ii 1 i !II' ' i !If li ii.i ii i.i I i I I,'i 1. i i.Iiiii;lil i@ !! iil * ("30 1 61 f-).@ T.7klANSCE.IPT OF PII.OCEEDINGS A,.@iD WELFPRE DIVISION 0,P! t;:,FOICAL PFIIOGRAMS AD HOC EFVT W CO@",L,'IITTEE a r y n Pp-res 183 t--u 4'fg HOOVER REPORTING COMPANY, INC. Olficial Reporters Wasbington, D. C. 546 6666 R 3 P-1@,-PAT@TI, -7,7 'T 01' @'k'EAT@TT-T j-,DUr'-ATIO' i@,TD 1,7FLPAP OF AD T @IOC CO'ISIJLTY@ITS Pj',VIM17IIT(, P,7,CIOIIPJ,) !4r,,DICPL PRO(';PMi APPLICATIO@IS Conferenc.-e RooTn I-T 'Pe.rkl.a.@-in PiiilOincT 5600 Fisbers Lane Rockvill.(-., @-laryla:n(-l 20P,52 Thursda,,, May 23, 1974 Panel B conveneO at 9:40 o'clock, a.ir,. l@ir. 'Pet@- rson Chai.rma.n, r)re--,iclincr. (A-, liereto-'7ore notnC-.) 1'0'4-A C 0 117 T r. @T- T 9- (Continiaprl) ar5e 7 !Medical Plan for I'Tec;tern 'Oenn-,yl.vania 33C) @loti.on for recommendation 350 Virginia R@@rional lieclic-al Pro(-rz,,m 35 5 motion for recorr,,en0ation 367 T.,],,@n for tie ti@ T@c7ket; @rei motion f(j-- recormene8tion .3 M') Motion for -r, c c c T-,T,@ c n (I. ac) n 40(, I- TE'v7 Rec7it-,nal "eoical- TIrorrrE,,.rp for t-ie State of ,@lar,,/Ic-inO, 14 illc)tion for rp-ccmr@,on-@z-tion Al.6 H.7W Rcc7io-ial @',e@ica"L T)I.an for tho Di-,tri-ct of Coli-ir-i@ia 4 2 'lotion for recor,.-,men0ation 431) 1T-'T@,7 Reciional ',Ileeical Plan for Lonc-T Isl.an(4, ',Ie@,7 York anO. Suffoll-, Counties 443 Motion for reco!rr,,(--ne,-.tion @55 TIF"t7 Rei7,ional !Ilan for Susciiehanna 461 notion for rccop.,Lr,,en0ation 4 7 2 P R 0 C E E D I N G S -- - - - - - - - - - iy 23 [Thc-, B P-ATiel @,ias called to order at 8 90 a.m. by Session a. L, Peterson, the Chairman.] CIIP,III-I)L@@ PETErSO-@i- We are still missing a coulnle of peonle, I took some stuff home last night and this is just to ive vou an idea of -vThat .,7e did yesterday. [Indicatinq the 9 blacl-,boarO..,] on iihich was inscribed P@,ec Pund- Overall Item ing in Ks %Rea % Tard,ot Alban,.7 (1) SU-? 3.0 1.066 100 70 i.@aine Sun 2.9+ 1,600 80 120 1 P-A S C,-) 2.5 7 0 0 67 52 C,j-) Valleii Al@ 2.5 2 , 3 0 0 82 83 C'-,l York Aug 1.8 615 77 61 ila,raiit Aucr 1.8 irioo 70 7n, Ariz (1) Blk 1.7 360 64 50 Conn BA Poon 1.6 510 30 22 $3,751 c 80 70 Ti,'.L CIIAIP-',,L@T It seemed to me clie rcaions fell out into about four nice rTroups. The first column indicates that sort of overall ratind- that reviewers aave "Su-)erior", "-@ove AveracTe", "Bel.o@,i Averaae", or "T)oor. " Now the second colurin is sort of an itemization. You will recall that you vrere asked to chec,,-, 'IC-,ood", "Average LUU I -!I 2 "Belo@.7 ,@@veracTell -- and I sort of 1.7ej-cThted that as "3"p "2" rind li,,, and didn't count in where peonle said there @.ias insufficient basis for judgment. And again, it seems to me those scores, that itemized kind of scoring is roucthlv consistent with the i verbal score. And then I indicated @.71-iat your recommended funding i levels i@7cre, in thousands. And the list t@,.7o c the percentage of that olumns are recor,,i-,(-,nO..ation vis-a-vis the recTuest in the first column; -vis the -Tct ficTure or level for L.,.a overall tar, at and vis-a rerTion. .ie do have -m "IT So arl-led disTDari.,L--ics @.aine , ..or e:@annl-- if -,rou -.,i-ll recall, t,icirs is onl-,7 coming in now (1) Connecticu@@ is at the very bottom of the lisL-.. @-S I it ha-.oponed, heir initial reuuest was really quite it,,odcst compared to what @-ic were exnectina. But this is nothing authoritative or final, but I thought vou might be interested in just sort of secina one T,!a@7 of cuttincT, ho%@7 thincfs came out yesterday. It did see-r.. to r-,e thev sort of fell out into four equal arouses, rather ti-ian t-.,"O small ones and then the middle we don't have a bell s'-,Iapeo. ,.i,iich I guess is something ::urve vet, that educators are ex- tre-melv interested in. DR. TESCIIA@,L - That's because tl'iev are saving money .1 For the nrogram. 187 t 3 Tlyr, CIIAIr,',,'@.JI: Well --yes. Those are rou(Th nercentacf@s at the bottom. You reco-v,,ended about 80 nercent of the requests in the acarcoate, and about 70 percent of the target figures -- on the eight regions we looked at yesterday. Tell, I'm not sure that we reallv @,7ant to wait on Bill and Joe. '.,7e @,,7ere aoinrt to take up Puerto Tlico first, and. both of those are Puerto Rico.pcople. DP.,. McCALI,: lio@,7 al)out taking 1-7cst virainia first? TIIE '%'7ell. r)r otherwise You haven't had your coffee vet, Sister Ann, @,7ould you mind if we go to @7est Vircfiriia? OtherT,7i-se, I was gci,-I(-, to'@ o to Orecion. She ,,,as the onlv 7oerson @@7e didn't aet to%--sterc@,ay 9 -- and, t@-iat @,iarn't entirely accidental, there @@,ar, a @i ir,.Ilan. It r,.7as r)art of the little collusion wit, ti-ie c'@ia' 1 noverient. (Lau 'iter.) eclaraenica q cbn't we start Haiti T,-@'est VircTinia, then, and let Sister IZinn drink her coffee -- and riaN7!De then bv that tir@ie Bill Thurman and Joe %,7ill be here. If thev aren't, the,.,'ll have two black T,-arks apiece thevlve alread@7 cTot one. And on l,"'cst Virginia, @7e have Paul Tcscllan and Chari@-s 'IcCall and you neonle have colluded or do vou ,@,Tant to fli- a coin? DR. TE-SCI,'@'q: !lo. r)r. I!cCall, I vield the floor i,,litli pleasure to Tiy senior colleague; from Texas. 188 t 4 -HE No@-7 if N-7e -:ire going to get into these Senate type protocol-, x,,7e're not going to ctc-lt fourteen regions don,---todav. [Laughter.] DR. !'JlcCALL: I'm not sure whether I accept the floor under those circumstances. I'm sorrv Bill is not here-. I wanted to point out to him that I find another "Superior" region, but that I'r@, olification, not one that cari.(,- in with t,,,70 volums of elaborate am,. T 1-le onnoslLe. quarter inch, non- .)er se -- but just t' bound, non-color, blaclir, and,@,7hi-te application that is one of t7,ie s jr,.o IV lest, clearest--, rio-@t concise aonlications that I e r.@ad and it's siiaple for a lot of reasons: One, is the state, itself, and thev the-k7 Have devel-o-)e--' the procrran, b 't also because this application is u a request for suoport for and onlv t,,7o continuation projects 7.7ith the plan to come in for all of ti@ir new nrograms in July. And that is clearl,7 as stated here, it is a region that car-,e in rather late in terTis of the overall -- 56 allies tha'L- ultimately @,7as our pealz -- so that they came in, developed their orogram based on the neeris of the recion, developed their Priorities, stuck with them, haven't had to shift them they have a strong.staff and region advisory grouT) leadership and an integrated program that has been consistent, right along. 189 t 4 A-rid I have already mentioned that it's reall-,7 a staff Lge 4A ,iarily -- just t@.7o continuation projects -;ust ?roposal, prir Some- tliin(Ts continued in other funds. I think the feasibility of their accomiDlishj-ncT, in the' of r,,ihat they say her(,. @.7hat they have done in the past, is excellent and @,.ihile there is not a lot of information on :7@..P relationships there is nothing that indicates there is no,.@i there, at all. r.@hc,7 are reauestil-irf, no-,,,, 663,132. The onlv thing 1 qould noi-nt out there is that there is a significant indirect ::ost in this that has come up before, about 130 some odd -- or 136,663 wlaic-i rias indirect cost but that is an establ-is'@iec@ L'-hi-,ig that @.7c couldn't do anything about at this ooink-- in tiT-e. it to 170u.- attention. 1 merely call -1 In I think i'll ston there. -Lhe regional -@,dvisorv rroun is a little hea,,r7 on tl-ic_ Drof,2ssional me.,=Crshj.n, but it's there I don't think it's 3erious Droblem. TIIE Cil@,I 71,iul? DR. m.11SCil.Yi: "l'ile have no reason to disagree ..7ith an,%7- :hing that ha- been said. It's a pleasure to read a proaram --hat has not onlv been able to carry not onl-,7 been able to accumulate funds currentl,7, and arranqe ongoing fundinc, -- ':)ut @,hd is able to accumulate funds concurrently in multiples @.e., %,!here the,,,ill put in half a Billion and they @,yill c igo running about a t7.,,o to tiirce million dollar program 5 that ,.7ho-n T?j4P vias going to -,)hasc out, the (.',ovo-rnor and the State Government were readv to take the staff on. it looks as if they are as far along becoming tic follow I operation of PLIP as anv re(Tion that i-7e have come across. @'.Ie have kno@,7n Charlie, in operation of @,lest !7irginia, because it's a mer@oership in the Southeastern Groun, and have been a%.,,are of this development in the general direction, un to.no@-7. rL"hev seem to accorqnlish more interaction, and starting of more services and develo-oincT of manpower, fe-iier dollars than almost any group T.,i(@ are a@@.,are of. So my recommendation -- if I can nreerqot the dignil@-v of my Predecessor I @,7ould reco,@,,cnd fundin(7 as requested. I'll second that. TT,!E C.tIAIP21A-;.,T: O.-T,\. Before .7p@ or)en that u-) as Charlie did indicate, this is a verv, in one sense, a verv modest adolication a continuation of -,)rocTrarq staff with funding a slight expansion in viei-7 there and a couple of projects so that it totals "1663,000.00 in round nu,-L',-L@rs. They do anticipate cor-.ina in with a major su,,oplemental-, application ini ,ulv for $1.2 million. DR. @l.cCALL: But that, added to this, would out then' above the target. i,le're recognizing that. But I ti.iinl-, we are in a Dosition to let them make igi the judgment of what they do come in with, in their new coiii-nittee. THE CIIAIP-1",@14: All we-, kne@i -- this is one of the reasons -- this is one of maybe eight or ten, where the initial application is, indeed, restricted to continuation and to program staff -- and all of their new activities will be reflected in the July submission. O.N., !