Iiiiiiiiiiii , II6 KI .. @ C 0 1-1 3 Alaban, a Regional fli@(,Iiccil Pror r,-n .1 4 ccorim@ndal!on 2.7 Motion for n 5 3 2 (lical Proqram Arl-lan,3as r,(;-@rional t!otion for Rccc-,iTii-i-.n(3ation 43 Di-Stat-o Regional Progr,@ri '51 notion for reco,-mciiclattoii Colo'rado-l-j'yominG Be@-ion 1,1@dical Program 69 .10 14otloh for Becommendai-,:Lon Georgia Regional.llcdical P@o@-rain co 12 Motion for recot-ni,,icn(lni;.Ioti I,'lorida,R,-,Lonal 1,lcdical ri:,o,-,r in ii, 14 ibtion for recotiiinen,,I,,.ition In(liana ll(,,UIonal Dledi.c@il Ivkc) Motion for 17 I-,Iisconsin Rc(;ional 1!1---clical Prorram ci Motion for recommenrlatl-on l@ano,-ta Regional @lic(lic"ll 20 Motion for fccomin--,ti(l.,itioti 1113 21 Inter-l,lotititain Ileriotial. Progrcim Motion for recotii,,@i,2t-ifl@ition 2:t l,lichigan aegional 24 I-loti.on for recotii,: ti, 25 (icon'.tnii,!(.1 oil lic@, PO.["C) let; co, INC. C 0 N T B N T.8 PA Gri 3 kliSI3 is t) ipp IRcgion.al I,,IoLlical P:roGram 4 Motion for recorninendation 192 5 Illinois Regional lied.ALcal Prot;ram :L93-A I-lotion for rocomtncn(lation 23.5 7 Louisiana Itogional Ilo(lical Pro,,-ram 217 8 14ot ton ror recoinmenclation 22-f 10 12 13 14 1 7 20 2 1 2'--) 2.1 @i I, rfive II u@ 4 @P R 0 C E E D I N G S ----------- 2 LISS: Let me take this opportunity to call, 3 Panel "A" to order and welcome you here to this particular 4- work group. '@l'think you should know that as we get into our 6 procedures for the next day or so that I will have at my right 7 and at my left two operations Branch chiefs, Mr. Lee Van 8 Winkle, who is the operations-Chief for the South-Central 9 operations Branch of-the Division of operations and Devel OP- 10 ment, and Mr. Mike Posta, who is the operations Branch Chief 11 for the Mid-Continent operations Branch, 12. I think the panel should know that we had expected, 13 as Dr.@'Pahl mentioned, Mrs. Silsbee to have chaired this-panel 14 and it's due-to her illness that I've been asked, just in the 15 last few hours, to chair the panel. 16 @-"Dr. Pahl and 1, as he mentioned, have been looking at other things over the last eighteen months and especially these matters having to do with OMB questions, with answering questions from the Devartment dealing with the congressional 20 relations, all the questions coming from the Congress having 21 to do with the phase-out and the status of the program, the 9.) inter-agency aspects of operating the program, and both of us have left all but entirely the operational aspect of operating 2:1 the division to Judy, who has, I might say, served with great 24 distinction. ]tLpoxllNa co, INC. ssachusetts Avenue, N.E. 5 When the annals of RMP are written, she will truly 2 be one of the strong people of RMP, a great person, great 3 lady, a prodigious worker, and a good friend to all of us. .4 Hopefully she will be here while these proceedings I. 5 are underway, but Mike and Lee will provide me with ateral 6 support, and at the same time we will have support f Om 7 members of the ODerations Staff and also a representative from 8 the Orants Management Staff in the person of Mr. Lar3 Pu en. 9 1 think the committee is well-aware of the fact 10 that we are operating under a court order and I will onlv say 11 one additional thing-. Dr. Endicott said that thingslare a 12@ mess; I agree. I will only add my word of wisdom, i@ you can .131 call it that, and that isi we have lived in a chaotic commu- 14 nity over the past few months and this, in a way, culminates some of the trials that we have undergone by reviewing the 15 applications from the regions that came in on May lst their application for funding beginning July 1, 174. 17 I think, as we get underway, you should know we will be operating under the Mission Statement that we all know so well. We are operating under no restrictions as relates to 20 the program activities of the RMPS. 21 And mavbe I at this time should call upon Lee 22 Van Winkle to just set forth in highlight fashion some of the 2:1 review guide procedures that we'll be utilizing. 24 Lee, won't you HOOVER KLFURTING CO, INC. 320 Massachusetts Avenue, N.E. n I, nnnn)I 6 I MR.'VAN WINKLE: I just primarily want to call your 2 attention to the review guides that you have, and I know that 3 Dr. Pahl said it earlier, but I think it should be repeated. -4 that I think this group has to focus on the over-all program 5 of the Region and the proposal as submitted rather than on a 6 technical review of the individual projects, and we do have 7 the criteria listed. 8 to mention I think the only other thing that I want 9 at.all is the review sheet that you find attached in there. 10 We will expect the two reviewers to fill.that out and we'll 11 collect those as we go along. 12. DR. MILLER: When do you want them? .13 MR. VAN WINKLE: Sir? 14 DR. MILLER: When do you want them? 15 MR. VAN WINKLE:. we'll give you time to ccmplete them 17 MR. CHAMBLISS: At the end of each review as we sit 18 here. DR. MILLER: As we ;it here? 20 MR. VAN WINKLE: Yes. Before we go to the next 21 application, we would like you to fill it out in talking 22 with Miss Leventhal -- and pick it up at that time. 2;1 DR. SLATER: I want to ha.ve some time-to rewrite MY 24 commentary on those, so I'll get it back to you during this session, but it won't be immediately after my oration. 25 HOOVER RLPUKTING CO, INC. 320 Massachusetts Avenue, N.E. 7 MR. CHAMBLISS: Thank vou, Lee. 2 I should mention that, as you have probably noted 3 in some of the background materials, that the focus of the 4 review will, by and large, touch on about eight elements. 5 The first is program leadership; second,, program 6 staff; third, regiona 1 advisory group; four, past performance 7 and accomplishments of the region; five, the region's objec- 8 tives and priorities; six, the proposal; seven, feasibility; 9 and eight, and finally, CHP relationship. 10 I think one additional item of procedure may be in ii order here, and it's a further elaboration on the focus for 12. review. Dr. Pahl mentioned that the policy issues would 13 -simply be flagged and we would not necessarily attempt to 14 resolve them here; that the target amount should be the 15 principal benchmark for a backdrop for the review. Lee has mentioned that the two reviewers will review 17 and the second reviewer will simply add additional comments or 38 observat ions. We hope to follow the exception principle if we are 20 really going to get through in our appointed time. 21 We also will have Staff comments as necessary and 9.) required and for each of the regions under review the Staff person handling that particular region will be at the head 2;t table here. 24 After that, a brief discussion, and we will attempt 2;-) HOOVER REFURTING CO, INC. 320 Massachusetts Avenue, N.E. 1 to clarify any items or matters that need to be clarified, 2 endation looking forward to the presenter,giving us a recom 3 and the rationale for his recommendation, ending up with a 4 motion on that particular recommendation, and from there wee 5 will ask each reviewer to complete the rating sheet as we've 6 touched on. 7 There are applications at the back table, complete applications on the back table, for each of the reviewers who 1 9 will need them, and we would simply ask you as a final matter 10 of procedure,, kindlv speak into the microphone so th t our 11 recorder can get all of the deta ls. 12@ Are there any questions at this moment before we begin to proceed? 13 14 Dr. Vaun? 15 DR. VAUN: I've heard Lee refer a couple of times to the fact that we're not geing to.do a technical review, if I 17 understand what he's saying. However, I'd like to know how weire going to reach a judgment about funding levels unless we 38 address some of the technical aspects of the programs. 20 On the basis of the guidelines submitted, namely, leadershipt past performance, it's going to be very difficult 21 22 to arrive at a funding level. 2:3 Lee, how do you want us to work this magic if we're not going to look at the projects? 24 MR. VAN WINKLE: Well, I think that you do have to HOOVER KLFUKTING CO, NC. 320 Massachusetts Avenue, N.E. Washington, D.C. 20002 9 look at the projects because that's a part of the total pro- 2 posal that came in, and if what you see in here is not 3 related to the goals and objectives of that region, then I -4 think you have real cause for concern, and certainly if there 5 are items included in here that are strictly against policy 6 of the Regional Medical Program, that also has to come out. 7 But I think you have to look at what they've sub- 8 mitted, the individual pieces; but as to getting into the 9 individual technical aspects of a particular activity, that's io what we're trying to avoid. 11 DR. VAUN: Okay. 12 MR. VAN WINKLE: The actual makeup of that activity I that you're looking at. .13 14 MR. CHAMBLISS: Let me just add one additional piece 15 of information so that we have something of a framework. The panel will have a total of 28 applications to review with a 17 requested amount of $65.5 million. There's one continuation recTuest; there are 23 continuation and new activity requestsi there are 24 additional applications expected from this set of regions in July. 20 21 Twelve of the regions that you will be reviewing 22 have had -- twelve of the twenty-eight have had new coordi- nators since the phase-out was announced. There have been 2:1 limited site visits. However, there have been Staff visits to 24 nineteen of the regions in question. Two have had review 2;-) HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.E. n (I ')Ann) 10 1 certifications; six have had management surveys; and twelve 2 others have had technical assistance-visits. 3 So there is a body of intelligence residing in the 4 Staff as to how the regions are functioning and operating., I 5 thought you would like to have that just as a backdrop. 