DR. WAMMOCK: But you put another word in there. IR. 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 22 182 This was Tony's point, that separate health systems dovelopment has to report to somebody. We are going to have it report to the state health planning -- DR, WAMMOCK: Wouldn't that be under state, or not? MR. OGDEN: Well, I don't think that this damages the sense of what I am trying to accomplish. MRS. KLEIN: Mr. Chairman, DR. PAHL: Yes, Mrs, Klein. MRS, KLEIN: This reporting bothers: me as to whether it should 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 on a state-wide basis, rather than reporting to any federal agency, for example. So, I would like 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. MRS. MORGAN: They will have this Bill. MR, OGDIN: Under this Bill, they will have to. DR. GRAMLICH: in the resolve, what do you mean by, “in the comments preceding this resolution?" MR, OGDEN: This was the letter from Senator Jiagnuson. DR. PAHL: Is there further discussion by Counsel? MRS, MORGAN: Question. MR. OGDEN: Wait just a moment. On the matter of information. Tony and I have decided that this should be 140 10 11 12 13 14 15 16 17 18 ‘19 20 21 22 183 "reporting to the state-wide health coordinatine council." Those are the people that have the 16 members. ‘2 have ; the wrong group to report to. We are going to report to the state-wide health coordinating council. Is everybody terribly confused? Can we vote on it? DR. PANL: 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: Ave. DR. PAHL: Opposed? No response.) DR. PAHL: The motion is carried. In closing, I would like to thank firs. 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 collectivel- f 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 wan “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 te 15 10 11 12 13 14 15 16 17 18 “19 20 21 22 our new error. Uniess there are further comments, I then * adjourn this meeting. Thank you. Whereupon, at 3:15 p.m., the meeting was adjourned.) i