\Torm, are there any comments regarding C-AP or this matter I recall T,!est @.,Iirginia has at least considered, overl I the years, some Dossibility of disassociation from the University but I'm not sure @..?he,--Iier that ever got much d sort of NOR!,L-X@l A-'IDETI S O'L@, AnNi AgOnc,7 Director isa I'ller,@,er. of ti-ie LecTal 2%dvisor-,,r rroup a nd thev did recor,)@Tend annroval of this Darticular anolication. And as I said, it I has been previously approved by the aqenc-,i, since the @vorl,,: is continuing on schedule. The major thrust of the uroaram we can anticipate ini the ne--,t application, @7ill be on the State-wide basis,' as opposed to the individual project, or community basis. l,lo,,7 I thin],, it urobably will be the size that thev will get. DR. @mESCIlPa,7: They have helped build P.NC aaencies in an area. rrOM THE CIIAII?J.LAJ.,l do you have anv particular insic,-..- 192 r@t 7 linto this as regards West Virginia? MR. SIMONDS: Well I think Norm summed it up very well. That's a pretty good state. THE CHAIRMAN: Most of West Virginia is still that way, I know. We do have a recommendation but are there additional comments, questions, observations. MR. BARROWS: I would like to ask a question, just as ia matter of my own information: What qualities, as you fellows I see it, accounts for this marvelous support on the part of their constituency? DR. McCALL: The usual fact of strong, capable Ileadership involving MR. BARROWS: On the part of the coordinator, or do they have a good RAG too? DR. McCALL: I think it goes on further than that. MR. NASH: The coordinator, the university, and the force of the medical society They started off with -- had the RAGs to start with and they haven't had to shift. They have been right on target throughout. MR. BARROWS: The university and the medical society &re united -- i.e. -- they both agree. Now, I didn't ilsay the relationship was good between the medical society and !the university, but both units support the PM POOVER REPORTING CO, INC. 320 t4.3ssachusetts Avenue, N.,-,. 'Olaship.Mon, D C. 2,jOO2 193 t 8 DR. TESCHAN: There's a very important phrase about ihalf of one line in the application that says that, in working with the medical societies in the health delivery area, they have restricted their activities to their legislative franchise. And then the thing goes on. Well, anybody who reads English in the context that we have all experienced it, will know exactly what they mean. That says that Charley's been very careful as a non-MD, he's been very careful and he's working with full understanding with the people who might otherwise take umbrage. MR. NASH: That's right. THE CHAIRMAN: I think I've observed something this isn't 'ust West Virginia -- it does seem to me that in 3 those states which have, perhaps less in the way of health resources, institutionally and otherwise (and Maine falls into that category certainly) and during the phaseout period, they seem a little more, for whatever reasonsi anxious to preserve at little they've got, including the RMP, than some states here there is almost an embarrassment of riches, in one sense. I don't know that that's an axiom, but I have that impression. tha-E in places like Maine and West Virginia, they eem to be, or to have been willing -- and I think they ha,7e ad good programs there, to try and preserve the RMP with tate and other fuhds, moreso than had it -jDeen Michigan or HOOVER REPORTING CO, tt'C. i, 320 M@assachusetts Aveni,,, N-E V@ash;ln,,ton, D @C. 20002 194 Illinois, necessarily. t 9 DR. McCALL: But I think also, in addition to that the good leadership, good program a lot of needs relative to the resources. THE CHAIRMAN: Yes. DR. McCALL: But also, a rather homogenous noncomplex region, too. You know there has been a lot of competing institutions and people, so that they were able from the beginning to focus it, and then have not only the need to recognize their function but they were productive in it -- and therefore, you can rally when the legislation gets shot out from under you. People come in and say: This is a worth while thing, and MR. NASH: There's a motion. THE CHAIR14AN: Yes, there is a motion, but are there any other questions or comments? If not, we have a motion to recommend approval of the amount requested, $663, 000.00 which has been seconded. I call for the question. [Approval of the amount requested was put to vote and carried unanimously.] HOOVER REPORTING CO, INC. 320 tA3ssachusetts Avenue, N.',. 195 still short Bill wt 10 THE CHAIRMAN: 'O.K., again we are Thurman. He's got three black marks now -- but he can afford it,'he's a dean of a medical school and he's got enough major insecurities without worrying about black marks from the Chairman. [Laughter.] I wonder, Sister Ann, since Bill isn't here, if we could again improvise, and ask you to review Oregon? This is a region where we only do have a single reviewer, Sister Ann, since Dr. James is not here. SISTER ANN: There is a staff person here. THE CHAIP2.,IAN: Yes, there is a staff person here, Dick Russell, and he's just coming up here. OREGON SISTER ANN: Oregon is presently at the $767,000i level and they are asking for $1.2 million. They are bringing in three new activities, and a total of eight projects, and they plan to come in, in the July review for a project at the cost of $200,000. The program, from what I can read, and I -questioned a few people who were there on a site visit, and apparently it has been a good program over the years. From the material that is presented in the book I was able to identify a strong program leadership, with staff, with the regional group, that has a good review process and apparently it functions adequately. .40OVER REPORTING CO, INC. 320 Mass2chusetts Avenu@, N.',. 'Nashingto6, D.C. 20002 19b The Regional Advisory Board select projects and wt 11 '!I assign priorities, and they do this through three standing committees, by which this is accomplished. It was interesting to me that the coordinator of the program is really in control of three projects with a total of $360,000. You might want to comment on this, this is rather interesting it kind of indicates the style of leader- 1 ship in this'program. MR. RUSSELL: Yes. SISTER ANN: There are eight professional staff and there are three vacancies that they hope will be filled. Credentials could indicate that the staff is well qualified. Their job descriptions are well written, and if they operate within that framework, they should be able to do a good job. In the past, they have had adequate technical review, problem analysis, and documentation of need and technical soundness. They have also addressed themselves to efficiency and containment of costs and this would appear to be on an ongoing basis. The project, submitted in two ongoing projects (approved but unfunded projects due to phaseout directions) and the new activi@s not reviewed by the Board -- the methodology for achieving the goals listed on page 42 of the project -- and I won't read it -" if the methodology is 40OVER REPORTING CO, INC. 320 Ma-.sach@e,,ts Aveflue, iN.L Washir,gion, D.C. 20002 198 wt 12 followed, it's very adequate. The three priorities are ones that were established lby the Federal Government -- the availability and accessibility and improvement of following, and containment of reduction of costs -- it would appear that they would be able to carry out the projects in the allotted period of time. And the CHP relationships appear to be good although as I looked at the letters and concurrence on the last project, I noticed that there was no return on about 50 percent of them, which kind of conflicted v&h some of the other impressions that I got. And these are the main things that I picked up. THE CHAIRMAN: I think Sister Ann was the only reviewer, but I think perhaps you will want to elaborate on this MR. RUSSELL: Well, let me respond to Sister Ann's quest--ions, because 1 think they are very pertinent questions: The one that you didn't quite understand the 50 percent return -- was this of letters? SISTER ANN: Yes, that's right. MR. RUSSELL: 0. K. This is a matter of procedure as part of the Oregon structure. They have a CHP subcommittee and all the project applications come through that subcommittee so they do have input there. HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N@'@. Washi,,igton, D.C. 20002 igg wt 13 And in the applications for Oregon, I think it was only nine of those did not respond formally. But the CHP relationships are SISTER ANN: Yes, that is very good. MR. RUSSELL: Now in terms of the staff, they do show two professional vacancies. Now those vacancies have been filled. They, you know, knowing that it is sometimes difficult Ito recruit just on short time, they are using interns from the Ten WICHIE program -- The Western States Commission for Higher Education. And these young men are on board. SISTER ANN: I think ther w e ere five they were going to bring in -- is that right? MR. RUSSELL: Well there were only two vacancies Ion page 53 SISTER ANN: Yes, but five interns were going to be hired into those vacancies. MR. RUSSELL: No, I think there were only two as I understood it, and those two are filled. Now the three projects which Sister Ann referred to which show the coordinator as project director -- which, I believe would be a CHP priority as 1, if I remember correctly. The other is an emergency medical service consul'ca- ition. Yet he is not project director, per se it's that 40OVER REPORTING CO. INC; 32OMassachusett@Avefiu@ N,',. l@these funds are controlled through the Program Staff budget Olaship,gton, D.C. 20002 200 and all of that money will be subject to Regional Advisory wt 14 Board review, and approval. You are right, the Regional Advisory Board is aware of them I sat with them for their four-hour meeting to look at the applications, and they have been very much involved, and it has been a very strong program. DR. TESCHNI: How many of the new activities are going to be processed through, or managed by the University I of Oregon? Just in round numbers -- one out of ten, or ten out of ten or -- there are a number of these projects who will be managed through the University. MR. RUSSELL: Very few, if I remember. DR. TESCHA.N: Wiall, when I se6. the list here look@ it looks as if they were managed somewhere else. "A hundred thousand dollars to CHP priority" was the, title, and I was interested in what it was. SISTER ANN: But that, then, is when it was under [Dr. Rhineschmidt] and that --.is under staff $900,000 and then ther6ls another $150,000 somewhere itis total $360,000 under his direction, so he keeps it in the program,hi@se DR. TESCHAN: What do they plan to do with that? Can you tell from that? SISTER ANN: No, I can't tell from the application, but apparently the staff is going to address itself to the HOOVER REPORTING CO, INC. 320 Massahusetts Ay,, r,,ue. 