6 MR.- VAN WINKLE: Can I add just one thing? 7 MR. CHAMBLISS: Yes, 8 MR. VAN WINKLE: Dr. Vaun, I think what we're seek- 9 ing here is the development of a level of funding and not a 10 funding level -- level of approval, if you will, not funding 11 level, and the funding level actually will be determined some- 12, where within that level of approval. If you come in, let's say, with a leval of approval .13 14 on one program at $2 million, the actual funding level will be made up to that figure, it won't exceed it, and it may be less than that. DR. SLATER: Could I 17 18 MR. CHAMBLISS: Dr. Slater. DR. SLATER: May I Make a point? I, like you, have been trying to get a grasp on this in comparison to the old 20 21 days and, furthermore, in the light of what Mr. Rubel is talk- ing about, and I have the same concern that you have, that 22 while not really examining these projects which are presented 2:1 in variable detail from one region to another, I'm attempting 24 to make some kind of an assessment, really, to give you, in a 2;-) HOOVER RLFUKIING co, INC. 320 Massachusetts-Avenue, N.E. sense, professional backup as to what kind of funding these 2 regions should have. 3 Coming through to my mind all the time is the fact .4 that since we're apparently going through such major changes 5 in the next few years in which RMP will be recast in some way 6 or the other that what we're here to do, really, is to just 7 look for the most obvious problems or errors which you as 8 Staff have to correct in order to justify the expenditure of 9 these funds and that we're not going to varv, really, very 10 much from the figures you have here, because the most 11 important role we have to nlay now in this interim period is 12! to stabilize those staffs out there in order that one as a 13 grouv of people that are well-trained and indoctrinated to 14 move ahead in some fashion in the years ahead. 15 So I must say I don't have too much difficulty l(i making assessments. I'm having to rely so much on what 17 they've already decided to do there, that I think we're 18 really here just to provide professional extramural moral support more than anything else -- obviously, t here are going 20 to be some holes in that, but, generally speaking, that's how I read it. 21 MR. CIIAI,14BLISS: I assure you we need that, too, but 22 we do need your professional judgment. 2:t DR. SLATER: I agree.", 24 MR. CHAMBLISS: And we need your views and we would 2;-t HOOVER RLFUKTING CO, INC. 320 Massachusetts Avenue, N.E. r, e, nnnn,) 12 like you to work on the exception principle. If there are 2 matters that are exceptions of policy issues, then we would 3 like to have your judgment on them. 4 DR. SLATER: I'm not trying to be soft, but what'I 5 am concerned about is that with the stability of the staff and 6 the projects and all they mean out there is perhaps the most 7 important element in the survival of the whole pattern of 8 activity that was started eight or ten years ago. 9 MR. CHAMBLISS: Mr. Thompson. 10 MR. THOMPSON: On the interface with kidney, EM 11 emergency medical services, and PSRO, did the Staff go through 12. and edit any of these in any way, identify those projects that 13 are obviously in conflict with kidney, emergency, and PSRO? 14 MR. CHAM-BLISS: We have in fact gone through all the 15 requested project activities and have seen -- attempted to i(i determine if there was a conflict with the policies of another 17 program. We have also had discussions with the key staffs of 18 the kidney program, the emergency medical services program, I!) and they will give us-some assistance in these reviews where 20 we find conflicts. 21 A number of these activities, the regions have been into actually before some of the legislation was passed -- 22 quality assurance, which borders very closely to PSRO, and so 2:1 on and those activities are )5eing continued. 24 However, in the case of EMS, you should know that it HOOVER RLPUKTING CO, INC. 320 Massachusetts Avenue, N.E. Washington, D.C. 20002 13 is a program decision and a matter of statute that the RMPs 2 or no other program will enter into EMS activities so as to 3 build a system of emergency medical care. -4 Our regions have had facets of a system and, theie- 5 fore, with the understanding that we have between Em and RMP, 6 those activities are permissible for funding under this set of 7 applications, so their basis they are not designed to 8 produce total systems. 9 MR. THOMPSON: But maybe the problem.-is that if vou 10 put money into those nobody will ever be able to design a 11 total system because those pieces will be out, you can't pick 12 them up-. 13 MR. CHAr4BLISS: Well, at the local level the CHP 14 agencies have been coordinating to see how the RMP proposal 15 fits into the total need,,a@.the local level, so there has een i(i a degree of coordination and cooperation there to make sure 17 that the pieces that we support have some relevance to what j8 else is going on. MR. THOMPSON: But 3: detect something in the appli- 20 cations I read, which, although it is not in direct conflict 21 with the PSRO organization, it is obviously addressed to the 22 tactic that hospitals, if they have any brains, have suddenly 2:@ got to realize that they've got to get their own quality assurance program, optioning (phonetic) subbing it out to a 24 PSRO or do it themselves, and some of these projects are 2-7) HOOVER ELFUNTING CO, INC. 320 Massachusetts Avenue, N.E. 14 asking for money to let hospitals build up their own quality 2 assurance programs so they can eventually do this for PSRO. 3 I object to it for two reasons. one is they should .4 have been paying attention to quality a long time ago ail 5 1 of a sudden they shouldn't have discovered the wheel',. But this isn't related to PSRO 7 MR. CHAMBLISS: indeed it is. As a matter of policy 8 Council policy, we have stated many times that the s could 9 not become involved in PSRO development per se;. they could not 10 use their funds for the operational aspects of a PSR9. 11 DR. McPHEDRAN: They could be involved in develop- 12 ment? 13 MR. CHAMBLISS: They could not be involved in the 14 actual development, but that if there were studies, data 15 collection or peripheral,.activities related to quality 16 assurance, that they could be involved in that using RMP funds, -one comment. As 17 MR. VAN WINKLE: I'd like to add 18 far as the Staff comments you find in here, they have flagged I!) items for your attention, items that they felt were of concern 20 that they wanted to be sure that you looked at. 21 Now, they haven't made any recommendation on those 221 to the committee. Thevlve left that up to the committee. 2:3 And in looking at the criteria that you're going 24 through as far as leadership, RAG, and all of these items, I want to assure you that the Staff have looked at all of those HOOVER RLPUKTING CO, INC. 320 Massachusetts Avenue, N.E. n i, )nnn,) items, too, and if you see no comment, it doesn't mean that 2 (sic) they haven't looked at them and are satisfied with what they 3 see, but if you have any question, we'll be glad to have the 4 Staff respond to it. 5 MR. CHAMBLISS: Mr. Posta. 6 MR. POSTA: I would like to make a comment concern- 7 ing, for instance, EMS activities. Many of our states are 8 making applications to HSA for various EMS activities. Dead- 9 lines in certain areas have been April 15th. 10 We have other opportunities in area resear for EMS that are going to be funded by another bureau and weihave, 12. from a Staff standpoint, made it clear that whatever;we -- .13 meaning RMP, DRMP -- will be funding will be double checked with the other agencies to avoid duplication in these ty 14 pe of 15 efforts. 16 MRS. WYCKOFF: Is that what you mean when you list -- 17 well,, four EMS projects under concerns, that you're going to check them with these other to see if,they should have applied 18 i!) somewhere else? 20 MR. POSTA: Right. And to see.also if they're 21 flagged whether or not the amounts of money requested in this 22 application is, in essence, double that of what has been approved for the first six months of the year. So we do it 24 both ways. 2.:') We keynote an expansion of an activity moneywise as HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.E. nf, )nnn,) 16 well as 2 IM. IIYCKOFF: I see. 3 MR. VAN WINKLE: Continuations here aren't of -4 concern in terms of the new legislation. Continuations are 5 not of concern insofar as the new legislation. only new start- 6 UPS. 7 MR. CMMBLISS: All right. Are there other 8 questions? If not, I think we should begin our review and our 9 listing shows that the first regional medical P-rogrami to be 10 @reviewed is Alabama. 11 The review is by Dr. Vaun and Mrs. Salazar and the 12. Staff person, who is already here at the head table,@is Mr. 13 Joe Jewell. 14 Will the.first revievier make his or her presentation? 15 16 17 38 20 21 22 2:1 24 25 HOOVER RLPURIING CO, INC. 320 Massachusetts Avenue, N.E. 17 ALABAMA REGIONAL MEDICAL PROGRAM 2 MRS. SALAZAR: Alabama has always led this@parade 3 MR:.CHAMBLISS: Use the microphone. MRS. SALAZAR: -- of the reviews, and I'm afraid'i 5 fell@into that trap and I may get carried away, but nope noti 6 The present fundina of the Alabama RMP is @687,000 7 .1. .1 in the third vear of a triennial status, with the year ending 8 April 30th, for a total of four operational years. 