i ;.I..E(-)C)l@3'1* ' A 2@ @'f! N G C O'@', P -1 POT HOOV'ER RE LiY, INC. D. C. 5,@"t6-66'0'6 rc DEF-PRT14ENT OF IEALTH, EDUCATION, AND WELFARE ME-ZTING OF AD HOC CONQ@ULTANTS REVMIING REGIONAL MMICAL PROGRAM APPLICATIONS Conference Room H Parklawn Building 5600 Fi,.zhers Lane Rockville, Maryland 20852 Wednesday, May 22, 1974 Panel B convened at 11:00 o'clock a.m., Mr. Peterson, Chairrran, oresiding. PA@F,L B: @Mr. Kenneth Barrows, West Des Moines, Iowa Dr. Joseph Hess, Detroit, Michi-an Dr. -Albert Heustis, Three Rivers, Michigan Dr. John Hirschboeck, Mi lwaukee, Wisconsin Mr. Joseph de LaPuente Dr. Charles McCall, Dallas, Texas Dr. William Thurman, New Orleans, Louisiana Dr. Paul Teschan, Nashville, Tennessee Sister -Ann Josephine, Notre Dame, Indiana C 0 N T E N T S @3.2ns: Maine 15 Motion 28 Vote 34 Motion 40 Vote 40 Motion I Vote 42 -A lbany 49 Motion 57 Vote 6o Northern New England 62 Motion 7 Vote 79 Connecticut 82 Motion 100 Vote 101 Central New York 103 Motion 115 Vote ii6 Hawaii ii8 Motion 131 Substitute motion 132 Vote 133 Arizona 135 Motion 152 V.@te 153 Motion 153 Motion a.,ne nd e d i.6 o Vote i64 I 2-a fie,7ions.(continued): EtZe Gree,ter Delaware ValLey i66 Motion 175 Vote 179 0 I 49 3 P R 0 C E E D I N G S PLITERSON: We might as well get started, (Discussion off the record.) 14R. PFTERSON: Before we do get down to individual regions, I would like to mention some thinrrs going back to what Herb took off on, not tryinn, to repeat, on the other hand, but get down to some of what I see as the more nitty-gritty details. You have already heard from Herb and the review guide that I hope ail of you got, the kind of things that seems@ to me is almost imperative that we individually and collectives ly sort of try and keep in mind, the necessity for trying to keep our focus on the overall reviod and Its proposal, need to try and cotich our review in terms of the criteria and factors which we soecified as beino, the basis for our jud,,,ment. Clearly if we try to look at very many projects, we are in trou'icl.= I think I calculated we would have two minutes per project if we operated on a project basis. On the other hand, there certainly are going to be some instances where the reviewers and staff will want to single out some projects. I ,7,uess primarily because they may raise policy issues or they have attracted strong negative CHP comments. So those are exceptions. On the other hand, as Herb indicated to the total group this morning, I think we are going to be;confronted 4 in a number of instances with projects which staff has already identified and perhaps others which you and in the application you have looked at, there are some policy issues about which WO, may not be able to resolve in our best tact at this juncture, maybe simply to flag those. .And certainly the time that Herb dwelt I think on tha@t last table, he passed out to everyone, I guess the column C we spent more time talking about than anything else. That tar@et amount, while it is not a formula, while it is not an assurance that the region will receive that much, I think yet in many ways It is going to have to serve as the i principal benchmark or backdrop against which we Look at these applications, rather than necessarily the much larger amount in! some instances that is being requested. But in terms of the review procedure itself, we have tried to assign each application to two people. We haven't designated them as primary or secondary reviewer, and the fact there is one column and another doesn't really have any oreat significance I may deviate from that certainly. There are a few instances, I know you have one or two, Mr. Barrows, Yihere dLie to last minute cancellations Dr. James I think just called the other day and I had someone call me who had their third numeral thorax within the past day who isn't here, so there will be a few applications where we only have a single reviewer because of last-minute canceLlciL,.Lvti,-. In a few instances we have tried to get to someone else. I knoV Bil4 apparently there was a contact with you on Northern New England since you had visited that region and possibly Bill will be able to pinch hitter as another reviewer on Northern New En- .land, Generally I would propose to not have the staff comments -- you do have brief summary sheets In your books, not to have staff comments precede the reviewers but rather to follow a--- appropriate after the two reviewers have, addressed themselves to the applications. I think in setting down with Dick Russell where is Dick? -- who is chief of the Western Operations Desk and with Frank Nash who is chief of the Eastern Operations Desk yesterday afternoon, we have singled out a couple of applica- tions where we will deviate from that rule where I think in the case of Hawaii, for example, there is some significant background we think we probably would like to present initially, perhaps also a Metro New York where we have got a different ki-n,,,' of application. But generally we will look to the reviewers initially and any staff comment subsequent to that if appropriate. Certainly apart from the two reviewers that will be called on, on the other hand, I think we do need to permit ourselves some tirm for a brie4L.