'Na@ington,D.C.20002 201 management of it, but I would think that CHP is going to be wt 15 involved in the planning, and I think the various agencies in the area- are going to be involved in providing the services. MR. RUSSELL: What this is -- this is, you know, in keeping with the emphasis being placed on the particular relationship DR. TESCHAN: That signal, I got. I wanted to know the content -- I can read this myself. MR. RUSSELL: And they have a number of.activities that now are in the developmental stage. These will come in as projects -- go through the advisory group interview, and then will be approved and awarded to individual CHP agencies. DR. TESCHAN: I gather the decision is exactly what the content would be -- it's open ended. They wanted to get some staff resource to move in that direction and to have it earmarked for committee for that purpose, to get the signal to you all and to the rest of us on that. (Reads from the document.] what they are saying, you see, the law is that 'they have to do this and most CAPs or many, would say: This in our experience has not been ready because they didn't have the basis to make the judgment. SISTER ANN: I got the impression that the majority lof the funds for these programs, that it's really kind of a ithrust into the future as well beginning in the present, and HOOVER REFORTl.4G CO, INC. 320 ti'ia@chusettsAverlue, Vjithinartnn D C- 2@)3,&2 202 f link '-hese programs iit really would be very difficult to kind 0 wt 16 together in the kind of a model that their Federal Government talks about at the present time. Is that right? Does that reflect MR. RUSSELL:- Yes. THE CHAIRMAN: Paul, with respect to the University of Oregon and the Medical School, I recently, on a flight, was sitting next to somebody from the University of '.Oregon', and I had the -- apparently, you know Oregon is a "different" state you see in many respects. They are trying to keep people out, and they led the way in gas rationing -- but also, its University is one that they are at the end of the line in feeding at the Government trough They get less money in terms of Federal grants percentage-wise, than any other medical school in the country. And the Dental School won't even accept percapitation grants and that, you know, is almost unheard of. So it isn't surprising in one sense that despite the fact that the University is a grantee here, that very many W4P a'6tivi-Ei'es now, or in my recollection in the past, has been university-sponsored. DR. TESCIIAN: You really must have a first rate coordinator out there too. MR. RUSSELL: Not too long ago there was a management. ,Ias@sessment this was by a management program -- and the best 4iOOVER REPORTING CO, @NC. 320 lv'iac@sach,,isetts Avent- V-Iaship,gton, D.C. 20002 203 wt 17 I can remenlber, the only recommendation was that the grantee ought to buy some curtains for the RMP Office. MR. SIMONDS: Well, that's a little exaggeration. [Laughter.] DR. HEUSTIS: Well, while you folks feel sorry for the university, I know that they are getting $163,000.00 in indirect costs.-- MR. RUSSELL: I didn't say I was feeling sorry for it, Al. THE CHAIRMAN: I seldom have bled for a university. SISTER ANN: But you know, for a university grantee, they get the lowest amount. DR. TESCHAN: What's their rate? .SISTER ANN: Oh, I think it goes up to 60 percent in some cases DR. TESCHAN: And how low MR. RUSSELL: 40 percent for salaries and wages. THE CHAIRMAN: Well, this is an application for, again, in round numbers $1.2 million. They have estimated that they will be in with a very small supplemental, roughly $200,000.00 in the July request but this is their major request. The total of those would bet again, almost their target level- figure of 102 percent by our calculation. HOOVER REPORTING CO, INC. 320 t@assarhusetts Avenu@, fit. Washington, DC. 20002 204 wt 18 Any other questions, or any other comments? Sister wt 18 Ann? SISTER ANN: I recommend that they get the amount ,that they are asking br $1.2 million. Their target is just 102 percent. I believe in rewarding good programs. DR. HESS: Was that a motion? SISTER ANN: Yes. DR. HESS: I'll second it. THE CHAIRMAN: We have a motion and a second, to approve, or recommending the funding at the level requested, $1.2 million. Is -there any further discussion, comments, questions? In that case, the question. DR. HESS: Let's Vote. [The motion was properly put to vote and carried unanimously.) HOOVER REPORTING CO' .1,iG. 320 klassachusetts Avepie ti.L. Washington, D.C. 20002 205 THE CHAIRMAN: Again, unanimous we re just wt 19 continuing the complacency of yesterday afternoon. DR. HEUSTIS: I think the Chairman should find a better word than "complacency." THE CHAIRMAN: Everything, in the eyes of the beholder, Al. Well, we are still missing Bill Thurman, so we're going to continue to extemporize. DR. HEUSTIS: If they ever subpoena these tapes, I would just hate to have anybody think we were complacent. THE CHAIRMAN: Well I don't think they will find very many explicatives, or, on my part, many "inaudible" portions. As long as we are on the West Coast, and if John and Al feel up to it, we might want to take one tenth of our MP, namely, California, which in terms of population, past funding, has roughly come out that way. Al, do you want to lead off? Or John? Again, I don't know DR. HIRSCHBOECK: No, Al does. [Laughter.] DR. HEUSTIS: You see, I have a voice problem, this morning. CALIFORNIA DR. HEUSTIS: Well, california is submitting two Ilapplications for this year, and the one that you have before you @40OVER REPORTINC- CO, INC. 320 Mas@Achusetts Avenue, N.'- ,Nas@.ir.gton, D.C. 20002 206 is for approximately $8.3 million, of which about $1.6 million wt 20 is for the program staff. And they would estimate that with the July application they would come to $14 million and you can note, if you care to look on your white sheet that the RMP are prorated figures at $12.5 -- so there are approximately $1.5 million ahead of what they were advised to do. They.served the area of California with two regional offices, both of them (note) located near major airports, one in the northern part of the state and one in the southern part of the state. The Regional Advisory Group has established si4,goals and six program elements, and the will implement these. y The goals are to be implemented through six programs, and they have assigned a percentage of funds, and have determined their priorities in this way to each of the majbr goals. The percentages are the largest, they held manpower at some 25 percent and the least is 4 percent with others ranging in between. The RAG is strong, stable, and very interested and this is judged by the attendance which has a very well- known committee structure. In addition to the Executive Board, there are three standing committees on program development, one on program .1review and one on evaluation -- and then they have what I like, HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, OVashington, D.C. 20002 20 wt 21 the program element committees in each of the areas and their charge is to develop programs and to monitor programs. Here, again, it seems to me that real guidance is provided to people that would request money, in what the money should be requested for. It came through strong and clear to me that the RMP Central Staff plays an extremely important role in actually coming up with the projects and trying to define what our RMP role ought to be in each of the general areas -- and trying to define what kind of applications they ought to address themselves to, and they actually have pretty well defined criterias for the program development and provide actual guidance and request preparation I don't know whether they actually write the requests or not, that wasn't stated. It was stated that the nine RMP Area Committees that formerly existed, had been phased out and that the program elements committees had replaced these, and that the they were well satisfied with the fact that the volunteers were now doing -- at least I got the impression from the ,Work, that they were now doing a better job than the good job they previously thought that the staff had been doing. The final budget, as requested, has been approved by the RAG, and first of all, apparently in the process the reports of the Program Area Committees goes to an Executive; HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, ti.E. 