9 The activities that were reported in the annlication- 10 are related to phase-out pursuits, rescinding of phase-out, 11 reactivation, retooling, in response to the off-agaio/on-again 12: syndrome that has bedeviled the regions all across the country 13 this past year. 14 In view of this, the Alabama application,. to me, is 15 somewhat astounding from A number of standpoints. First, after the phase-out orders in February of 17 1973 only two projects were approved for partial support and 18 only four which were funded through contracts were continued beyond June 30, 1973. Two: the Regional Advisory Council elected to remain 20 21 intact -- the RAG is called RAC there --: it retained its work- 9.) ing committees, and, indeed, throughout such troublesome times of adversity it grew in strength and.wisdom, guiding and sup- 2:1 24 porting the RMP efforts throughout the region. The RAC has met four times, reviewed proposals, set priorities, implemented new 25 HOOVER RLPIJRTING CO, INC. 320 Massachusetts Avenue, N.E n(,. ?nno? 18 by-laws, counseling and opening avenues of communication in 2 their respective geographic areas of the region. 3 Vacancies that have occurred on the staff have been 4 filled very promptly and attendance at all meetings has 5 averaged better than 66 percent. 6 There is a nine-member executive board of the RAC. 7 It has met six times, average attendance at 75 percent. The 8 chairman is a member of the State Health the State Board of 9 Health Department. 10 The third astounding feature of this application, to 11 me, has to do with the ability of the region to seek and 12. obtain local support for twelve out of sixteen of their con- ..13 tinuation programs, tifenty-one out of the thirty new proposals 1 14 Spoken or stated Another way, in addition to the $2,648,000 15 they are requesting, $1,1922,000 almost $2 million -- will i(i be supplied by state, local, and other federal monies. 17 Or still another wav, 73 percent of this application will generate other grant-related support, resulting in a total of $4,500,000 for the Al!abama RMP is that correct,, 20 Joe? MR. JEWELL: That's correct. 21 g-) MRS. SALAZAR: The Review Committee and the EMS Com- mittee have remained active, with the latter forming the 2;@ nucleus of the State Advisory Committee to the Governor and 24 the State Board of Health. 2;-) HOOVER RLPURTING CO, INC. 320 Massachusetts Ave nuej N.E. ... I I@ @ @@@nn I 19 The membership of the RAC is adequately represented 2 by providers and consumers from each of the 10 CHP B agencies 3 and it includes the Director of the State CHP A Agency and a 4 representative complement of health educators and providers, 5 officials, and the like -- there's a mayor, too, as 1 recall. 6 The University of Alabama in the Birmingh@ Medical 7 Center serves as the grantee and the present Executive ,8 Director of the Alabama RMP is on leave of absence f om the 9 university at 100 percent of time. Maximum resource support 10 from the universitv is accorded the Regional medical Program. 11 The present Director has had extensive experience 12@ with the Alabama RMP, having served on its first Re ional 13 Advisory Committee in 196.7. She has been a member of various 14 committees for about three years, has served a-, a part-time 1;5 professional Assoc iate Director. She has also been a member of the faculty of the School of Medicine for over 25 years, 17 and for the past twelve years as Assistant and Associate Dean for Continuing Medical Education. She is active in medical affairs throughout the state. 20 The Deputy Director has been with the program since 21 October 1970 and the Assistant Director for Operations has 22 been employed by the Alabama ME? for seven years. The position of Associate Director for Health Care 2:@ Services, which will provide liaison with health providers 24 throughout the region, is open. Recruitment is underway. 2,7) HOOVER RLPOR [ING CO, INC. 320 Massachusetts Avenue, N.E. Washington, D.C. 20002 20 This unit is pursuing PSRO efforts and will provide 2 an appropriate channel for,emerging national health insurance 3 information. 4 An Assistant Director for Multimedia Activities And 5 an evaluator round out the professional staff and bring the total to its approximate prephase-out status. 7 There's a sense of optimism and enthusiasm that 8 domes through in this application. It communicates a feeling 9 of confidence in the competency and the wisdom and the motiva- 10 tion of the staff. 11 The region appears to me to be on target in meeting 12. its goals and objectives as revised in 1971 to meet the chang- 13 ing national and local priorities. 14 It is quite apparent that enormous staff energy went 15 into creating four of the initial six B Agencies in the state and it is still wielding a great'influence on the @emergence-6f 17 the other four. The Director of the CHP A Agency is a member of RAC 18 and several members of the Area Health Councils are also RAC, members. B Agency members frequently attend RAC meetings. 20 21 There is excellent communication among all groups. g-) The endorsement of the Alabama Advisory Council for CHP A Agency is quite guarded, and there are some stated 2:3 reservations concerning the duplication in sponsoring 24 agencies, but for the most part these are fairly superficial. 2;-) HOOVER RLPORTING CO, INC. 320 Massachusetts Avenue, N.E. n r I)nnn)I As far back as 1967 the Alabama Regional Medical 2 Program proposed in its first planning grant the development 3 of six community-based health education centers to serve 4 regional needs for health manpower education, service, and' 5 continuing education for all health professionals in the 6 region. Eleven programs are now ongoing, covering a 1 geo- 7 graphic areas of the state, and one is emerging in the 8 resource-poor southeast section. 9 There is an exciting program that is-entitled 10 "Project HELP" which emerged from a tripartite agreement among! -11 University of Alabama, Birmingham-Auburn, and the State Healthl 12! Department for health education of the public. It utilizes -13 the services of the Agriculture Extension Service at Auburn 14 University and county agents and councils in every county of 15 the state. This program,will receive future funding through i(i state education funds. 17 The present application, as I said, generates a 18 feeling of optimism in the reader. Cooperative arrangements have been achieved. Staff of both CHP A and Bs are actively 20 involved in RMP affairs. Projects, both proposed and ongoing, are timely, relevant, and appear to be viable. They are par- 21 22 ticularly applicable to the region's health needs, but also in line with national emphases, such as PSRO and quality and cost'! 2:1 controls of the health delivery system. These are all spoken 24 to* 2.r) HOOVER RLFUKTING CO, INC. 320 Massachusetts Avenue, N.[. 22 For the July submission the region is preparing 2 additional projects in neonatology and one to develop a rural 3 community health task force. 4 It is significant, I think, to note that the 5 1 Regional Advisory Council incorporates in its committee structure the CHP B planning agencies. These areawide 7 1 advisory bodies formulate policy and approve plans pertinent to health issues,, not only project proposals from A b 8 la ama RMP 9 but others requesting federal and state funds that a@fect 10 their geographical areas. 11 From the very limited information to be gleaned fromi 12@ the report on the HPA-T4, I believe it's called, which is the 13 Equal Employment Opportunity breakout and my previous 14 knowledge of Alabama,, it does appear to me that the Alabama 15 Region has made progress,.in its Equal Employment Opportunity for minorities, but, I believe, still has a long way to go in 17 achieving adequate representation of these minorities on their 18 committees, particularly in the professional and clerical I!) staff, as well as membership of planning groups and committees 20 at the community level. 21 I'll cite you one example: the Regional Advisory Council membership is fifty-eight, only four of whom are blacks; the total Professional staff is sixty-three, with 2:3 24 eight blacks. I will withhold my recommendations, Mr. Chairman, 25 OOVER RLFUNTING CO, INC. 20 Massachusetts Avenue, N.E. I:%,zhi,icrfnn f) r 2nnn2i 3 until the other review. 2 MR. CHAMBLISS: Thank you. 3 I will now call upon the second reviewers, Dr* Vam. 4 DR. VAUN: I'm not going to address attention ex@en- 5 sively to the background because I think Mrs. Salazar has 6 covered that well, and in a discussion that the two of us had 7 initially, we agreed that she would address the background and 8 1 would talk somewhat about the projects. 9 I will start exactly opposite. I will address first 10 and foremost my recommended level of funding, and then tell 11 you how I arrived at that in analyzing the project. 12 ded that their requ st of $2,648,439 I have reccmmen e .13 be reduced to $2,028,389 -- this'may be backwards, but this is 14 my approach to this one with the background you've gotten on 15 Alabama. 16 1 think they've done a good job. I think the I-, projects that they've submitted are congruent with their is stated objectives, and I saw one thing that came glaringly I!) through in the Alabama application, and that is that they gave 20 me a feel for priorities, both from the CHP point of view and 21 from the R14P point of view, and I hope this doesn't act to 22 their detriment because it was really a splendid job and it's part of the way I arrived at the reduction. 24 Also I arrived at the reduction on the basis of some experience with like projects and observations about the HOOVER REFOR I ING Co, INC. 320 Massachusetts Avenue, N.E. 24 1 successes of like projects. 2 For the core operation of the Multimedia learning 3 skills, the only reduction in core was $10,000 from that 4 specific aspect of their project and not from project staff itself. 6 From the continuation projects and I really won't 7 go into the details unless you want me to I have arrived 8 at a level of funding reduction of $107,753. From their 9 $565,005, I have come down to $447,252, and there is only one 10 project that I really didn't feel warranted funding at all and 11 that was the No. 82, which is entitled "Audio-Visual Assist- 12! ance in Educating Hypertensives." 