i ;.I..E(-)C)l@3'1* ' A 2@ @'f! N G C O'@', P -1 POT HOOV'ER RE LiY, INC. D. C. 5,@"t6-66'0'6 rc DEF-PRT14ENT OF IEALTH, EDUCATION, AND WELFARE ME-ZTING OF AD HOC CONQ@ULTANTS REVMIING REGIONAL MMICAL PROGRAM APPLICATIONS Conference Room H Parklawn Building 5600 Fi,.zhers Lane Rockville, Maryland 20852 Wednesday, May 22, 1974 Panel B convened at 11:00 o'clock a.m., Mr. Peterson, Chairrran, oresiding. PA@F,L B: @Mr. Kenneth Barrows, West Des Moines, Iowa Dr. Joseph Hess, Detroit, Michi-an Dr. -Albert Heustis, Three Rivers, Michigan Dr. John Hirschboeck, Mi lwaukee, Wisconsin Mr. Joseph de LaPuente Dr. Charles McCall, Dallas, Texas Dr. William Thurman, New Orleans, Louisiana Dr. Paul Teschan, Nashville, Tennessee Sister -Ann Josephine, Notre Dame, Indiana C 0 N T E N T S @3.2ns: Maine 15 Motion 28 Vote 34 Motion 40 Vote 40 Motion I Vote 42 -A lbany 49 Motion 57 Vote 6o Northern New England 62 Motion 7 Vote 79 Connecticut 82 Motion 100 Vote 101 Central New York 103 Motion 115 Vote ii6 Hawaii ii8 Motion 131 Substitute motion 132 Vote 133 Arizona 135 Motion 152 V.@te 153 Motion 153 Motion a.,ne nd e d i.6 o Vote i64 I 2-a fie,7ions.(continued): EtZe Gree,ter Delaware ValLey i66 Motion 175 Vote 179 0 I 49 3 P R 0 C E E D I N G S PLITERSON: We might as well get started, (Discussion off the record.) 14R. PFTERSON: Before we do get down to individual regions, I would like to mention some thinrrs going back to what Herb took off on, not tryinn, to repeat, on the other hand, but get down to some of what I see as the more nitty-gritty details. You have already heard from Herb and the review guide that I hope ail of you got, the kind of things that seems@ to me is almost imperative that we individually and collectives ly sort of try and keep in mind, the necessity for trying to keep our focus on the overall reviod and Its proposal, need to try and cotich our review in terms of the criteria and factors which we soecified as beino, the basis for our jud,,,ment. Clearly if we try to look at very many projects, we are in trou'icl.= I think I calculated we would have two minutes per project if we operated on a project basis. On the other hand, there certainly are going to be some instances where the reviewers and staff will want to single out some projects. I ,7,uess primarily because they may raise policy issues or they have attracted strong negative CHP comments. So those are exceptions. On the other hand, as Herb indicated to the total group this morning, I think we are going to be;confronted 4 in a number of instances with projects which staff has already identified and perhaps others which you and in the application you have looked at, there are some policy issues about which WO, may not be able to resolve in our best tact at this juncture, maybe simply to flag those. .And certainly the time that Herb dwelt I think on tha@t last table, he passed out to everyone, I guess the column C we spent more time talking about than anything else. That tar@et amount, while it is not a formula, while it is not an assurance that the region will receive that much, I think yet in many ways It is going to have to serve as the i principal benchmark or backdrop against which we Look at these applications, rather than necessarily the much larger amount in! some instances that is being requested. But in terms of the review procedure itself, we have tried to assign each application to two people. We haven't designated them as primary or secondary reviewer, and the fact there is one column and another doesn't really have any oreat significance I may deviate from that certainly. There are a few instances, I know you have one or two, Mr. Barrows, Yihere dLie to last minute cancellations Dr. James I think just called the other day and I had someone call me who had their third numeral thorax within the past day who isn't here, so there will be a few applications where we only have a single reviewer because of last-minute canceLlciL,.Lvti,-. In a few instances we have tried to get to someone else. I knoV Bil4 apparently there was a contact with you on Northern New England since you had visited that region and possibly Bill will be able to pinch hitter as another reviewer on Northern New En- .land, Generally I would propose to not have the staff comments -- you do have brief summary sheets In your books, not to have staff comments precede the reviewers but rather to follow a--- appropriate after the two reviewers have, addressed themselves to the applications. I think in setting down with Dick Russell where is Dick? -- who is chief of the Western Operations Desk and with Frank Nash who is chief of the Eastern Operations Desk yesterday afternoon, we have singled out a couple of applica- tions where we will deviate from that rule where I think in the case of Hawaii, for example, there is some significant background we think we probably would like to present initially, perhaps also a Metro New York where we have got a different ki-n,,,' of application. But generally we will look to the reviewers initially and any staff comment subsequent to that if appropriate. Certainly apart from the two reviewers that will be called on, on the other hand, I think we do need to permit ourselves some tirm for a brie4L.-discussion fromthe others, questions and answers,, hopefully al@-red at either brin@ina spe- cific information or general impressions to bear, other people 6 on the panel have where they may have them, or to get some issues crystalized. We will ask the two reviewers in those singular instances where there is only one, the reviewer, the two or single reviewer to prepare the ratind- sheet which,,again, I believe was sent out to everyone along with the review guide and it is my understanding that each of you in the folders that ou had In front of you have about five or six blanks there, e have got additional ones if anyone runs out. But subse- quent to each review, where Dr. Hess or Dr. Teschan is one of the reviewers, I would like to ask each of you to, as we go along, to, the best of your ability, to try and complete a rating sheeti .Lor each of the regions where you have been asked to review it @nd to either let myself or Shirley Simons have those. Because we are going to try, as we get back on Friday, that will be one Dasis upon which we will try and give the totalgroup aLain an impression of how the two -roups have looked at their respec- tive regions. We also will need to get from you, from the group, some kind of recommendation, as toyour recommended level of funding with respect to each region based upon their current application, recognizing that in the overwhelming number oi, instances, regions will also be submitting applications in Julyi 3ut we do need that. I think we have heard enough about the kinds of 7 constraints that we are operating under. Not the least of which are lack of really good current information in many instances. Time is obviously something we are going to be wrestling with I think for the next 2-1/2 days. There are, for those of you who may not have brought all of your applications with or misplaced one in the cafe- teria, or indeed If there is a region you weren't asked to re- view you might be interested in taking a look at, we do have a small supply of applications for all of the regions this panel is concerned with back on that table behind Tom Simonds. So feel free to pick up an application if you have any desire to do so. -As far as conflict of interest is concerned, we have tried to arrange these two panels so that at least in the gross@ 'tutional sense, people from Great MidA,--st are geographic inst-L Looking at the eastern and western parts of the country than vice versa. In other words, Joe and At are from Michigan, we are not going to be dealino- with Michigan and hopefully at least CD you won't be dealing with Michigan in this context. DR. HEUSTIS: We couldn't really help you on that* MR. PETERSON: On the other hand, there may be in- stances, Ican't think of any, but where based on your own knowledge, where you feel there is some potential conflict of 8 interest that-- if that does occur) that you acknowledge itland, we will -- then the individuals can leave the room whi le that region is being discussed. HopefuLly that will not occur, be- cause we tried to arrange the groups where the obvious conflicts of interest would not arise. One final thing before we do get into the actual re- view. I do need to know if there are any people, particularly the reviewers ason will not be able to be who for whatever re here on Friday. CharLie IvIeCall, when we asked him to participate in this, indicated as part of his participation he had a long- standing commitment that forced him to leave late tomorrow afternoon, and thus I am going to have to make some adjustments n vis a-vis the regions CharLie has been asked to participate i the rev.-Le@i. But if there are any others of you -- Iaul. DR. TESCH-AN: I am paled on airline computers-- MR. PETERSON: That seems more like a bowl of jelly, from airline computers I have dealt with they are not that shar,--. DR. TESCHAN: Loused up so there is not much I can do about It. So I will let you know. MR. PETERSON: You are going to let me know if You have to leave early? DR. TESCHAN: The reservation says we will be leaving Friday morning. @IR. PETERSON: Okay. 9 DR. TESCIIPN: Ear ly. MR. DE LA PUE14TE: I have only one commitment this afternoon that I could not avoid.. MR. PETERSON: So as far as you are concerned,Joe, we need to avoid Looking at the regions, Northern New England and a few others you are coinc, to be the reviewer on, we have to defer those until tomorrow. 14R. DE LA PUE14TE: Yes. 14R. PETERSON: Okay. MR. BARROWS: I have a 4:30 f Light on Friday. !AR. PETERSON: No, Ithink we calculated-- @IR. NPISH: We would Like to get to Northern New England sometime today if wecan, because Spencer won't be here tomorrow, if we can work that out. MR. PETERSON: What time is your engagement this afternoon? MR. DE IA PUENTE: Three o'clock. MR. PETERSON: Okay, -vte wil-I do that this afternoons It may not be a good decision, but that is what is important in Washinoton -- don't worry about the judgment, do It on time. In addition, because some of the staff Spence Colburn Is a prime example, but not the only one some of the staff that have departed but have been brought back -Lor this also have some crunches and commitments. We are going to have to do some adjustment there and I think I have Identified most of that in my discussions with Dick and Frank yesterday$ i but we are going to try to handle all of the applications Spence has the backgrounds on, because he is going to be out o@, town beginning tomorrow in connection with his new job in the Bureau of Quality Assurance. Well, with that brief introduction, before we get started, I wonder if there were any additional questions in terms of details, procedures, or quite apart from details and i procedures, profound philosophical issues,, sorm of which I would be willing to take up at lunch. @IR. BARR(3TS: I believe some of us are bet er pre- pared on some than others, T went down mine alphabetically, PETERSON: You are better prepared on Albany? MR. BARROITS: Than I am on the last two* I hope to do that tomorrow. I think Paul is in the same boat. I don't know ,lbou'u the rest of us. MR. PETERSON: Well, again, if I should call for an application where you or someone else would like a little more i time, if you would Let me know that, I will, on sort of an ad hoc spontaneous basis, at least in the beginning we have all kinds of flexibility. When we get down to the last two appli-I cations, our flexibility is considerably reduced as to the num- ber of adjustments we can make. 1 L MR. DE LA PUENTE: One issue we could discuss very briefly, it has to do with vacancies that many of the applicants have made in view of the fact we are dealing with i just one year and that has a. conflict, you know, as to-- we let them fill all the vacancies because as far as the money is concerned, they are within range. I have a problem. Does anybody else have it? 14R. BPRRO@TS: Yes, we have that, we have it from another direction. -Assumin,, they get the budget, wil'I they be able to fill the vacancies and do the job within the time span available? @. DE LA PIENTE: Precisely. @M. B-AliRO,t[S: I would cyuess we had better take a look at those on an individual basis. They tend to vary, criti- cal shorta@e of staff or-- DR. TESCHAN: One philosophic coanent, I think yo.Q put your finver on as usual, mainly the local decision may be CD the ultimate reality. RMP's think affirmatively in the most distressing circumstances and I think riaht now the stance in many of the RMP'Ldis to think affirmatively about the transit I tion in the future. I think quality of the professionalism even in the short ran,7e -- talents, if anybody has any -- is goihcr to pick CD CD up the staff in whatever mode it will be. Whatever is recruited for next year is available for 12 .Lo I low-on. I am not nearly as much worried. MR. PETERSON: There is only one thing I would have to say, the issue Joe has raised, we did see the RMP's with the announced phase out in January of 1973 go down in the agmrecrate C) CD and there are obviously considerable variations here from roughly 1400 full-time sta.ff to about 700. In other words, las fall, Septer.,Lber, when we got to -- well, it was the November application, but it sort of reflected the s ituation as of last September, the Rx',IP's were down in terms of program staff about half of what they had been prior to the phaseout, By January o@" this year they had picked up about 300i additional people. That was durinc, the period when neither they nor we knew what the court was doing to order, and, in C> other words, it was at a time when I think the imponderables were even worse than they are no@i. At least now I can see down the tunnel for 15 months,i, maybe less. It is only 13 months now. It is almost the end of llay. In December and January, I really couldn't see down the tunnel for more than at the best six months. So I don't think that answers your concerns, Joe@ but I think it is not irrelevant. DR. HESS: I think III founded though It may be, we must have some confidence between the Congress and Administra- tion that the intents that are now being expressed will find 13 expression in so me legislation that will allow this type of activity to continue in some form or another. I think that is what you are sayin@. I think that has sort of been a backdrop and if thEY fail to come through, you know, I guess that is not our response sibility. But at the same time, looking at the public's need, i and the fact that this type of activity has proven itself to be effective for doinf7 a job that needs to be done, that somewhere or other there is enough broad support that somewhere'; or other the political element of this system will find a way to continue it. DR. TESCH-AN: I think the corollary for me from all that is we should make some efi'ort, i hope we oet some acree- ment to that, make some effort to make sure that as well as possible, each of the re@ions is ready for the transition for the follow-on. I think this is the time to get ready. DR. HESS: Yes. DR. TESCHAN: Even though the imponderables shut ofL' the enthusiasm for that in the region, I think perhaps we doLild'@ help stimulate what chances need to be made to vet regions in i line. SISTER JOSEPHINE: You know, in going over som o.L these applications, 1 have noticed in many cases where they were i looking for stafg they picked up staff from CHP pro-rams, whic'iill 14 to me is the direction toward the change in total administra- 'Uion, and this should be commented wherever they do this, be- cause I think this is addressing itself to the transition you are talking about. MR. PETERSON: WELL, I am sure there are @oina- to be all kinds of issues of both a, generic and specific nature sur- facing during the next two days.' We might kick off and I thouZht my sense of geography what it Is we might kick off w I th I,'Laine, since it is in the upper right-hand corner of the M(?.P of@the United States, itcbviously is not at the head or end of the alphabet, neither the larger or smaller states, but that is my rationale. Besides, Spence Colburn, that is one of the states we are lookinc, to Spence for some additional comments, since we do have two reviewers there. I wonder, do you want to Lead off on that, Charlie? DR. McCfiLL: Be glad to. MR. PETERSON: Okay. 5 DR. McCALL: I wish I had had an opportunity to re- view this program back when I found a, direct line, I found opportunity to look at a quality program@ and it obviously has. strong leadership at the staff and advisory group level. It comes through loud and clear this program makes great plans not only in transitioning what is coming, but in continuing and financial support from other sources. -And I really don't think there is any-- there is no question raised in my mind in terms of their conflict, in terms of their stated objectives end their program, the lements to achieve those objectives. The only question I had in my review was since ti-eir funding seemed to be a little low currently, and I assume that@ was because of all of the vagaries of the past years that we have been going over and the excellence with which the prorran CD has been based, other sources of funds not only planned but in hand and being utilized at the current time. So that that needs to be looked at when we come up with a figure or recom- mendation. DR. TESCHAN: Who Is the grantee? DR. McCALL: Medical-- MR. PETERSON: IL@dical Care Foundation, Incorporated. It is a private nonprofit corporation and has been since day one, DR. MOC.ALL: I will confess when I received these two i6 volumes -- this is only half of it, oh,gracious (indicating) material, just padded in here, and I since learned they were asked to come in with a complete application but I enjoyed going through this application. It is clear, it Is informa- tive, and I really found this operation useful certainly. MR. PETERSON:, Al, you also looked at Maine. DR. HEUSTIS: All I can say is I had two Impressions I received these two beautifully bound books and thought who are they trying to convince? I received this other one from California with the other material, and I didn't really think they were trying to convince anybody. Beautifully done -- graphs, different styles in the typewriter, different colored paper and so forth. And. I looked at it with a negative prejudice. DR. McC.ALL: I a-ree. DR. HEUSTIS: -And I read it. Everything you said isl@ true. DR. McCALL: Unbelievable. DR. HEUSTIS: This is the only one I reviewed that had any need or basic population data. DR. McCALL: All there. t DR. HEUSTI8: This is the only one I reviewed tha indicated the other than the RMP support that was going into the current programs, 17 This had a pretty definite and clear-cut attention to process ac@ far as priority ranking in how you got that way@ All of the questions I had were answered and a few of the questions I didn't have also were answered. I thought it was well organized, that certainly their record right down the overall list we had, all of the different criteria. I took this document which you have in the review sheet and broke down each paragraph into the number of thin-@s that you mentioned, plus a few of my own. And on Maine, I rated everything that was ratable in the good column except for the reflection of needs identified by comprehensive planning, which I put down as insufficient data. This may weLII be about as comprehensive planning has not identified a ny needs and not been doing the overall job. I would support any extra money that anybody has inii goinv to the Maine program as being capable of bein- extremel' y I well spent, with creat results -as far as continuation pro- jects at cost levels. I was particularly impressed that they were able to get some help from the state government. Not only in pickingi up some of the projects that RMP had started, but help from state government as I understood it, at least to go into the regular day-to-day operation of the program for the next fis- caL year, I feel very strongly and very positively about this program, It was a refreshin- one to read and made reading some of the others -- well, it even compensated. It was a ver-y % I refreshing one. DR. McCALL: No collaboration, but I obviously had the same impression. My recommendation was funding maximurA eligible. MR. PETFRSON: What about the other reviewers who may have questions or comments about 14aine? DR. HIRSCHBOECK: I don't have any comments about the application. I haven't seen it. But I have always been cur3-ous about the interface with neivliboring states an Northern New En-land, whether this is well taken care of. DR. McC.A LL: If it is not spoken to one way or the others I have no knowledge other than the application. DR. HEUSTIS: Any more than 14icIiigan's at least as it used to be a number of years ago doesn't say anything about Ohio or Minnesota or Wisconsin; maybe it should have. DP,. HIRSCHBOECK: How they relate. MR. PETIMSON: Maybe Spence or Frank have something to say on that9 MR. COLBURN: They have been very close working staff, three programs, tri-state who has New Hampshire and Maine end Vermonto all of New England. The New En@land pro@ram, an epidemiologist used 19 to go to Maine quite frequently and he has helped the Yiaine pror,ram, has capitalized on what was done in Vermont with re- gara to coronary care networks,,safety program, Now they are movino, into the area of establishing Guidelines and standards within the corona,ry care network foi- treatment. And I thitiK r,.n-is is capitalizing on the success of that ty@ of activity in Vei- mont just as an example of the exchange that takes place be- tween those three pror,-rams in the upper part of New EncLand. i CD MR. B.APRCIEIS: If the titles of the Project,are at all valid, the direction of the program seems to be excellent, very much on tar&et. DR. HEUSTIS: There isn't any question in this par- ticule,r program where there has been great leadership, at least material available to me, by the proo-ram staff. They haven't tried to sit back and say, 1%, hat would you fellows like to do and we will fit it Into an overall pattern." They have come out and said: This is what we went t6 do; would you be willing to work along that? That is the kind of regional program that I think is carryinc,- out the real mission. DR. McCALL: They list their new projects, continuing CP projects, list those they are requesting no further RI-@IP funds for, exceeds-- either they have finished their mission or have other source of funding. DR. TESCHAN: I want to ask about the CIIP relationship, 20 I am not quite clears there are no functional (b) Is, Chattergy has not done anythinu with the (b)fs to try to CD get them going or he has and they aren't functioning, or-- I an, not quite sure, or can you tell? DR. HEUSTIS: I cannot answer. MR. PETERSON: There are four orfive. MR. COLBURN: Five. MR. PETERSON: Functioning, there are five funded, be (a). (b), (c). DR. TESCHAN,. He is getting no statement of prioritie: objectives? DR& HEUSTIS: None from (b)ls. All I could say was there was really insufficient data presented on what the (b)ls were contributin- to come to any value judgm-.nts,at least on my part how the cooperation was. MR. PETERSON: Again, I think Spence or Frank will have to help me with this. I do not recall that 14aine is a region where the CHP comments either were negative or pointed a direction, but perhaps I am wrong. I,M. NASH: Spencer, didn't he invite the (b)ls in and have them sit around durinc, the discussion of these applica- C> tions? DR. HEUSTIS: Excuse me, may I I misspoke a moment, ago, I looked in the wrong column. HOOVER REPORTING CO, INC. 320 Massachusetts Avenu -@ N.E. W;oqftinc,ton D-C. 200OL' 2 L DR. McCA LL: He, rea 1 ly me t w ". th them ahea,C of t iriie, the (b) a-encie@-- even care into the R@ review I think. DR. HEUST@LS: I have down "@tended cooperation and coordination with the CHP is good. Hivhest possible effectiVE relationships are good. Joint activities are satisfactory." I misspoke; I was looking at the next column. Sorr I misled you. DR. TESCHAN: Trying to get a feel, DR. McCALL: It seems they did. 1,C .BA RR O@,S It would be awfully difficult for us I to pull dollar figures out of the air for reconLnendation, but would it be feasible for us to say break these down into groups of fives and the preferences we think they should share in the bud@et? It sounds, for instance, this should be one of the top ones. MR. PETERSON: I an. not sure when you say break there,' down into aroups of fives, what-- MR. BARROWS: Top -- DR. HEUSTIS: Aren't you thinking of this overall assessment activity? MR. BARROWS: If that is what it Is to be., then, then fine. I thought we had to come up with some financial recolln- mendations. NR. PETERSON: We do need to come up with sorw HOOVER REPORTING CO, INC. 32OMassachusettsAvenue,N.E. n f, gf)niig 22 d recommendations. It is obvious if the recommendation excee the total supply of money, there is going to have to be some adjustment. But perhaps I can answer your question in part. At least it was our hope that as a result of the-review dis- cussion and the rating sheets that had been ab,le at the time we get the two groups back together, be able to sort of display literally what the two groups had come up wi h separa ely and probably failing out into not unlike a bell-shaped curve, 1 there were some at one extreme considered among the better, some at another extreme that were considered poorerp with parenthetically the amounts recommended for them, and I think, perhaps triparte -- again I don't-- but this w ha ope to be able to do. Because I think it is difficult, because some of this indeed is comparative. DR. McCf,.LL: -And we are goinr,, to come back and look at what we have recommended here. MR. PETERSON: That is our intent. DR. McC.ALL: Set maximum rating, I would like $2 million requested. DR. HIRSCHBOFCK: How do they deal with their fund- ing? They don't get as much as they have? DR. McCALL: Yes. It has been In use all alone, one has been in use and is effective. DR. TESCHAN: Do you recommend two? NR. N-ASH: It is target figure, bear that '@n mind. 23 DR. McCALL: I didn't when I put my $2 million down, I didn't see the target figures and it exeeds it by over half a million dollars. DR. HESS: I would like to introduce another element in this discussion. What is the population served by that EMP? IvE. PETERSON: Slightly under, one million if my-- DR. McC.ALL: -About a million. MR. PETERSON: The State of Maine has a little less than a million people. DE. HESS: I think that factor has to modify, put into Considerations. Now, another factor is what, within that document-- apparently they have done a better job than most in term of outlining the health needs of the population. In my own mind I don't think of Maine as a-- well, It is a rural, but com- prised o4 at least my image is of pretty hardy self-sufficient people who, you know, can take care of themselves pretty well. And that may be a reflection why they have oot such a vood application, I don't know, leadership there. It bolls down ultimately to a handful of people. But be that as it may, I think we have to -aodify ourl thinking about how the needs, of the people in Maine compare with the needs of people in Mississippi or-Alabama, or, you know, other areas of the country. And look at the HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.E. Washin2ton. D.C. 20002 24 i relationship between funding recommendations, the'size of the popuLetiono and what we know about the health nee6s of that particular region. If they have got a million people, just to give us a rougher Index, and @y2 million application, roughly '@2 per capita, RMP funding for that; at the other end of the scale t erE are lil4P's that come out with something like 25 cents per capi a. And I am not su,7cresting a, capita thing except I think we do have to keep In mind the needs of the population, how lar@e i the population and the amount of money that is goinc, in. CD There ought to be some kind of rational way to rationalize that at that level as well as just how good the program is. DR. McC.ALL: I totally agree with you, having come from a region that had 12 million people. And under ,ny great leadership was reduced to .