'tVas,6,ington, D@C. 20002 2o8 Board, and the Executive Board reconunends a division of the wt 22 Ili funds among the Program Ar@-as and then the RAG makes the decision as far as the -- within that context, with regard to the applications. I think they have a really well defined review and approval process, which is adequately described and interestingly -- and before I reviewed this, I didn't know that this was exclusive. They used technical experts, apparently from outside the region -- but the technical. experts work under the supervision of the Review Committee. The one matter that I felt was defective, and yet I I am extremely understanding, because California is a pretty complex state -- and other large states have been having similar problems -- and that is: First of all, who speaks for CHP? And how do they effectively communicate what they think, to RMP? I gathered that RMP has, what I would consider an arms length" relationship with CHP and that RMP was extremely strong, relatively, and CHP was relatively extremely weak and there was no described CHP development or input into the preparation of requests prior to the RAG action, except for I the legal review and comment -- and that seemed as though at minimal, CHP ought to in some way formally be consulted about what they thought their needs and priorities were. IIOOVER REPORTING CO, INC. 320 M3ssachusetts Avenue, N.'@. Oiastiington, D.C. 20002 209 hey don't h @t 23 Of course, the whole problem may be that t ave any need for priorities that have as yet been developed but that is rather reading between the lines rather than reading what's there. I DR. TESCHAN: Well, they have had seven years time to acquire DR. HEUSTIS: The staff is well seasoned and exper- t ienced, although substantially cut. They used to have approximately 50 percent of the total awards that went to staff@ and it's now down to 12 percent. The past results that I found, seemed to be impressive both with regard to the numbers trained and, I guess I have to interpret some of these figures, I'm not quite certain how meaningful some of this is, as far as the meaningfulness. We talked about new medical power resources created or new medical people power resources created" and the number wasn't really very impressive. I think it was a little better than 2,000. But the access to care -- it seemed as though the two major provider systems that had been started and now were expanding with other funds -- they have given attention to and they have done some work with the Iurban Indians, California Council of Free Clinics -- all helping the under- iprivileged. HOOVER REPORTING CO, INC. 320 M,3ssachusctt@ Avenue, N.[. 210 ojects without cord of continuations, the pr The re d that out of 76 ongoing 24 RMP funds, was impressive. They sai s that had terminated since projects, or a total of 81 project rcent had continued with other funding July, 1960 -- 70 pe sources. In the first year, it said that following the RMP discontinuance, the projects that had previously been funded over three years fot a total of IUAP funds, in the amount of $7 million - in the first year of going along with other funds -- the people came up with $4.5 million to continue what was going on. I thought that that was rather an impressive figure. The continuations supported by all kinds of money, including voluntary funds, university funds, hospital funds, State Governmental funds In the proposed program, they are trying to set u@ a network of what they call "Health Services, Educational Activities" to cover the entire state -- and yet some 14 of these formed ten of them are incorporated and four are developing -- and these are supposed to improve the quality of health care for coordinated state-wide system for health, manpower, training utilization and health education. And again, it mentioned that over a hundred colleges and 120 hospitals(seemed low) and clinics involved in this with some 200 people on the boards of 211 of directors of these organizations. wt 25 In high bloodpressure control programs, they have a state-wide plan, and I thought it was interesting that of the 36 applications that had been received, the project said that sixteen were selected for funding. Then I think the others were, of course, pretty much there. Again, as I indicated before, the thing that probably bothers me the most, and yet probably shouldn't bother me too 'much, knowing what the facts of life are -- are the relationships between CHP and the Regional Medical Program. THE CHAIIUMN: Oh, I think Staff may have something to contribute to that -- we spent four days in California DR. HEUSTIS-. It is very difficult for a person with just the information we have, to evaluate the real meaning- fulness of the CHP comments -- whether they are just bemoaning the fact that they haven't been recognized and watt to say some things, or whether they really have a beef and maybe the staff could be helpful there. But before we get to that, as far as my assessment was concerned, I have rated on the Review Sheet, all of the items from -- on the first page, program leadership, program staff, the RAG and the performance and objectives in the "good" to "excellent" category. HOOVERREPORTINGCO,14C. 320 Massarhusetts Avent,.,, N.',. Wasiiin@ton, D.C. 200OZ wt 26 on the second page, I had to break down the three items in the proposal, thinking that they were congruent and that they were addressed to areas of emphasis, and because I didn't know about the CHP input of plans, and because there were criticisms, I rated that down to "Above Average." And then on CHP relationships, I thought these were very I couldn't make the determination, and if I had to vote I would have to vote that these were certainly "Poor." But the column that I checked was the "Insufficient Data' and then the overall assessment of the program was "Above AVerage." And the recommendation was made that as far as the funding level, that we ought to know more about CHP. And tnen, I should say after that that we need to have staff comments. THE CHAI.@'4AN: Well, thank you. You have raised the matter of CHP. Perhaps I would comment on that before we ask John, and then Rebecca can complement some other things, as relates to California region. Relationships with CHP there, are uneven, but even i CHP relationships one to another, are uneven. Let me explain that: There are twelve B agencies in California and I think the relationship of the California PDAP, with most of the medium-moderate sized ones (Fresno and the northern counties, Empire Valley, which is Sacramento) we met with, during the HOOVER.IEPORTING CO, INC. 320 laassachtisetts A,4enue, N.',. Viashingtoii, D.C. 20002 213 Icourse of our four-day visit, Rebecca and Sandy and I, met at 27 !with six B Agency Directors and the A Agency Director. !The relationships -- I would describe those agencies as "Fair to Excellent." Much of this has been as a result of the Health Service Educational activities where the State is blanketed by those which have been sponsored by the California RMP tagain, the development has been somewhat uneven, but in many instances, one finds that these health service educational 11 activities, most of which are now incorporated as private non- lprofit groups, are in a very real sense, the health planning arm, or at least an important adjunct of the local CHP agency. Relationship, on the other hand, with the three maDor CHPs in terms of Population areas -" Bay Area, Los Angeles, and Sany)iogo -- are arms length to "awful." MRS. SADIN: Well, LA was all right THE CHAIRMAN: Well, yes, LA -- at least the word we got was that LA wasn't doing anything, so that they weren't getting into anybody's way. But some of that is a matter of personalities, I think. We found, for example, that in the Bay Area, the Director of the CHP (and that's sort of a federated CHP, as there are nine counties, and each of them with one exception I believe)-- DR. HEUSTIS: Yes, but it seemed to me that in HOOVER REPORTING CO, INC. 320 assac@iusettsAvenue,ti.'i-. Viashington, D.C. 20002 214 wt 28 addition to the B Areas, that every county had its own CHP, and to kind of sort out the comments it became very complicated. THE CHAIRMAN: Well, the Bay area is an interesting CHP -- certainly the most vocal, outspoken, bidder, director we ran into, that was Don Ardell in the Bay area. He was having problems with his eight County Directors, and they sort of meet apart from him. Correspondingly, those B A@encies, and perhaps the B Agencies in general, but certainly the larger ones -- I'm not sure it's constructive, I think there was some destructive tension going on presently between the A Agency and the area wide agencies out there. I think the @IP has, on the while, pretty good relationships with the A Agency. Now part of that may be the fact that the A Agency is, comparatively speaking, poor So that it has been getting some money from the State EMS Office, or from the RMP, to do some of the things that it really hasn't been able to get State funds or State positions for. But the picture is a mixed one, but certainly based on our site visit, Rebecca has thrust in front of me here both our report to Dr. Paul and our feedback letter to Paul Ward -- while we did have some recommendations about their HOOVER REPORTING CO,.Il'v'. 320 Massachusetts Aver;ie, N-1. ;.,- @@ 0 innni 21 5 relationships, I think there are more that have to do with wt 29 details, that they really ought to do a better job in insuring ithat the letter, as well as the spirit of the law is followed. If for no other reasons, the defensive purposes. They were kind of sloppy in logging in things, and showing that they you know somebody wants to get you over a barrel But we felt that on balance, that the requirements for CHP reviewing comment were largely being met in substance as well as technically. We did, also, have a chance to witness at the RAG meeting we attended, that there.are several CHP representatives on there -- one from the State CHP and the area-wide agencies have a California Conference of CHPs -- it's kind of their "trade union" and they have a representative on the RAG and at the RAG meeting we attended an alternate member was sitting the fellow from San Diego -- and they certainly,, not only spoke out, and they had some objections, but the RAG took them under advisement to the extent that they deferred -- they were going to look into the matter and either accept them in whole or ignore them and I think, you know, that even that slight demonstration suggested to us that in the RAG councils they have the ability to make themselves heard. So it's kind of an uneven picture, Al, I don't HOOVER REPORTING Co, :,','C. 320 Massachusetts Aven,te, N.'