13 I don't know, I feel that there's so much of this 14 around now that spending $7,000 on it in another area just ir) doesn't seem like it was worth the effort. The other $100,000 came from reduction of funding of 17 several of the projects. As I say, I'd be delighted to submit, 18 my recomendations to Staff or go over them here, whichever you wish. MR. VAN WINKLE: I think it will probably depend on 20 21 what the final recommendation is. DR. VAUN: Why don't I go through the rest of them? 9.) MR. VAN IIINKLE: All right. 2;t DR. VAUN: From their"new projects, they submitted 24 25 $1,422f440; I would recommend a reduction of $492,297 to bring HOOVER REFURIING CO, INC. 320 Massachusetts Avenue, N.E. IAI-.t.:..4.. f) I' )nnn,) 25 their new application award to $930,143. 2 I was a little concerned again, although the pro- 3 jects are congruent with their stated objectives -- I thin% 4 $11,000 for trophoblastic disease left me a little cool at' 5 this stage of our development; immunofluorescence for renal biopsies in the State of Alabama also left me a little 7 concerned at this point; a rather sizeable sum of money for 8 cervical cancer screening, I reduced substantially. 9 And then the PSRO which was $151,000i and a few odd 10 dollars, I thought should be substantially reduced by 11 $100,000. I just didn't feel this was appropriate. 12. So you have my recommendation in the light of Mrs. @13 salazar's background, and Iwonder if that couldn't set the 14 pattern. Don't you think it would be wasteful for both 1.5 reviewers to spend a great deal of time presenting the back- i(i ground? Couldn't we arrive at some agreement and one person 17 take one task and the other person take another task and, 18 hopefully, come together on it? MR* CHAMBLISS: Certainly I would await the judgment 20 of this committee on that point. I think it will tend to expedite things. 21 MR. THOMPSON: So moved. 22 2;3 DR. WHITE: I take exception to it and object, in 24 the sense that many of us have done work already -- admittedly 2;-) scanty -- but it might be somewhat difficult for us to recast HOOVER RLPUftllNG CO, INC. 320 Massachus!tts Avenue, N.E. 25 ourselves in roles which we hadn't been expecting. 2 DR. VAUN: In the light of consultation amongst the 3@ two reviewers 4 DR. WHITE: If time permits. 5 DR. VAUN: maybe one would have spent more time 6 on one thing than the other, they could agree on a presenta- 7 tion. 8 DR. IIHITE: If the two 9 DR. SLATER: Mr. Chairman, I think it's quite easy 10 to draw up background. Anybody can do that. But I think if 11 there has been a fair amount of time spent in looking at the 12 projects and considering them in the terms of the criteria you 13 want, I think the individual reviewers have to go into this. 14 There won't be that much duplication except as to background 15@ historv. That seems redundant. MR. CHAMBLISS: I se@'to get a sense from the com- 17 mittee that you would prefer to hold to the original approach. DR. WHITE: I think everybody has to play his own role, and if you don't like @ way I do it, you can holler at 20 rue. 21 MRS. WYCKOFF: I tried to follow this thing, which is quite different 22 MR. CHAMBLISS,. You are seemingly suggesting that 2:3 we have the clock before us andwe can always call tiTn@@.. '-)4 All right. Can we get a motion, then? 25 40OVER REFORTING CO, !NC. 3N Massachusetts Avenue, N.E. nr 9nnn? 27 DR.:VAUN: Mrs. Salazar hasn't made her recommenda- 2 tion yet. She was going to withhold her recommendation. 3 MRS. SALAZAR: I defer to you as the principal 4 reviewer. 5 DR. VAUN: Again,, Bob,, I'm new to this. Do I make 6 the motion, or does somebody else? 7 MR. CHAMBLISS: You can make the motion if you 8 choose, Doctor. You've already given us a level of funding 9 that you have recommended and the rationale for that level, 10 If you will put that in the form of a motion, the chair will 11 entertain it. 12 DR. VAUN: I will move that the request of the .13 Alabama Regional Medical Prc>gram,be reduced from their 14 requested amount of $2,648,439 to $2,028,389, . 15 MR. CHAMBLISS: There's a motion on the floor that the recommended level of funding-for the Alabama Regional 17 medical Program be placed at $2,020,389 DR. VAUN: $2rO28,389. 1 8 MR. CH-A-MBLISS: $2,0,7-8,389. 20 Is there a second? MR. TOOMEY: I second it. 21 MR. CHAMBLISS: It has properly been made and seconded. 2:3 Is there any discussion on the motion, please? 24 Dr. Miller. HOOVER REPURTING CO, INC. 320 Massachusetts Avenue, N.E. W-@hinatnn 1) r. 2nnn2 1 DR. MILLER: To what extent do we need to pay atten- 9 tion to these motions for dollar levels in terms of the 3. relative relationships of the various RmPs on this list? This 4 motion places Alabama at a level that -- does it or does it 5 not -- it exceeds the targeted available funds item, and with- 6 out any consideration to the probability of what the3r state- 7 ment was, an estimate of $1.1,million application to be sub- 8 mitted in July-@ 9 Are you goina to count them out, almost surel_vo, 101 from much of anything on July lst by this level at this time? 11 MR. VAN WINKLE: Dr. Miller, again, this is just an 12i approval level. That's what's being recommended, an approval 13 level. It does not necessarily mean that when it's actually 14 funded that's what it's going to come out to be. DR. MILLER: Could I ask, then, another question? 15 What happens if this committee ends up with an approval level 17 of $114 million this time; then you decide who gets what, right? I.M. VAN WINK LE: I suspect Council will MR. CHAMBLISS: Council will then make its recom- 20 mendations based on the findings of this committee. 21 DR. WHITE: I think that's quite appropriate. The 22 2:1 fact that someone here has seen fit to suggest that Alabama deserves more would be taken into consideration even though 24 e they may not get that amount -- they might get more in HOOVER RLPURTING CO, INC. 320 ?Aamchusetts Avenue, N.E. Washington, D.C. 20002 29 proportion than some other region. 2 MR. CHAMBLISS: That's quite true. 3 DR. WHITE: It's simply a guideline. 4 DR. SLATER: I'm just wondering how to deal,with' 5 this, too. I wondered how, as Dr. Vaun has, to deal with 6 dollar amounts, and I guess what I'm searching for are guide- lines. I've wondered whether or not we can't- find the same 8 problems that you have and indicate that our guidance is that 9 within the framework of whatever cutbacks you have to make 10 they shall not -- that they will have to redefine their distri.- 11 bution of funds to exclude the coverage rather than try and 12 set a dollar level at this stage of the game. i 13 In other words, I'd rather find fault with the 14 thing, with the specific project, if we get into that degree I-.5 of detailing, and then leave them with whatever funding level is ultimately going to be made possible, but within the guide- 17 lines that they're not to spend money on those particular aspects. MR. CHA14BLISS: Thaiais correct, Doctor. 20 DR. SLATER: That gets us away from dealing with odd 21 dollars, and I don't know whether that satisfies your thinking DR. VAUN: I'm not sure I understand it. 22 DR. SLATER: Rather than assigning dollar cutbacks 2:t 24 as you have, identify the concerns that you have and give guidance to the Staff and the recommendation to the Council HOOVER REPORTING CO, INC. i2O Massachusetts Avenue, N.[. Washinzton. D,C. 2ON2 30 1 that within the framework of whatever dollar cutbacks -- 2 they're asking for a hundred and thirty-six -- there probably 3 is going to be some cutback, but in whatever framework, the, -4 money they receive shall not be spent on those particular 5 projects. They have to define how they 6 MR. CHAMBLISS: Well, I think he's simply been 7 generous in giving us the dollar amounts and where, and we 8 will -- the Staff will certainly take that into account as 9 this goes through the review process. 10 MR. VAN WINKLE: And we would like Dr. Vaun's 11 written figures -- details. 12I If you have them, we'd certainly appreciate them. .13 DR. VAUj'q: Maybe I'd better get clarification of 14 that. Does that mean that if I submit the details that this 15 is a mandatory translation to them where they cannot spend the funds? 17 That's what you were saying. 18 MR. CHAMBLISS: It does not. You have simply, based on your professional judc jment,'indicated those areas of concern, and they will be passed on through the review process 20 and finally acted upon. 21 22 DR. VAUN: But it will be up to.the region to decide 2:3 finally? MR. CHAMBLISS: Yes. 24 DR. VAUN: Fine. 25 HOOVER BEFURTING CO, INC. 320 Massachusetts Avenue, N.E. r)r. 2nnfl9 31 DR. SLATER: Your indication of dollar amount is 2 simply a reflection of your ektent of concern. 3 DR. VAUN: Gut feeling. 4 MR. CHAMBLISS: Is there further discussion? I'll call the question. Those in favor of the motion, may I have the usual 7 signal of voting? 8 (Ayes respond.) 9 MR. CHAMBLISS: And those opposed? 10 (No response.) 11 MR. CHAMBLISS: The motion, then, is carried, and 12 we have finished our first review. 13 14 15 17 18 20 21 9.) 2:1 24 2;-) HOOVER REFUNIING CO, INC. 320 Massachusetts Avenue, N.E. Washington, D.C. 20002 32 1 ARKANSAS REGIONAL MEDICAL PROGRAM 2 MR. CHAMBLISS: In our next region we have only one 3 reviewer here at the moment. That region is Arkansas. And 4 we will ask Dr. Carpenter if he will carry the entire load'for 5 that region. 6 Dr. Carpenter. 