@1.2 million funds. D So that is a very important point that I am very sensitive to, and my only reason for taking this hi@ii level at this point is to say we don't know where these others are r--oing to shake out. If you are goinv to come back when these things are C> finally looked at in terms of the total dollar available for quality, needpopulation served, it would be final figure, this program comes throu@h at such high quality to me I would like to see us not start low and not be able to give them the maximum they should get when you look at the overall. EFORTING CO, INC. 320 Massachusetts Avenup, N.E. Washington, D.C. 20002 DR. ILESS: These folks sound to me like peop.Le -viro can make efficient effective use of money. DR. HEUST@LS: Thio is really what came through to i MP-* DR. McCALL: They are going to function if we don't give them a dime. I think you shouldn't penalize them for thv,,@. MR. 13ARROWS: That is important;as a taxpayer I hate' to see these bucks spent on the basis of need without produc- tive use of them. DR. IIEUI@.,TIS: I recognize need, but in these troubled times it seems to me efficient productive use of money might be things that would impress the Congress rather more than taking another program that I reviewed that has a.,Iar@e need and a large problem and not as L7,ood a program. DR. HESS: I am not recommending puttinLT a lot of i money into a poorly managed program, but to carry this argu- ment to a ridiculous level, if they could use @"5 mill-Lon, woulIci you give @laine '4@)5 million just because they are a top-notch pro,rre.,,n you see? DR. HEUSTIS: I think you have to balance relative--I DR. McCALL: Fine thing, I am not sure I would even recommc-znd- @2 million. MR. BARR(I-@S: I wanted to bring this down, bring another factor into the decision. DR. McCALL: It might ,@ake it easier for you to try o i r,'- to make some better jucic,,r@.ent of all these thinvs at this p La ID CD MR. PETERSON: I think, you knows our judgmental process which is collective and right now bifarcated, I am not goinv to intrude too much on that. CD Let me only mention one thing, Maine is requesting sli@htly over '@'2 million. It is one of the few re-ions which has indicated to us tais is their total package, so their ,@2 million is not goinv to be a supplemental or additional, or CD further request in July. Their target figure, column C, was rou-hLy @1,4 million. I think that again looking at it in terms of some rough per capita, Maine indeed exceeded the national norm at an earlier point in time by virtue of the fact that it had been considered a good program at the tirmvie were steering towards selective funding. I think what I have heard is a range from @2 millionj and somebody said they are goinrT to continue whether we give them a dime or not, so we have got@.between a dime.atid Q@2 Would somebody Like to put somewhere between those two points, perhaps lay a recommendation as to an amount on tell floor? 14R. BARRA-IS: That Is the thing that bothers me. We do not have a target budget for our whole business. If we i had something like this and then could say classify them,;and then cut the melon when we get them all through on-the amount Ho REPORTING CD, INC. 32OMamchusettsAvenup N.E. WashingtQn, D.C. 20002 of money to be spent, it would be a lot easier. Just picking fioures out of the air, I am afraid our results will be very fortuitous. MR. PETERSON: I didn't mean to. DR. HEUSTIS: It seems to me you have on overall assessment five categories. MR. PETERSON: Right. DR. HEUSTIS: In all good conscious, more data is available in Maine about previous funding than any of the others I reviewed and there was just insufficient data about background and use of money and about progress to really make C) a valid fundinT judgment on the basis of the written material that they --athered together with all of the constraints. I feel very strongly the same as you do, perhaps the best w.e can do is to say that this is an interior program and it is entitled to maybe better treatment if the need Is there and-- of coutseo if there are two superior programs and both have needs, I would agree with you. Some of these things on the basis of more infornativi,i we could come up with dollars. MR. BARR(IIS: Even divide them into groups, the plus oroupr average group and minus group, and cut it Like that, MR. PETERSON: Let me see if I can heLp.us out of this. Since we will in one sense be operating against a HOG ER REPORTING CO, INC. 320 Massachusetts Avenue, N.E. Washinaton, D@C. 20002 28 benchmark of a target firfure, vill-at I hear. the group say.I @,D CD is that it would like to make a recommendation vis-a-vis Maine -- correct me if I am wronc, -- that says here Is a region that, in our judgment, without giving a specific amount@ it should perhaps be 9,bove the tartc.-et-figure, whatever that Increment is. I think we, again, as staff, Dr. Pahl is the Director, in the final analysis, who is going to have to divide $109 million or A@LL4 million up, certainly is going to be influenced I think by virtue of the fact that this whole re- Vi -ew process is ooeratino, with a great deal of lack of infor:,.,a tion and the like, -Ard that the pluses or minuse-.- will be in-@i dremp-ntal rather than order of magnitude. it is more defensible to say let's cive this region CD 20 percent or 10 percent more, as opposed to 100 percent more or less. Because I don't think any of us feel comfortable with that process. I wonder if in those terms sombody would DR. McCALL: @laybe to help you have tte figures,, the sense is there in what you are saying, I think we all recoc,,.--- it, with all the constraints and time) we have to come into focus. We really can't go back and write all the imbalances i and 'inequities that my exist. Maybe@pl.@, million reconraendati 'n C', does that, it is a little abov requested, It reflects its e super.Lor rating. If there are others, that is the' sense. -And it would take into consideration per capita needs and other things as well as their quality,. DR. TIfURd,4AN: Second. MR. BARR(aiS: Their request Is $2 million, DR. McCALL: Yes. MR. PETERSON: You are saying recommendation of $1,5 million? MR. C OLBURN: I was going to say in the past,the previous procedure was to make a recommendation regardless of the availability of funds. Then you know the distribution of funds would be based on total recommendations. MR. HASH: I think Dr. Pahl wanted some sort of recommendation. DR. HESS: I think it would be helpful if we go through and we come to grips with a specific figure on each project, and then come back if we want to adjust it at the end of time. DR. McC.ALL: This is what I am integrate nT into the $1.5 million. MR. NASH: I think that gives us a benchmark to woric with as we move along. DR. HEUSTIS: I wou Id have great d If f ic u Ity on anything except political orounds of recommending that you approve anything except the reqoest. I can-- if-you asked me to make a technical decision, the prouram is worthy of support@@ H REPORTING CO, INC. 320 Massachusetts Avenue, N.E. Wash;ngton, D.C. 20002 30 If you ask me to make a political decisions there is not enough moneys then it seems to me the political decisions at least as I see It, ought to be made at a higher level than which I have said at the present time. SISTER JOSEPHINE: I would like to say I made a site visit to Maine with Dr. Brandon and Dr. Vaun, who is in the other i7roup, end I guess in 1969 or 1970. It was at the time when theyviere first be(,-inning to get their resources together. CD -And I had an opportunity to stay several days and so-a couple of us went around and we visited in different places in the state. And in response, Dr. Hess, to the number of people, you know, I am so impressed with the distance, the distances, the scattered population -- really, the total lack almost of services, you know, that were available. I was also impressed as we sat end talked with the peoples with the fact that, you know, they had already been ir,- volved in the process, the people'viere listening to what they need. And the program that has been developed, you know,, I would be reasonably sure has been developed in response to needs that were really identified, and I don't feel that is tyUE of all programs. DR. HESS: No, I am not questioning the needs were identified. I think that has been well done. 14R. BARRCFWS: Introducing the equi y, If we adopt this thing, what we are sayin(ci then is EPORTING CO, INC. 320 Massachusetts Avenue, N.E. Wastiinp.ton. D.C. 20002 we have concluded our formulas as an outstanding programy and E,,et 75 percent of what they asked for. DR. THURlilP.N: No. Not at all. I think what we are sayin,7 is can any group operating at $1.5 million leap to $2 million? Now,.i,in seconding the motion, I am not proposing we give 7!) percent. I think this ib a re-ion that gets results. I rather doubt if it would be able to leap -to 'qk?2 million. MR. BARR(7.,@@S: You are brinoino, up a very valid con- sideration, do they have the capacity tp do this job; in effect, they are askinr,- for two times present bud@et. CD DR. THURTA.,:AN: The other thing we have to consider is,i there has never been a human being who wrote a grant who didn't add something to it. DR. HEUSTIS: I disagree, but go ahead and make your point. DR. TH@l,!AN: That is my only point. They knew they! might as well ask for everything they could c-et. But I don't believe it is possible for them to spend $2 million in a reasonable way. DR. HESS: That is a 100 percent increase. DR. HEUSTIS: Mr. Chairman, the thing that bothered me was the fact the only fi-ure we have on this sheet is this 32 currently annualized level of what they are getting. This doesn't take us back to what they did before they were out, and not having that information and not having the informa- tion on how well they had spent their money before they were cut, I am just wondering -- IM. NASH: That figure, Doctor, does not include a large supplemental award for EFS or HSA activity out of 1972. -Actually they have been operating at a level over .@l million. Spence, do you have MR. COLBMN: I am trying to recall DR. HEUSTIS: I am just saying on the basis of one year of restricted allocation MR. NASH: You are talking about ability to handle a large group ofmney and this actually isn't that. @IR. PETERSON: There are, as Frank points out, in a number of regions, @laine isn't the only one, where the current annualized level which is really the present six-month award times two, It is that simple, is perhaps misleading -- not in all instances. In some ways the column C figure, which reflec,,c a percentage of the immediate pre-phaseout level is more indic@. tive of the kind of annualized level, approximating the kind of annualized level that lvlaine and nearly all the other were operating on prior to January 1973. But a,--lain, in-the interest of moving the discussion H REPORTING CO, INC. 320 Massachuse!ts Avenue, N.E. Washington, D,C. 20002 along, we have got a situation here now where two reviewers one in effect has laid a recommendation on the tabl@e for $1.5 million, I heard -Al indicate that he would have problems with anything less than the full amount requested. I think simply in terms of the order in which those two figures were mentioned, I would ask if Charlie regards his $1.5 million as a recommendation to that effect? If so, if there is a second? DR. THURIIAN: I seconded I MR. BARRO/TS: Did you say a real Index of their pre-crisis fundi ng was this targettea available thing. IYM. PETERSON: That target figure is an extrapola- tion from that and it more clearly approxiiiate8 the level of activity in the re,-,ion than necessarily the first column which doesn't reflect in some instance rather significant supplemental funds. Maine, for example, had a good deal of actiVity fund for a couple of years which,now does turn up again in some of these projects. MR. NASH: Actually at one time they were managing $2,872,000 in one year. DR. TESCHAN: I would like to make the point, Frank, If we would be able to have that kind of figure, at least ready during these discussions, that would answer that kind of question. MR. PETERSON: I think we do. EPORTING CO, INC. 32OMassachusettsAvenue,N.E. Washington, D.C. 20002 MR. STOLOV: For every region we have computer funding printout. MR. PETERSON: Is there any other discussion? Again, I think I have heard a motion, a second,for i $1.5 million, and I think if there Is, I would put the question to the group. Those in favor of the motion? MR. BARROleIS: Is the $1.5 million based on what you just said is not a significant increase in the level of activity they have been carryinc,? IvM. NASH: No. In fact, it is a decrease from one prior year. DR. HESS: But they have also cut back in staff probably. MR. NASH: No, they maintained basically pretty well staff even through the phaseout. They lost a few, but basically it is pretty much the same staff. MR. PET@SON: I wonder if I could ask the question., Thix e in favor of @@1.5 million? (Shoii ofhands) 14R. PETIMSON: Oh, we are,going to have one of these'. No, divided -- all right. No, It isn't divided. I am sorry, Sister, and we have r,,-ot nine people; Iwas looking at the ei@ht, four for a n ri 35 five a-ainst. IC. BARROIIS: Could we p Ll t the z'PL.5 ml ILion on the hook.and come back to it? DR. HEUSTIS: I think we should do this, Is this motion lost then? MR. PETERSON: Yes, it has. DR. HEUSTIS: Is not column C the amoutn of money available for 'Lunding ',.his fiscal 1975? 14R. PETERSON: That was our estimate at a time when we weren't even as sure as we are now* DR. HEUSTIS: So it may or may not have any rele- vance to the previous fundin,7 levels of tile prograiio') YLR. PETERSON: Oli, I see. The column C does have relevance to the previous funding levels, Al. We took pre-phaseout levels, annualized levels, and calculated a percentage thereof. -At the time-- it still does, it adds up to '@114 million. At the time we did that, that was our best -uestiiote of rouc-hLy what we were CD CD going to have, and we were trying to give regions a target. It so happened that we are going to, in all likeli- hood, end up with either '@'109 million or $114 million. DR. HEU,@,TIS: lilay I suggest If we have to make what I Call a political decision, could we Lay the funding amounts for each of these programs on the table until after we have had a chance to look at them all, and then we can look-at the HOOVEP REPORTING CD, INC. 32OMassachusettsAvenue,N.E. request, we can look at what you have got down here and then we can go through and decide what can we do to com@ out soirie- where within the available money and be fair. DR. TESCH-AN: I think we could easily Indicate that Maine is in the top, divide the regions into approximately three big groups and with the details of the population, and the kind of other comments we have had. Ard then begin to adjust after we see the total group. MR. PETERSON: Is that the sense of the group that we lay recommendations as to funding amounts aside until Thursday afternoon, Friday morning? IC, BARR(I-IS: No, we could strike a tentative figure, but I personally don't feel that we are doinc, justice to these by just picking a figure out of thin air. I have no way of knowing whether 6pl.5 million is better than @l,,450,,OOO or @ol,750,000. To me it Is just picking a figure out of the air, DR. HIRSCHBODCK: We have to deal with this proble-rft, those who are not applyin- for July Ist money. This is exactly the significance here. If we do not take that Into consideration, we might be short chanuing them considerably. 14R. PETERSON: Charlie. DR. McC.A LL: I am concerned, as we had reviewed, on the whole, the gaps, the changino- situation, and we are Ho R REPORTING CO, INC. 32OtAassachusettsAvenu,;,N.E. W2,hinott)n D C. 20002 cominc, here In the last chapter of this p' tur roo-ram, the struc @laving-been designated, very fine people still here, but @qina.Li in nLunbers, overworked, mechanism torn asunder. And even when is I it-was there, we knew there were some inequities and son)e things that needed correcting, we were wor ng on, It seems we are really taking on something that really doesn't make sense. To think with all those limitations we are not-- as last gasp, use some sort of judgment, start a new bench- mark, write all of this in terms of population and everything else. Not that I am not for doing those things; it seems to me this is not the point in time at which we are armed wi-thi and able to do that any better than takinc- all of the problems and our disagreements about them, the former benchmark, and usin- it as where we start, and then ,noclify up and down in light of what comes in here rather than tryin@ to go back and go throu,,,h all of these and now come up with --,ome sort of new-- MR. BARRCJ@IS: I wrestled with that in my own mind ano- came up with this generalfeelino,-, whether right or wrong, any--,, body can say, but I felt we had a responsibility to preserve reasonable stability of the procram. But we should take away from programs that didn't appear to be able to use this one-ti.,Tie money effectively within reason and give that extra money to the programs that are doina- the top-notch job. DR. HEUSTIS: Great. MR. BARRO,@IS: 1-Thether that is good policy or not, that Is the way I came out with it. DR. HESS: Ancl you do that purely on the quality of the job and setting aside any other factors about the region? I,,IR. BARRO@IS: Well, one factor, the population inequities being on historically, and I don't think we can dramatically change that now in this short time,. DR. HESS: It is not a matter of changino, it. But to my mind it is not a matter of carrying that to excess. MR. BARR@,iS: I would keep a reasonable stability sa-y-- int- treat the averace in one way, cut down a little bit on tie pro-rams that are not too effective andpive that money to the pro-rams that are. But not make violence with 30 percent to 190 percent. DR. THUR@N: I hope we won't have this emotional kind of discussion with each application. A lot of us would like to have more information than we have to make a decision, yet we have never had enough information at any time in the past to make any better decision than what we have been asked to make ri(xht now. I don't see any difference as we sit here, except the understanding the proo-rams as they exist have.gone through 4D Living hell as far as from an organizational standpoint. But EPORTING CO, INC. 320 Massachtisetts Avenu N.E. Viashington, D.C. 20002 .i @ I either they have had the relationship and capability of doin@ it, they have known their state, they have known their capability -- but the only rationale -- I don't mean that in a, derogatory concept. The only rational comment was Sister's tD because she was there. To me I am not the least bit concerned about reach- ln,-@, into midair pulling out a figure in May of 1974 and I C> was concerned in June of 1972 doing the -same thing, with the .same kind of program. So that I think we are trying to find an excuse for our lnabi I,-ty to approach something in an irrational fashion when we have always approached it in an irrational fashion. So that I just-- this sheet doesn't mean a damn tii@Ln@ pardon me, ladies -- doesn't mean a damn thing to me, becalt: Ise here is a program, the people have come in, excellent .7rant w ri ters I two reviewers have been snowed -- ar,-ain, I don't mean that derogatorily -- been snowed by this preparation, Sister has said that the people in @ia,ine are interested in lt.i These peoole have 9,sked for $2 million. They have got one year of self-sufficiency for a small population. -And then they have @.ot to carry these proc,,-rams without us. What more do we need to make a rational decision tlic,,n those facts? 14R. BARRA[S: I don't say this is going -to be without us, the succeeding programs contemplated by Congress C3 will absorb at least some of this? DR. THURI@,IAN: Let's see,if yoti and I knew the answer to that, we would be the world's greatest -- DR. TESCHAN: What i-s the punch line? MR. PETERSON: What is the figure? DR. HEUSTIS: l@,Lr. Chairman, I @7OUld offer a motion. MR. PETERSON: Fine. DR. HEUSTIS: To bring this to a head. Motion was for @PL-5 million, request is $2 million; I'll be rational and split the difference. MR. PETERSON: Is that a motion for $1.75 million? DR. HEUSTI,'>': - @i)1.75 million. MR. PETERSON: Do I hear a second? DR. TESCIIPN: I will second it. MR. PETERSON: Second to get a vote. Any other comment? Question: How many would recommend -- and I thin we do have the sense that all of these are tentative plus, min,@s kind of motions, it is again a rough motions It Is again-- how many would concur at '@@1-75 million for the Maine R14P? All those that do,show their hands. (Show of hands) 14R. PETERSON: That motion is voted down also I think, four toflve again. E TING CO, INC. POR 32 assachusetts Avenue, N.E. Washington, D.C. 20002 (202) 546-6666 I dontt know whether we are moving in the right d lrec tion. Do we have another motion? DR. TESCHAN: Let me fly this one., 10 Percent more of recommendation to Dr. Pahl that he consider llaine in the top group; secondly that he consider funding at more than the approximate ratio that he has dealt with before, on which these fio-ures were completed, say some thing like 10 CD Percent or so more then that, on up to the totalamount of the application, depending on availability of funds. DR. HEUSTIS: I @fill support that. That sounds good to me. l@. BARP,,UiTS: C) DR. HESS: Cop out. DR. TESCHAN: Sure, it is a cop out, DR. HEUSTIS: As I understand your motion, you are leading us to put these into ranking things, so that some will be financed more than before, some at about the same level and some at less than figure to be decided after we have all of the evidence* I think this gets me off the hook from making political decision for which i do not feel qualified. I am perfectly willinc- to make a political decision. DR, HESS: I think that Dr. Pahl wants from us a figure end that for us to avoid the need for making that recor,,;- mendation, difficult thou-h it may be, even though it feels like we are rolling dice@ as we like to Pride ourselves in, you bei-ng very logical, rational people, but ;then if', comes right down to it, you h ave to take a Leap and make some judt- me tit s. I would say I think we ought to not avoid the re'- sponsibility that we have been asked to assume and do it even thou,7h we are uncomfortable about it. CD With that preface, I would like to offer a motion for @L.6 million. 14R. PETERSON: We have a motion of $L.6 million. Do we have 9, second? DR.McC.ALL: Second. 1,4R. PETERSON: Question, DR. THUP14AN: Call for the question. PETERSON: Call the question. DR. HESS: -Pre you asking for? MR. PETERSON: Yes, for those in favor, @1.6 miiiion,p five for and four presumably against. Okay, the recommendation of this group, by painful process and high degree of tentativeness, is $i.6 million. DR. THURIAAN: FulLy with the understanding we may come back. DR. HESS: We may come back and revise this. This is kind of a breakinc-in process.. MR. BARROVIS: We are cutting the melon without H*OEPORTING CO, INC. 320 Massachusetts Avenue, N.E. Washington, D.C. 20002 1-@@, I., I'll knowing how many shells we want to cut. DR. TESCHAN: Bic)-ht. PETERSON: Dick, you had wanted to say somethin@. NR. RUSSELL: Yes, I was a little bit disturbed and concerned durin@ this discussion. It seems to me we are get- C) ting two issues mixed up. One is the role ai this group in terms of making recommendations for funding leveLs; the other, as Dr. Heustis talked about, was the political part of the decision Dr. Pahl and the Administration will have to make in nia,kin@ the funds actually available What I heard in this discussion -- I have no vested :Lntere.