@. i&'ithinoinn f) C 7(jDO2 216 at least from what we've wt 30 DR. HEUSTIS: From what you have said previously what comes up with what I get out of the thing -- I had written down a summary of the comments that had been made, and that was marked in red -- and I admitted that the ones that I thought were important, and I had imported negative comments from six of the twelve areas -- at least what I thought were impor- tant negative comments of the six MR. BARROWS: I don't think we can charge them with the responsibility for resolving these intramural conflicts within the CHP. THE CHAIRMAN: Oh. no. MR. BARROWS: But we can grade them on their effort to relate to CHP -- and would you regard that effort (and this should be a positive one) as "Good" "Average" "Weak?" THE CHAIRMAN: I would have to ask for Rebecca to comment too. My judgement, I guess, would be "Atrerage" to "Good." I think there are some situations where my impression is that California RMP feels that it has walked the last mile. For example, when the Area Offices are abolished, that was a kind of a structured cross-over situation., When they abolished all their area offices and with them the area advisory committees, and came up with the Program Element Committees as a substitute -- there became a number of vacancies HOOVER REPORTING CO,:.ic. 320 Mamchusetts Avenk@@. N.'@ Olashin@iton. D.C. 20002 217 on various B Agencies you know our slots targeted for the wt 31 RMP, we found in the Bay Area that an issue of longstanding the B Agency Director wants an RMP person, but he wants a consumer. But it just so happens that in that part of California Paul has only got some providers on his RAG, and you know, I think there is a real personality kind of conflict. But I think on the whole -- and one of the suggestions we have in our feedback letter, was that they should consider the possibility of having a fairly senior staff person as kind of a liaison with the Conference of the Aqencies -- they have met with them, and again, this is not a monochromatic picture at all DR. HEUSTIS: Have we any kind of a written agreement that has been either tried, or achieved, as to what each of them have thought they were supposed to be doing and what their responsibilities were DR. TESCHAN: The answer to that is: Yes, as I recall. Now whether it is current or not is more to the point, but I recall that there was circulated to the coordinators some two to three years ago -- and this was the first example of a written memorandum of agreement as to what RMP and CHP roles were going to be and how each would interact wlth them. I'm quite sure Paul Ward was HOOVER REPORTING CO, INC. 320 Massnhuretts Avenue, N.[. 'tiashis.igton, D.C. 2COfJ2 218 DR. TESCHAN: I thought it was a marvel. As a wt 32 matter of fact, when we got around to signing a statement in Tennessee, we used that as one of the bases of ours. MRS. SADIN: But I think it's uneven -- the relationships are uneven. The only suggestion I could think of and we discussed this -- I think we need a Rabbinical Council -- you know, you mediate. just need it, to i'm awfully sorry, Sister Ann. (Laughter.] I You know, in the old days, they didn't need lawyers both parties just went to the local Rabbi, and I kind of thought that's what they needed.. [Laughter.] They are doing, you know, the legal part of it and getting the review in comments and submitting the things, etc, etc,, etc, but it's a relationship thing that's the proble,7, in some areas. They are now logging in, as you can see in their applications, all of the comments that are sent out and all 76 projects DR. HEUSTIS: 76? MRS. SADIN: well 75 not that's a lot of projects@ for review and comment -- and they just sent me another whole batch from the LA -- and this is all just LA CHP (Displaying a dossier.] DR. HEUSTIS: That came in late. HOOVER REPORTING CO, l'IC. 320 Massactiusetts Avenu,, N.". WashinRton. D.C. 20002 219 MRS. SADIN: Yes, that came in late. [Laughter.] wt 33 So it is -- you know, one of the things we suggested and this is the letter sent back to Paul Ward -- and one of the things that we suggested is that they have a senior staff person as liaison, to spend more time and pay more attention to that problem. DR. HEUSTIS: Well I am satisfied from what I have heard, that I would change my recommendation from "Insufficient Data" to at least a "Satisfactory" relationship. THE CHAI@IAN: Correct..me, Rebecca -- but most of the program elements committee do have a CHP representative on them. This is really their program development thrust. Now DR. HEUSTIS: Yes, it is pretty good. THE CHAIRMAN: Well, I wonder if we want to hold withhold other staff comments, and let John as a second reviewer, take a look at California -- we have spent an awful lot of time with CHP but given the fact that they are probably 10 percent of the CHP in California, also. At least, in terms of family, I wouldn't think that was far off. DR. HIRSCHBOECK: Well, I won't repeat the comments which Al made because I think they hit the target right along the line in most instances. I am troubled in one way that in reading this over, I didn't see what really happened when the areas were dissolved HOOVER REPORTING CO, INC. 1020 Massachusetts Avenue, N.' . WashinRton, D.C. 20002 220 wt 34 and they were put into two. Is CHP, again, is it moving into the area-wise approach here that existed with@ the regional setup? I think that because of this, maybe this is one of the reasons for some of the problems that they are encounL@-e--- ing there in relating to the CHPS. The other point that bothered me is this enormous ll'project that Dr. White is in charge of -- it's how many millions? Altogether, I guess he's asking for a state-wide consortium of colleges and universities and hospitals and this enormous arrangement seems to me really going too far. At the practical level, I don't know how they are going to work this out, but if this is the way to go in California, maybe it should he allowed, but I have my druth6rs about that enormous approach to dealing with area- wide health education aspects. MR. BARROWS: Resolving that at Berkeley DR. HIRSCHBOECK: I guess so. [Laughs.] I have made several visits, site visits, to other agencies in the California region, and there is one for the California RMP and one in their Review Team consulting visits, and the thing that impresses me out there is that things are HOOVER REPORTING CO, INC. 320 Massachusett-- Avpnue@ 221 wt 35 @i so different in different parts of the State that to try to resolve a problem on a state-wide basis becomes extremely difficult and this is recognized initially by their setting up a CAP region. And now that this has gone, I am uncomfortable. It's like setting up a Regional Idedical Program for a whole nation, and doing it in one'-- as a sub-set of another nation. I don't think DR. McCALL: That is difficult to do. We tried it. [Laughter.] DR. HIRSCIIBOECK: So that my overall evaluation is: Sure, the leadership is good. The problems are difficult. The program and staff is good. The Regional Advisory Group I might differ a little with Al on all these he has perhaps read it in a little different way. I had the feeling at least that the Regional Advisory Group- was@ not really involved in the actual process of evaluation as much as other Rk4Ps are. In other words, they take the word of others very readily, without being, themselves, directly involved. Now I may be all wrong on that but I sort of sensed that HOOVER REPORTING CO, 14C. 320 Massachusetts Avenl,,,,, N.[. Washington,D.C.20002 222 wt 36 Past performance and accomplishments ... objectives and priorities -- I think these are well defined. Feasibility -- here, again, the whole idea of true regionalization on a state-wide basis, I think, is very difficult. In general, I would say "Average" or "Good." "A,v3rage" would be my overall evaluation. MR. BARROWS: Let me ask a question: One of the things -- California, as you both pointed out, is not only vast, but extremely complex. One of the very unique complexities is the strength of the foundation movement. Now nobody has commented on how this program relates to the practices of the community which happens to be an unfortunate bias of mine -- have they been relating to these foundations at all? This is including the interplay between DR. HIRSCHBOECK: Well some of their projects are involved in the quality insurance. DR. HEUSTIS: They mentioned particularly some of the foundations have picked up the check for some of the projects which had gone on THE CHAIP24AN:: Great. DR. HEUSTIS: Now how extensive this is, I don't know@ HOOVER REPORTING CO. iii 320 Massachusetts Averl:e N.[. ik;t,.hintrtnii DC 20002 223 11 or how wide. MR. BARROWS: Good well- boy, that's the acid wt 37 test to this hard-earned DR. HEUSTIS: Whether this was two foundations or twenty foundations I couldn't -- I believe my notes are not clear. FROM THE FLOOR: Could you tell roughly how mahy grantees there are, other than their sponsoring grantees programs? DR. HEUSTIS: You would have to help me there. DR. HIRSCHBOECK: Let's see the agencies other than central staff that are handling the money -- as grantees. MRS. SADIN: They have subcontractors -- or contracted, that is, most -- for instance, all of the health service activities are contracted to the independent facilities. They are calling their shorts And almost all of what they have, when they develop a program element, they have sent out RMPS, you know, throughout the state, and in which they really outline what they want and then they contract it out. They have in their access, which is going to be coming in in July, they have had something like -- from their RMP they have something like 250 isn't it? I think it's 250 letters of intent, which is the, way they go about this libusiness. HOOVER RENRTING CO, INC. '120 filassachusetts Avenue, N.' . 