7 DR. CARPENTER: Thank you. 8 I don't have anything like the kind of background on 9 this region that Mrs. Salazar did. My view is that the region 10 has maintained the mechanism of the regional program adequate- 11 ly. The advisory committee remains intact; the review system 12 remains intact; and that what we have is an application pre- 13 pared by a reduced staff in an appropriately reasonable 14 fashion, but in a depressive time which has forced them to, in IF) the first place, be responsive to a large number of federal 16 initiatives, some of which I don't believe were at their 17 emotional heart. 38 Secondly, they had to respond, obviously, very rapidly and they,, in the process, were forced to give up much 20 of the matter of pressing for very detailed program objectives 21 and there's essentially nothing in the application about 22 evaluation either of the past program or of the -- and no suggested specific evaluation of most of the projects. 2:1 And, so, one has -- as I read the application, I 2A 2;-i have the feeling of a regional program which,is a bit at sea; HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.E. n r )nnn,) 33 1 has no real continuing thrust that can organize Arkansas in 2 any significant way, though it does have enough thrust to 3 contribute here and there in a kind of stopgap way, which I .4 think most regions are going to have to be content with. 5 I believe that if I were in Arkansas I would spend 6 the next year trying to document -- trying to develop a highly 7 professional staff and document what its effect can be in 8 terms of a detailed project plan. 9 I have in view the July submission. You can see 10 from your computer print out here that the present funding 11 level is $1.4 million; that -- as that somewhere, if we go 12 through with their projected application, in July we'll be at a level -- which I'm having trouble reading -- of only 15 per- .13 14 cent higher than what might be expected. on the other hand, 15 it would be twice what they're now spending. 1(; And I just don't believe that they've had an oppor- 17 tunity to organize a coherent program that's twice as large as 18 the one they're presently involved in. So my inclination weuld be to fund them at about the 20 same level now and if the July application shows progress in 21 terms of more detailed planning, then I think there's an opportunity to provide them with what will, I suspect, be a large enough amount of money for them for the next year. 2;1 So I'd recommend a fu@nding level of $1,450,000. 24 MR. CHAMBLISS: At the current annualized level 2;-) HOOVER REPUxiiNG CO, INC. 320 Massachusetts Avenue, N.E. Washington, D.C. 20002 34 MR. POSTA: Excuse Me, Doctor. That current annual- 2 ized level projected over a year for Arkansas is $1,848,000 3 the first column. 4 DR. CARPENTER: My first column shows a r Llion four. 5 MRS. WYCKOFF: So does mine. 6 DR. WHITE: Do does mine. 7 MR. POSTA: I guess it's the 17th edition., 8 MR. CHAMBLISS: We're working from the May 21st 9 edition. 10 MR. POSTA: I'm so@ about that. 11 MR. CHAMBLISS: Thanks for that presentation. 12, 1 would like to ask if Mr. Posta will provide, in the absence of the second reviewer, the committee with any 13 14 additional information that he chooses on Arkansas. Mike? 15 MR. POSTA: I hdve been associated as operations 17 officer to Arkansas since 1970. The Mid-Continent Operations 18 Branch considered Arkansas to be' one of the better programs in the Mid-Continent Operations Branch, primarily because of 20 the coordinator who has.just resigned in February. I think that Dr. Ca rpenter's comments were quite 21 relevant because Dr. Silverblatt has left the State of Arkansas. There is a question of leadership. 2:3 However, Mr. Roger Warner has been the evaluator 24 the monitor and evaluation chief of.that particular section HOOVER RLPOR I ING CO, INC. 320 Massachusetts Avenue, N.E. WashinRton, D.C. 20002 35 and has done a good job in this regard and is serving in an 2 acting capacity now. 3 e The Search Committee is in process of sel cting 4 another coordinator. Mr. Warner is one candidate. 5 Seven of their top professional people have been on 6 board for about seven years. 7 Now, last year when they came in -- meaning the last 8 Council meeting in November of 173 -- the region responded to 9 the five initiatives which DRMP had sent out to all of the 10 RMPS; that is, "We want to do more in planning; we want to do ii more in quality care; we'd like to get something going in 12, kidney, EMS, and hypertension." -13 Most of their ap .placation -- or their thrust during 14 that period of time was in these five areas, and in this par- 1;5 titular application they,-have what they call an "umbrella concept' within the core staff of ten particular areas where 17 they have maintained those five original ones that we've men- 18 tioned and brought in position extenders more of a program force, unified health planning and new legislative concepts more in the area of hypertension and a couple of others that I 20 can't recall. 21 22 Seventeen of the activities are.new; seven are con- tinuing. 2:1 I might refer you to your yellow sheet in the book. 24 I think you all probably have that. It more or less reflects 25 HOOVER RLFUKTING CO, INC. 320 Massachusetts Avenue, N.E. 36 what Dr. Carpenter just mentioned with reference to staff. 2 They have currently on board 16.6 full-time people. They do 3@l propose 29.6 in order to do the job that they've set out. 4 I think there's been no problems whatsoeve'r-with'the 5 CHP A and B agencies. Arkansas was one of the first regions 6 to have acomplete blanketed state with eight CHP funded 7 agencies. 8 The ARMP and the CHPS,, along with what we call an 1 9 "Estes" (phonetic) program, the Experimental Health Delivery io System package, have been in operation in Arkansas for about 11 four vears. They have been funded with about $3.4 million of 12 EMS activities from HSA. In this particular application they do have an .13 14 umbrella concept since the core,staff did develop the EMS 15 proposal that was approved by the then-HRA agency. 11 I could go on, @u-E I think I'd better stop. 17 MRS. WYCKOFF: What do you mean by "an umbrella concept"? I see this in a number of these, and I wonder what does that consist of? MR. POSTA: Well, within the total program staff 20 budget, they have said, "We would like to administratively 21 break up our entire program staff into tan areas," and they break out their budget accordingly, and those ten that I men- 2:1 tioned in hypertension -- they have one on arthritis that I 24 didn't mention each of these people on staff would be HOOVER REPOKI ING co, INC. 320 Massachusefts Avenue, N.E. WA-hin,-tnn DC-20002 37 1 working in these particular activities. 2 Within the application, which does request $890,000 3 in this total program staff budget, you have about 13 percent 4 of the over-all request in what we used to call a develop-, 5 mental component or, as they call it, contingency funds -- or 6 as some of us would call water. 7 But I might say in all fairness to Arkansas that 8 that is a mechanism of funding, and I dare say that all of the 9 applications you see -have. certain developmental component 10 funds.listed. MR. CHAMBLISS: All right. 11 I wonder, at the end of r 12 this p esentation, if 13 'there's a motion for Arkansas, or are there further matters to be discussed? Are there further questions? 14 15 DR. WHITE: Their request is for a million eight, that's only $400,000 more than they are getting at the present time. 17 18 DR. CARPENTER: Yes, and they're going to come in for some more in July. 20 1 think it's very hard to set the funding level. For me, it was very difficult. If you try to go by you 21 look at the projects and try to see which.one would amount to 22 something. I just don't have any confidence in anything from 2:i what they've described, and I, obviously, don't think we ought 24 to make it impossible for them to start any projects. I think 25 HOOVER RtrURIING CO, INC. 320 Massachusetts Avenue, N.E. 38 1 their core needs to be protected, which I and, sot I sort 2 of added a few projects to core. 3 DR. SLATER: The question I'm asking is whether you 4 feel that they need to re-present what they have apparently 5 done ineffectively for the July deadline so that they in fact 6 are going to be coming back for the total amount tha they 7 were shooting for? 8 I'm not quite sure what the guidelines arelthat are 9 associated with your suggestion for a continuation 0; funding 10 at the present rate. 11 DR. CARPENTER: I was wondering about that," too. 12@ DR. SLATER: Are they just to be given the,money and 13 then permitted to cut back where they see fit? How does this 14 help improve their function? 15 1 feel the same way you do; I'm at a loss as to how to react to them. MR. VAN WINKLE: It would be too late, though, I 17 think,, to amend their July 1 proposal because their RAGs are meeting at the present time on that proposal -- I think most of them are, aren't they, -Mike? 20 21 MR. POSTA: Yes. They expect about $800,000 new 22 activities to be @ mitted in that July 1. DR. CARPENTER: Let me comment on that. I think 2:i they do have RAG approval on these Projects, and I -- it's 24 obviously suggesting an enormous am ount of work in an already 2;-) HOOVER RLFURIING CO, INC. fjr 39 1 overburdened st f, but if I was to be convinced that the af y 2 could spend more money effectively, I would need additional 3 information about their -- the goals and the evaluation 4 systems for the projects that they intend, and I would think 5 it might be interesting to think whether we want to suggest 6 that some region provide that kind of information in view of 7 the difficulty of the rush (phonetic).of the projects. 