-;t 'Ln llaine whatsoever -- here we have an application that apparently is ,iell put together, the projects do fit the goals and objectives; historically this program has been very strono'. -All the pieces fit together. I think it is that type of Information on which th@i-s group should make Its decision. Now, In terms of the target figure where we have programs that don't come across as stronr.,,I think that is goin@, to be important to look at that, so you do have to take that into consideration. But I really don't think it should be whether or not the actual funding made available will come out as your recommendation You do have a chance-- DR. TESCHAN-. But, Dick,, you are not helping, you EPORT[f,'G CO, INC. 320 Massachusetts Avenue, N.E. Washington, D.C. 20002 i4 '4 are at variance with the imperatives to come up with a number.@i I am comfortable with that kind of ambiguity, say "hoorah for Yiaind and leave it at that. But if we are under an imperative, maybe we should settle the question, are we or aren't we. If we are, we have to go beyond where we are,, MR. PETERS014: Herb PatiL's decision in terms of de- cidin@ signid- agrant award, statement for Maine with a figure, CD that is Toin.- to take place after the Council meets. I think with a Council that insisted upon a review committee, kind of restructured review process, 13 new members that while it is true that the Council is in a sense the formal recommender, I think they are going to have more diffi- culty coming up with numbers if we don't provide some bench- mark for them, I think, Dick, at least in our skull sessions, in the precedin-- daysi you know, I think we can belabor a-nd overdo the numbers game. And I am speakino, personally, not as your chairman. I think we as staff, and Herb -- you know if there are no numbers, we aren't all that helpful. MR. RUSSELL: I am not saying-- I think you need numbers ultimately. IAR. PETERSON: Right. 1,4R. RUSSELL: But the viewers have a chance to rate the RMP'S. DR. ,McCfii LL: I think there may be some Abstaining. MR. PETERSON: I am sorry. DR. HEUSTIS: Mr. Chairman, I object to this. lyle spent already too much time on this. DR. 14cCA LL: I don't mean -- I am talking about the future. I am not talking about calling for Y@ine. In the future. I don't want to go back and do thati on this one. DR. HEUSTI.S: I have the very strong I like what, you said and-I like what you said and it seems to me even though we have done it before, and I wasn't a party to it, I may have gone along the same as you did. But it seems as though if we give him the arnnunitic4 if we have extra money, this is what you do with it, this Is who you give more and thiis is who you take away, that is our primary function. DR. TESCHAN: I feel better about that, DR. HESS: He is not bound to use these figures. DR. HEUSTIL@i.- Not bound but as he makes the political I decisions, I don't know the gentleman, but being a politician probably to better or lesser degree, and sombody questions it@ he says, "But, haha, the Ad Hoe Co@@, ttee, -Advisory Council, this Is what they recommended." And he justifies in some instances where it is convenient, he justifies it. And he is no different from any governor or any legislature that tries to EPORTING CO, INC. 320@assachusettsAvenue,N.E. Wastiington, D.C. 20002 (202) 546:6666 t his budget so 'that he doesn't havel get a, protTram person to cu CD to mt-,e-the political decision. is DR. HESS: Al, just let me comment on that. If I understand the purpose of this ad hoc review, it is to brino- some additional perspectives to bear on these CD very complex issues and so to ask this group to weigh in our best we can all the various dimensions that should goi mind,.-, -as into decision making about, you know, this national program on a region by region bqsis. And that the most preci.se re- flection of the summation of those judgments is in dollars at this stage of the game. And that the role that the Directo.,' iLrid Council are not bound in any way, shape or form by those recommendations, but nevertheless that is the most concrete translation of 'udgment that we make. MR. BARRO,4S: Pete, let me make a. proposal that may simplify this whole problem. We clearly have two distinct philosophies on this thing and we are going to be tallcinv about that all night. Could we do this, could we let these numbers come out of the air from the frequent revelation from the record or 1, wherever, get them altogether, take a look at them when we are all done and go over them and do-- MR. PETERSON: We propose to do that. 14R. BARROWS: Do our equity on it. MR. PETERSON: I feel less concerned about spendinc.- H*REPORTING CO, INC. 320 Massachusetts Avenue, N.E. Washington, D.C. 20002 ,qnn% rAC tzrgg 47 a Little time with the first few applications, because I thi ni,c this is where we are gol.n,, to have to wrestle with some issu@@; and set some guidance to ourselves as to howue operate. It seems to me there are at least three things that, will go to the Council and Herb Pahl, at least there are three inputs from this uroup. There Is a, number that may be e CD softest and least offensive. There may also be in most instances some kind of half quantitative rating based on several people; and thirdly,i there will be the o,-eneral sense which I hope staff will be able to reflect accurately and which in the case of Mainequitn apart from more or less, that there was a. general, general sense consensus that this was, n.ll things considered, a com- paratively good stron- program that had %,Iaine stability durlnc,i the period of the last 18 months. And I think, you know, it is not as if the number is the only thing we are go ing to feed him. I think we need to keep that in mind, So we are triano-u!- lating. Sister Ann. SISTER JOSEPHINE: Yes. May I say one other thing. I think the 53, out of 53 pro-rawq there are only 6 that CD are complete,as we are going to review them, that aren't goi rE" to have anything for the Cray Lst review, or the July Ist revi.F--I,,,. I think that that is a consideration also, we have to keep in mind,and this is one of them and I th ink this is very important. MR. PETERSON: Well, I would like to ask the group at this juncture, It is ten after twelve, our cafeteria is probably most crowded now; on the other hand, by the tire you a,-et to certainly 12:45, the fare starts becoming severely diminished. Not that it is all that great to start with. It seems to me we have crot to make a decision either to go to lunch now or try to wrap up and let our beLlies push us in terms of one more before we go to lunch. DR. THUR@IAN: Move for one more. Nobody here needs the fare that badly. DR. HEUSTIS: Who do we give these things to we don't need any more? (Indicn,ting) MR. PETERSON: You can put them under the table. Hand them behind you and somebody will put them back farther. RUSSELL: As usual, we will pass them on down. (Lau,hter) @M. PETERSON: I ,Ionder If we could take Albany. This Is an Instance where, by virtue of the fact of a recent last-minute cancellation, we only have one reviewer, Mr. Barrows, and move on with -Albany then, since you said you were best prepared' for lbany. EPORTIliG CO, INC. 32010a,,@chusettsAvenue,N.E. Washington D.C. 20002 (202) 546-6'666 .A LBA NY 4 9 MR. BARROWS: That is a small tribute to my prepara- tion, I assure you. I think most of us on this committee can make extended and culpatory statements of the same kind, that were made on behalf of staff, I quite honestly had difficulty in doinv, justice to five applications. I say that in advance, because if I didn't say it, you would detect it as I went along. In any event-- DR. THURI,4AN: We won't be critical. MR. BARR(NIS: No, but you would cut hell out of the budget. To end the suspense, I have a pretty good impres- sion of the Albany proolram. It is a 24-county proc-ram. The grantee is the Albany Medical Collece, These were all the figures, but 1 had to go by them. Budget request was for $i,056,000. Their present funding for half a year was $556,000 so about the same level of fundin@ they are seeking. The director Dr. Kraft, has been with the program since its inception except he has be director since January 1973. The chairman is a retired physician hospital adminis:- trator. Executive committee represents a wide variety of H REPORTING Co, INC. 320 Massachusetts Avenue, N.E. Washi6gton, D.C. 20002 Interests and remarkable -- Includes edu(-ation, labor, com- munity agencies business, and so on, Staff of 70 full time, two part-time professionals. They plan to add two more. Their survival, staff survival through the phaseout looked to me good. Variance ranges from two to eight years. Regional-Advi8ory Group 43 of them. I noted the director Is an ex-officio member of RPG. 10 I think that puts him in a This is a philosophical thino-. peculiar position to influence the whole process. -And from the looks of the staff, I think this is kind of a one-man type of programs but that is just a guess. The executive co,@4 ttee exercises planning. Basically the committee structure looks Pretty good. Logical structure, I can't say who dominates from what is reported* Past performance, the direction has been I think quite acceptable. They made a prompt effective response to the '71 change. Their track record is -ood; of 27 active projects since RMP support, but '71., 12 are continuing with 10 they are flying under other support. OnLy two have termin-i ated. Their goals and objectives are very well articulated and very con@;,ruantp as the record shows the RMP mission. i The proposal situation to ,ae better than averave compliance with their own stated objectives. I had more troub @ with that factor* Everybody states the same objec- tives in glowina terms, then they go off and do something else; but I think they stayed pretty close to their objec- tives. There is no CHP agency in their area except in Western Massachusetts, They are working with that one. That seems to be harmonious. And they are trying to get another one off the ground. So I think their CHP agency relationships are good. I think they have got a reasonable chance o SLIC- cess. 14uchp of course, is going to depend especially on these pro-rams designed to serve the underserved areas. Much will depend on future funding from a variety of sources. Icame up with a good to excellent rating for the total proaram. I summarize it this way: ARMP has retained essential strengths, Well =named and well oriented. Proposals consistent with basic RIMD mission."ReconLnend funding proportionate share of what is available, at least equal to past level. MR. PETERSON-. You have heard Mr, Barrows' review. This is one we don't have two reviewers. Check with Frank, I don't think any people around the table in their prior in- carnations had at least site visited Albany, but I am sure *REPORTING CO, INC. 320 Massachusetts Avenue, N.E. Washington, D.C. 20002 (202) 546@6666 52 there are some of youIwho have some impressions perhaps have So had some specific information about the Albany RMP. before I check with staff, I was wondering if there is any-- from the rest of the reviewers whether there is anything specific or general they want to add to what Mr, Barrows had to say? DR. TESCHAN: What Is the population? I missed it. MR. BARROIIS: 24 counties. Metropolitan area -- Albany, Schenectady DR. TESCHAN: I just ,neant millions. MR. PETERSON: We don't ha-ve a fact book, do we? MR. NASH: No, I don't know. MR. PETERSON: I will have some population figures after lunch. My guesstimate in the Albany area is probably approachin- or over a million certainly. It may be a couple C3 of million. You have Schenectady, Rensselaer, Troy -- you also have a lot of -'Adirondack, without too much population except up around the Plattsburgh area. MR, BARROWS: Pushing over a million and a-half. I have one quest2!on. Let me just throw out, obvious" ly, on th e basis of my information, it is terribly difficult for me to say what is the proper problems for relating to liother federal initiatives," that is particularly true in the i, EPORTING CO, INC. 32O MassachusettsAvenuL,N.E. Washington, D.C. 2000? case of emergencies here* there has been $L38)000 The activities for which looked to me to be fairly consistent In that they were more preparing to get ready for entering the emergency systems program than they were in doing the same things that the emergency systems program I understand is doing. I am just mentioning that as something that ran ray mind. through MR. PETERSON: do you or Norm have anything-- there were a, number of projects listed inthe summer here that reLate to HMO'S, E24S'@ et cetera. Are there any significant problems or policy issues that you see posed by these? 141. NA SH: I th @ the HMO, I be lie ve , is afeasible study. MR. PETERSON: Within our guidelines, earlier policyi, i c,uide line so MR.NP@@H: Yes. Yes,Ild say EM activity Is continuing. MR. PETERSON: Sorethin@ started by the EM leglsla- tion. MR. NASH: Yes. MR. ANDERSON: Also pro-ram activity supports previous approved policy we had; It complements. MR. PETERSON: And I know Albany is one of those piaces that are few in number now where there is no major 54 (b) agency in the Albany area. There Is one they overlap ,with in' the Berkshires, northern Iliassachusetts. I Albany said, "Throw this sheet away" -- not-- figuratively. Albany Is a region which, again, we ha.d indicated CD target figure of about 1.5 million. We have an application here which is entirely continuation program staff and some projects continuations. They have indicated that they will be coming in with an additional application on July 1 for new starts totalinf7 about half a million dollars, This one, CD this request totals just slightly over a million. Thus our estimate at this juncture is that tlbany will be reqi@esting-- happens to be a couple of thousand less. Just about that f icure. target CD But the present application is for @l.,-'6,ooo.1, DR. TESCigiN: I wonder, management assessment, re- view verification, if there is any indication whether, In essence, the grantee is behavinu according to policy? Any evidence on that? IAR. PETERSON: Norm, we did have some problems I know some years ago, but boti, with respect to review and management, review process has been verified and found in compliance. MR. ANDERL'DON: Yes. Right. MR.NASH: Right. NR. PETERSON: Are there any recent management assessment figures? MR. SI1401iDS: That is one of the very early ones. That has been several years ago, would have no relevance today'. MR. A@TDP",RSON: We Here program staff, support what Mr. Barrows said. MR. PETERSON: Can you lift that up four decibeLs? MR. fiNDERSON: Durin- the phaseout period,, they were able to maintain pretty much the program staff$ kept it pretty much intact. The RAG did continue to meet on an every-I two-,,nonth basis. I They continued to maintain a stable level of opera- tion throughout this time period. DR. TE'",@'HAN: Would you identify the program as bei,,,@ in the big middle o,,roup? MR. BARRGJS: The big-- DR. TESCH-AN: Middle group? Would you put it at the top of everything you have seen or bottom? MR. BARROWS: I would say probably top of the middle@ group, I was impressed with something concerning which I. have mixed feelings, perhaps more than any other pro@ram CD that Ilooked at, They have Addressed themselves to the prob- lems of the underserved. That is a high risk type of activity'. So prospects of success are low. Brownie points for trying to do a good job are high. I co,@- o,,,It with a stand-off on Ui I don't know how the rest of you feel about this. MR. @MSON: Are there any more questions com- ments, observations from the review panel members? Staff? Norm? Frank? MR. NASH: No. DR. TESCHAN:. Do you want a motion? .MR. PETERS014: Yes. I was go ing to say it looks like -- much as I regret it -- novi this is a request only for *1 million. DR. TESCHAN: Yes. MR. PETERSOii: So I don't think we are-- DR. TESCHAN: I am sensitive to Sister Ann's point here, that we have to consider the later -- perhaps after considering the later-- 14R. NASH: Even if you consider what the@- Propose to come In with July Ist, they would still be a little less than the targeted figure if you give the targeted figure any force. MR. PETERSON: Yes. I think here we clearly have toi be guided, Paul, by the fact while in Albany and in many, many; others of these,we will be seeing a second request which will total X or Y amount that really our recommendation at this session, certainly the other inputs will have a bearing on tt,.e; second set of recommendations, hopefully many of the same people will be involved, that we have L-ot to look at this re- quest and make our recommendation in those terms. So that I guess I am saying DR. TESCHAN: 14otion for $ipo66,ooo then, approxi- mately. MR. PETERSON: That Is the maximum. Yes, John. DR. IIIRSCHBOECK: These request figures include tie indirect costs as weLl? MR. PETERSON: These are total costs I believe, tha is a battle I think I have finally ,on. We used to show you people direct costs whichwas very deceptive. These are total costs, direct and indirect. And that is vihat it costs to run the Albany proo-ram. DR. TESCH-AN: Do you have the indirect cost rate? MR. BARPaiS: Yes. Somewhere. MR. PETERSON: i@edical Collegeo it is probably in the neighborhood of 40 or 50 percent of salaries and wages. DR. THMIIAN: 50 percent on salaries. MR. PETERSON: That is rou@hly what you are runnin-- on, MR. ANDERSON: 6o percent. MR. PETERSON: Probably the best guess I will make in three days. DR. TESCHAN: The record ought to show that is one of the things that kills a progra m in Congress. And we ought tb raise the question as to whether this isn't-the time for the Albany group to recognize that fact, and see whether or not I they can begin the staff processes necessary to get them rea.dyi for corporate grantee. MR. PETERSON: This I don't think has ever been actively considered in Albany, has It? M. 14A SH: I don't think so. MR. PETERSON: I know what you are saying, I don't know whether it is even in our jurisdiction to recommend it or@'i to move it, or whether that is our duty; but it seems-to me if we have responsibility for the program, for the public accountability of funds, that this is one critical issue. MR, BARRO@IS: They will be doing that under any pend ing new legislation, won't they? DR. HEUSTIS: Mr. Chairman. -St Ale MR. PETERSON: Ye MR. HEUSTIS: Out of t@e projects I reviewed, it seemed to m California and I think Maine made no provision that I could see for any indirect costs whatsoever. MR. PETERSON: Thae are private nonprofit corpora- tions established essentially for that purpose, so.those be- came direct costs. DR. IMUSTIS: This is even for-- MR. SIMONDS: Both of those programs right now are in process of negotiating indirect costs, because they are managing funds other than RMP funds, so if they don't, RMP ,noney is going to be spent on the management of these oLit-I side. DR. TESCHAN: They generally pay Indirect costs to universities, but the direct administrative costscoordinators put together varies with the years, as you may remember, and 10 percent being a pretty good figure to put on it. DR. HEUSTIS* I think Maine had a policy, if I re- call correctly, of not being indirect cost to anybody* I don't know whether It is carried out and I may be in.error. 14R. =, ERSON: Paul, I think many of the thin-s you say are true, but I wonder .whether the issue of direct cost or indirect cost is something which this review group -- it mayiriore appropriately be a matter of Council. I happened to a number of years ago once sat and tried to take on indirect costs at National Foundation on the -Arts and Humanities and I had three university presidents ,-Zittina- on that Council., Princeton, fellow just left the University of Washin@ton, and Brown. I didn't realize what kind of tic7er I had walked into. I at least at that juncture acknowledge everything you say, but I, one, question whether the review group is really the forum in which to deal with it, and two, at least in the next 14 months, I can see, of some stability, whether it is a polir-y we are probably going to accept as regions take it on themselves and many have, but Albany Is not one that has made any move to disassociate itself from a medical college and sets up a nonprofit corporation. It is a cost of doing business. It may indeed have done the program harm, Again, a personal view. DR. HESS: Maybe the best thing can be done, notelin the comment, the question was raised and would be worked out administratively. 14R. PETERSON: Right, and I have done that. Did I hear a motion recommending the amounts request ted for this application, @l,o66,ooo? DR. HF,,,ULTIS: Somebody made it end I support it. MR. PETERSON: Okay, you seconded It. -Are there any other comments If not, those in favor of that recommended amount raise their hand. (sho,i of hands) MR. PETERSON: Everyone* Anyone against or abstaininn'? I think I saw nine hands up. All right, we have in an hour and ten minutes which comes out to 3r,', minutes per application -- disposed of two easy applications. So while I am encouraged, I don't think any of us ought to cet overly encouraged. I think It probably would be a good time to break for lunch, as I say. DR. THURMAN: Will we finish today? MR. PETERSON: If we take some class action. What would be a reasonable tirie to ask the group to, reassemble? 1:15? 1:30? DR. HESS: 1:15. MR. PETERSON: Can we try and be back by 1:15. We will start with Northern Nei,, Enrrland by virtue of the fact Joe has a three o'clock deadline. Thank you all so much. (I-Ihereupon, at 12:30 o'clock, p,-m., the meeting was recessed, to reconvene at l@15 o'clock, p.m., the same day,) ,NORTHERN NEW ENGLAN.U AFTERN0014 SESSION (1:17 P.m.) MR. PETERSON: We were goint@ to pick up with Northern New England, but I did want to mention a couple of things. Again, on the rating sheets, I am not going to,at least to the best of my abilityo let you get out of this room tonight where you have reviewed a region without lettinu me hate those rating sheets. Secondly, to the extent that any of you have,as I think perhaps llrl, Barrows did, had some notes from whence you spoke, even if they are in longhand, I would also appreciate your leaving those with us, althouc,-h I won't Insist upon that., Because there has been a f7reat deal, as you know, of litigatio about correspondence and notes in Washington of late, and I don't want to get into that. MR. BARROI@TS: What was that you were referring to? (Laughter) MR. PETERSON: I should also have mentioned this morning that if any of you need any assistance with travel andi@ the like, I think we can handle that and maybe I can ask Shirley or someone, but to the extent you have got those kinds of probl,- lemso let us have them and we will take care of that. Finally, and th!6 Is really directed to staff, I would appreciate it, for the benefit of Mrs. Chian-, that when staff does speak up for the first time, if you would identify yourself -- not for my benefit, not for most other people,.-but for her benefit. With that brieC. if not lue@,.Cil introduction could we push on for Northern New England, sometimes known as Ver- mont, Joe de LaPuente. MR. DE LA PUENTE: This is an application for the support of proo-ram staff and selected continuation of on-@oing CD projects. They will present some new projects that have a high priority in their July Ist application. The prouram is committed to addressing Community problems and the development of their solutions. By now they have developed P- cardiac care management system, a respiratory disease communications network, a high risk infant care and transportation system, and a strategy for addressing emergency C) CD medical services issues. Their present thrust will be that of encouraging ends developing coir..munity involvement in program development, in pro-r@i,m plannin--, and in program evaluation. The region -is particularly involved in the continued!, evatuation,and improvement of the medical care system, land they are doing it by developing specific guidelines and delivery of selected services. They are doinu it through the support of "Disease management committees towards 'the assessment and the! maintenance of established guidelines. And also they are doit-,@, eiri It through the support of providers enga@ed in improving 'h CD LI programs towards the maintenance of established guidelines. They have Linkages with the Department of Medicine at the University of Vermont, the State Health Department, the Medical Society, voluntary agencies, and most hospitals in the state. Community support seems to be demonstrated by the continued involvement of their Regional Advisory Group during this period of indecision. Their Regional -Advisory Group continues to be intimately Involved not only In the management of the proc,-ram, but also in the development-and support of sLib'r, stantial prooram priorities. The Regional Heart Management Committee, for examole, includes 29 standin@ members, and they have continued the,@r activities durino- the last 12 monthsL CD The present core staff Includes eivht persons, four of whom have advanced degrees. Their steffino- pattern appears CD to be very similar to that existing prior to the phase-out order. The present vacancy pattern may represent an oppor- tunity for the director to develop a sta.ffinc7 pattern more consistent with his future proo-ram plans. Their present request is for a core budget of $432,800, including i'?'292,800 for salaries and wages. Their request for the seven projects envisaged amounts to @687,000, for a total request of @'L,039,670. Thi s represents approximo.t@l 40 percent core staff activities. tinuqlly involved in The core staff, however, is con the support of disease management committees. Their present application is for $1,039,670. It-is estimated that their July I request may amount to $1,,839,670 compared with a projected availability of $lol99,300. I will not go into the cluster of projects. I was very much impressed with the type of projects that they have: a, regional end-sta@e kidney treatment program, a project o increase the capability of rural ambulance and emergency room personnel, a reulonaL proc,-ram for hicri-i-risk Infants and mothers, a regional respiratory disease program, an ambulatory', pediatric care project, a voluntary problem-oriented,health care inforr@ntion system, and a program addressing the sources of communication among school children, 1-n summary, this recion possesses a @ood track record' CD in obtainin@ community support for its activities. They want to shift their prorreua emphasis to improve primary care and CD strengthen community level organization Presently they are involved in providing an environ-11 ment where quality assurance can become a living reality. Their present request alone exceeds that of previous funding. But special consideration should be given to determine whether or,not the staffing level presently proposed is consistent, both with the activities proposed for the coming year end the level of support tha-t they will probably receivers, This is not to detract from h(y much I m,@s impressed by this reoion In terms of how precisely they develop their priorities, how the project they have forthcoming agree with those priorities. So I have a recommendation. MR. P.