2211 wt 38 In answer to some of.your questions on the definitions of area offices -- one of the things the CHP -- or some of them, told us was that well now that they don't have the area offices in California, that we could kind of take their place in terms of local input. And when-we mentioned that to Dr. Mitchell, he said ';Yes, do you think this is the first time I have heard it>" They have never communicated this to us. (Laughter.] Some said that they missed the area offices and some of the agencies said they were glad they were gone. You know, it was kind of a 50/50 kind of thing, almost through- out the state. The result of the definition of area offices really you know they had something like a three-months visit when H7--,',' audited them and this was the latter part of 172 "- that was a fact that one of the strongest recommendations was that they not have all of the area-- offices. And I think Paul Ward took the opportunity to follow the advice of the HEW auditors, and they now have a northern field -- it isn't just a central office, they have a northern field office and a southern field office. THE CHAIRDIAN: Yes, but these are quite different from the old areas. These are essentially administrative HOOVER REPORTING CO, INC, 320 Massachusetts Avenue, N.[. 225 wt 39 or for program development, and monitoring purposes. MRS. SADIN: Right. DR. HIRSCHBOECK: One@ wonders whether they shouldn't really make two RMPs instead. MR. BARROWS: Right. From a management point of view this is too damn big for one MRS. SADIN: Right but MR. BARROWS: But we can't do anything about it. THE CHAIRMAN: I think that represents, though, a very conscious, deliberate, decision made at the time Pj4P came along and involving what, at that time, were a lot of the influential people in California. At that time you will remember, Breslow was the State Health Officer, and Brown was the Governor, and they made a conscious decision and they wanted a "state-wide" PIIP even though it might be juggled. They came out exactly the o posite from N'ew York, which now has six or seven P14Ps. p So they didn't blunder into it, and I'm sure, like any decision, it had both then and in retrospect both its plus and minus qualities. MR. BARROWS: Well, there's not much we can do about history now. What's the recommendations SISTER ANN: I was interested in your comment where you said the technical experts work under the direction of the IOOVER REPORTING CO, teiC. 320 Massachusptts Aver,@@e, N.I@ W,,iqhington. D.C. 20002 226 IReview Committee of would this be inhibitory to the technical experts? wt 40 DR. HEUSTIS: Are you talking to me? SISTER ANN: Yes, you indicated in the report, that the technical experts work under the direction of the review committee. What's the purpose of bringing in these technical experts? DR. HEUSTIS: Well, I think the purpose of bringing in the technical experts, as I understood it from a person that made a site visit too, with me one time when we got into this discussion -- is that this is to get rid of the local bias and the local conflicts of interest and the local antagonisms between the centers from which the experts come. SISTER ANN: Then you said that they work under the direction of DR. HEUSTIS: Well, the "direction" -- perhaps if I said the overall direction or overall supervision DR. HESS: Or "they report to" MRS. SADIN: I started in on that -- to review particularly the manpower, and they do bring in top experts and they have to counteract the ones in California -- and I think what was meant was that the recommendations go into a review -- but it isn't DR. HIRSCHBOLCK: But this is exactly the point I was@ tryingto make a little while ago. I think that the distance 40OVER REPORTING CO, INC. 320 klassachl-,sett., Av@-fiue, N.',. 227 wt 41 between the RAG and that technical review process, is at least at the time that I was out there it seemed to be a larger gap than really should be. That the RAG should be much more closely involved in the actual review of the project itself and not just take the report with the badge of an expert pinned onto it. MRS. SADIN: I don't know if they changed it since Twelve been there, but they now have a member of that RAG Represent at every one of these -- which helps tremendously, and @i he reports back. THE CHAIRMAN: They have two standing committees. A review -committee, and; An evaluating committee. Under the Review Committee, the technical experts operate in a panel fashion, sort of. They look at the new projects. The Evaluation Committee, on the other hand, doesn't have that close line of the smaller committees, and they are the ones who look at and then forward to RAG. And then, both of these standing committees are RAG people, on continuation, so that they have that kind of relationship And what goes through RAG, if it's a continu- ation of the Evaluation Committee -- if it's new, it goes to the technical panel. So it's the overall "umbrella" supervision HOOVER REPOPTING CO, INC. 320 Maszchusetts Avenue, N,@L. 228 of the Review Committee. wt 42 SISTER ANN: And then @re, too, on page 3 of the Staff Comments, they have 70 requiring surveys, four kinds of positions -- they are adding the 19 but one of the concerns is the proposals are not being monitored and evaluated on a systematic basis. And here, I just wondered if adding more and more people would complicate the issue. MRS. SADIN: There is some urgency to this. In fact, they have added evaluations to their staff, and they are asking -- part of the 70 is for more. But we had, after their supplemental application we sent an advice letter back to Mr. Ward. We had suggested that such a vast program would merit that they spend more time on surveillance and monitoring. And when we were there in April -- if anything, they had gone the other way. They are sending the people in the Southern Field Office to the Northern Field Office and require a monthly progress report. So if anything, they have gone overboard. So they are monitored all their people in their Field Offices are monitored -- every single contract -- and' this is the contracts mostly, so that they have a condition written into the contract. HOOVER REPORTING CO,'NC. 320 Massachusetts '@iaship,gton, D.C. 20002 229 wt 43 DR. HESS: I see. DR. TESCIIAN: I would like to say that the evaluation effort of what public accountability of funds really means in terms-of output benefit -- that whole concept was jelled for all of the RMPs in the country by the initiative of Paul Ward and that staff in California. And a good deal of some of the numbers you are,seeing, John, and all the rest of us are aware of how that ultimately became generalized in order to get the data together, to show to various critics what the numerical impact of these activities was. I am interested that you consider that some of it became a little bit more compulsive than others -- but I understand the atmosphere in which such compulsion can be generated so that I even have some tolerance for that as we 1 l.. MRS. SADIN: In terms of the H.E. Doctor, you asked a question about the manpower. When we said "supplemental funding" in July of 172 California of course as usual, got the most money in the supplemental funding for manpower control -- they started out with something like 10, plus the Central Coordinating one. They now have something like 15 and they just about cover the state. Some are in the planning stage but most are now independents consortium with independent boards. HOOVER REPORTING CO, "IC. 320 Mamc-husetts AvenL,, N.@'. Washinaton, D@C. 20002 230 It's interesting though, that at conferences like wt 44 the schools of Allied Health Protection -- and they have had some -- there's a national conference in Boston this year they had Dr. White speaking in some of the consortia of the directors. The people at the conference were so excited about it that they then sponsored their regional California conferencEs they have done some exciting things. But it is a lot of money, though. DR. HIRSCHBOECK: Well, I would like to see it sometime, to see how it functioned. It sounds good on paper but I would like to DR. TESCHAN: Well, John, the thing that bothered us is that each one of their nine regions was about as big as one-point-some million as most of the other RMPs we are talking about -- and to see Paul Ward, in one application, with a dissolution of area offices, jus-. boggles my mind. And Ken's point of "management, how do you get ahold of it?" I am surprised at the HEW Audit. We know a little bit about the origin of that, or have suspected some of the origin of it, and I'm wondering whethe: acceeding to it -- the fact that it has some budgetary require- ,Iments isn't a "giving in" to what would in Ken s view be sound management since we would have insufficient data to mark HOOVER REPORTING CO, INC. ',120 M@,@@s;ichusetts Ayepue. N.[. 