8 MR. VAN WINKLE: All I was looking at is that 9 Council will be meeting and we cannot relay any information 10 back to them until after Council meets and their July 1 appli- ]'I cation would probably almost be in the mail to us by that time 12 DR. CARPENTER: But presumably -- and this is what the key issue is in July if you are not going to do a .13 14 project review and you are going to have only an application that describes projects 15 MR. VAN WINKLE: I/ it'll-be a full-blown map -- 17 DR. CARPENTER: Well, you see, that gives you -- 18 MR. VAN WINKLE: it'll have to stand on its own. DR. CARPENTER: Thea that, standing on its own, 20 could say, "Hey, look at all the progress we've made since last time in our project plan." 21 9.) DR. WHITE: May I ask a questio n,, Mr. Chambliss? MR. CHAMBLISS: Dr. White. 2:t DR. WHITE: This was a highly regarded region at 24 one time; is that correct? 25 HOOVER REFURIING CO, INC. 320 Massachusetts Avenue, N.E. r) r )rtnf),) 39 1 overburdened staff, but if I was to be convinced that they 2 could spend more money effectively, I would need additional 3 information about their -- the goals and the evaluation 4 systems for the projects that they intend, and I would think 5 it might be interesting to think whether we want to suggest 6 that some region provide that kind of information in view of 7 the difficulty of the rush (phonetic).of the projects. 8 MR. VAN WINKLE: All I was looking at is that 9 Council will be meeting and we cannot relay any information lo back to them until after Council meets and their July 1 appli- 11 cation would probably almost be in the mail to us by that time 12. DR. CARPENTER: But presumably -- and this is what the key issue is -- in July if you are not going to do a .13 14 project review and you are going to have only an application that describes projects 15 MR. VAN WINKLE: It'll'be a full-bloi-7n map -- 17 DR. CARPENTER: Well, you see, that gives you -- MR. VAN WINKLE: It'll have to stand on its own. DR. CARPENTER: Then that, standing on its own, 20 could say, 'Hey, look at all the progress we've made since last time in our project plan." 21 DR."ATHITE: May I ask a question, Mr. Chambliss? 22 MR. CHAMBLISS: Dr. White. 2:3 DR. WHITE: This was a highly re ded region at 24 one time; is that correct? HOOVERRLPURTINGCO,INC. 32OMasgchus@ttsAvenue,N.E. 40 1 MR. CHAMBLISS: It has been a highly regarded region 2 DR. IIHITE: The question now, Bob, is that there has 3 been a change of leadership and some disassembling of things? 4 DR. CARPENTER: You know, it's hard to tell whether 5 there's been a change in leadership or just, no matter how 6 good your leadership is, this is an impossible situation, and: 7 it might be possible to say well, look at this -- I don't 8 know if you can -- but as I look at the staff, they're being 9 asked to do some very difficult things in terms of, you know,, io the details of the sickle cell project, for instance, and 11 they're not able to do it, and I don't know whether that 12. maybe in the past they would have gotten the.expertise they 13 need from their voluntary groupsi For some reason or another, 14 they don't seem to have it now. 15 I can't tell whether it's the leadership or the time element. 16 17 DR. SLATER: Your real concern here is not, I 38 gather, on a project basis whereby you feel that one wants to cut back there, but some sense that the program isn't as strong, that the staff leadership isn't as strong, and it 20 21 doesn't satisfy these criteria as well as you would like and, 22 therefore, it should be generally kept at.the present level? DR. CARPENTER: Yes; I doubt that the staff can 2:1 enforce high-quality projects of the type suggested. 24 DR. WliITE: That's a reasonable concern. 25 HOOVER REFURTING CO, INC. 320 Massachusetts Avenue, N.E. 41 1 MR.-POSTA: i feel very awkward in defending the 2 region. I really do. I don't think that's my role as Branch 3 Chief, on top of that. 4 'DR. SLATER: May I speak to that? I think it's very 5 important -- if the Staff have direct contact with the people 6 there and they have a sense of history that we certainly canot 7 pick up from one reading 8 MR. POSTA: I assure you this is not the best 9 application that Arkansas has ever submitted, and that's true io because 15 days after they got instructions, the coordinator 11 had long departed. 12 However, they do have what I consider a good, small staff. Arkansas has never had a big staff. We're talking .131 14 about a state that's forty-ninth in the country as far as 15 average income is concerned, They have limited providers. T think that just as an example in this particu- lar application, for the amount of other sources of support 17 which is included in your conglomerate budget, they have state funds, local funds, and other.federal support of $415,000; 20 mainly through the RMP, the EMS application was approved and 2,1 plans put into the CHP A agencies were likewise approved. They, along with the VA, were instrumental in draft- 22 ing the proposal whereby Arkansas has a state Estes program. 2:@ These folks have been working closely together. The Univer- 24 sity personnel is involved and definitely involved with these 25 HOOVER RLPUKI ING CO, INC. 320 Mamchusetts Avenue, N.E. R p )nnn9 42 1 e application, including particular projects that are in th the 2 particular function, such as quality care. They have the 3 nucleus of the program in the form of a contract nowigoing on I 4 which has set the stage for the other eleven bigger or larger 5 hospitals in the state to follow that pattern. 6 The hypertension program which was athrus--. from 7 us, as of last year they have .carried the ball with @hat and s@ . (sic) 8 have hypertensive programs going on in each of the ates. 9 They have drastically improved as far as the 10 minority concerns their Council and review committee have 11 had in the past. 12I Their turnover of the Regional Advisory Group is almost nil, and I feel that the ARMP, the Arkansas RMP, is 13 14 much of a stronger agency when you look around at the CHP and 15 its leadership there and,.the E:ttes program -- in particular, in the EMS portion that is being funded under Estes. They're i(i 17 looking to ARMP for that leadership and guidance to carry that 18 program in the State of Arkansas. Now, that's not to say how much money they've come in and gotten for cancer -- or have received from the cancer 20 program or the heart program or others. 21 Now, I'm responding only because of what was said 22 earlier with the previous region, and you're coming to a 2:1 decision here. I agree that the token figure of 140 percent 24 is something to shoot for after the'May 1 application is HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.E. 43 received, and I really don't think your recommendation is that 2 far off, but I felt that I needed to defend this region just 3 a little bit more, because we feel, at least at this@levels 4 that they haven't done that bad a job. 5 MR. THOMPSON: You see, this comment is now pushing 6 us down to looking at specific projects. This is what worries 7 me. 8 MRS. WYCKOFF: And we can't do it. There'5 not 9 enough information for us to do it that way. @io MR. CHA14BLISS: We do not propose to look at speci- 11 fic projects, but simply the program and the objectives of the 12; program at this particular state. 13 I would say, based on the presentation from the 14 presenter and Mr. Posta -- I would ask -- I perceive.the 15 recommendation that Dr. Carpenter has made with regard to the level of funding. I have heard a number of items of rationale as to why he arrives at that point, and I'm wondering if I 17 could get a motion on the floor for your recommendation, Dr. 18 Carpenter. DR. CARPENTER: Well, in view of some of the dis- 20 21 cussion, let me move that we approve $1.5 rhillio'n@for Arkansas. MR. CHMIBLISS: It has been moved and seconded -- 22 MR. VAN WINKLE: No second yet. 2:1 MR. CliAl4BLISS: It has been moved that the level of 24 a million five be recommended for Arkansas. 2;-) HOOVER RLPOKIING CO, INC. 320 Massachusetts Avenue, N.[. 44 is there a second to the motion? 2 DR. VAUN: Second it. 3 MR. CHAMBLISS: it has been seconded by Dr. Vaun.. 4 Is there discussion on the motion? 5 DR. WHITE: I can sympathize with Bob in trying to 6 come up with a figure that's more than he wanted but less than 7 they asked for, but I don't know how we come to that ration- 8 ally. Is there some other alternative to this? Is there some 9 way of saying they deserve to be considered for an increase in 10 monies beyond that which they're currently getting? We would 11 not like to see them get more than the --'what do they call 12, it? targeted funds, and preferably less. They didn't ask for the target -- -13 MR. THOMPSON: 14 they only asked for 80 percent of the target. 15 DR. CARPENTER:,.But they'll be up to 115 percent by Al . the time it's all over. 17 MRS. WYCKOFF: They want $782,000 new. That's a lot 38 of new. DR. SLATER: May 1!) I ask a question on this? On !:he 20 next round that we're going to be sitting on, are the criteria 21 going to be different than this round, or are we really going 22 to be looking at projects in the old way? 2:@ MR. CHAMBLISS: The criteria will be the same. DR. McPHEDRAN: We will not be looking at projects? 24 MR. CHAMBLISS: We will just engage in the project 25 HOOVER RLPURIING CO, INC. 320 Massachusetts Avenue, N.E. 45 1 review. 