-bTERSON: 14aybe we should hold that, Joe. 14R. DE U, PUENTE: Yes. PETERSOlq: This is an instance where Dr. Jams was the other reviewer, but I wondered, Bill, since you had been up there either in a structured or kind of offhand fashion, if you might want to briefly address Northern New En@,land and then I will ask staff iL' they have any comment before we open it up to the whole group. DR. T'@a.URI,,@IAN:Ihad your e:-@,phasis---- first of all, since our site,visit, there test been a change of directorship.; The new per---on q-ec,-.qs to be a relatively strong leader. Tile re has been stability of a corporation now where there wasn't before, which was one of the recommendations that was made at the time of the site visit. One of the stron@ continuing strengths as Joe indi- CD cated was the RAG chairman who was the strongest person at our meeting, much stronger then the director at that point in til.,,,e@ is still there and still actively involved. I think that some of the things that was su,@Ic,,ested at the site visit have not truly been carried out and many people here know that Vermont or Northern New Enc@rland had I more data than anybody in the country, including Census BureaLI; -And the feeling was that RMP money did not support that in a significant way. They have cut it back, but it is still there, sig- nificant amounts in the project they are bringing forth right now, I would second what Joe said from the standpoint community pro-rams are certainly strong as are the disease committees and those have c ontinued to develop. One of the most significant things to me in reviewin(- this now is that when we were up there before, the state Liaiodns were not well worked out as far as continued support for nia,ny of these programs. This is now very clearly defined and woric- inu quite well. CD Staff is quite sj,,.all. Staff goal, 10 percent of the total money related to the project, but that doesn't come out in their proposal, It is written, but that is not the way the figures come out. I th ink the projects in essence show good cause, Kidney project is needed in their state. EMS,despite data base, does not expect, what you expect to show in the application.we have in front of us, they have one of the best high risk infant programs in the country. I think they have certainly met the goals and priorities with this application and I think that they will with the others, I have just two concerns. The first is each of the@ projects is overbudgeted for what they-expect to accomplish in a period of time; a.nd the second is they clearly state in the application that core staff should be 10@percent of the i project and yet it is almost 50 percent of the project. Su that I think subsequent to the time that expense and our group were up there, this program has made a lot of changes in ref- erence to the advice letter that went forward from staff after' review committee and Council, And I think that the director is an unknown factor because he is totally new. He was not in@ the procram then. I Would SL',pport everythinc.- Joe said. MR. BARRU,,[S: Could you identify on this list of items the ones that you say are-- DR. THURLI.AN: 007 has a very strono- -- ER, emergency services program has data base information. The respiratory disease Is very much that way, -And, of course, 037 is P@--L mary data proo-ram. And 038 is ao-ain data base pro@ram related to the school system, but was already available to them. So tho6e are the ones that still have a heavy -- th,,,,t is nothing when were we up there, '72 August, you should have seen it then. It was nothin- but one floating base of data. So I think IV-his program hs come a lono, way and certainl@- deserves-- 14R. BARR(31S: You say these items are too fa,t in une,.,r data bud.-et9. DR. THURI.IAN: Yes, sir, MR. PETERSON: Let me ask staff, before we fully open this up, as to whether there are any particular concerns or policy issues that we see posed by this application, which I would hasten to point out is essentially a continuation of program staff and some ongoirib previously ongoing pro-jects It totals a little over a million dollars. We have an indication from Northern New Enc,-Iand that they will be in for alriiost-- -Loor roughly @'800,000 worth of activities, all new with their July submission. So that it is a little difficult, 1 I suppose, to deal with what is no more than 60 percent of vlhat we anticipate, although this is sort of core and on-r-oinc, activity. or Frank, do we have any particul Spence ar infor.T;a- tion concernlng the policy issues? Yi.R. COLBLTIN: I have no kidney, PSRO, liMO.Idon't think we have any conflict with policy. MR. PETERSON: Okay. Frank. MR. NASH: No, I don't have anythino, to add. CD BARRGIS: Let m ask a question. 14P,. PETERSON: Okay. NR. BARROVIS: The continuation request is based on some thino-s that have been suggested,are really not all that productive. Does staff have any idea what is going to come in or will they zero in more on immediate needs? MR. COLBURN: I didn't. MR. PETERSON: Spence probably,ha,s been away from DR14P, away from us-- 14R. N-ASH: llost of these regions gave us a'projected! dollar figure of what their July application contains. DR. THM@f@,tN:I think through their application, you feel strongly they are coming in more id '.-he priority line. It never specifically says that as Frank says, But their proposals that they are discussing in the distance in their actual application Lor continuation indicate that they will be much more in the line of priority, rather than this group, MR. B-ARRGN'S: I take it you would be Inclined to be more generous with what is coming up than what they are asking fcrhere. DR. THLIR14AN: Correct. I am interested in seeing what Joe's proposal is. I think I would be different. MR. PETERSON: -Are there any other of the reviewers who have comments, questions, observations? DR. HESS: General policy question about renal, In the material we were sent ahead of time it was indicated thr-u this is an area, of at least decreasing concern as far as RI@IP, because Social Security rules, and so on, permit funding there .A nd yet, on the other hand, We@iere told this ,aorning that, YC)U@ know, their restrictions are essentially lifted, so whatever was being done two years aco could still be done now. C> In this area of renal disease, what is permissible and what is not is still a little fuzzy in my mind. mr. peterson; let me try to clarify that,.althou@h CD I don't think I can state it very feli.tiously. There was, of course, with the enactment of HR-10 the extension of Iliedicare to really cover most end stage. On the other hand, most of the R14P activities, both prior to tha.ttir.qe and now, are more aimed at resource development, training, and some other aspects, One of the things that we have a.s a matter of rou- tine,I guess, in the earlier award we made, sort of a formula basis during the past year, have had to do, is, Ln efL'edt@- here I am groping for words and perhaps some of the other star' can be a little more clear on this. As you know, under the Social Security, those Soc-le.1, Security amendments, the reimbursement for the actual end sta-e treatment, dialysis, transplantation, is restricted to certain@ approved facilities and if facility is not approved, they have to request an exception under what are still Interim regulations I believe. In the process we have, In effect, told regions th@%ti before you go ahead and fund anything,, you need to make sure vis-a-vis that particular institution sponsor@ et cetera, that this is a facility that either has or-- you know, the kind of approval for reimbursement under Yiedicare or is in the process of getting an exception. I am not sure that really answers your question, But we certainly -- we have not in our previous approvals i nor is clearly in this case, we have not said end-ste,,cre kidney activities are no longer eligible for support. I do think we probably, even if the program were to continue, Rlj',P, for two, three, or four yea@ we would probably see a downswign in that as reirabLirsemnts arrangements begin CD to possibly be@in to pick up the other costst the kind we have CD We, of course, pay for little or nothinc, in the w,,-@y of direct.patient services* I)R. TESCHAN: llaybe experience would help; that is, as Pete has been pointinc,- out, the HR-1 primarily has addressed reimbursement. Indeed@ they have tried to oet a quality because of the limitation of where centers are. The instructions we have here I think are very ex- i plicit In saying we don't fund things that will result In nevi facilities being constructed, or new services made available without prior clearance Nqith But what all that discus- sion leaves out is the enormous piece of work t-tidt nothinc,,@ covers, that has to do with building relationships between cen- uers and organizing some kind of rational patient flow, so that the right kind ofpatients relative to their stage of renal i disease reach the right kind of talent end facilities. And that whole thing has to do with the community end and educational function which I don't think can be paid for under SSA so fari as I can tell, although I notice your comments just at the end there, that is very-- I mean, if that is substantiated, i tha,t is great. We were wondering where additional fundirLfr, of those, thl@n@s is. We were concerned SSP-,, in dealino- with these thin@,@' CD ard in the regulations, totally ic'nore one of the most impor- ntributions; namely, the organization of the patients te,nt co flow, And we are disturbed about that. It seems to ,ne there is a big job for Rie to do in that. DR.HESS: I was a little confused about that state,,ren@4t-l because RMP never wos,or supposedlyin business of subsidizing direct patient services, although in a sense they also were,, .P,ny time you train people to care for patients to some extent you are subsidizing it, but the bulk of it was in organizational wo@ developing a plan, the workino, out of-- collaborating relationships this kind of thing we are taLkin@ about. I have, you knows wondered whether if indeed that was being picked up by some other Mechanism So it is just unclear. 14R. PET@RSON: I think. our concern, RMP's concern ati this juncture is that the kind of what you referred to as indirect subsidization sort of activities not continue or be created in an,institution or facility that doesn't have or isn't likely to have the patient care reimbursement under Lt. P sidelight, if you will, it is not relevant to this application, but there is almost a separate quality of care, many PSRO arrangements being established for end stage renal CD disease treatment find that is what Spence and some of the staff left here are workinT on specifically In B@ We find that in many of the rer.,'.ons, these local re-@ view boards -- that is I believe what they are called, isn t it, Spence, but they really have a quality assurance function among other things,that local review board at the regional CD level will be handled out of the H.-bll regional offices; that in many re-,-ions they are turning to existin,-, kinds of RI-,,IP arrangements, resources, people that have been collected bo establish that. That is not true across the country, but certainly in some states -- I recently was in California where there would be a number of such local rev@w boards. -And that pro- cess is being greatly facilitated by the kind of planning rese-Lirce development end people have been pulled to,-ether under the aegis of the California RI,IP in connect-ion with some!, of its'end sta--e renal disease activit@T. We have had reviews by Joe and Bill. -Are there any additional questions, comments from the other reviewers or from 2taff? DR. HEUSTIS: I would like to hear Joe's recommenda- tions. l@IR. PETERSON: Yes, I am sorry@ Joe, Thank YoQ.- @L.L. I don't kno@iitiat I would do without you* -'f the rec (Discussion oL ord @IR. DE LA PULIEE: The chairman wi-IL have to check me on this. But it would 'ro something like this: 000, at thisstage of the game, with strongl Thus @700, recommendation for maxirqu-,m funding on the July I application, if they are the types of request from tqe size of our expec- tation. MR. PETERSON: Let me make sure I heard that; more importantly that all of the othei-@heard it# $70b,000 recommended at this point against 7 I mi- ques 4 a slightly over 'Ilion re t, but with a strono, coroLlar recommendation that the anticipated @800@000 request that we I will see in July and you people will be lookino- at then be looked at if the proposals in a very fair Light; is that the sense of it, Joe? MR* DE 1,A PUz'ZITE Yes, that is about the'size of it. DR. TESCHP.N: Second. @IR. PETIMSON: Is there any discussion on that? Yes, Al. DR. HEUSTIS: I was not doing the fire parts Only thin- I know about is what I heard you say and what I read in the staff document. But as I looked@at the staff document,;, iat the numbers for the projects that were indicated as having perhaps more than their necessary sehre of checks, it adds up to a substantial number. Then I like what you said about the program staff perhaps thinking twice about filling the vacancies and reacting to the other, and it seemed to me that maybe you were being a little generous recommending "'?700,000. The figure I had tentatively written down was 'i)6oooot_,. I v7as wondering could I have your comment as to why you chose C> the seven rather than perhaps six? MR. DE LA PUENTE: In the spirit of havino.- them make their own choice, 'Q@1000000 figure I had in mind, to pe-r- mit them to get staff if they feel it will fit with the new projects that are goinc, to come out in support for them, givinc@ them sort of the benefit of the doubt. So they can do hear own administration. And not fully saying go and fill all the vacancies and go full fledged. But that was the only reason, DR. HEUSTIS: You are not bothered by the 25 percents for program or central staf-f rather then the 10 percent which the-t y say in the document? Or did I misunderstand you? NR. DE LA PLTE14TE: Tell me that aoain. DR. HEUSTIS: I thourht I understood you to say the written document said for their central staff, they were in- terested in havinr,- about 10 percent. Did I misunderstand? CD DR. THU.Lqjll-4N: That is correct, I said.. DR. HEUSTIS: 25 percent according to the document, 50 percent, 430 -- not quite 50 -- out of a million, 43 percent. Does that not bother you or didn't it bother you when you made your recommendation That is probably where our dij"-!, -ference is. I'M. BPRR(Yvl'@-' Discrepancy of that magnitucie,I won,,3eri if there could be an error? DR. HESS: In the accounti.no,-, DR. TE-@CH-AN: First of all Ithink unless you have !i-@, enormous program, primarily contractual work, to run a programi on 10 percent I think would be a, little unusual, especially when you see the developmental activity staff should be In. I think 10 percent would be unrealistically low. DR. HEUSTI@: Iaa not disagreeing, but this is what ram. This is all I am going by. they said in their proC DR. TESCH.AN: I think that would be a mistake. DR. HESS: The total staff is 14 people. Bulk has uo be for programmatic activities, not for staff'personnel. MR. DE LA PTP',',iTE: This is what happened, the way I fig ure before is actually about 40 percent of the management core staff activities, however the core staff Is going to be continually involved with management committees, which is a pro-ra,,@,tic issue. So whether you call It a program or core ID CD staff, council -- they support -- it is a group of staff that spends an awful lot of time with these diseased manac7c-ment CO.%raittees and they gLve them other support. D% HEUSTIS: Is 40 percent too much? DE LA P@, NTE: LIO percent would be too much definitely, in my opin-Lon, if it was just staff ronagin@ the 1 projects or beinc-- supported by the RIIP. If it is the staff doing what I call intramural support and supporting some of the activities, then it is not really 40 percent, probably comes down to 20. And thau was the reason I looked at it, DR. HEUSTIS: I don't care to pursue it. 1,M. PETERSON: @le do have a motion, $700,000, which has been seconded with the caveat that the favorable cast I towards the July request proposal subsequently warranted. guess there is a concern of the group that the $400,000-plus may be a, little on the large side certainly in terms of the action taken today, but a@ain if one looks at the -@800,000 request which may be coming in that that perhaps could be expressed. Are there any other convaents? I.,M. DE LA PUENTE: I would like to include LI U LIU L comments of Dr. Heustis, concerning personnel situation in the@ ward problem. MR. @ERSON: Okay, that concern be expressed. DE. DE LA PIC@LTTE: Right. PETERSON: Particularly until action -- we don't@i know how many projects they will have to manace until their new activity is Looked at in July. You know, it is possible the group's action would be! much less than what they request in July. Certainly that @concern I have down, Joe. DE LA PUET-ITE: Okay. MR. PETERSOII: If there are no other corfiments or questions, may I have the question. Those concurring with that recommendation raise their hand. (Show of hands) IC. PETERSON: That is everyone, including a weak yea" -Lrom Bill Thurman or tired riding on the airplanes DR. THUR14AN: Tired. MR. BARR(3[S: If I were the coordinator, @G chair,,,,@ak up there, I would very much appreciate ',,,nording the basis for our conservatism on continued funding and basis for relatively optimism on future funding. Will that be transmitted to them? PETERSON: Let me make sure. I see no reason that it wouldn't be. The basis for the less than requested wa,@ still a concern with the overly richness of the data involve- ment in some of the projects. Is that correct? Is thatan accurate reflection? DE LA PUENTE: That is right. PETERSON: -ALI right, having disposed of Norther., New En-Lando I would like to suggest we try to move now to C) West Virginia. Joe, your r@-eetinv isn't until three. You are more than welcome to stay until then. On the other hand, I am goinc,- to avoid brino-ing up any other regions this afternoon that you are reviewer on, so if you do want to le@,.ve, feel free to do so. He will be here tomorrow, I assume that. DR. TESCHAN: I am not ready to talk about West Virginia on the bas'-s of the application. I would have a little bit of past history, you knoii,i previous contact. PM. PETERSON: I am not sure what you are saying* DR. TESCHliN: I think it would be better if I had a chance to read the application. l@. PETERSON: Okay. What you are saying is we to put West Vir,,inia until tomorrow. We have to get it in the iTiorninoo beca,use Charlie i@IcCall is goinc, to have to leave I guess around two o'clock. DR. TESCII-AN: Be happy to accommodate a busy co I lear-,t;e . MR. PETERSON: Well, if we can't come to grips wit-- i if you prefer puttin@ off West Virgine, until tomorrow morning, I am will,-n(,- to do so,if that doesn't pose any problems for C) Charlie. I wonder in that case, though, how are you -fixed with Cornecticut? DR. TEcCl@-14: Fine. 14R. @b ERSON: Because you are also a reviewer there.4 I thought since we were sLidiri@,, with the easy ones, maybevie ought to take a look at Connecticut at this juncture where Al and you a-re the reviewers. ,Al, you came second last time. I will let you lead off,this time with @he nutmeg state. DR. HEUSTIS: Thank you. L; @q t@u -I.Lk/ U I DR. HEUSTIS: This application from Connecticut is the'first of two applications and together they anticipate that these two amounts of money will approximate @2.6 m-LLlion,'@ The current request provides for one year for central staff or core staff, or prorram staff, which I think I am usILr, all interchangeably, although I know there are some little @oi inuendos as faras differences. And there is approximately D percent level of increase requested for the core staff over the level, pro rated level of funding in which they have for the first six months of 1974. They have sometwo months request for continuation n each of 13 specific projects in eight proc7ram areas. The CD only pro,7ram area in which they have more than one project is in the area of hypertension, where there are five. blems with this document, I had some pro I found it to be written in extremely general ter-,n@@ with very minimum attention to process. There was much repetition. -Also it referred back from one place to another, something that was allegedly covereG in an earlier section. Some important thino,-s, And I just,- when I checked back at the earlier section, I had great difficult in findinr,,. I couldn't help but get the impression they were CD trying to use all of the right words they thought would impresF people. I couldn't help but uettlncT the impression the RegionaL Advisory Group was following the lead of most people that were requesting projects and staff as well,'rather than providin(7 any direct and stroticr leadership in program develop- ment. I saw no great evidence of ,ny real central staff Involvement in a true leadership role, It may well be there, but I just wasn It able to see it. The predominant Leadership seemed to come from the chairman of R-AG. I had to base my decision on he Is-the fellow who responded to all the problems and his response seemed to me again we,s not really how to adjust to the problem or how are you wrong in bringing up the problem, but kind of why diW t you come to the meetings and if you had come to the meetin@s, you would know all of these things. 0 I could be very sympathetic with his point of view, but it didn't seem as thourh he really approached this 7roup, Now, the Regional Advisory Group has been a well- rounded compliment ornpresentation including the representa- tives of 5(b) and the l(a) agency that I could identify. One other representative of a planning group on it. It was quite obvious that they, at least at the time this document was written, they hadn't succeeded in getting compre-. hensive health planning to understand or appreciate @7ha ey thought they were trying to do. There are many letters from the planning folks that helped to bring this out. They do have a hig4 medium and low priority desig- nation or rating system for both accomplishment and for the request. But there is no su-mmtion, whatsoever, that I found. It may be there, but I didn't find it. But no infor'- w,tion whatsoever as to what kind of criteria they used for high, and low, in this area,, And i t came out that most of the ones as for as they requested were high. I think eighti out of the nine. -And as far as progress, there were five, and four or five hi@hs and four mediums. There weren't any lows. Then it referred to seven states hadpriorities whichi, I -I had one devil of a time Pinding, I finally found one tiny paragraph in the middle of a parpe in which some very YeneraL thino's were said about seven specific areas, but there weren"U-: any specific short-,term priorities or objectives by which thec.-e seven important areas could be implemented. It is a new process which involves a number of com- mittees in the RHA and says this took place over a period oi time, and I certainly read by inference that there were meet- ings, that therewas a process. But very Little information about them. While quite a bit was made of the complex of workable system of reo-lonalizatiori, the y were tryin,, to carry out complex yet worl-,able-- (inaudible) and formal network of cooperating institutions The reference to accomplishment was in very genercii termts, I gathered that,sofne of the projects which they had started they continued funding, but the extent as well as the meaningfulness of the effort.was unclear as well as it was also unclear as far as continued funding as to which areas ithis had already occurred in or which area it was hoped for. In general, I was riot impressed with the staff activ,,- ties. For example, the central staff, as far as the material that was presented, and on specific forum, it said something about the staff plans will rapidly unfold ao-ainst background C--' CD the CR,@,111's program facilities and strategy and will further see CR@@,,IP's responsibilities to emerging national priorities. This kind of lanc,,,ua@@e doesilt say very much. tD C) IJ,ateria,l reported what the staff had done. Golly: it seems to me they must have done more than they wrote down. They developed a ,7,ood staff. They achieved some alternate financinr,- of prof-,rams, staff skills, assured central direction. They did do some planning and specifically m--ntionf_-C. hypertension pror,-ra-m end they claimed more effective coopera- tion with CHP. But a@ain, the nebulousness of it all bothered me . In ratinr7, in thinking about this, fortunately Connp.cticut was not very hiuh on my list. I rated prorrra.,n leadership from poor to adequate, equally unkind to program -staff.' Regional -Advisory Group, except for the review pro- i cess, gave the saw kind of ratings for past per ormance and accomplishments, objectives and priorities, and feasibility because I couldn't tell whether these folks had any feasibility of doing what they said they were doing, because the.tliinG i that I suspect is that in complete contrast to Maine, they must be doinu some things they just did not put into the appl@i-- cation, they just must be. I rated this as a poor application and as far as funding rriechenisiii, we will r,,-et to in a moment, it seemed to me they ought to be on the very short end of any funds that M-Lc.7b.t be available and so forth. MR. PETERISON: O@cay. DR. HEUSTIS: I did -- I was disturbed. Connecticu was the first one of the five which I had that I looked at. I Yias so disturbed by it end by my reaction I guess I was disturbed by my reaction to it -- that I ,lent back anti took this sheet which we have here, this review sheet, and z;o@ of the criter-La we used, and some of the background Judy had,, made myself a chart which I endeavored to not only pick out the ;nain headiiic,@--, but every one of the subheadings c'-r' the paragraph and tried to rate these Foods fairy and poor, CD to see "even thOU2;li this was a subjective evaluation, w as there any -- were theyjust being too unkind. -And it just came out the same way. i I am sorry, but that is the way It impressed me, IC. BPRRU@IS: Doctor, Let me ask a question for clarification. Are these deficiencies you speak of, do they appear to be the end of a lack of leadership and management capability and staff? DR. HEUSTIS: Yes, sir, and the Rlll.'