-discussion fromthe others, questions and answers,, hopefully al@-red at either brin@ina spe- cific information or general impressions to bear, other people 6 on the panel have where they may have them, or to get some issues crystalized. We will ask the two reviewers in those singular instances where there is only one, the reviewer, the two or single reviewer to prepare the ratind- sheet which,,again, I believe was sent out to everyone along with the review guide and it is my understanding that each of you in the folders that ou had In front of you have about five or six blanks there, e have got additional ones if anyone runs out. But subse- quent to each review, where Dr. Hess or Dr. Teschan is one of the reviewers, I would like to ask each of you to, as we go along, to, the best of your ability, to try and complete a rating sheeti .Lor each of the regions where you have been asked to review it @nd to either let myself or Shirley Simons have those. Because we are going to try, as we get back on Friday, that will be one Dasis upon which we will try and give the totalgroup aLain an impression of how the two -roups have looked at their respec- tive regions. We also will need to get from you, from the group, some kind of recommendation, as toyour recommended level of funding with respect to each region based upon their current application, recognizing that in the overwhelming number oi, instances, regions will also be submitting applications in Julyi 3ut we do need that. I think we have heard enough about the kinds of 7 constraints that we are operating under. Not the least of which are lack of really good current information in many instances. Time is obviously something we are going to be wrestling with I think for the next 2-1/2 days. There are, for those of you who may not have brought all of your applications with or misplaced one in the cafe- teria, or indeed If there is a region you weren't asked to re- view you might be interested in taking a look at, we do have a small supply of applications for all of the regions this panel is concerned with back on that table behind Tom Simonds. So feel free to pick up an application if you have any desire to do so. -As far as conflict of interest is concerned, we have tried to arrange these two panels so that at least in the gross@ 'tutional sense, people from Great MidA,--st are geographic inst-L Looking at the eastern and western parts of the country than vice versa. In other words, Joe and At are from Michigan, we are not going to be dealino- with Michigan and hopefully at least CD you won't be dealing with Michigan in this context. DR. HEUSTIS: We couldn't really help you on that* MR. PETERSON: On the other hand, there may be in- stances, Ican't think of any, but where based on your own knowledge, where you feel there is some potential conflict of 8 interest that-- if that does occur) that you acknowledge itland, we will -- then the individuals can leave the room whi le that region is being discussed. HopefuLly that will not occur, be- cause we tried to arrange the groups where the obvious conflicts of interest would not arise. One final thing before we do get into the actual re- view. I do need to know if there are any people, particularly the reviewers ason will not be able to be who for whatever re here on Friday. CharLie IvIeCall, when we asked him to participate in this, indicated as part of his participation he had a long- standing commitment that forced him to leave late tomorrow afternoon, and thus I am going to have to make some adjustments n vis a-vis the regions CharLie has been asked to participate i the rev.-Le@i. But if there are any others of you -- Iaul. DR. TESCH-AN: I am paled on airline computers-- MR. PETERSON: That seems more like a bowl of jelly, from airline computers I have dealt with they are not that shar,--. DR. TESCHAN: Loused up so there is not much I can do about It. So I will let you know. MR. PETERSON: You are going to let me know if You have to leave early? DR. TESCHAN: The reservation says we will be leaving Friday morning. @IR. PETERSON: Okay. 9 DR. TESCIIPN: Ear ly. MR. DE LA PUE14TE: I have only one commitment this afternoon that I could not avoid.. MR. PETERSON: So as far as you are concerned,Joe, we need to avoid Looking at the regions, Northern New England and a few others you are coinc, to be the reviewer on, we have to defer those until tomorrow. 14R. DE LA PUE14TE: Yes. 14R. PETERSON: Okay. MR. BARROWS: I have a 4:30 f Light on Friday. !AR. PETERSON: No, Ithink we calculated-- @IR. NPISH: We would Like to get to Northern New England sometime today if wecan, because Spencer won't be here tomorrow, if we can work that out. MR. PETERSON: What time is your engagement this afternoon? MR. DE IA PUENTE: Three o'clock. MR. PETERSON: Okay, -vte wil-I do that this afternoons It may not be a good decision, but that is what is important in Washinoton -- don't worry about the judgment, do It on time. In addition, because some of the staff Spence Colburn Is a prime example, but not the only one some of the staff that have departed but have been brought back -Lor this also have some crunches and commitments. We are going to have to do some adjustment there and I think I have Identified most of that in my discussions with Dick and Frank yesterday$ i but we are going to try to handle all of