2 DR. SLATER: Since this is on the floor, and having 3 known Arkansas in the past, I have to give the benefit of the .4 doubt to the staff in Arkansas under these situations'. I 5 think they've been through the mill and if there is a proposal 6 that comes in that looks as if they're a little bit at sea, I 7 don't know what else to do except say, "That's the way our 8 country operates right now," and I'm inclined to move the 9 money out of here so they can stay alive in their present- jo state of health or at least their desired state of health, and 11 I'd like to speak in favor of giving them what they ask for. 12. MR. CHAMBLISS: Any further discussion here? DR. CARPENTER: I have-obviously thought of that, too, as an approach we can take. I have-in the-back of my min 14 Iguess, something which is going to surface repeatedly, and 15 it might as well surface now. I think that local planning efforts have been slip- 17 shod and we're now moving toward a time when weire going to I 8 J!) try to redo the mechanism for-local planning, and I believe 20 that one of the messages that has to get back, one of the 21 matters which deserves our consideration, is that you just can't reward low quality planning, and I don't see that -- you 22 know, for instance, as this region begins to choose who its 2:i leaders will be in the health plann.ing business, I think they 2-1 need to choose very talented people, and I'm not anxious to HOOVER RLPURIING CO, INC. 320 Ma@chusetts Avenue, N.E. I lead them astray. 2 MR. CHAMBLISS: Is there any further discussion on 3 the motion? 4 MRS. SALAZAR: In an attempt to sort of meet halfway 5 between these two points of view, I would hope that the 6 message that goes bac k to this region is not punitive in any 7 way. Certainly the staff must be having a pretty hard time 8 with their strong leadership having disintegrated, and I think 9 they need to be encouraged at this time rather than punished. 10 MRS. WYCKOFF: What about the kidney and the EMS and 11 that sort of thing there? Did you discount those as things 12, that should be supplied from other sources? DR. CARPENTER: llell, frankly, I didn't. I don't -- 13 it seems to me that the health planning leadership in an area 14 might well invest some monies in assisting that area to meet 15 very specific goals of categorical federal programs, so with 17 that philosophy, then, I didn't get -- and from what I heard 38 about our guIidelines, I gathered that we could permit some of this. I didn't really -- I can't say I discounted those. MRS. WYCKOFF: What about this arthritis money? 20 MR. THOMPSON: That's separate. There.'s a @cial 21 group of people out there (indicating). 9 DR. CARPENTER: Is that a core I think that's 2:i part of their core activity to assist the region to develop an!, 24 application for arthritis funds, and develop the regional 25 HOOVER RLPURI ING co, INC. 320 Nlassachusetts Avenue, N.E. 47 1 system in support of that application. 2 DR. SLATER: I wonder if there's some other alterna- 3 tives available here. lielve in the past been able to send .4 messages back. For instance, staff guidance. We've been able 5 to lay out visits if we're concerned -- site visits if we're 6 concerned about Providing allocates (phonetic) of money. W e 7 have been able to Pass things on -- for instance, hold it over 8 until the next round subject to review by an elite group. 9 Are we under sufficient pressure here to respond to 10 this one-time allocation? It's a survival matter, and we just 11 use our best judgment here? MR. CHAMBLISS: Certainly we're called upon to use 12 @ .131 our best judgment, but the region will get advice as this 14 Whole round of review terminates, and the concerns being expressed here now will be incorporated into the advice letter 15 going to the region. 1(; DR. CARPENTER-. Ihave a question here. When their 17 July application comes in, will it be a request for a certain dollar amount of supplemental'funds or will it be a reque st fot 20 a new funding level? MR. CHN-IBLISS: It will be for both. You will note 21 in your column 'July 1 Estimate" that the region anticipates that it will request a stun approximating $800,000. 2:t MR. THOMPSON: Additionally. MR. CHAMBLISS: That's simply a request. That does 25 HOOVER KLPURI ING co, INC. .i Aienue, ti.E. 48 not mean that that sum will be awarded, because you know the 2 over-all limitations that we have on total funding. jAll of 3 this will be fitted into the amount of the available dollars .-4 that we have once the final decisions are made by --..e court. 5 DR. MILLER: That $800,000 is going to be 6 series of projects, new projects, right? 7 MR. CHIU4BLISS: Right. 8 DR. MILLER: On what basis are we going to make a 9 decision about awarding Arkansas $800,000 for a bundle of new jo projects? 11 MR. CH-A-M-BLISS: That is only an anticipated figure. 12: That is what 13 DR. MILLER: I don't care whether it's $100 or 14 DR. WHITE: It's going to be on the sam6,amount of 15 concrete evidence that we have today-. MRS. WYCKOFF: Exactly, 17 DR. SLATER: It seems to me that we're going through, 18 a problem whereby a traditional review committee is having a hard time learning how to operate like a council, and this is in fact what we're being asked to do. We're being given a 20 211 list of projects we are not able to technically analyze, but we're asked to look at their conherence within the framework or 2-1 the history of the pro4qram and the objectives of RMP. And it 2:3 seems to me that's what the Council used to do, and it may 24 well be that in the future, whatever comes out of the 25 HOOVER RLPURTING GO, INC. Au;-.niip. N-E. 49 1 legislation, some other kind of-systern will have to be put 2 together, but I would guess that we're not going to be able to 3 operate comfortably like a traditional review committee and 4 we are having to look much more at policy and staff security 5 and so on. 6 MR. CHAMBLISS: We share your discomfiture. 7 DR. SLATER: I don't know how else to make these 8 decisions. 9 MR. CHAIMLISS: Dr. Vaun? 10 DR. VAUN: As the seconder of the motion, I'd like 11 to reaffirm my,second of the motion on the basis of the dis- 12@ cussion I've just heard. I don't see that this is in any way a hindrance to the group. 13 I think it would be dangerous to give them more 14 money than the leadership can use At this point, and they have 15 an opportunity to come back again, and if there's going to be a total and complete presentation, if they get a few messages 17 38 on this round, there's no reason why the discussion can't be different on the next. I don't think this is a punishment or a harm to them. 20 I think it's a rational decision on the basis of their leader-! 21 ship at this point. 9.) MRS. WYCKOFF: Call for the question. 2:1 MR. CHAMBLISS: I would simply ask that those in 24 favor of the motion let it be known by the usual sign. 2;-) HOOVER KLYUK II NG GO, INC. co (Ayes respond.) 2 MR. CHAMBLISS: Those opposed? 3 (opposed respond.) .4 MR. CHAMBLISS: There are two opposed, Dr. Slater 5 and Mr. Thompson. 6 The motion is carried. 7 Did you have further 8 MR. PBSTA: I wanted to know what is the official 9 motion? 10 MR. CHAMBLISS: The official motion is tha@ it is ii recommended that the level of funding for the Arkansas 12 Regional Medical Program be placed at $1,500,000, with the concerns expressed by the members of the Review Committee 13 14 going to the region. DR. CARPENTER: Particularly that they support that 15 core. 17 MR. CHAMBLISS: Shall we move then to our next region, Bi-State? 20 21 22 2:@ 24 25 HOOVER RLPUR I ING CO, INC, 320 M3SS3ChLISetts Avenue, N.E. BI-STATE REGIONAL MEDICAL PROGRAM 2 MR. CHAMBLISS: The reviewers are mr. Toomey and 3i Dr. McPhedran, and Mr. Frank Zizlavsky will be the Staff 4 person here to give the necessary support. 5 Mr. Toomey. 6 MR. TOOMEY: I utilized the review THE REPORTER: I'm sorry, sir, I can't hear you. 8 MR. TOOI-EY: for the basis of this discussion. 9 In reading the application I think the first thing 10 that struck me -- was the microphone -- was the fact that the 11 Regional Advisory Group disbanded and turned over the respon- sibility for the program to a 15-man executive committee. 12; That 15-man executive committee has functioned. However, as 131 14 time went on, very recently the program coordinator himself, Dr. Stoneman, resigned, and in the material that was sent I had, in reading it, a tremendous feeling of frustration on the part of the material that was written. 17 All of the program staff, however, seemed in terms Is of their experience to be an Experienced staff. I could look the figures up, but it seems to me at the present time they 20 have somewhere in the neighborhood of eleven program staff; 21 whereas, their organizational program would call for about 22 nineteen. 2:1 In looking at the past performance and the accom- 24 plishment of the Bi-State RMP, it seemed initially in tune 2 HOOVER KLPUKIING CO. INC. 52 1 with the heart disease, cancert and stroke programs, although 2 it was affiliated with both Washington University and St. 3 Louis University and these two unive rsities were the granting .4 agencies. 5 Later in the program the major thrust was in emer- 6 gency medical services. 7 In looking at the even more.recent programs, thev 8 have not substantially addressed the problems of accessibility 9 and availability of care with the exception.of the emergency I,o medical services, nor have thev addressed themselves to the 11 needs of the minority groups, nor to health deliverv systems. 12 In fact, they are in a very, very particularly difficult kind of situation because they're attempting'to provide a program 13 14 for the rural Southern Illinois and the urban St. Louis area, and I'm sure that the conflicts in terms of the needs of both 15 these areas are expressed in terms of the variety of programs. 17 At the present time they are requesting EMS con- tinuation grants, assistance to local planning, including some 18 health manpower planning, quality assurance, manpower recruit- 20 ment for the disadvantaged, and projects related to cancer and 21 kidney disease. Now, with the exception of the EMS, the projects 22 that they propose do not in fact fall within a document which 2:1 was in this proposal which was called, "The Health Needs of 21 Bi-State RMP Region as Identified by Joint MIP and CHP 25 HOOVER KtrUXTING CO, INC. 320 Massachusetts Avenue, r@.E. 3 1 Planning Conference." 