. Again, I hope I thorou-ialy qualified this, a LI I know Is I read. l@,M. @@TERSON: I think I would like to ask Paul, who was the other reviewer on this, if he has what he would like to add to it. I know, for example, John Hirschboeck was on a so site visit 104 years a-o in Connecticut. Paul, what do you have to add, subtract from, ;ihau you have heard Al say? DR. TESCHAN: I would like to add a couple of -- oh,, supplementary points which will not chance the basic them I CD don't think. First point Is as you read Connecticut, it is unique: in my experience, having talked to the predecessors of the present --roup also, in that its basic Philosophy says if health care is going to be approved in a state, in any region,, it is goinu to be done throu,-h primarily interinstitutional netwo@ starting from the university centers, and throuoh 0 faculty type and educational contacts in community hospitals. If health care is then going to be benefitted as individual consumers in the state receive it, it is going to b by those consumers coming to those centers influenced by this network. That is, there is virtually nothinv other than the outpatient department of the hospitals in which the full- time staff have been impressed by the prior history of Connec-I ticut R'L4P. The individual ambulatory patient is goinc- to be particularly benefitted, that is not quite true, there are exceptions. But the overall driving basic thrustthat program apparently has been monochromatic like that, at least as a fund- a.mental concept. It is quite different from ,nany other R@IP's., And I gather HaroLd, Stan Olson probably had wrestling matches on this same subject, but if anybody didn' t know that about Connecticut, that is one fundamental piece of it. Now, it followed from that that the budc-et has I certain characteristics. It follows that if you work at it you can find out of req@-.,,ested total amounts -- and my figures are a little different, they are added up a little differently,@- out of approximately, I came out with a fic,-ure of 942 000, you can find annualized rate, that is this is six times the two-month rate just to get'an annualized rate of their application. To get out of 942,000, you can find about 180,000! that appears to be outside the immediate jurisdiction, either of the CR&,P staff or of Yale, or of the Univ ersity of Connecticut. That is, how far out I don't know. I don't know whether this institute for health manpower is not a child or progeny of the universities; it may be. Could very well be. It may be the EfiS. I can't find the sponsor to be sure. It is stated as Yale University. It Is a committee of some sort that appears to be a sponsor.- I can't tell whether that is a child of the univer- sity. Otherwise, it appears all the cash is floviin@ into and through the universities and is not turning up with inde- pendent applicants or independent group. So you have to sort of figure whether you buy the philosophy and if you don't buy the philosophy, you are uphill against the X years of 167, seven years of precedents that istuation, so that is one main point. The other point is that the staff is missing a controller and is missing an evaluator. And our feeling is that those two seem to be critical. There are, you know, I raise serious question whether the staff canim-nage the busine@ of the-prooram. I would agree fully that the RAG chairman appears t( be the active person in Connecticut. Everythinom seems to hl-nr.'Te@ around him and his activity, that that CHP is a disaster obstruction. I thought whoever wrote those letters in reply cit least, among all the wordso seemed to do a professional Jo about @Lnin@-- up the facts. I aoree with your comments on the C> CD I argumentative nature of it, But there were I thought a gouu deal of professional stance., documented, and seemed to be well done. DR. HLUSTIS: CHP*9 DR. TESCHAN: No. llany of the arguments CHP brought up were after the fact, almost written in ignorance, because he was able to show in that CHP's own district CHP -nembers had been contacted. Interview indicated that. Well, comin-r out to the other end of it, there are minor differences in the rating. I felt that the feasibi lity was probably prett y high in view of a seven-year precedent that that kind of activ:@-- ty does ,iork. If I buy that, my problem is, is it a performance Does It setp up the pike? I think if you are this far down, activities are feasible, I looked at a below-averao.,e rating. However, I felt somewhere between 80 and 100 percent of the program staff f undinr, that is two-year extension and yearls extension of staflf, either somewhere between 80 to 100 percent of that was at this point a reasonable step in order to carry them throuc-h,;! a,t least to their July I application, with the contingencies that the staff positions be recruited for. And that the new application does need to be considered in terms of widened participation and initiative come in from elsewhere. I also feel the domination of university, which,obvJ.c)us- ly from every corner of the thing, the theme ought to be est,,ib@@ lished as a precedent, it ought to be undertaken, running by itself. And the application projects are primarily invoLvi-n@@ -Students of various sorts doinv primarily theoretical studies, rather tiia hav-Lng something actually happen. So I think that, you know, I would move to chan@,e the grantee and to @,et this influence totally excised Ln the course of the next little bit, and to shift this thing over to a situat4,on where other applicants will have a chance to begin to do it. 14R. PETERSON: Does that-- DR. TESCHAN: The alternative is to stop the Rilip funding, That Is possible to do. MR. BARROIIS: Do any of you fellows see any prospect, of turning this thin.@ around? CD (Lau,hter) l@. PETERSON: I wonder if I might help-- DR. TESCIIAN: Question, turning it around if you mean turning it all the way around, so that all-- BARRAIS: Even sort of in the direction DR. TESCHAN: -- all the habits of the seven years are reversed, of course, is abstllrQ, But I disagree with the notion we are dealing with a-i one-year story. I viouldn It make this suggestion if I thought this were a one-year proposition. Last year wech-alt with It as a one- to three-year proposition. I don't think that is right. MR. PETERSON: I wonder if I might do this before i I ask staff to comment, there may be one or two staff cori-Lients' then throw it'ooen for broader discussion. John, since you were on a site visit. which was made when? DR. HIRSCIIBO---CK: I think three years a-o. IAR. PETERSON: That lonc, ac.-o?@ C) Everythino- has been a year and e..-half, two years a DR. HIRCCHBOECK: I have to agree with -@iost of what Paul is saying, although I riust say the grant idea, when R.14P went into Connecticut, it had a @ood test, identifying every hospital in the schools with medical schools, so a full-time person is linked with 'Utic medical school and trial hospital, whether that is v, @iorlcn.ble thing in the United States. Whatever results have occurred will perhaps give the, ,9, n s@l er, There is something that has happened I think, but whether this is going to continue in the way that Clark orig- inally thouf--ht it was goinv to, of course$ is not the case. am par"u-'Lcula-.Ll@l impressed with the fact they stil don't have anybody in evd-tuation and their staff is lean. This is the major crit-4c i sri. This is pretty much a one-rnari show, as Dr. Clark left shortly after that. Morse is his deputy. lie has followed throu@h the sanieway. So I don't think there is much more to say. @IR. PETERSOll: Frank or Sp,-ince, are there some specific things here including the CHP which -- at least one of them 1,2. NASH:- I think that was @he major thing, CHP really yes. I,IR. COLBURN: @lith rec,-ard to the chief of staff, they are not supporting those positions any more, I think this request is to bring different chiefs into networks to exchanger DR. HIRSCIIBOECK: I might say too, there was an on_ goin@ fi@ht the medical society. I don't know how that will end. 914 PETERSON: It hasn't resulted in the same py r o t e'@, i-,. - niques, letters -- they were more adv e,need, they sent tele- gr@.ms to the National Advisory Council. Nobody has pl-iomd us yet. lvlaybe because we don't have a phone in this room, I don",t know. Paul, I think, made one important factual kind of point. 1-te are loot,,-inr here at a request which Is essentially to continue a nurnberof on-c-,,oing proc,-ran@s for just two months. DR. HEUSTI@': Just two months. l@. PETERSCP,\T: P@nd then to continu(5 somewhat expand not a great deol,core @-taff,and we will probably be taking a look at the lar@er port!-on of the picture in July. So that I think I have heard both -Al and Paul, and some of the other comments, I have phrases duan like "liot impressed, troubled, be low average rating-, short end of fundinrr, That certainly, I think we have vot a cost as to how we would look at that larger portion in July perhaps. But we are lookinr,,- at a relatively modest portion in terms of duration and amount of funding in this particular application. Other comments, observations? DR. TESC@N: That su--estion is to fill those vaca n- cies. I think theevaluator has to be in there. That is ti-ic- point. I like the idea they have had the evaluator separate 95 from the planner inthe staff. lai. NASH: Dr. Shan--- I thin[,- this is probably Dr. Clark's evaluation on evaluation. He didn't want a sinc,,Ie individual on his program staff to have ttat responsibility. I don't know if this comes through in his applica- tion, but he relied very heavily on the procram planning, program setting, prioritizing, evaluation of activities, on a review evaluation committee. I think another stp,.ter-,--nt should be made about t@ii si .reo-ion, they are to be processed, certified by RI@IP. The basic reason is the staff aswell as previous site visits, almost everyone who reviewed the program agrees the evaluation conlmi-ttee in Connecticut has done in the past and appears to still be doing those fucntions that we feel nal advisory group should be doing. a regio For that reason they have been so advised of this, c--,- withheld their due process for that reason. DR. TESCHIN: I think you know my reaction to that'. would be that funding becontino-ent on getting that squared C> away. I-IR. NASH: It concerns me a little bit because-- I certainly understand the concerns of this review crour, here because we have them also, but if you look at the current application onthe one hand and try to take action based on tri@s application to ,nake seven years' history in that rer-ion, thi, :7u would present me a problem, perhaps Dr. 14cCall one, if this ic@ what the group wants to recommend, I would think the July application might be a better place-- DR. TESCHAN: I think if'it were approved In July, if we'vere to look at the ConnecticQt application, and recom- mend fQndincT that sho% the ramifications and other issues turni.nc, up, I think the rqessa@e would be spelled ouu- in dol- lars, spell it out. l@4R. NASH: Yes. l@IR. PETERSON: Any other comments, observations? DR. HEUSTIS: Is my arithmetic incorrect there was a 50 percent increase i-ti.the money, ona pro rated basis, re- -questeo for the central staff? MR. PETERSON: I will have to ask Frank or-- DR. HEUSTIC,: Evaluator -LPor those two important positions,I 'wonder what the dollar may be. They may well ha,,7e@ made a data-- DR. TESCHAN: I don't have the data. DR. HESS: Is the funding sheet available, printouts MR. PETERSON: I thou--ht you were goinD, to ask a question about what was the arithmetic really added up to? I was reminded of 1-4ark TwE),in's man who only spelled a word one way, DR. HEUSTIS: So six months award "k@168,000, one which at least according to my yea,r request for '@")1179)OOOP arj-thrac tic is three times that, or 50 percent. MR. PETERS01i: It doesn't seem right just look'nf-, at it, el-fht to twelve kind of junk, but I must say am not that familiar with the figure. DR. HEU@@TIS: Maybe there are other factors in this,l I have no breakdown than the total amount. I,ffi. B.ARRi3TS: On this sheet you show $297,000 for six months. YiR. PETERSON. I have tha.t sheet, toQ I,IR. BARFC@,,'S: As compared with what we are asking for 395-4790. DE. HEUSTIS: I have-@158,000 for six months. @IR. BARRU-I.S: Summary proo.ra.m to date. I,IR . C 0 LB U,-RN I know one problem. One of the incre@ce 'in prorpram staff is due to the fact DIIS activity was funded out of pro,-,ram staff, rather then a separate project. Tha.t.is what it is. Staffin- pattern is consistent with what it has been for seven years. DR. HEUSTIS: Okay. Can so= approach be made as fee, as the-AMS--DMS to limit that for two months also. MR.. C OLBURN: I think ltis beinu done. CD DR. TEL,C@N: It is a ti-io-month f in, ure. DR. HEUSTIS: I am lookin--r on page 3. I see the 158 OC)O. MR. COLBURN: P,-nge 3.9 DR. HEUSTIS: Fare 3, bottom of the paoe, "'158,000 for six months. Next to the last line above the total. And 'I'@,'479,000 for the full year. M. COLBURN: Yes. DR. HEU,13TIS: 159,000 times three is three undred times almost I","479,000. MR. COLBURN: Oh, this request is for 14 months and for projects for two months. In other words, take program staff throuo,,h "'I)675,000 through June 19'T@ PETERSON: How could it be-- COLBURN: @@uestion of requested support for staff throu h June L971.; and projects throuc,,h.August L, 19"4. DR. HEUSTI'@: But the -staff starts first of June 19-i-"'* 14R. COLBUs-"dl: It would be 12 months then, 12 months staff, two months for projects. DR. HEUSTIS: Something we don't have to worry about. I have concern about 'Lt. DR. TEr@-CHAN: Do it ric-ht. PETERS014: Yes. We always seem to be embarrassed by nu,-nber.@.. Whether it is the @,laryLand lottery or what have you, it is never the ri,-Iit one. Given the nature of this application, which is for program staff for 12 additional months, but the limited n urit e r of on-@-o@Lnc,- projects for only two months, thus totgllno, )637,000 volume, does anyone have a recommendation as to e,,,no unt either of the reviewers or someone else? DR. HEU'@"TIS: Would you care to commit yourself? DR. 'LESCHAN: Sure. I move to fund either between 80 and 100 o--rcent of the amount requested;i namely, 80 to 100 percent of $6j6,220, with hopefully the conveying to-- perhaps it is too late to convey to the group concernitl@- .their July I application the concerns we have about it. DR. HEUSTIS: Do you feel stronvly about the 80 to 100? What about 80? DR. TE.SCHliN: I would be perLectl.y happy with 80 percent. DR. HEUSTIS: I can support 80. I would have trouble with 80 to ioo. DR. TESCHAN: The only reason for the latitude, I kn@," it Is slightly hypothetical a situation. The other feature, if the funding doesn't have all the money needed to get these people for-- Ifeel the salary level,5 I think hypothetical DR. HESSL: They certainly have the option within tl-,e:. total funding p,.3,clcac,-e to reallocate. 'DR. TESCIIAN: So 80 percent is fine. @IR. PETERSON: 80 percent If any arithmetic is wort'Ll a dime, is about -,')509,000. Somebody had better check me, on that. DR. HEUc,-TIS: Did- you,, make a@ @,motion? DR. TEZ")C.L@N: Yes, I move 80 percent fund of the request for a month. l@. PFTER.SOli: We will say '@,')510,000. DR. HESS: That is somewhat low. IvM. PETERSON: Your feeling is that is low? That is a recommendation. DR. HESS: That sounds Less than 80 percent.. I am auestionLng the arithmetic. DR. TEQ-CHA-N: @@)508,000. DR. HESS: You dropped it by one-sixth9, DR. TESCIVN: it would be a fifth. DR. HESS: Olmy, I guess that is right. MR. PETFJ@@@@'ON: Is my arithmetic at fault? DR. HEUSTIS: No. DR. THUR.@,,IAN: Second. DR. McCA LL: Second thin,-, you have clone right. 1,R. PETERSON: Was that a second? DR. THUR.,4AN. Yes. YiR. PETERSON: Is there any other comments, discus- sion, with respect to Connecticut? to provide funding, We have a motion and a second i)500,000 -- @10,000 for this particular application, recoc.-niz-,n.--, that a major additional amount, if I can read, nearly '@42 is anticipated in the July action, so we are dealing with t he tail of the doov at this juncture. If there is no further discussion let's call the question. Those in favor of the recommended amount? (Show of hands) 14R. PETERSON: Unanimity. Okay, there is no need to ask about those who are i against or thos e who are abstaining. 14R. B'@Rr%G,,IS: A@ in, in order to save a lot of extra!; work on their part and acony on our part, it would be approp- riate to tell them this future discussion would be contingent on chant7e in direction. DR. HESS: Not change in direction. All they can do is be niore selective than they might have been in what theyi submit, because they have to submit what is already piped. One of the things so amusing about this discussion we have two new reviewers who hadn't reviewed this re@ion be- fore, they come up basically with the same answers I have i heard,twice) maybe three times. There have been strong messages, including special site visits of that region, tryin C) to turn them arounad, and it goes on and on, The comments, trying to turn this around one year, before, you end up funding is totally out. ALL you can do is cut off disapproval to-- DR. HEUSTIS: Help[hase out. DR. HESS: Help them phase out. Evaluation. You are not going to get evaluation that rqeans any- thing in one year. MR. PETERSON: What gather Joe izsa-ying, we are still continuing to send a. message of essentially the same kind. DR. HESS: Yes, Thumbing your nose in a sense, aLl direct.',.on they have gotten from the review committee, Council,@ staff, all the way down the line. DR. FEUSTIS: Still give them 80 to 100 percent. 14R. B-ARRGI,,15: Pete, how do you answer a phone when Senator Ribicoff calls up? I,[R. PETER SON: Careful Ly and courteous ly (Laughter) I have never had a call from, Senator Ribicoff or the other 99 members of the U.S. Senate, Tha-t doesn't Mc-an they don't call. MR. NliSH: Their staffs do, I wamt to assure you. MR. PETERSON: See, Frank c,-ets those calls. I suppose he at least starts where I do, courteously. DR. HEUSTIST. Is it possible, parenthetically ma@y'! I speak off the record for a moment? 1,M. PETERSON: Yes, off the record. .(Discussion off the record.) IIIR. PETERSON: I don't think in most rec,,i-ons the flack we have had in years past has riot been essentially fromi a Con,@.ression al delegation, although there have been exceptic'@zs to that. That hasn't been a major problem on a re@ion basis. C:) I think we are at another juncture we have to make -one of those crucial decisions. We can go on with another region and if so, we are probably goinr.r- to miss coffee. The cafeteria is operated around here for the benefit of what, I am not sure whom, help or customers, closes at three. We can take a, quick ten-minute break, butI thi rk it would have to be a quick break. I hear one vote. MR. 14ASH: Two votes. MR. PETERSON: Ten minutes which would mean 2:35. Okay. (@Thereupon, a short recess was taken.) MR. PETERSON: We are mis,-,inc, Bill Thurman of the group. Because I haven't had a chance to check with Bill we still will have t-i-ne for H.-@iaii if Bill wasn't really prepared. With him not in the room, since he is one of the revewers, at7ain to extemporize, perhaps we might pick on Central New Yorko which you indicated, Joe, you were prepared to address, and then we will pick up on Haiqaii after that. I that way we will take care of one of your additional recion,@: Charlie, Central New York. CE-i,4'TRAL IM@4 YOR@ DR. McCALL: Yes. 1,M. PETERSON,: I will Let you sort of be the second reviewer on that. Let's pick up on Central New York, then. Dr. Hess and Dr. McCall are the reviewers. I will let you lead off, Joe. Central New York, Syracuse. DR. HESS: First just some uenerat consents, I had some difficulty setting a very good feel for this proc-re,,,n from the application, and I have hadno prior personal history on the basis of site visit or having been in a primary or secondary reviewer on this region. I do have so-@ie vague recollections being in some di,.:@@7 cussions, but those are not of much value at this point. But 'what I would like to do is just go over and coal raent and convey, summarize for the corffqittee's information what I have been able to abstract from information available, and then have this supplemented by Stolov who is familiar with the region, First, in terms of program leadership, I --ort of get a rftixed feeling here, on the one hand, the application indi- cates how active the RAG has been. The number of meetings, something like 15 meetings of IU.G in 12 months, and the PJ-IG members of the RAG have been on the review committee and inti-i m,,-itely involved with reviewing projects and this- t@rpe of thir,@,io So I think one can say that assuming this Is true, that the WG has been speiiclit-ir,, a lot of time on Central New CD York activities, and it is stated that they reef--firmed the-,@r goals and priorities. However, I did not find in this particular application their goal statement. They do talk about major thrust which I would infer are similar to goals, at least they have stated certain direct tions they plan to follow DR. licCALL: Health resources, planning, rer.7ionali- zation, and primary care. DR. HESS: Yes. So that there is that incongruity the goals and priorities I do not find to use,as a yardstick to measure some of the other things here. They indicated in an area they have given due con- siderati-on to that. The program staff is quite small. At the present time there are five fuLL-ti,,ne professionals, one part-time professional. They propose to @o up to eir-ht, eight full- time Professional and one part-t2Lme plus four other personnel. So it is a relatively staff. I would gather -Lrom some of the background inform tion, howeverp that the management skills of this staff leave 6-oriethinr,.to be desiredo that there have been concerns con- veyed to the staff from Council and from central RMP staff that ha,ve Iguess to say mi ldly if not been completely acted upon or accepted, and perhaps someone, Mr. StoLov can fill us in on that. I mentioned the Rer.,Iional Advisory Group. They ha,vei had goals and oriorities and the listing of projects, priority, rankings have been @iven included in the application, but hc;i that fits with their overall priorities I can't determine. Now, on terms of past performance end accomplishments, their report Indicates some thinf,-s which to we are quite exc I t I n6 For exz),mp le @ le t me j us t read a paragra ph, or two here. "In the north area of the re,@ion,"that to me Indicated if they can take a major credit for it, I would consider it a rather substantial accoiiioli-shment. The report states: "As n, result of our efforts and cooperation with health care institutions and citizens groups over 60 doctors have come into the area, within the Last tiio years, This is more than 25 percent of the total number of doctors practicing in this area,,, prior to our effort. Success- ful physician recruitment can be attributed to our widespread thrust." Then they list ten different activities in whichthe R14P enr,-aged in that area,, which they believed were related, and somewhat instrumental in attracting the 60 new physicians into the area. I will just indicate one of these is a series of @iel@L baby clinic3developed by citizens group using professionals whose time is donated by institutions. From one 1972, the operation has expanded to fifteen clinics in April 1974. @o in this area, in particular, it seems they have a re- marl,,,able accomplishment. They have a, number of activities In the area of pri- mary care and in health education net@ior@ they have actively been involved Ln EI,7iS development in the region and so on. So that I think there q..re a number of prograrimic plt,,12- es -'L,,i terms of accomplishments that they deserve credit for.1 I have gpoKen about the objectives and priorities. The proposal, I have had a little difficulty relatitir,., to i specifically the proposal, the projects to well, as I rqen- tioned, there are no objectives, priorities; there is the provrar=ic thrust. But I would gather most of those program- ric thrusts are core staff activities rather than project related e,c t 2L v 1 tLes The feasibility, I have some difficulty judging that! one. Their past performance has been reasonably good. I would think that in these types of thinrrs they have done previously, coordination, organization type of things, that you I-.now they have got a pretty good track record and probably' is feasible. asonably good The CHP relationships appear to be re although it is indicated that due to the time constraints, that all these have not been specifically reviewed by CHP prior to submission, aLtho@h there was some indication there, have been some telephone contacts, some effort at liaison with CIIP during the time available. 