the applications Spence has the backgrounds on, because he is going to be out o@, town beginning tomorrow in connection with his new job in the Bureau of Quality Assurance. Well, with that brief introduction, before we get started, I wonder if there were any additional questions in terms of details, procedures, or quite apart from details and i procedures, profound philosophical issues,, sorm of which I would be willing to take up at lunch. @IR. BARR(3TS: I believe some of us are bet er pre- pared on some than others, T went down mine alphabetically, PETERSON: You are better prepared on Albany? MR. BARROITS: Than I am on the last two* I hope to do that tomorrow. I think Paul is in the same boat. I don't know ,lbou'u the rest of us. MR. PETERSON: Well, again, if I should call for an application where you or someone else would like a little more i time, if you would Let me know that, I will, on sort of an ad hoc spontaneous basis, at least in the beginning we have all kinds of flexibility. When we get down to the last two appli-I cations, our flexibility is considerably reduced as to the num- ber of adjustments we can make. 1 L MR. DE LA PUENTE: One issue we could discuss very briefly, it has to do with vacancies that many of the applicants have made in view of the fact we are dealing with i just one year and that has a. conflict, you know, as to-- we let them fill all the vacancies because as far as the money is concerned, they are within range. I have a problem. Does anybody else have it? 14R. BPRRO@TS: Yes, we have that, we have it from another direction. -Assumin,, they get the budget, wil'I they be able to fill the vacancies and do the job within the time span available? @. DE LA PIENTE: Precisely. @M. B-AliRO,t[S: I would cyuess we had better take a look at those on an individual basis. They tend to vary, criti- cal shorta@e of staff or-- DR. TESCHAN: One philosophic coanent, I think yo.Q put your finver on as usual, mainly the local decision may be CD the ultimate reality. RMP's think affirmatively in the most distressing circumstances and I think riaht now the stance in many of the RMP'Ldis to think affirmatively about the transit I tion in the future. I think quality of the professionalism even in the short ran,7e -- talents, if anybody has any -- is goihcr to pick CD CD up the staff in whatever mode it will be. Whatever is recruited for next year is available for 12 .Lo I low-on. I am not nearly as much worried. MR. PETERSON: There is only one thing I would have to say, the issue Joe has raised, we did see the RMP's with the announced phase out in January of 1973 go down in the agmrecrate C) CD and there are obviously considerable variations here from roughly 1400 full-time sta.ff to about 700. In other words, las fall, Septer.,Lber, when we got to -- well, it was the November application, but it sort of reflected the s ituation as of last September, the Rx',IP's were down in terms of program staff about half of what they had been prior to the phaseout, By January o@" this year they had picked up about 300i additional people. That was durinc, the period when neither they nor we knew what the court was doing to order, and, in C> other words, it was at a time when I think the imponderables were even worse than they are no@i. At least now I can see down the tunnel for 15 months,i, maybe less. It is only 13 months now. It is almost the end of llay. In December and January, I really couldn't see down the tunnel for more than at the best six months. So I don't think that answers your concerns, Joe@ but I think it is not irrelevant. DR. HESS: I think III founded though It may be, we must have some confidence between the Congress and Administra- tion that the intents that are now being expressed will find 13 expression in so me legislation that will allow this type of activity to continue in some form or another. I think that is what you are sayin@. I think that has sort of been a backdrop and if thEY fail to come through, you know, I guess that is not our response sibility. But at the same time, looking at the public's need, i and the fact that this type of activity has proven itself to be effective for doinf7 a job that needs to be done, that somewhere or other there is enough broad support that somewhere'; or other the political element of this system will find a way to continue it. DR. TESCH-AN: I think the corollary for me from all that is we should make some efi'ort, i hope we oet some acree- ment to that, make some effort to make sure that as well as possible, each of the re@ions is ready for the transition for the follow-on. I think this is the time to get ready. DR. HESS: Yes. DR. TESCHAN: Even though the imponderables shut ofL' the enthusiasm for that in the region, I think perhaps we doLild'@ help stimulate what chances need to be made to vet regions in i line. SISTER JOSEPHINE: You know, in going over som o.L these applications, 1 have noticed in many cases where they were i looking for stafg they picked up staff from CHP pro-rams, whic'iill 14 to me is the direction toward the change in total administra- 'Uion, and this should be commented wherever they do this, be- cause I think this is addressing itself to the transition you are talking about. MR. PETERSON: WELL, I am sure there are @oina- to be