231 wt 45 11 or to be able to make that judgment from here. MRS. SADIN: Well, some of the things Dr. [Hirschfeld] has-said -- nobody knows this is going to happen -- they had more than a norm -- they recognized that -- perhaps not DR. HESS: You are dealing with a state of some twenty million people, and $2 million for health, education though it seems a lot in one lump sum, is not a disproportionate amount for the population. THE CHAIRMAN: Al, you've been trying to DR. HEUSTIS: Yes, I've been trying to push and I would like to make a motion. THED CHAIRMAN: Fine. We have a request here for a little over $8 million and we have an indication that California will be in -- and this is a request just for continuation and program staff. Roughly, they are at the $6 million level for all new activities in July. That would total, if my figures are correct, almost $14 million. DR. HEOSTIS: If you would then look at another column you would note that if they did that, they would then come to 111 percent of the amount that you requested for them. And because both John and I have rated this as "Above Average" it seems as though, in conformity with our HOOVER IREPOPTING CO, INC. 32OMass,,chusettsAveiiue,N.',. ;Vashin-7tr;n, D.@. 20002 232 wt 46 policy of rewarding the people that do well, and taking away from the people that don't INDEX I would therefore, move that it be funded at the MOTION requested level, some $8,170,374.00 (Th6 motion was properly seconded.] THE CHAIRMAN: All right, we have had a motion to approve at the requested level of $8.170,000 DR. HEUSTIS: 374. -- it's a separate item. THE CHAIP24AN: $8,170,374. Are there any further comments, or any additional questions? SISTER ANN: Excuse me. Are there any things that you feel we should look at, or that you think should be looked at, serious enough t at-- by reducing this funding (since they are coming in in July) might be an impetus for them to look at the funding? Are there any points or things that bother you about the region that maybe could be looked at? DR. HESS: But the point is, there is no time for them to look at anything. DR. HEUSTIS: I guess the answer, as far as I'm concerned, Sister, is that I thought it was a good program with good management and that the CHP situation bothered me HOOVER REPOPTING CO, INC. 320 Ma@chus@tts Avenue, li.',. rlr. @fICif)2 233 but that has been resolved satisfactorily for the moment wt 47 they still ought to work on that, but at this time I think I would say no" to your question. SISTER ANN: As I read those notes here and the Staff Summary, I'm not all that impressed with the good management, and I think part of it is because it is such a difficult region and as I have heard it reviewed from time to time and the management hasn't been its strong point. But as Dr. Hess says, there is nothing that can be done about it now except in terms of a recommendation. MR. BARROWS: I feel as you do. We can't reverse history. I would certainly not recommend this as a model program for the new House Resources Agency -- it's too monstrous. SISTER ANN: Well now I would think thatwould have to dome through -- it would make me much more comfortable if that came through as a :--recommendation. MR. BARROWS: But I don't know what -- it's bigger than both of us. MRS. SADIN: The target that's figured though, you knowi which is, I guess, less than what they less than the $14 million they have communicated over the telephone and they have allocated percentages to each program analysis -- and' of course if that came down to -- say $12 million instead of 11$14 million -- the man had written 25 percent of 12, etc HOOVER REPORTING CO,;.'iC. 320 Ma@chusetis Avep,:e 14.',. THE CHAIRMAN: They have pretty well -- you know, I wt 48 assume there is some ability to make adjustments at the tail &49 end.of the process. But they have gone through a process lby which the RAG has said in effect: One way of expressing priorities is that we'll put essentially 25 percent of our money into the access program -- now whether that is X-plus $2 million or X-minus $2 million -- so I do think we have a notion both here and looking at a new application, of what the or where the cuts would come. DR. THURMAN: Yes. Question. THE CHAIRMAN: All those agreeing with the recommend- ation to fund at the level requested indicate. i [The motion was properly put to vote and passed "by a vote of 6 in favor and 3 opposed.] THE CHAIP-IIAN: In that case, I guess that's by default. I can't think of any better solution. There should The one, but I can't think of it. O.K. for California. HOOVER REPORTING CO, INC. 320 Massic@usett-, AverueT N.E,1 1 1 i Viashin?ton, Dk,. 20002 (202) 5A,6-6666 235 THE CHAIRMAN: O.K., Bill, since you guaranteed us, wt 50 last night, that you could dispose of Puerto Rico in ten minutes, we'll take you up on that. And then after Puerto Rico, we'll see if the group wants to take some coffee. You and Joe -- I'll call on you first, since you are on the site visit -- well Maybe you were too, Joe, were you? COMMENT: No. PUERTO RICO DR. THURMAN: Just a reminder of the fact that a site visit was asked for by Council, as to whether or not Puerto Rico would get any money at all -- whether they should be discontinued. Mr. Nash was on the site visit with us and the most important thing about the site visit was that we had a multi" lingual team, and I think that resolved all our questions because in our meeting with the Puerto Rican groulD the Coordinator now, he was the Associate Coordinator before he has the respect for the program and control of the people. They continue to have real translation problems, even during the site visit and even though we were multilingual. Some of the concerns that came out were onl handled y by a girl who was even more fluent than the Site Team was. The RAG is very strong. It's very representative despite the differences involved with Puerto Rico, and poor HOOVER REPORTING CO, INC. 320 Wash@@ggton, D.C. 20002 236 wt 51 transportation and despite the phaseout as concerned that 11 part of the program in toto, the RAG has continued to work quite well. The real strength of the program as far as the future is concerned, is that 70 percent of all health services in the island are public, and the grantee being the University I of Puerto Rico which is also a public agency has forced the staff to flow from agency to agency, but nevertheless, has worked quite well. I think the most eloquent thing that we heard was several testimonials that came from cnnsumer groups about what Puerto Rico and the medical program had meant -- the delivering of health services to the underprivileged groups in the continuing organizations. Therrojects were just superb, when you really under- stood them (which is not true on paper, and this has been out problem the whole time.) They have an operational VSRO which is phenomenal in every sense of the word. They have a very good plan for their EMS and they are working hard at the geographical spread. I think that this program, having gone down there thinking it wasn't worth supporting for another day -- the Site Team came away totally satisfied that it was an excellent program, and I would recommend approval of their request. HOOVER REPORTING CO, INC. ,120 filassaChdSetts Avenue, 237 wt 52 DR. TESCHAN: Second. THE CHAIRMAN: Joe. MR. de La PUENTE: Well I have many good things to say about them. I have discussed with friends of mine who lived there and who have been living with the government structure, which is quite monstrous and they speak of Puerto@ iRico P14P as La creme de la cr6me" as far as entered into l'our conversations -- with living over there. And under the circumstances I have written I @,lwrote a lot that has already been said, but in summary, this application represents tenacity in the face of austerity in that a viable program is being presented. It is possible to enhance the staffing pattern with the introduction of a physician who possesses some training in the field of epidemiology, and this is tremendous. It is apparent that the Regional Advisory Group ihas continued their efforts towards program development and review. Their track record in terms of the number of programs that are eventually adopted by the community appears to be better than average. Most of the present priorities appear to coincide with the needs of the Island. Special attention should be paid to assuring the dissemination and application of findings for additional sites lin Puerto Rico. HOOVER REPORTING CO. INC. 238 wt 53 But I certainly, strongly concur with the present recommendation. THE CHAIRMAN: Thank you. Yes, Al. DR. HEUSTIS: I am impressed by what was said. In fact I was so impressed by what was said that I looked over into the next to the last column on this tabular sheet, and I noticed that Puerto Rico is one having the honor or distinction (or otherwise) for requesting the lowest amount of the allocated funds, for any group. THE CHAIRMAN: Yes, the lowest percentage of that so- icalled target figure. DR. HEUSTIS: Yes, the lowest percentage. THE CHAIRMAN: Yes. DR. HEUSTIS: Now, with the obvious need, and I say "obvious" need, it's from what you have said after a one- week visit -- and whan I was there under different circumstances and not for RMP and quite sometime ago Is this because they were tired, or because they were:, discouraged, or because there was a lack of understanding on the part of what RMP was looking for? Why this low figure? DR. HESS: I don't think that's a good measure, lat all. HOOVER REPORTING CO, INC. 320 Massachusetts Aver;ue, t4.F. Vloshing.ton. D.C. 20002 239 wt 54 DR. THURMAN: I think I had better respond to that. I agree with you, I don't really think it is. It's not a matter of being tired, it's not a matter of being fed up, or anything else. This program has been going and again, we didn't understand how well it worked with all the other health affairs and activities. Now th ey have wanted to avoid an outward appearance of affluence, and that's why they were so well accepted, as Joe points out. Again, I would just emphasize that -- not in talking to people who are getting anything out of it, but in talking to the little people -- and these people were able to speak in Spanish to the people involved -- it really is the cream of the program and they felt that they can use this money wisely and not jeopardize the future of anything else -- and they would only ask for the money they think they can use well. DR. HEUSTIS: Now in view of this, do you not wish to retract the statement that you made yesterday about the people "always asking for more than they need?" DR. THURMAN: No, these people have asked for more than they need. I would never retract a statement, like that. [Laughter.] HOOVER REPORTING CO,:,iC. 32OMa.