14y overall assessment of the program was that iu is-I I would rank it in averarye category with some pluses and some minuses, the pLuses in terms of some of the thinus they have i been able to accomplish, the minuses mainly being in the I management area which in part I think is reflected by the mture of the proposal, the way the proposal is put together and or@anized. I sort of had the feeling perhaps they may be a, some@- what better program than the proposal reflects and I am not sure, But a-s I indicated, I am impressed with some of the things that they had done and they are reportin@- on. So per,-.@,-@ I can stop there. lv2. PETERSON: Okay, Charlie, you were the other reviewer on this one, DR. 14cCALL: All right, sir. Just a few comments to basically agree ,4ith Dr. li-.ss'@ evaluation. There is a tone in the rather poorly put too-ether proposal, optimism end enthusiasm, which I think most of us I-"- to see, that you couldn't tell from this application how %q.2LL and he founded that optimism end enthusiasm were, however has already alluded to, the small staff in spite of m@i r,@ y projects, multiple activities, without goals projected. It'is afragr.,iented programs doesn't hang together well. But it's accomplished in sort of a short-gun way many things, but with the multiple activities related to small staff It docc raise serious question of capability of monitoring such diffu&e activity and fiscaL management thereof. One place in our evaluation Dr. Hess and I.differed, I checked de--ree of CIIP. relationship. Nothing from the CIIP In here. Application says what the process is, but the only thing we are asking for here is really a, continuing application. They really aren It re- viewed now, but some 84 proposals are to be reviewed by CHJI, So I felt that I couldn't really say that that was plus or minus at this particular point. And last question, they have the arthritis prooosa"- This is legitir in here. .ate, I suppose, as a continuation project. Jerry can tell us whether that creates any problems. @IR. PETERSON: Okay. Do you have any sort of sum- mery, one word, one phrase impression oL' the region, Charlie? Yours was sort of average, some pluses,.some minuses'7, DR. HESS: Yes. DR. McCfi LL:I also had him as an average region, i, almost exactly. I think, we would have the same pluses a.nd @ninuses. BA@qaIS: Before we get around to numbers, nia y I ask, budc-et 100 -- 20 percent, "'L47,000; E14S radio conmuni cations. Is that the purchase of equipment or is that sorpethin--- else? MR. P.FTERSON: Jerry, would you react first to the arthritis point? l@,IR. 5TOLOV: -As far as I know, the only project we felt did not get CHP comment was the hypertension to'some .time constraints up there. -As the arthritis, I have not been in contact with the-P,rthrit'Ls Review Group. They are t,?,kinu into considera- tions whether or not CHP did respond to it and they wil 1, through their own m@edhani2, ,iies2aoe to Council or others, will let us know whether (b) contents were missed. But the only project that hasn't been seen or reviewed in the rc@gion was the hypertension project. As to the EL@LS, the EMS we put in the items to be looked at in terms ol' only the mobile units were not cart of the rCCIL,.est, and interestingly enou-h, the RAG looked at the CD r,iobileunit almost as a, -second project and rated that low, but gave the Bay stations a higher priority, as you see in their application. This was a tarr-on throu h local pressure, to the F,,IS@ council,-, which they are supporting. So total EMS is not just equipment, but to continue their EMS councils and also to go to complete the base station network, but they slipped in the mobile units to Let Washington make the decision. This Is the way I interpreted it. MR. PETERSON: How much of that particular "'147,000 is mobile units hard@,iare? MR. @TOLOV: @6360150. One point not mentioned, which is a plus, is this is based on local rnat-chinr,-. Very stron- point for the rbo-i.on, th ir equipment was locally rnatched. DR. HES@@: BrincoD,ing in outside funds, much of this is shared funding. -And they have had a@ pretty good record of-- well, they have listed o, nu,,-.qber of activities, they have started, which are now phese(3 out as far as RI,IP funds were ed, so they do have a Food record, of gettinrr thinrs concern CD started, or@-anized, goinr, and findin.- other fundin sources, I think they certainly deserve credit for that. MR. BA@qC?,,[S: is that outside support for this ,$147,000 raobile unit and so on? MR. STOLOV: What was your question? Was there outside support? 50 percent matching on form 16. MR. NAL@IH: What they did, Mr. Barrows, the first part of the Z@,IS activity they o,rpreecl with the hospitals @n the area to purchase half or pay half of the costs of com- munications equipment if the hospitals would put up the other I 17,a If Now, they are proposing I think to do essentially the I thing on this. 14R. P.LTERr-'Oli: ocaL funding in the Q300,000 Plus, I vih6le conjury of El@,,IS activities. What we have hereof course, is an application which is lar,),ely continuation, thatriay be a Little misLeadinc-,,. There are only a couple of small new projects. We have an tppLication with just a very nou 800 snia II a@ ,OOO nt ol new act vity. '@bni-- of the continuation, I think it is particularly true of the Ei','IS, is continuation at an expanded level of fund@ in@. You w@i 11 note from your table that we, have an estimate t;!,-i CD CentraL New York is @oinc- to core to us in July with like -,I lion dollars plus in new activities, while they are requesting now roughly -- not quite q.')800,000 against a tarvel-a, overall target figure of rou-hly a@'ain c3, million dollars. Were there any other thinc-,so Jerry or Frank, of sir,-ni.f-'Lcance, policy issues, ,najor problems or other thin@s we want to point out to the @roL@,p? IIR. STOLOV: By and large, the CHP relationships he.e been -ood. In fact,they are the subcontractors to the E14S councils. Again, the hypertension was an oversight. We don It know the arthritis. As to the ,nanal,@,ement assessment, the gentleman LLD I who prep,-,,red the report is away doing other management assess-i ra(@nt to d,,,y. @le have only received a brief feedback on it. YR. HASH: Do you have -,ny general ideas? SIMO@TDS: Didn't even talk to him about it. Nothin- about it. 14R. STOLOV: It appears the fiscal management end wa considered much improved or found satisfactory upon review. There were other mriavement problems related pos- sibly to how the director conducts his business., et cetera, but the major thin,, we did want him to focus in on was the L3 f i-scal aspect. There is just one other thing. Goals, objectives, and priorities were forwarded to the region throu,-,h the las letter from council as not being syste.,n@,tLeaLly identified. Based on that we do have that and the Director, his onsl,,,er to this was that he put staff on to do modified review process, rather than redes-'-Lr,-,n his goals, objectives and priorities. So that is where It stands now. He still has not, '@-o the best of our satisfaction -- or my satisfaction -- changed the g6als, objectives and priorities, but at the @ar,,e time h does address it in his project. I-IR, PETERSON: -Are there any other comments, objec-@ tions, observations from the review panel members? I,R BARRA@TS: I would like to ask one. If in the li"ht of the relatively modest ratinc- thi-,r-,, program has come up with, if we were to scale back there with a reOLl-@est here, would it have any wholesome effect on riakitio., them a little more selective or i Little sharper on their riev,, i project applications? DR. McC.ALL: They are going to have to be fairly Selective, they indicate they have 8LI-- IIARRO@TS: They are goinT to ask for another 800., liM. PETERSOII: They a,re cominc- in with astatement of mi I I'@on. You know , this may have changed. Obviously I .it has if you loot,, at the EMS. Qne of the recent character- istics OL, Central New York was that it tended to have 4 lot of small -Lnvitational contract type proposals, you know -- Q5,000, ,@10,000, @25,000. So that 84 may not add up to, you know much more than a million dollars. I don't know, but that cerli, ta.!-nly was true in the recent past. STOLOV: I think it was million, adds up to about ,nilll-on now. We estimate about c), million. I ean't ,,nswer your questJ.on. I think the review committee has to further discuss it* 1,M. PL,'TMSON: I think what we are'faced with in many cases here certainly is -Lor all practical purposes thin-s are in the pipeli ne and movinr,- out there and may not have had final ILAG action, but nothing we do or -zay by and Large in tey,,-s of July applications, if I got on the phone with the Senato" from l@ew York this evening, which I am not about to do, arc CD we h,3d something very definite to tell Central New York or any other region, I think the timing is such that the cast ol' application we are going to see in July is pretty well set. DR. l@eC A LL: Simply Idon't know how, many dollars, 'vi ewould limit the number you could fund and Limit the number of activities that would be monitored satisfactorily. DR. HES'-O': They Haiti already, if their performance on the july application is the same as they will already .have prioritized those project applications so,wher, decision is made, they will already have the framework for rating their,' decisions about which -et funded c,,,nd which don't. So in that sense they are well organized and prepared. I,IR. PETMISON: -And the group in that sense would have sc>.@pe rou--h notion that if you gave them 50 or t@)O or go percent of the request, how that would fall out, rou@hLy. DR. HESS: Yes. 01-i@ MR. BARR(7vl@@- But giving t,@em,,say, @700POO or @800, they are askin@ for now wouldn't whet theLr appetite for the remainder. M. PE@TERSON: I can't answer that, DE. HESS: I would like to get to a recommendation, i MR. PETERSON: Certainly. DR. HESS: In goin@ over the applications, it se-...- to rcie I could pick out well, approximately $180,000 worth of applications that most of which are low priority on their list and which would not do great damage to the program in '@;200,000 more than my estimation. And would still give them the" are currently operating on and there is another batch y coming down the pike for July, and would require them to be selective -- for this batch -- and then we can further exercise some selective advice via funclina, Level In the Jul y batch, I think that would-- you know, we can deal with them in a fairly what I would consider fairly even-handed and equitable fashion. So I would like to recommend "@'615,POO for this particular package. DR. TESCHI@.N: Second. l@IR, PETERSON: @")615,000 against the request of not i quite $800,000 at thl-- juncture. DR. IIESS: That's right. D R . C f@, L Li was going to say recommend @Q@6oo,ooo. DR. HEULTIS: I will support his. Maine was the same, MR, PETERSON: Did I hear a, second? DR. TE'@-CMN: Second. IvM. PETERSON: Okay. We have a motion and a second. Is there any more discussion or comment with respect to Central New York? If not, those in favor? (L'how of hands) 1,M. P.-LTERSO'ii: -A@ain, I think I see unanimity. Okay. I think we are again doing reasonably well not very good circumstances. 'Would like to, because we have spent all of our time thus far with rer.7ions that are at least for our adminis- tra'tive purposes in the Easterit Operations Branch or Desk, I would like to switch our focus, if you can, for a moment D'c ros3 'he continent end take up at least one or two regions @out of the.Western Branch. I couldn't Set much farther away. I thou-ht we would try Hawaii for starters. John and Bill Thurr,,i-an are the reviewers on that, I rairht ask you to Icicl,, off on that, John. I believe, you were on the site v,.sit out to Hawaii. DR. HIR.@C.IiBOBCK: Yes. @IR. PETERS014: You have lost ,,rour tan I see. That was sufficiently lonr,- ago. DR. HIR"';CHBOECK: Yes. Thatzs January. Well, the rec-ionaL medical probram of Hawaii, as I CD review this application and read correspondence of what has @ppened since our visit, I am pleased in the very positive cher,,-e of direction and ini;,)roveiiient in the affairs of the program there. So although the history has been turbulent-in the past, it seems there is some opportunity now to see some pro- gress bein,-,- made with new leadershi P.D The present coordinator, Sg,toru IzutsLi, was a coordi-L-,-@-- tor for the E'acific BC-Is,-n Program. He is now, since fle,y Ist, coordinator of the Hawaii. The staff is quite stable. There have been no serious departure as a result of phaseout activity. Staff is presently full-tinio equivalents of 1575 with proposed expansion. The question of proo-rani leadership I think is now -or seems to have somewhat resolved in that the coordinat taken over,well -- certainly t@ way the application was put together, If this is an example of his ability to take over, think this Is one evidence. There is a new rate chairman and the relationship of the grantee agency apparently has also been approved. It seems to be a criticism a small clique was operating the re-iont).l rxdical program of 11,3,waii and I think this is pretty well cc.-one now with these changes. fis far as the program staff is concerned, it is a reasonably good staff. They have an economist there who eve n as a result of the visit I wa.sn't quite clear in my own mind just what his role was other than perhaps work in the problem of cost control. The rest of the staff had strong community interest and certainly the man involved in char-e of the Pacific BasLn now seemed to have everything well In hand to take over -the responsibility. The local involvement of the staff I,,ith other agenciel-@ seems to be quite evident. This is not ,,n ivory toiqer stafL'. They seem to be involved l@n many, many thing--, Re,@iona-1 -Advi----ory Group hasn't changed very mulc'n CD since its inception until recently. It's I think n-n average Lonp-I advisory r-roup reg, -s I know them. Review evaluation of projects was carried on with a ii L ation C-01'17. special committee or project implementation and evaLu mittee. This seems to be done almost apparent from the Rer,-ional Advisory Group. Past performance and accomplishments, program has had its troubles. It perhaps has not risen to the challenge of rrreat opportunities that presents itself In this far-flun,,,r, pro-ram, where innovative ideas may have been experirrie nted with. It has been using more traditional approaches to ,nony hea,lth care serv5-ces, and much of this, of course, is right viel-iin Ilawail itself. Only recently, according to the applications that are in this particular package, has there been a great spurt of projects for the Pacific Basin; the new projects are being proposed for the Pacific Basin. Truly not great in dollar 9,niount, but they are for the 'benefit of specific I peopLe* The objectives in priorities-are, again, as I -said, rather traditional and we think there micht be others they could come up with as a result of the opportunities, increase in medi-ot-il program. They are fairly, fairly rational. I will read SOI"le of the@n; Encoure e innovative arrangements for organization of health services, methods of financing, reduce unnecessary duplication of health resources, encourage improved produ,.ctiv@;t,,.- CD of individuals and organizations, and so on. The proposal itself is for the continuation of some on-@oinL@, projects that were started this year, and a nu,,nber of@ new projects. They intend to have substantial package in for the July lst review. .As to thejbasibility cf this particular program carrying out its program functions, likelihood of proc.,,oer,@ty, @i progres I thi nk under tie new - leadersiai P we w I I 1 have a chatit,,a to see whether there will be improvements. I think that in general thin--7s look pretty optimistic LD compared to what they were before. CHP rele,tions@ips,certainly here is an area of great improvement. This is evident in the application. Underi the old re-ime the relationship with the CHP, H&-C, was almost nonexistent, althou.@h the director of the CHP was a member of the advisory c,-roup, yet collaboration at a working level -wa@@ apparently not very evident. And now I notice in the application that there-is active criticism and comment about the various projects that have been proposed in this particular application. The whole problem of CHP in the Pa-cificB-asin is an unknown quantity as far as I am concerned and there is only one (b) agency in Hawaiian Islands itself, so that It is a ver, unusual type of situation to deal with, although this is a very a,etive CliP ao-ency at the so-called state level, My overall assessment. is I would say avere,@e with possible imorovement in the near future as a result of the chanr-e in management direction. IvM. PETERSO'Lll: Thank you, John. I wonder, because of the'lonr,, history of Hawaii, the,i kind of problems that we has had there, I had intended, in spite of my best intentions, had for"otten, I had intended to CD depart on this one from our for-@t and idas c-,oing to ask Dick Russell initially to fill you in, because there have been 20 many developments literally within the Last few months, And if you have no objections, Bill, I will try and make that ha,lf good and ask Dick to perhaps fill In some of the background very quickly as it relates to Hawaii and the developments literally of the past tvio, three, or four months since the new coordinator come on April 1, I think it was, rather than I,,Io-,y 1. It is a matter of months in any case, Dick. RUSSELL: I think Dr. Hirschbo--ck has covereu some of the points very well. I would like to say that this particular q,pplication', was put to,-ether under the direction of the dept.ity prior to i Dr. Izutsu assLLnin-. coordinatorship. Unfortunately the deputy -s still operatinc- un er e old philosophy that anythin@- was fair. There is goinE to be a' lot of money. He still hadn't gotten the message about what the problem had been with the pro@ra,m -- he has it now. The Regional -Advisory Group has not yet come to the maturity of setting priorities. This has been done bya small groups planninF,-Impleraentation-evaluation committee. I think they try to do a c,-ood job, but it is all on a, personate CD criteria. In view of the s, Dr. IL'zutsu 'Ls now orienting RegionaL -Advisory Group, new mei@ei,s as well as t@-e OIL! raeniber@,-, and at their June -- I think It is June 23rd meeting, they are -oiiig to reset priorities. I think 35 letters of intent they have now that wilil probably come in as projects as well as those projects in thi@-@ application. In other words, by that time he hopes to get some sort of system where the Re@ional -Advisory Groupvil.11 in an .ob-'ective manner seu- priorities. I was in Hawaii for a week wi-th Dr. Izutsu, a rLd is a completely new program, no dodot about it. @adersh-I p here is unbelievable. He has iiliip@occl the staff into shape. They are part-@@-cipatinrr sh,@ritl,-, information which before the inforr,,,.a'- CD L) tion was not shared with icey staff nor was it shared with the Re,.@ioriaL -Advisory Group, It was a cl!qL-,,e, no doubt about tha' L, The RPG has been revamped. Dr. Izutsu has gone bacl,@ to our advice Letter, which came out of the November 1973 visit. ldr. Barrows was on it. lie has gone back -- Dr. Hirsc@'boeck had a. copy of a progress reoort, All I can say is what he says -Ln there is indeed fact. The Hawaii ',L,Iedical Association is now very wiLLLn,-,,,i to be involved in the pro-r@n-m in view of the absence of the former coordinator. The University of Hawaii School of 1,;Iedici.ne, Dr. Ro-ers is very much Interested in being involved now as well as Mr. Michael, dean of the School of Public Health. CHP relations, night end day, it is really great* The co,,nmunity's image to the RMP has changed in the six.or seven weeks -- he tells the same story to everybody and that is a rarity in that RMP. We have just recently, as was noted in the summary here -- there is a duplication between trust territory, cerebral cancer projects, and one taab has been submitted to NCI. I worked with NCI staff. TICI staff is in touch with Dr. Izutsu.1 in with NCI, and thi .P,nd he is plu c-in@ the trust territory aga .;s is the type of-- he is really the Rl,(iP, now has become fecilita-I tor which it has not been all these years. He is having meetincps between hospitals -- hospitals never met before be- cause nobody ever called them together. Tlaereis a -,rantee relationship with relation'to EL,.IP that's very good. @le had some concerns because the execu- tive director of the Research Corporation of Hawaii was what do you call it -- proctor? Dr. Izutsu, soffe were con- cerned there might be this type of influence on Dr. Izutsu, I sat in a iieetin@ between these two -nen. Dr. Izutsu gave it straight from the shoulder with the grantee as with anybody. It is unbelievable what he has done. There are some weak spots In the staff. Dr. I Izutsu in seven weeks hasn't had time to cure all of the ills of the past, but no doubt in my mind he will. DE. TELIJCHAN: lfhet is the population? IvE. RUSSELL: Of Ha@iaii? DR. TESCH-AN: Of the re-ion. MR. RUS,','E LL: 100,000 in Hai-i a i. i 14R. PETERSON: 100,000? I think it is over a mil- lion in the Island of Honolulu. 14R. RUSSELL: 800,000 in Honolulu2 II:R. -@2ETERS014: Ancl trust territory. And all that c- r e e, t b ic,, expense of blue water doesnlt7 add a heck of a -lot, I im-3,(@-ine a million when you add sand crabs -- we spent occasional beer-drinkinr sessions in 1945. There may be people there now, weren't many then. i I'M. RUSSELL: Not @olny people, but it is a 3 million so,uare mile area. 14R. PETERSON: Sister Ann, who often thinks ttn distances comin@, from the west, l@'laine, Utah, and even -Alaska I think, pale by comparison to what in one sense is the turf c;: the geography of the Hawaii R"i'4p. Bill, you were the other reviewer on this, I wonder@@ what you have in the way of addition-,I rel@n-Lorcing/sub- tractinv'kind of comments, both to what Dr. Hirschboeck and Dick have mentioned? DR. THURIIAN: There are two points that have co.-,,ic. 7- three points I would rflakep and that is cOM- over here, munica 1. tion situation) I)J-ck.has discussed, is very obvious ople and they recognize they have not really talked to pe Iam sure they will take care of it. They still donl.t understand the priorities. They a,re ill defined and they are working on that, I think the last thin g thatdisturbs you about the thing, all of us knew this before from when Len, Shirlis and others went to Haviaii, was when projects terminated, no- thing ever happened from then on, you know. o hid,-.- ever came of the projects that were funded in the past. Pndt think that is going to be the real thing here, Really it depends on whether or not they develop some llqiiali projects. if they can't develop Hawaii projects, this is goin-,, to be still not a c--ood program. ,Almost everything they have put In there is basic. MR. RUSSELL: I did just get the minutes of the plan- ning-impleraentation-evaluat-'Lon con-nittee, what point they are screening -- last eieek they were letters of intent. Here one hears comments, we will consider this if these three letters of intent are taken, worked together, as c@ sin le project. So this type of thing is occurring, You know, herep again, when we talk about unified health planning, that Hawaii of all the states, because of I geography, is in excellent position to pull the resources together and work together. I think this is the type of direc@ tion Dr. Izutsu is going to give the program. MR. PETERSON: IvLr. Barrows, I didn'trealize you had been on the site visit. MR. BARRA-IS: I was. As these fellows found it, I found it completely fascinating, positive sure for me-. The pro-ram is hard to compare with the ones we are ,--customed to first in terms of geography, when you start thinki .ing a-bout the Pacific Basin. AsI recall, it is somth,-nE like-! seven hours flight time to c,-et to the nearest point fropi- HonoLulu, -ind so you can't be making daily calls-- the Pacific we are famil Basin is terribly tough from ,,nythinEr iar with econor@u.cally and socially. Therefore for health resourcesit is almost wholly dependent on government operations. There is no private, to provide health care. It is quite unique in that respect. Back into Hai.,,ali itself, the islands are physically sep,o.rted, which poses some problems for the" You can't have i ambulances shuttlinr,- back end fort4 that kind of thing. And then on top of all of this@ their social attitudes still reflect considerable Oriental influence, and they look at thin,-s a Little differently than the way they do in Chice,@o. C) Maybe t'@iey shouldn't under our creed, but it just happens to be.'