2 In February RMP and CHP met together and they 3 selected three or four areas that they felt were necessary for -4 the development of programs within the Bi-State area a need 5 for improvement of emergency medical services -- and@that one, 6 of course, they have worked on. 7 Secondly, need to improve accessibility to quality 8 health care. 9 And the third was need to improve the availability io of trained health manpower for the entire region. 11 And the fourth was need to coordinate heal h care 12 de livery planning. 13 Skipping the feasibility for a moment-, as far as the 14 funding is concerned my comment here would be that the projectc 15 prob@lv could be accomplished, but they do not seem to be compatible with the needs expressed in the joint -R-MP-CHP memo. In terms of their relationship with comprehensive 17 18 health planning, despite the memo that is in the proposal from RMP, my feeling in reading the comments from CHP -- well, I noted them as being polite but restrained, and very restrain- 20 ed. I think I read into it, certainly, that there was not a 21 tremendously happy relationship with that relationship. 22 As for the funding -- you can read this with me 2:1 I did not have it and I am interested in seeing it -- but at 241 the present time the present level of spending annualized is 25 HOOVER RLPUKTING CO, INC. 320 Massachusetts Aienue, N.E. 54 1 $870,000 -- almost $871,000. The targeted available funds, 2 $1,256,000. The May 1 request which I am pres ently discussing 31 is $1,129,000, but there is a July 1 estimate of $410,000 -4 which places them at a figure in excess of the targeted avdil- 5 able. 6 on the basis of my own review of this, reading this 7 material, frankly -- and the feeling that I got from@reading 8 the projects and reading the comments and relationsh.' s with 9 CHP, it would seem to me to be the unsuitability of -.,'le 10 projects in terms of the direction in which I felt -RMP was 31 attempting to move itself. 12. I recommended only $800,000 in funding for this 13 current recommendation. 14 MR. CHAMBLISS:. Thank you. 15 We will now call upon our second reviewer, Dr. McPhedran. DR. McPHEDRAN: Mr. Toomey and I both were on what 17 18 1 guess was the latest site visit, formal site visit, to Bi- State, and the program -- this regional medical program we 20 thought at that time had had a lot of difficulties with 21 organization and there was some delay, as I recall, in their 22 getting triennial approval, and I think that was true of several other regional medical programs, but we were always 2:3 concerned about leadership in this program. 24 They had had a great many'problems with-their HOOVER RLPURI ING CO, INC. 19A fiq@rhij@ttt- Avenue. N.E. 55 relationships with the medical schools and it was perhaps a 2 blessing in disguise when the medical schools withdrew, but I 3 don't really think that the program leadership appears to have 4 entirely gotten -- once they got rid of what was really an' 5 incubus, that is, their relationships with the medical 6 schools, I don't really think that they got any sort of 7 coherent direction of their own. 8 And I'm surprised to see that the Regional Advisory 9 Group seems to have relinquished its responsibility -- I agree'! l'o with Mr. Toomey's assessment of that. I thought that the ii Regional Advisory Group itself was capable of providing 12:, stronger leadership than that. 13 In reviewing the projects, I looked at the two new 14 ones sort.of as a touchstone for what direction they wanted to take rather than, I thought, technically reviewing them. 15 I think that the RAG-or what was left of the RAG when they met in February with CHP, I think that they felt 17 that the rug was pulled out from under them when no new EMS 18 projects could be begun and what they have actually-requested 20 in thd way of new projects are perhaps a dim reflection of 21 what they would like to have. Of those two projects, though, one of them does 22 2:i address minority recruitment and it . has been such an important lack in this program before that I think note should be made 24 of the fact that they seem to have come up with a project that, 25 HOOVER RLPURIING CO, INC@ 12OMassachusettsAvenue,N.E. t'Ja@hincfnn nC, ?OnO? 56 I in the bare bones that are given here, looks reasonable. 2 The other new project, which is a study of what's 3 happened to manpower trained in a consortium that they partly .4 sponsored, is something which I find myself not much in 5 sympathy. It seems to me that the study -- I don't see why it 6 requires this separate funding. So that, rather than use this as a-part of technical 8 project review, I think that I would like to present it as a 9 kind of example of what I think are the difficulties that 10 they're having in getting a program direction. 11 Similar things could be said about some of the con- 12 tinuation projects, but I was interested to note that the requests for quality assurance -- two of the requests for 14 quality assurance relate to programs in out-patient practices, 15 and I don't know whether,.that comes under the same kind of scrutiny as PSRO in hospitals Mr. ThOMT)son shakes his head and says not -- because this is 17 MR. THOMPSON: Right now legislation restricts it. DR. McPHEDRAN: The'restriction relates only to 20 hospital-based activity, hospital and nursing home activities. 21 Well, that's what I thought, but I wanted to be sure about that. 22 MR. THOMPSON: With the option, and you know damn 2:1 ii well they ain't going in that direction. 24 DR. McPHEDRAN: But the purpose of these projects i HOOVER ELFORIING CO, INC. 57 1 for continuing support seems to me laudable, although I must 2 say I didn't like what I saw as a technical matter in one of 3 them. Nevertheless, I felt that their purposes were laudable. .4 1 don't disagree with Mr. Toomey's funding level, 5 because I find such difficulty in coming up with one of my 6 own. It's very hard to know. I think that, for example, the request for core staff, which is about $550,000, as I recall, 8 for direct and indirect costs -- I assume that that's based on 9 an expectation that they would have their eight plus five 10 staff, a total of thirteen staff. Since that is at least half 11 of what we -- five-eighths of what we would be talking about, 12 I don't really know whether they can get along and do anything .13 worthwhile without increasing the core staff, but I'm reluc- 14 tant to accede to the request to increase it by that amount because I'm not really sure that they can use the staffing. And Mr. Zizlavsky has been there recently, I think, 17 on technical matters., and maybe he could address himself to that question. MR. CHAMBLISS: Mr.oZee, will you fill in there? 20 I-lR. ZIZLAVSKY: There's about three or four areas 21 I'd like to comment on,Iand I might as well comment on the I program staff area right now. 2 That $550,000 figure for program staff is really gobbled up by indirect costs from these two universities. ,)4 That's Point 1. HOOVER RTFURI ING co, INC. ii. E. 5 8 1 These five additional staff four of these staff 2 are secretaries. They may be a little heavy in the secre- 3 tarial area in the secretarial-clerical area by having .4 seven secretaries for eight or nine professionals, so that may 5 be a little too much. 6 The basic other program staff request is for a 7 deputy coordinator and what they would call a programs opera- 8 tion -- regional outreach person. I think these two are 9 legitimate requests. 10 A comment about the RAG responsibility and the ii decrease from 75 members down to 15 members. Going back into 12. our history, not to drag this out, but May 1973 was aof go/no go" type of month. Everybody was down. The results from 14 RMPS came out in terms of recommendation for funding on the 15 phase-out plans. Bi-State's Program -- final recommendations for Phase-out on this program were pretty skimp y. 17 By June 30th they probably had five or six total staff on board. I'm not asking for any sympathy from the reviewers, but it was at this'time in may that the Regional Advisory Group thought RMP was really going under, and this 20 21 was the main area where they delegated their responsibility to the executive committee. 22 Subsequently they have come back and they are start-ii 2:3 24 ing to build right now in terms of increasing the RAG. They had not made that decision yet because of the future problem 25 HOOVER RLPUH I ING CO, INC. .l2DfA2ssachusettsAvenue.N.E. 59 in terms of health resource planning. why put types of 2 people on Regional Advisory Groups which might not be the 3 future type of people? -4 Mr. Toomey is correct that in several areas they, 5 have not addressed accessibility and availability. rhey hav 6 improved in the area of minority representation. Du ing the 7 phase-in period they have been able to hire one minority 8 person on program staff and they're leaning heavily On this 9 person to really get into the St. Louis area, Which really in 10 the past they have not done.an effective job. 11 I would have to go along with the recommendation for 12 $800,000 considering the factor that the July request is a $410,000 request. They are under review for 31 projects 13 14 presently, which there isn't any information in this.applica- 15 tion. 16 My best estimates in talking to the program involve 17 that they decrease the 31 projects down to 24 projects, and 18 this is the $410,000 estimate coming up. MR. TOOMEY: May I ask Zee a question? Was my feeling right about the relationship between 20 the CHP agencies and the RMP agencies? I got a elinc 21 fe of some conflict. 22 2:1 MR. ZIZLAVSKY: The only area of conflict is dealingi e I I in the area of EMS. There was a subtle arrangement that when i 24 l@ the EMS activities started up and the eight contracts were 25 HOOVER RLPOK I ING CO, INC 60 1 awarded from HSMA (pho