-@husettsAvepue N.,. Ar-hi.ainn ri P. 9,llf@fl9 24c) tit 55 DR. HEUSTIS: For the moment I thought I had you, but I couldn't go further DR. THURMAN: No, I am going to defend the sheet, a little later on, with the fact that.I think it's useless, so I only bring that up No, the only place that -- the place that I would criticize their budget, if you still look at the core of the staff program -- as to what was indicated earlier -- they just pick up all the staff, and they didn't really, physically pick them up, they just moved them to other budgets within the medical science campus, and try to find a place for them and then they kind of flow them back. And that "flow" is very worth while for the very reason you bring up -- that these people will be able to do an awful lot with a very little bit of money. So that we are approving more money than they can truly use right now, because they are funded through other mechanisms. So that I'm not defending my very dogmatic statement too much. [Laughter.] DR. HESS: The point is: How many people are there ilin Puerto Rico? DR. THURMAN: Higher than New York City per squarer HOOVER REPORT!Ni'3 CO, INC. 320 4@,lassachusptts Avenue, f4.' - ViashinW@r,, D.C. 2O,,jO2 24i. foot it's the most densely populated region in the United wt 56 States. MR. NASH; About 2.5 million I guess. DR. THURMAN: But a higher density than New York City, per square foot of ground. And yet the most of the island, you couldn't set foot on if you wanted to, because of the trees and the water. MR. NASH: Dr. Heustis, that figure may change -- 69 percent -- depending on what comes out of their application that they will submit. DR. HEUSTIS: I didn't care to explore that any more but it just seems as though where there was need -- was there a language problem. But I think my question has been satisfactorily answered. MR. NASH: All right. THE CHAIRMAN: We do have a motion, and a second, on this one -- to approve in the amount requested, which is $696,862.00. Is there any additional discussion'? All those in favor [The motion was regularly put to vote and carried unanimously.] HOOVER REPORTING CO, INC. 320 Ma-@-lhu-.etts Avenue, N.[ ,,Vaship@gton, D,C. 242 (IT wt 57 THE O.K., it's ten o'cl.oci-,. T;,,Ih a t i stLi c Pleasure of the qrouT)? Do @ie @,7ant to take on another one or do %@7o- want to break for fifteen minutes and have a cu-o of Cofi@ce? Do @.7c have anot@i@r ten minute one? How about the Tloul-it@-ain States of Idaho, I'llontana, 1,7yortinq, and Nevada? '-"O'i,IEI,TT: Is that c-ilT.-;ca,,7s that same four rtates? It's al%.7ak7s been a little unclear in m,,, mind'. @-7"lat i'vp- read nor,.., suc-rgcsts it's sort of a northern ir-7,7 half of omin,@ -@ it doesn't really make much difference as "7,701"i.na has been "I-IlPs "P-oland" there arc three .7Z.'!Ps @L. 0 -olot over; in the mountains: Colora6o, !,7yominq, and -- the mountain states THE 1.10@-iTAIN STATES DR. 1@!cCALL: They have cot a tableLof staff and a pri-oritv aroun, and a Priority setting on a ori-oritv basis, they have handled that in a hiah, mcditip., and lo-@.,7 c@,roun,-nq in this application -- @,7hic,-i is a good application -- clear and I think it n@-esents a picture of the recion Pretty ,@7ell. Tliev have had rcction review certification visit and management assessment visits ii7hich came out as, I think prett-,), much all "nlu@,cs" from that rcaion. Assessment of their Past performance and accomplish-, ment has also been T)rcttv (-,,nod. 243 d with -vit 58 The current pronozal8 seem to be in accor their stated objectives and priorities, and I thin]-, thev are feasible. The C@'!P there are four A Agencies and sevenB @lgeiicies that have to be dealt i,7it'L-1 by this -,2,cgional "-Icdical Program, and thev have received in this application, comments '%gencies, and fo gcncies from all fourA ur of the seven B A are included. The ICia@o A Aaencv disapproved one of the T)rojects the physical assessment field -- nurses and the D .7\-ccncv hE,.d nec@ative cc-iiqcnts on about four -)ro]ccts -- but @.7cre no an in (fto--,oth stt,,-Iv or criti.ql-,e of t.iosc it @.,,a!3 just on(,-. sentence co-L-,ionts. I state that to sav tiat I C@on't have ant7 T17,1@7 to evaluate the auali-.tv of the CliP reviexi and relations'@i4--)s th2ra but these were --- t@-ie extent of the necativo tv-De co@--,@nL---. L,,Iat would neee deali.nc, by the and from the applications, I ,votild -feel Seasonal comfortable, all@-houch I @-iould ,-7arn the Sta-Ff to comment on these if 4--liev @70uld wis.-i to deal -,,i4-th them. This application contains 27 orojects. 11 of these are for continuation, and 16 are new,-- makina uD in dollars an eleven continuation of about $1.5 riillion; and the sinteen new ones, at $640,000 -- the staff buduct being some c7uarter of a million dollars -- the total recuest $2.4 million. 244 -liey intend to aniolv'for aaipplement of some 59 $220,000.00 in iulv. I rated this "Above Avo-racre." CI"AIPJ-@--',l Thank you, Charlie, and Joe. DR. IIESS: I generally concur with that. It is evidence to ri@ that the people @.7ho t)ut this iTDplication toac-@thc!@- thin]-, clearl@7, concisely, and are v7ell organized, and are using apiDronria-IL-.c Procedures. They have atterinted to reach out and nrovi(,c c-ood service to all four states, and they havc,,@ offices in each of the four states, and seem to have aood @7otkinc relationships %,7ith the state Governments, and the CHP and so on. Just to comment on that one oroject that @Te ave ne",atiVe comments on -- aivon a little TDri.ority in the list;-nc, so I think that -ia,-l be a result of the Cl-!P 7(-,vie@,,,. CT@p I t'i-link'the- comments on that Particular one Zero relevant but t.,Iat ,vas ta'i',en account of. The onl@r real- (-Iue-sti-on I had about t'li,2 bu@cet @.;as, the rather larce amount of mone,l goina into Elt4s from ?--,IP. I leave no doul:)t t.iat in that area of vast distances -ind so on that an @-!IS system is an important element to aet orc-anj-zed and goina. But there has been a substantial increas in money goincT into that and I su-,)nose that it @,iould be ap proor4 a--@ to sort of flaa that as an issue and ask them to take a close 245 wt lool@ at that when thev ce'k-- their arcint a@-,,ard. it ,.;oul-d be anprooriate to have DR. @cCALL: a staff comment on that. D'P,. IIESS: Yes, I was goincT to sav, that i@.7as sometninr I meant to point out -- and because of the distance, of course, it miaht v7ell be justified, but vou can't tell. r',.IHT:,' Cl-LAII@'L@l: Yes. Some of- the -- N@,,Iiile a good nart of this is continue, ation, some of that continuation is really oxnansion, and it's'. larcfelv in the Y,@.i-S area. Dic@, T don't 1-nO7.'7 @,71-iother vou 1.@@ould i-7an- to co:7,j,,ien+- k- on this, or arc, any police,, issues. @t tills 7DOi.nt til@ere are no notice,, do.@s not annear to 17)c .in-,,, T-ol.ic,,7 flagged this to raake douL)I.v sure,. I.,i terms of the 7"',-S nrocTrFt,-@a in t'@@ic @lountai.n States area, all of those nroara-.is starl--@C, cut 1-iit.i assistance f-ro.@. ,,Iauntain States in terms of vor@;, small. contract-,. Like, 7!@-vada, for instance, started out @@7it",l and as a result --,jou can see. @lontana, is the same @@7aV. Idalio. So this is one of their big, major Program we do have some concerns about that larger DR. 1IT7SS: This is one of the things that impressed 246 me about their management techniques; and that is that thev Tt 61 used the contract mechanism as a device for getting thin(7F-, done that they have identified and perceived as a means and thc,,7 ',.iavc, i7"jnc-,Oiiately tal,--cn the initiative -- as opposed to ,..7aitino for it to come in. And I -tlaink tlliis reflects very sound, sor,,'-ii-,ticatc-(2 inanac,o@i,,,.l.ent on the part of 71?1'P. @@c(7ALI,: Just one other tA-ii.nq, one Point ti-la-i@- I thinir, L--i-ie Stz.,.ff might 1,7(.int to on, too. L It is no@ecq- that thev clearly clio@.7 the allocation o-T- -7,oll-rs ObV40 anr,@ rrograrLs -- and L U there is a strong stiL--F, and t'liev have generated and involved in a lot of znr-!. sc-cr.-, to be involved with An-,. T!I.entionc(l in tl.,iesc,, oro3ecL,-s the grantee auencv. In -.anv of the activities, I -)rctt,'/, t"lat ,-,o-.L-.bodv kne-,.7 the rcaion I)ctter than I did, m,7sel-@ -- and that was accentible @.7ithin the re-Tion it @,7asn't too much generation. Is "-his IT'.'!S exr)onditur-c, -For i-)r@-.nara",@,-, for a system. for the purchase of hard@,.7aro> @iR. RUSSI@LL: It's preparation of -- rat,@ier than the T.)urcl-lasc. THE C I I,@ IL%,-. ISandy Flythe, and D4C]Z RUSSCIJ were both out in the !Iountain States, I quess this -.7aF, -larch, or carlisli, on a review verification of th(,, management. l@ 247 6 2 I goes it @@7a.9 combinccl: neview Verification of @"ana.cTer,,cnt 7%ssessr,-Lent --- p @-iould a\r(-, some o T3erliap@3 Sandy an(!/or Dicl: comments as it relates snocifically to CHP and also the abilit,7 to manaae projects under the accis of -oroQrar-@ staff which I train}:. I heard Charlie raise a ctucstion a,'@out. Sandv. is. ILYTHE: Basicall@,, the CITLP rclationshin within the region are qood. T'l-lore is one nroblem, 7-)crliaT)s, but they are i@.7orli-inci i at worked o