. that way. So I think when you look at Hawaii, youhave got to i look at that qs this Is a unique -- judge on Its own merits ,.nci not necessarily compare it. MR. PETERSON: Any comments from the other reviewers, DR. HEUSTIS: Has the word got to the new &Cminis- tration about the great opportunity that, Dr. Hirschboeck mentioned for innovation on the,part the staff had raised, here is a real fertile field2 I a,,-a tftinkingttiatyou had such a thing off.tfte boast@ -of Maine, not 7 miles away but shorter distance, they put a, nurse with a television connecting herto the mainland, -thinf,@-S. like this, where she can Teta less well trained person can get consultation. Has li@-waii thou ht of anything like this? Can they be stimulated to do-- 14R. RUSSELL: We a,re talkinrr about two programs; we talkin,-, about the proLrram In the State of Hawaii, we are also talking about the second program which is the PacificBesin, So Ihave to ask,.you kno'wl-- DR. HEUSTIS: I just understood from comments, I had not read -- the comments about the vreet opportunity for C) innovation apparentlyfcom the standpoint at least I heard the reviewer saying was not exploited taken advantage of, capitalized on. DR. THUR14AN: I think my answer for that would be yes, In the pro,-,ress report the new man has just forwarded, he aees what has been talked about over and over age-in. lind II think fromthe way he writes, he has got the moxy to pull it of@'o DR. HEUSTIS: Okay. DR, THUPIMN: He understands what you are saying and wha,t we have said in the'past about 'It. So I would feel comfortable, he may a,-et egg on his face but Ithink he knows a,re talkin- about, ye.S. what we DR. F@USTI.S: Just corollary, does he need'support -from us, help getting the egg on his facb? DR. TIIUR,';'.4 I think Mr. Russell is providing that support In a very rqeanin,,-ioul way. Putting grease skids under the last ,rian was a very essential thing. MR. RTJSSELL: Yes, I think he could use support front the reviewers. You know, quite frankly, no one quite knows the prob le we have had there. If one looks at this type of application, the types of projects in th,.s application, and a new direction that the pro-ram staff is a-oinc- totake; facilitators, it seems to m CD CD this is perhaps where they might want to concentrate a little bit more on perhaps in the future than being so project oriented as in the past. DR. HEUSTI'@: If in sone way, In whatever way Is appropriate, he could get some encouragement so that he could oo to whoever the traditionalists are and simply say this is what the Re(,,ionaL -Advisory Group or the Council or the staff whink I should be doing in getting support, sometimes this Is helpful. DR. THURIIIAN: It might be worthwhile for us to con-;, sider in our proposal he be asked to consult with those who are beyond the traditional realm. .As Mr. Russell indicated, the @uy whojust took overi C) the school of public health out there is an innovative schemer for delivering hea.Lth core. It is his big bag. I think if we were to push Dr.lzutsu tovia,rcl this man-- RUSSELL: They are already together. I sat in a joint reetinx with them, together. DR. HLUSTIS: P, fellow like this needs all the support he can get to keep somebody from knocking him down. DR. HESS: He only has a year to go, so far m we know, under this particular pro-ram, So I think our enthusiasm fo:r you know, specific recommendations for gettin- all @ea.red up and wound up have to be tempered by that life span. DR. HEUSTIS: Something is going to be there. DR. HESS: Yes. But it sounds to me like this guy will find his way in. Figure out what can be done. SISTER JO'@-EPHINE: Two things I have been impressed two ways of -ettin- a procramto bone up Is either to deny funds or pressure the poor coordinator to Leave, when we RUSS-LLL: He just happened to resign were out there. DR. HEUSTIS: Tha.tls right. MR. PETERSON: John, do you have a recommendation? DR. HIRSCIIBOECK: I will make a recommendation thgti maybe we approve the @1.5 million. 14R. PETERSON: That is the full amount that they a-.re requesting this time. They are coming in we understand, and I think Dick has much better intelligence on this rec,-ion than we do on most, in terms of what is like Ly to- be comin@,, ",-n, They are cominc., in with another request in July, 'which wLLI perhaps bear more of the imprint of the new doordi-r,@,',-@- tor, the reconstitute of lll,,G, et cetera. Roughly a half MiL- Lion dollars. I am readino' my figures correctly. We probably, over the two sessions, will be lookin@,- at close to a 'y2 million package; three-quarters of it is re- quested at this time, a.ge,inst, again, a benchmark or target figure of about rL,1.5 million. DR. TIIURI,4AN: I am going to have to take issue wi he a fellow reviewer and say I would cut this $1.1 million to 4')L,2 million to let's see if he can do all the things we are looking at. That is the only place I would disagree. I think it needs our approval and support, but I think @1.5 million, althour,-h they are already at $93@(,OOO -- he is In a situation now where I think with adequate staff support, he can bring about a change in this program even though It is only for a year, to answer Joe's question. But I thiik @L.5 million is a Little more than they will be able to utilize if they are coming in with another half-a million dollars. DR. HEUSTIS: Thaty would leave some money to take care of the half million. DR. THUIUIAN: Yes. I would put it at $1.1 million .I believe. DR. HIR.@CHBOECK: I think I agree with you. DR. HEUSTIS: I Qupport your motion. MR. BA-RI@O@,TS: 1. think they mic@hlv- relgx a little bilv.@ It might go too far. Give them a little bit of encouragements! DR. THUR@N: I would wake a substitute motion of @l,l million. DR. HIRSCHBOECK: I second it. MR. PETERSON: John seconds that. I gather one of the important things we want to convey, because we are talking about a dollar figure, but thati the Croup, and presumably the Council, if it listens to your advice end what have you, th@ the group feels that the pro- gram is at least showing indications of moving In the right direction. We are going to ask the new coordinator to do what 133 he has probably already started to do, started to looking beyond the traditionalists out there; so the figure of million, which has not been voted on yet, we need to be care- ful that isn't interpreted as a largely negative signal if I heard the discussion. It has been moved and seconded we recommend $I,l ml.l@@- lion in this case. Are there any other comments, observations, or questions about Hawaii R14P In this application? If not, will those in favor, if they will raise their either one will do. (show of hands) IIR. PETERSON: regain -- I don't know whether It it the lateness of the hour or monotone of the chairman or what, but i we seem to be drifting into the complacency of unanimity. DR. THUI@i,,IAN: Never, never. MR. PETERSON: Never. I was going to try possibly to put a little life into the meetina, by suggesting that if we have dealt with Hawaii, now, we might pick,up on another one of the Western I)el@Zlk re-ions. This happens to be -Arizona, Paul Te,-zchan, by virtue 0-@ Dr. James not beina- ?.ble to be here, will be the only reviewer, C) I think staff will have some comments here. But if it is satisfactory with everybody, we will move from Haw,,,,ii and the- blue Pacific to the southwest and take a look at l,'rizona,.which I think is one of the fastest gro@7ing st-ates in the Union. Paul. "ORIZGI;,A DR. TESCH-AN: In contrast to tt,e fastest growirio, state in population, I find. the application a fairly pedestrian production. The application is for proir3m staff and for six projects, five of which a,re continuing. There are evidences of three more coming to the end 1, of funding in the process of working up the various pa,ges of the form, In going over the application, we are unable, realL@, to find what program goals a.nd objectives have been stat-ed. There is moreover in sorae of the ancillary inforrrp-- tion we were sent In the sunL,"ary of program status, iSSL@es raised by staff onthe basis of theLr visits, et cetera, tha,t a review verification is pending, pending conformance to DRI,IT policy. And the issues are that the bylaws need revision and the RAG membership needs better representation The application is silent on the subject of bylaws, bylaws revision or anything about the process. The RAG membership, the application is silent on the .1 question of RAG membership chanr--e. The membership continues to have 18 individuals. Tl-;ey tend to show at the rate, according to the application descr'LP7 tion, of'Ll to L2 per meeting. And in Lookinc, at the member- i ship of the @.G, one does not vet the impression that the C> principal leadership of health of the health forces in e thi n@ Arizona are in fact members of th There are issues of racial balance and I a.m not a good enough geographer of -Arizona to tell how Geographic the balance is. But it would appear the issues that 9,re raised in that document are still with us as far as I can tell from the application, no change at all. hlow;'ithe staff is indeed stable since L967 and you get the sense that there is not, as a matter of facts so.me - where between the coord'i-netorEAG chairman, executive committee, .abiLity for pro-ram leadership and direction in lj.'ne with at least the administrative issues having to do with rev'LeAl oro- cess verification. On the other h-.rAd, there are issues of expansion O-" health service sites having access continuation pro@ect for one more year, extension of medical manpower, a recruitment procrr,@lil extension for one more yea.r, and a fairly localized health inforwtion dial-access type of pro--ram, which by the title itself provides health education which is also scheduled for extension. There is E,%IS project and hypertension control pro- ject. There is a carry-over into two more counties of a stre@- tococcal infection projec@ control project. There is in addition a rather surprisingly, I t@.ink@ from the buildup, apparently a, cessation of the continuation education service area project. It comes to the end as we see! it in the end of 1974 according to the application. However, I thl.nlr- in supplemental l,nformat ion I got across that I have just received and.have not carefully stuOie@@, it may be that there is a further extension of that, because In the application on page 19 the PP.G suggests that there slao,lil(i be maintenance of activity In the continuing education service area project. have to ask for staff help on that particular point@, particularly In how there Is actually organized, in view of tried fact there appear to be in the sites pages 19 separate committees -in various places which are sopposed to identify local needs a-rid assist in development of those local programs. IliR. BARRO,@4;S: Are those rura.l? DE. Well, I, would i.T,-ar,,)ine small They are not in Phoenix and Tucson primarily by any -r-@ieans. They are scattered out quite wi-delir. The interestin-- feature -,bout that particular pro@cl-- statement, ho@iever; why I am, o.inbi-uoLis about it, Why T tho@,, t its discontinuation was a plus, is because the evaluators, at lea,st the capacity for evaluation, pan-e 61 of the application, CD say there a,re at least three ba.sic changes that have-- two baz:'.c changes have to be made to qualify for further R14P support beyond June 30, 1974. Did you want to clarify? I certainly wander am urid that one, because that is the state the application is in. MRS. SADl-t4: The CESA program, try are goino- to LD continue it for three more months without additional 4L' u nd s requested until It cets a, complete review., They may come in July I but I am not sure, They have had problems with it. The staff feels that it should change its emphasis even thou,-,h it does have that many committees and it is throuc,,ftouu- the state. They also feel the medical school, university In @enera,l, should have taken over some of it, or some medicaL society or some other professional organization. In order to help the staff, they asked an outside co.,nmittee, ad hoc consultant, to come in and evaluate C ESP, I guess unfortunately for staff, the outside committee felt It was marvelous,, end recommended to PAG that it is a very uood activity end ou@ht to be continued. And I was at the G rneetir,c, where all of this was being discussed. The way they handled it was, as I -,aid, just asked for two months without i additional funding have (0, complete review of the CESP, progr<@:.,.-,,.@ If they do come in a-ain, there be a different empfta,sis that it not-- well,several ti-iingsp one is that there be a different emphasis in terms of need, patient care need, rather than just what you think you would like toknow, Two is the university and heft,Lth professionals put some money in themselves. -And they were going to have all of this ready by July 1. That Is iihy-- but it Is not in here for money right now. DR. TE'@CHAN: I mentioned this simply to say it ijg seemed to me that the comments made richt here showed m more staff. I had been developing a fairly @destrian picture@, of staff function and all of a sudden I come across some very good "sort of either it shapes up or we don't continue Lt'.1' a nci I thought that is great, that is a plus on that. And I i,iE!,S seein@ the thing end based on thetarminal date here, And they are basically saying the thing so I won't go further on that. So I am sort O.L at a, questionmerk on program lead e r-' ship under insufficient basis. That really is pretty limited jud ment. It is hedc:,-ing one's bets pretty severely. But it looks to me as if-- it looks like there r, in,, y some pluses,rraybe sor,,ie ,ainuses. I would say I can't quite-- it sounds Like the sta--"f,l is rriovinc, particularly because of their access projects, s, stef' has more life in it @on projects. It looks like the than the application would su@c-'ec,,t and that the i@G is inade- quate to deal with this situation. So I left the leadership in questionriark, progrcri staff probably satisfactory, and it is because there are PLL,-Ises andr,inuses, and that the Recrional Pdvisory Group has to set Goals, objectives and priorities, they have oot to come to grips with the rev-Lew process requirements, the bylaw system, and I don't have any evidence that they know how to do techi-ii-- cat review. I don't have evidence. @IRS. S.ADIN: Yes. Okay. 14R. PETERSOTI: We are back recentlyi guess it has been couple of months now. 14RS. SADIN: One month. 14R. PETERSON: One month she has in Arizona, on ci review verification visit, which I think it is very relevant this consideration and I wonder if you -- I am not sure at juncture, '@Oaul. DR. TESCHAN: I am goin,--, to finish Lp readin,.T-- YiR. Pl,,TERSOII@l: Why don't you do that, then there are some issL-@es sta,ff micht comment DR. TEc@@CH.'m'N: That would allow you to comment as yo@ @0, IIIR. PzfE@@'So",q: DE. TE"-"CHPll: In pa.st performance, it added up to be satisfactory I tt,.ou-,7@ht in the sense that substantive proble,-.is of availability @:,-nd access, I didn't get a sense there has been any-,@nput from the region in the defining of They did launch renal, end so Llorth. They got funding after termination, continuation funding for this. So it was from poor to @ood on ti-ia,t. Objectives and priorities, @ain we don't ha,ve that, for pro-ram, -And that note was noted in CHP corres- CD pondence, which was in this application very extensive. -Also the arguments back and forth are very interesting. We will get to tha,t in a moment. The proposals I simply wasn't able to clett-rmLne what the explicit objectives and so on were, and I have the dis- tinct feeling, ocrain CHP comes up here, In terms of 6(c), the CL-IF has been virtually silent in any useful way. That is to say, when this comes to the CHF, say something to which Dr. lvialnik should address the @ogram they don't help him. What they do is complain after the fact in loud and sor,,,-@vihato oh, vituperative language which doesnlt help enythinc, in particular. LD I should add at that point the correspondence between the director end the CHP, various CHP'S, is very interesting in that where the replies have been has beenvery substantive. You cet a feeling there is a professiona,L expert who knows how to reply, how to deal with the situation, in those arguments. Feasibility,@ie felt what was goiri- on could be achieved,I felt this was a below-avera@@e situation. It currently, based on their request, has nearly 49 perc nt of the total bud[--,et will @,-o to program staff as we e see the story. You know, depending on which numbers you use. But it Looked like a hinh degree, amount at most of the u CD activities are either firizona Rl,',P staff-- there are two pro- Crams out of the total of '@@'l-3 inilLion; namely, to the time ofi 207,000, which appears to be the league of Cities ',nd Towns 142 .Arizona Ifea,rt I..ssociation) that a-re not either the Colle,.,,e of Ijedicine or the RI.,IP. There are two Colle-e of Medicine proposals which come to "?88, 000. So there is a, large proportion of RMP in ColLec-e of Medicine type activities in the application. @-TERSOii: Thank you. Do you want to comment on what Paul may have said, but also the issues that appeared to you as a result of the review ver,'Lf'ica'U-'Lon? It was made in ApriL-',4ay. MRS. SliDIN: It wa,s spent both times. Actually I spent a lot of hire in Arizona, lately. PETI'@SON: Cl-Lra-ate agrees with you. Californi,@.,i too. @IRS. S-ADIN: There ,re several times-- sometimes we leave too little to our reviewers. I do remember a review process verification reports* DR. TEc.'CI-IP,,%': One up. MRS. @lf-DII,-,T,: I do have it. We were there at actually several sta,-es of our re- view process. One is where they just provide staff assistance' in the development o'L' a project, project development, and we saw one iihere-- this was in an appraised project, this is their ad hoe committee, review coia.,i,-ttc-e met. We saw ',-,hat kta@@c. -And we came back later, saw three different sL',a,r.--es. Their review really is pretty -ood. Their staff assistariiz- is good. Their technical reviewers -- as a ,,natter of fact, the technical rcv-ewers had ML,CH to saypbout this pc),it.-ticuler potential, they 'wLere Looking a,t -all of those colrirnerA@,@,, were taken into consideration and modified by the it came direct, so they did make those changes. Your comment about RAG, we have been sending letters,, to Irizone, yearly about their RAG composition. The RAG has remained riore or less the same since it started-- DR. Tz@'SCHAN: Appointed by whom? "ill.DltN: Appointed by the dean of the l,iedic,,,l School. Now, they had adra@Lt of revised bylaws end they decided to shelve it becatl:..-e of -,ifiSA. When Nie@,ere there befcre the review visit, they said they were not confo-,,,-,iin,,-,ro They are now revising -- they have to have 30 days before they can consider any ci,,an--,es, that is in their bylaws. They know, ID it is said In their letter t@ey must revise their bylaws and they will. And their revised bylaws of which we have seen draft, and which trans-rratia,.-,,erqent has seen, looked a,t, to conform. On the other hand, we have indicated that we can't certify until it is done. So that will be taken care of. At their last RAG meeting ttiey-did vote to increase their RAG membership by six. -And they indicated that these six @ipmbers wouLd be from, areas not presently within the state, both f-peo-@ ,raphi%^,aLly end nonprovider types. And this, again, Is In the next letter, Dr. Malitc, after review process. There was another visit, that was in January, and I made that one with Dr. '@,annon, who'.used to be in our Councii, he had visited -Arizona. with us before;this was done@ because their supplemental application, which showed they red, I ly had ipLde a lot of chanves since their pre-phaseout applications, we wanted to w-ke sure they really did it and it wasn't on paper, And there were a lot of chances. Their ILAG had recommended, for instance, they work with CHP and they hod visited and worked with CHP. So this -really the (b) Cents tellinc- what the needs are. tD It may not be true of Phoenix ari& Tucson, rei",iote areas of the state they ore @)ork,@nZ there 0 At the ir IIPG meetinf,-, as I Indicated in that suiL-,iary I gave You th,,-s iro r n there was a lot of discussion about what Dr. Hess Mentioned this riorninr- which Is, you know, the cost; do you spend C3 where there are 150,000 peo@,le, or do @350,000 in remote areas you concentrate on South Phoenix, areas that are hiuher densL@@- population? That can be a philosophical question. Agci,.in, in reraote-- they are,what they are tryin- to do is provide services and provide sites and provide where YOL'@ can't support a professional now, they can't support one pro- fessional -- it may not work out if you are go-Lng to do it per 14@ person* DR. HESS: This is an example of where I think @gup- port ought to go. They have unusual obstacles and limited resources, MRS. SADIN: Yes. -iink this is wh re RIT ou-ht to b DR. HESS: -And I ti e limited role in whatever it sees. playing a If government doe,-@n It play at Least a facilitating role, it be a long time before people get access to heal,h servi-ce.c,. Maybe you are misinterpretiti@ what I am sayin 90 ST@DIN: No, I am not. I say you couldn't do it' on a population basis. DR. HESS: You have to take -,eography, needs, and ob,- stacles that have to be overcome into ci,ccount. MRS. That, by the way, is part of the pro gram staff bud,,-et, even though ter,,ned an activity. So the prof-ram staff bud-c"-, is kind of not -i, true budget. It could just as well do a project. Your conumnts on leadership are kind of interesting because it is kind of yes and no. I don't know if I go off the record or not. (Discussion off the record.) MRS. SADIN: IU-,G grantee policy will be taken care if they pay any attention to their advice letterand I im-,-, inc,, they will. What you Go about the coordinator I don't know. Their review process, as far as staffing is quite thorough. -A nd in terms of objectives, that is really kind of ironi.c, because one of their main criticisms, when we wore there, i us t@ before phaseout, was that they had the mostbeaLit'ifLil chart I onthe iialls which is still there -- I guess always will be. (Laughter) Shoqing not only just goals, b ut objectives, sub- objectives, sub-sub-sub-sub-objectives. It reminded one oLil!' lented it looked like somebody all dressed the vsitors cor@L up and no place to rTo. So they have that. DR. DR. TFQ@Clil.. N: It is in the book, but it doesn't come t',-irouoh. ci bi, I I fall @IDIN: It is in all their other books. They do have very eloquent objectives. DR. TESCII.AN: What I recommended, was thinkircr o recommending, was something like 80 percent or so of request. Funding approximately 80, you know -- we go back and forth, up and down on this. But something like 80 percent of the request. In order to particularly cet the message that we C> encourage their move out of the metro areas, that is to say It seems to me a movement is afoot which has a reason for being supported. We want to be sure that if the group @Leets, that is the easel if we want to do this, that thevget that raessa,--e and not other massages, that all the funding, et cetera, should be contingent on the verifications that you haVt-,, just already certified, so that this appears out of it. That there should be some attempt to possibly in terms of the total funding to double up on staff if they can, because the staff costs relative to the total request is pretty high, a.ithough I am not now talkin-,-, aboqt-- not core project so ra u c But I think with the new applica-tion-- i,iRS. SADIN: They are also putting some people out as area, repre--ntetives. DR. Yes, I that. SISTEF,. JOSEPHIi,4E: l@y I ask, what is the possi- bility of seein- th'@ reco,,rrnencl auainst this policy." He says this to the whole l@Gl Now, you don't vet an instant reaction on"@,@ell, okay, Mrs. Sadin, ,ie are goJ.ncr, to do that tomorrow. You have these factors to deal with. And-I thick they are real factors. DR. TESCIlAiN: They are real factors. It is. DR. THUR.Lv.PN: Real factor. We never want to undercut staff, Never be in that position. DR. THM,,,LIAN: You know, from sitting in before w,, have always come back and said, "How is it going to affect staff?" MRS. SP.DIN: I think staffs morality could be up- lifted now, especially Billy V. and some of the others who have really been tryin@ real hard to work with the area-- it is their push,tha.t has done this. They are the ones who were tryino, to terminate CESli. It Is the staff, you know. .And they got an outside committee to try to help them and Lt didn't work out. DR. TESCI-LAN: And they do it against every obstacle MRS. .@.",DIN: Every obstacle in the world. It Is staff that is tryin@ to do It. I would hate to punish them. On the other hand-- DR. McC.P-,LL: Maybe if we up this to @86o,ooo, cur- rent level. -- I,IR. BARROIIIS: I could -,-o along with that. DR. iicC.ALL: And at the same time get a strono, mes- C> sac,-e, not satisfactory with, YOU know, recognizing some progress,, some change, at least not cut them below their current level. DR. HESS: Let me ask another question. Are their projects prioritized -Ln any way or ca@n you tell? YLRS. Sl@I)Iii: Yes. They have it in the application. .And, you know, expansion of service sites wag the lowest priority. DR. TESCHAN: Program staff was number one, as I reca, DR. THURI,,IAN: Yes, it Is. DR. HE@.S: Ti-.at is natural, but what about uoinF, from thi2? IC S . D IN One was program staff, two was hyper- tension; seven is the lowest. StreptococcaL infection -- no, EMS was three, four was streptococcal infection, consumer education is 'Live, manpower recruitment is six, and expansion seven, That was done verbally, 9,s I said,, and I really think they would not have arrived at this priority ratinc,, Lf It had been done by written document, I really think PeOPLe chanc,ed their minds. But nevertheless, those are the prioritie@- you have in this application. DR. THURI,4AN: R&-Yi has supported that streptococcal infection ad nauseum. It never'should haveeven started. IviR. BA RR (7yT SDi@, @IcCall, is that a motion? li@. Pt,T,z,Rsoi@T: I think Bill did, he threw o u t '@'8 0 0, and I don It know whether he reo-arded that as a, motion or whe'u-,'C:I- he would be WiLlinf,, to adjust his motion to $86oooo. DR. THIJBi',IAN: c--'o rao v e . DR. TE'@@CHPN: Lecond. l@. PETERSON: We ta Iked i ni t ia I I.y about ro u.@i-i ly t560,000 level. I just throw! 'PI. I mi Ilion, now we are down to it out for consideration b--cciuse I didn't want to extend this caution much longer if we can -- we seem to be coming to a decision. I think one of the things that again we need to kee,-- in mind as a possibility here, and others, that one could possibly make a orant award, whatever the sumo with some fa,irly specific conditions in terms of some things tha,t had c,@ be met or reflected, or they didn't get that full amount. That Is, aaain, a possible option that you may want to think about. lb I DR. HESS: What I am concerned about is that priority listinx, the things are goin- to be cut are the ones that I would be most interested in seeing kept in. Now, if that somehow, with the award letter, you know, the feeling, thinking they ought to reconsider those priorities. Ile feel in lic,,-ht, you know, of the need of the region, the study that went into developing those particular proje--ts, that theybucr,@ht to consider -.,-ivin,,T, a, higher priority.,I Can't tell thcrn to give them, but strongly suggest they give high priority to those two projects, I would feel better. DR. TESC!iPiN: But they are on ,-).nnual review status and I think DR. HESS: This is the last review, thouch, isn't C:) It? DR. TE@-'Cl@IA'ii: The point I am sayino- is the dearce of national intervention in Local proc-ram is di4L"Lerent, is it not? DR. HESS: They still are on annual. DR. TESC@-LAN: I don It know what status is now. @S. Si@'DIN: They were, it was taken back. @.RU.SSELL: We too have the same problems with this4, We finally asked staff; brou ht this to the committee and to the Council, triennial status was taken away from this pro@r-cri,, DR. HESS: That modifies it,then you do have a bette' DR. TESCH-AN: But- do you? That is the plan. Do You iri on trienn!aL-- have mor intervention here the Px'Jc@SELL: Yes. Dc,,potidin,,- on the de-ree. In taking away the triennial status, the next the program is being reviewed a year later was to be based on I Councills site visit. Ancl then being phased out -- Dr. Cannorii went, and we are really not quite sure what happened, are we? ,V,RS. SPDIN: Yes. DR. IIESS: The issue is what is our status inmla- t@Lon@hip to being able to offer advice to them about changing their priorities? Is that ler--itir"@ate with them beino, in annual ste.tu@- or is it not? i@IR. PU'@SELL: I think very legitimate, because, as -i Rebecca pointed ou4 in the letter goint- ba;ck to the review that they Xioritize their-- process, it was su@--e,,ited well, projects by ballot or something to this efLect. Arid we ca,n always suggest they go back and do it. I dont mean they have to. MR. BARR07vlS: They have to follow what this guy says anyway. MRS. SIDIN: There were people there sayino,, considerinc,- wha,t you just said, I will cha.nge my vote, tLR. BARRA[S: That is what I mean. It seems to me you are fooling around with esteb- lished policy if we attach internal constraints on RPG i63 through this grant. But is it possible for staff to infor-ma say that these are the questions that occurred inthe review committee and if you want to fair a little bit better, the next time you had better-- DR. HESS: There is no "next time." MR. BARRO,4S: There is when they come in for July Isit. DR. HESS: It is too late. 14R. BARROVTS: No, if staff communicates now-- MR. PETERSON: Can't communicate now. I think this! action has got to be confirmed by Council. Let me again, to try to get us off both the substance tive end time dilemmas would there be any recognizing that it is not the usual order of the day, either now or in the Pastp Vou'ld the group perhaps want to, in a sense@ partially punt to the Council on this sa.ying we do feel either X amount or somewhat lar@er amount, provided that a couple of the t@iin@@s we think ourTht to be of hi-h priority, if there is soim assurance that they remain in? That one project you are .talking about, Joe, is really a significant amount of money, @339,000 or wha,tever It is. The health sites in remote areas,l! DR. HESS: Yes. YiR. PL@'TERSON: Otherwise I think we are you know, DR. IIEUSTIS: Excuse me. Before -vie do thi:s, would I for the question on the motion to see if we are go,.nL-- you cal to -.et IbLi I YiR. PETERSON: -All rigi-it) let'scall for '-he question on the motion: A860,000. filL those in favor raise their hands. (Show of hands) MR. PETERSON: Seven . And I think in one sense, the problem has been resolved. MR. BfiRRG,,IS: This brirCs up the numbers, though, to brin@ up another Council policy question. Taking the whoi,,- past history of review committees and councils dealing with the regional programs, is it appropriate to be too severe in our swin@s -- this is an old problem and is thiD the ric.-ii- time u to apply an entirely new, harsher solution than in the past? DR. HEUSTIL: This is the thing we really leave to the Council. It is their responsibility. @ffl. BARROII@@: It is their baby, not ours.. DR. T-ESCHAN: Do you then[,, it is possible to nor@e in this connection, that the approve at this Level, reconLiends tt,@e funding to the RAG in lirizona that the COOI, 2, and 3 be .funded. It doesn't say how much, but it clearly states leve@ I of priority. They can rearran@,e the budvet. Does that help? I,IR. PETERSON: WELL, I think, that is the kind of first advice that you people if that is what you are suo-- gestino, we ought to give to Council and ifcouncil feels L> 165 strongly in the sameway, then I think that again, as advice, 9 ought to be passing it on to Arizona. DR. TESR.HA N: I so. move. DR. TH-L',IR14AN: Second. IM. PETERSON: Okay. That is on 1, 2, and 3, those three projects. Okay. Arizona Is our record for the day -- 50 minute region. There may be some correlation between problems and time. I wonder, do we want to try and put one more? We have put one more region under our belt tonight. IIR. BARP%agS: Do you have an easy one? IVIR. PETERSON: No, I didn't necessarily have an t easy one, I thought since @uess it was l@L or somebody i ea,rlier in the day was -vionderinc- what we did when Senator Ribicoff called, I thought we might escalate to potential call. and discuss greater Delaware Valley. DR. THUP,@iIP.N: Wonderful. '14R. PETERSON: Either John or Bill or Joe, feel ready? I think you indicated youwere ready on that, Joe. I GREATER DEUWARE VALLEY i66 T ,)R. HESS: I read most of it. DM. PETERSON: Do you want to lead off? Both of you I know wer e in on the site visit, I was on. But that has been a long time ago. Greater Delaware Valley. MR. HESS: Well, there have been changes in leader- ship since I was there on site visit. The new coordinator is Dr. Dean Roberts, who had been the coordinator for Hanaman -- perhaps I had better give a little background here for this region. This region was organized basically around the five Philadelphia medical schools and the @rantee is the University, City Health Sciences Center, which is a kind of consortium of educational institutions which was gotten together for funding!, of educational and related proo.rams and research and so forth." The Initial district was the @ynedicaischools which tc)c",- the initial leadership and got the pro@ram coing, This region,and many others, the problem then was to bring in a broader balance into the leadership and manage- anent of the program. Pnd that was one of our concerns when was there-- were we together, BilL? DR.. THURMAN: @lith Pete. MR. PETERSON: . December '72 I believe. UR14AN: '72. DR. Tll M. PEFERSON: Or '71. 167 DR. THUI@l@N: 17L. DR. HESS: And we were concerned about tryinc, to bring a better be-lance into the management program. We also recognized tha,t there 'were some good thing going on thereo but that there v7as probably unduly hea,vy medic@.-,,l school involverfent still at that point. One cLthe good things I felt at least that had hap- pened was that the schools had looked over the entire RM? and had di vided up responsibilities for oroanizi.no, supporting a,nd workiri,@,@ ',,,ilth health care institutions, providers throughout the re@ions. There were five areas within the total region which were the responsibility of a c7iven medical school in terms of providing -@up,@or They ha,ve developed area offices, ou might say y satellite offices, in each of these five regions, wi-,ich,.as I understand it, are not medical school controlbd, but medical! schools do relate to these coordinating offices. And they have been doin,- a, lot of orSe,niza,tional planning, coordi-natinc,,l work in each of the areas. So that from that standpoint the region -.s quite well developed, well organized. Going down the major cri,teri-.g,, the pro-,ram leader- CD ship, at the time of our site visit I was quite favorably impressed with Dr. Roberts. I don t now what his performance has been since@he has been in that job, but he seems to be a I man with a good back,-,round, seemed to be reasonable, and know how to proceed. Dr. Wolfe, I believe) was the 1,LAG chairman th--ns sti.i I is the chairman of the ]iAG,, and again seemed to be for- ward-lboking, had the best interest of the re-ion at heart. He at that time was dee,no now he is vice president for planning of -- I forget the name of the school, or college. But it is an upstate-- I,,a. PZ2ERSON: It is up in the Scranton or Wilkes- Barre area,. DR. HESS: So he was a,wey from the Philadelphia area and brought that perspective. One of our concerns at that point was the domination of the executive committee of the RAG by the medical school representative. That seem,,--, to me to have been balanced out a bitt now, and there is a broader representation on the RAG.@ The program staff, they have a rather larc,e program i staff when you consider both the central staff plus the a,rea staff. There is something like-- is it 2 7 all told? So it is a large staff. But a,Lso we have to consider IV-his is a larc,-e population area of Iiir--h density, including Philadelphia, and the surrounding area. I don't have population figures here, but ray guess Is it is probably in the neighborhood of five or six million people, so that that would require 'Lairly large staff to try to cover the many organizations, institutions and problems that are there. The Re,-,ional Advisory Group has been quite active. They subdivided into executive co irnittees and in addition, there a-re area committees that relate to the area coordina- tors find look at the problems with each of these five areas of the re--ion. They do have a, set of -,oats, objectives, and pr-Lo.L - ities a.,nd the application is well put together in that every project relates.to acroal and objective. So you know they know her to think and manage in those terms. Their pa,st performance, there have been a number of activities in the City of Philadelphia., metropolitan area, a-.s well as in the outsk-late re,,,ions, that have been effective in bringing to-ether health care providers and try to improve both the quality and accessibility of care. The proposal is a sizeabLe one, both in terms of number of projects and in dollar amounts. Most of them seem to be fairly well thou@@,@it out. fi@nd appropriate for the region. FeasibiLity is a little bit difficult for meto estimate, but ir@ feelin@ is probably with the experience o f group and so on, that these are things that could be done. The. CIIP relationstil ps generally seem to be quite good as near as I could tell from the document. Maybe the staff will have som other comments, but it seems to me a ,rood working relationship between the CIIP a nd Pd,4P. My overall assess @-i-it of the rp-gior,@,a.s based on th! Si was above average considering the complexity of the region anti the organization. There is one question that was a continuing problem or issue, let me sa,y not necessarily a problem, there is a, 1,9,rce proportion of the funds still goin- to the medical school. lind I was surprised o,t the apparently high salary levels, at least compared to our school, of some of the people who are pa-id partly It-lhrouc;-h the RMP budget. I have no way of knowinc,- vihether commensurate servi-r@ ces are being rendered by those on part-time R@.,IP salary. DR* TESCH.PN: How ma,ny part-time professionals r e A lot of people? there? DR. THU.-e,14AN: Fi-fty-tv;o altogether, about ten or twelve. l@M. PETERSON: Ten or twelve. I am tryinla" to recall how many it was when wevere up there. That may be somewhat Less, but it has always been I-phenomenon of the Gt-.'D pro-r@n,m, I guess it has al@iays raised CD some questions In a lot of people's minds. But I think it is twelve, roughly, my count, if tho@-,@e figures are correct. Bill, how did Gl!'O revisited look? DR. THURIL4AN: I think I would second what Joe said from the standpoint -Roberts was a stronger person and one of 171 the few stron@p people we saw on our initial visit really, so I think that could do nothing but help. The l@egiotial Advisory Group is still largely 8. One- man realtionship and that is Wolfe himself, who does run it ici runs it reasonably well. I think that they have developed some new projects, but they have largely used idc;a,s from other people and other proc@-i@arnz and have added minimum innovation to it* They have not terminated some projects a@ain they LD were asked to terminate multiple times. I arree with Joe's assessment, I would just emphasize the points he made; that is, there was not a, single medical school budr7et in this whole proposal, that iza realistic thincr, and one of them, for instance, they have had the chairman of preventive medicine @ettin- 50 percent of his salary for rQnnin@ a community hypertension program in on-- se@-- ment of the Pennsylvn-nia community, end that is not realistic., Where we don't have professionals, we are payin@ secretaries. So that is acaJ.n an unreal situation. C) Some of the projects are overfunded, but I think their analysis of their programs and proc-ress they have made since we were-there is significant I think they have come a lono, way. DR. TESCIIAN:. How is the RAG appointed, do you l@no@,,,@i that? 172 DR. TESCIiA!i: You 'viouldn' t necessarily pick it up here. IC-@. PETFR@SON: I dori It know, Spence? COLBUPN: They have their own nominating com- mittee. They do have institutional representation, that type of thinu -- is that what you are @etting at? There is Guaranteed representation from the Medical School on the RAG, also on the executive committee. But all 1 six schools are not represented -- in fact,I don't think we have more than three medical schools represented. DR. HESS: That is r(a(Iticed substantially. MR. COLBUR'il: Policy Board of Director--- used to callI a,il of these shots, now t@iey have a. true executive co=,iittee, Doesn't have a great deal of exoerience. DR. HESS: Ten part-t'Lire medical school profession,,tL,,:@ at the doctoral and @..ster level, so they are not all physi- ci,,i,ns. @ome with n@aster degree. DR. TESCHftN: I just was summarizing the general notion part-time people are dreadfully hard to keep track of, especially when they @re orofessionals. I,IR. BliRRU@iS: Am I right in rending these figures, four segments of the university-based staffs total about "e-250,000. DR. THliRl@N: You are. f lot of jrone,r I,ffi. BARROETS: That is a helluva MR. PETEFSON: Used to be "e'600,000. I was ,,Oin.- to s, -iy you airit -seen DR. THURlitiNI. nothing yet. I-IR. BARRO,,@S: Lot me ask a question. They are in-an, i area ;"Ith a, Large undetserved population.-- Have they addressed themselves from that? DR. THUR-,.,,IAN: Yes. DR. HESS: They got into that from the very becinni-n--,, That is where the medical schools have put a lot o' their effort. B@ RR U,-l SIt is not all bad. 1,M. PETEI@@@0',',!: I wonder, Spence or Frank, if there were any particular aspects of this application -- T don@t@ recall who it was that mentioned now whether it was Bill or Joe about some project that my have -one beyond what we con- sider to be the normal funding period. Council did have a poL'---,, of generally not to exceed three years, whether you have any comment to that question, which I thouc,,ht I heard raised specifically,,or any other significant point; policy issue or problem as staff has perceived them with respect to GZA? I,,M. COLBUR14: As I recall, they have several new projects. About the ti-rae 'vie phased out, they were fitting an application for review. They ,iei,e pliasinr7 out continuing act ivi t, le s. They went on the shelf. When they were ted to phase out, they discontinued the other activities and the @c@ran was almost just, you know, an inch away from bein@.7, completely ot-At of business in -Auo,ust of 1973 when they qte,r'Ued@@ bee,tincr pror-raras on a iaonthly basis, spoon-feeding on a quarterly basis; so you have grossly here the new projects in the application not reviewed. DR. HESS: Tan continuous and ten new. @IR. PLTERSOii: I notice froni our summary sheets i-hich, need Leos to say, I am ,iot very conversant with any of these applications in any detail, but most of the projects 1,4 aA elicited Cli? reviewing co=ictits. There were a couple where they had not. We do have Tom @rath here from the PhiLadelphia Refrional Office. CD I don't k@-io@,lwhether you, Tom, had any particular information with respect to CriP comment or relationships P. this area; specifically, @reater Delaware ValLey, Phi-ladeLphi-a. TCI-;I: To the best of my knowledge the relationships were reasonably good. 1,M. PETE'-RSON: The chief CIIP a57,-ency, of course, is Philadelphia and there also happened to be an experimental system there. Thereis also another one greater up north, Representative FLood. l@IR. BPRROWS: I-le came up with the conclusion this j- I wa.s pretty appropriate? DR. HESS: Yes, I rated it overall above z),,.vera,-,eo DR. HEUSTIS: Budget somewhat inf Lated? DR. TH@, i',',.AN I think so. They are askiriE,; for @2,8 million end they have been at $L.7 million, and they really -- eyactly half of the projec@ continuing project. Irany of them in the year phased down. They said that very clearlyi this is the last year of si.ippor@ either they will be termi-nati'i@'-L-, or supported by someone else. So that I tend to say yes to that all the time. 'lienever indicated? DR. HEUSTI' @l THIT%;,Y,@N: Not necessarily. I'do it when .t is not indicated. It ,s a f'autlt. I think it is overinflated. l@. PETERSOii: We do have -- this application is "2. mill CD ion request which, as Bill points out, i.,, a s roL,, h ly a cotis,Lderab ly above; their sort of f und in@ le ve I now i s rou@!,@ ly L., equal to the sort of tarr-et figure we have had an indication that they are @,oino.- to-- Greater Delaware ValLey is going t o ing in with a rou,c7hiy '4@I.3 million second phase two be com request which would put this pror,,,ram at least in terms of its request in the @Q4 mill!-on rance, so 9,gainst that backdropI don't know whether either of the reviewers has a recommendation. DR. HESS: I have a figure. DR. THUi-il@Y,,N: Go ,ihead. DR. HESS: I would recommend @2.3 million, which !7b recognizes that this is the good region reasonably good region, rated above average, seems to have good Leadership. They have got a laroe population, many underse@-ved, who need assistance. They seem to be addressing those problems Also I was aware of the JuL Ist estimate i@eaLizin,)- 'Y t@ that there is goino- to be another big batch coming in at that '@600,000 increment over their!I time. And this seems to me is a 4 current level, which is rather substantial. It seems to me to be a fairly reasonable compromiser MR. B.ARRC,,IS: 35 percent boost, is it that stronrp? Over where they a-re no@i? IVIR. PETERSOI-,': Ac@ain, Mr. Barrows, I don't-- it does -seem to me that the present six months fundin-. rate in i many re@ions, that could be coluniri one which is a function of times two. It has one sense of reality and the o4.-her; it i does reflect-- it tildes son)e things in some instances and certainly is not indicative in most instances, including tiii s one, the kind of level the regional is functioning at pre- i January 1973. 1,M. BARROWS: .@2.3 million would reflect what per- centage increase over-- I try to get this feelfor other procrre,.T--, DR. HESIU: I personally feel they have management ability to use that. MR. BARRa-,TS: What percentage increase? CD DR. TliUX4AN: That would be 86 over 17. I am no t cn, mathematician. I;IR. PERERSON: A little more than a third. IC. BARI@0,-IS: Seventeen isn't a real figure. DR. I-LEUSTIS: These white sheets show a, billion one hundred thousand plus for a six-month budget, so that is rea istic; 174 to 674 present one, six months; multiply that by "2.3 million. two. You are not too far away from I,, a@ .BIRRC'e,'.S: That find of move-- DR. HEUSTIS: Thereis a good deal of difference between the material in the white sheets and the other on this:, printout. Great difference. f MR . BA RR a@vi S Your recommendation if the white sheet@ is ri@,ht, keep this about where they are. f DR. HEUOTIS: Into, @ive them a little bit more. I,,IR. PETERSON: I have got to cry help to staff here." What are we tall.,Iing about? NA@SH: I am not talkin@ about the one on the printout; I am talkino, about the one this sheet here (indicating). Is this an accurate figure? DR. THU@lAii: Is that figure accurate? MR. COLBIF,.N: Pediatric, pulmonary -- is that added in there? Included there? IAR. PLTER@ION: It may well have earmarked funds. Also "@170,000-- 1,Ul. COLBMilT: You are right about @$L.8 million. .P,fter estate visit. That is what we recori,,nended. They were funded at that level, so half of thatwoulc@ be 'I-@900,OOC). -And they had about 'q')400,000 for pulmonary, that! is pretty close. DR. TI-IUPd,@.N: Mr. Cl-iairman, ray recommendation 2LS $200,000 off from his, but I have no concern about Joe, say 'y2.3 milli-on. I was Lh @ki n,- '@,2. L ini I Lion. But I can easi ly live with ,"2.3 million, because I think this is a good pro- @IR. PETERSON: Do you two want to talk together fox-i 30 Seconds? DR. THU.@@1,YiN: I second the motion. 14'tl. NTASII: lb you want-, to include with that dollar figure recommendations, any further recommendations fro,-,I committee so far as removing additional funds from the =Uicai School? DR. HEUSTIS: You are speaking to Dr. Hess? @,H: Yes. DR. HESS: This I didn't think was something we rea'Lll-y have enour,-h information on now, but I think perhaps the concern as to whether or not the re(,-ion is vetting value received for C) u the money that is goin,@ to medical school now, the RAG may or may not need a little muscle to take a look at that. It is hard to ask that kind of question unless you have got some 179 reason for asking it. But I personally don't feel I am In position to ,,m,ke a jud.-ment on this. I don't know. IvM. PETERSON: But you do see that as-- DR. HESS: Potential concern. loIR. PETERSON: Despite the fact figure is down from $6oo,ooo to 250,000. DR. HEUSTIS: You gave Paul about 50 percent salary obviously. You would think he would be more busy carrying out his administrative work-- didn't sound very realistic. DR. HESS: See, there may be some compensating fac- tors. He may have sor.,Ie oL' his people doing some running and for bud@et,-ry purposes, you know, it gets too much of a ha,,tLe to out somebody on part-time salary for so and so. DR. TE'@--,CHAT-1: That is very optimistic. Our exper- ience 'Ls the opposite. DR. HI--SS: It may be justified. DR. TESC@N: Here is where a site visit would be helpful. DR. IlLcC.ALL: Still talking about unknowns? liM. PETERSON: Yes. DR. McCALL: The way it is expressed, it seems to rqel as far as vie can uo now. Call. the question. CD MR. PETERSON: Those in favor of the motion for @2.3 million with indication ofconcern, fed back, about the 180 still quarter of a million dollars of medical schools, all those in favor? (Show of hands) 14R. =,.cERSOII: We still didn't ma a,--e to --lip out n 04L' the complacency and unanimity. It is ten til five, -As YOL),R chairman I am at your beckend call. Do you want to c,-o on with still aciother? I a.rl prc- pared to do that. If you want to wrap it up for-- I,IR. B-ARRO@@IS: I have some homework to do.I would just as soon wrap it up. DR. THUIIl@@,@l I have a qui-c".@y -- no, I will conce i. V -1@TERSOY,, What is your qui-cky? DR. TII @, ',,Il@N: Puerto Rico. It's aquicky. about a ten or l@IR. FETEISCII: We are really tal.kina. fifteen minute discussion. DR. THnil,:AN: -Pit the most, yes. @IR. PETER.-'ON: It is a very unusual-- would that do too much violence with your needs? 14R. BARRO.-,"E: No. I,]R. PETERSON:I hadn't pror-ramred Puerto Rico, but let's pull it-out. The reviewers ere on that, in addition to Bill let me see that sheet of paper aGei-n, Bill -- I don't think we would do violence if we confirm our review 181 and recommendation with Jill in the morning. -Again, I don' think it Is ooing to take that match time first thin,,-, in the morning, Bill. DR. THURI,'@N: I don't mind putting it off. I,IR. Bl@RRaiS: It might be a little more courteous. MR. PETERSON: Ye4 Okay. Before we leave, a couple of thincs here. Feet free to Leave your Materials in the room. On the other hand, if you are goinr, to be doin,- homework with them, you o b v -'L oLi@ly can't do thc,,t, Secondly, I did have a, note handed to me late this afternoon. If any of you did not use RTET- -'If you please that is the @-rain IBM card that buys an airplane ticket if you would return them, to the desk, to Mrs. leventh,@,.I, if tiaerei are any that were not used. I Before we break, on the other hand, I would like to have your indication of what time -vie would like to @et startc-(,@. By my calculations, we reviewed eir'lit re-ions today which means we have 17 to Lo.'vTe did not really start the review process until well after eleven. We convened at eleveni and I took some time with generalities So on the one hand we are not in my view terribly in arrears. On the other hand, we don't have a lot to coast on. I don It know how they are doing, but I just figure @,,e would beahead of them. DR. TESCHI@l,',,': I would like to stc,.trt about 8:30. Y,R. PE2ERSO'@l: -All right, 8:30 with a Pledge to dis-pense with Puerto Rico and CaLiforni, before nine. DR. HEUSTI,'j: AnCi California will only taVe ten minutes. 1,4R. PETERSON: I know, end you are reminding nie that@@ is a very simple application at this juncture. It is one of the few regions which the Council, alonr7 with Ari--o,,ia and e,-pressed some great concerns about la-st November; it was site visited. Bill Thurman was on it and I think without telling his story, it happens to be a site visit that case back ,Iiore than alLay@Ln,@, the kinds of' concerns the CounciL@-,d at the t lrqc. Okay, with th,),t, I wa,nt to certainly expy-ec-s ny Personal tha.nlcs and appreciation for your worse to,@iay. I would only make the plea, at this juncture, it is e plea rather than intimidating request. If you haven't given me your review sheets for those re,-,ions which we have looked at, would you please let me have them before you go home, then I will be able to ta,ke them back up to my office. Thank you and we will see you at 8:30, this half of the room. (Ivihereupon@ at 4:53 o'clock, p.m., the meeting recessed, to reconvene at 8:30 o'clock, a.m., Thursdcn-y, 14ay 23, 1974.)