all kinds of issues of both a, generic and specific nature sur- facing during the next two days.' We might kick off and I thouZht my sense of geography what it Is we might kick off w I th I,'Laine, since it is in the upper right-hand corner of the M(?.P of@the United States, itcbviously is not at the head or end of the alphabet, neither the larger or smaller states, but that is my rationale. Besides, Spence Colburn, that is one of the states we are lookinc, to Spence for some additional comments, since we do have two reviewers there. I wonder, do you want to Lead off on that, Charlie? DR. McCfiLL: Be glad to. MR. PETERSON: Okay. 5 DR. McCALL: I wish I had had an opportunity to re- view this program back when I found a, direct line, I found opportunity to look at a quality program@ and it obviously has. strong leadership at the staff and advisory group level. It comes through loud and clear this program makes great plans not only in transitioning what is coming, but in continuing and financial support from other sources. -And I really don't think there is any-- there is no question raised in my mind in terms of their conflict, in terms of their stated objectives end their program, the lements to achieve those objectives. The only question I had in my review was since ti-eir funding seemed to be a little low currently, and I assume that@ was because of all of the vagaries of the past years that we have been going over and the excellence with which the prorran CD has been based, other sources of funds not only planned but in hand and being utilized at the current time. So that that needs to be looked at when we come up with a figure or recom- mendation. DR. TESCHAN: Who Is the grantee? DR. McCALL: Medical-- MR. PETERSON: IL@dical Care Foundation, Incorporated. It is a private nonprofit corporation and has been since day one, DR. MOC.ALL: I will confess when I received these two i6 volumes -- this is only half of it, oh,gracious (indicating) material, just padded in here, and I since learned they were asked to come in with a complete application but I enjoyed going through this application. It is clear, it Is informa- tive, and I really found this operation useful certainly. MR. PETERSON:, Al, you also looked at Maine. DR. HEUSTIS: All I can say is I had two Impressions I received these two beautifully bound books and thought who are they trying to convince? I received this other one from California with the other material, and I didn't really think they were trying to convince anybody. Beautifully done -- graphs, different styles in the typewriter, different colored paper and so forth. And. I looked at it with a negative prejudice. DR. McC.ALL: I a-ree. DR. HEUSTIS: -And I read it. Everything you said isl@ true. DR. McCALL: Unbelievable. DR. HEUSTIS: This is the only one I reviewed that had any need or basic population data. DR. McCALL: All there. t DR. HEUSTI8: This is the only one I reviewed tha indicated the other than the RMP support that was going into the current programs, 17 This had a pretty definite and clear-cut attention to process ac@ far as priority ranking in how you got that way@ All of the questions I had were answered and a few of the questions I didn't have also were answered. I thought it was well organized, that certainly their record right down the overall list we had, all of the different criteria. I took this document which you have in the review sheet and broke down each paragraph into the number of thin-@s that you mentioned, plus a few of my own. And on Maine, I rated everything that was ratable in the good column except for the reflection of needs identified by comprehensive planning, which I put down as insufficient data. This may weLII be about as comprehensive planning has not identified a ny needs and not been doing the overall job. I would support any extra money that anybody has inii goinv to the Maine program as being capable of bein- extremel' y I well spent, with creat results -as far as continuation pro- jects at cost levels. I was particularly impressed that they were able to get some help from the state government. Not only in pickingi up some of the projects that RMP had started, but help from state government as I understood it, at least to go into the regular day-to-day operation of the program for the next fis- caL year, I feel very strongly and very positively about this program, It was a refreshin- one to read and made reading some of the others -- well, it even compensated. It was a ver-y % I refreshing one. DR. McCALL: No collaboration, but I obviously had the same impression. My recommendation was funding maximurA eligible. MR. PETFRSON: What about the other reviewers who may have questions or comments about 14aine? DR. HIRSCHBOECK: I don't have any comments about the application. I haven't seen it. But I have always been cur3-ous about the interface with neivliboring states an Northern New En-land, whether this is well taken care of. DR. McC.A LL: If it is not spoken to one way or the others I have no knowledge other than the application. DR. HEUSTIS: Any more than 14icIiigan's at least as it used to be a number of years ago doesn't say anything about Ohio or Minnesota or Wisconsin; maybe it should have. DP,. HIRSCHBOECK: How they relate. MR. PETIMSON: Maybe Spence or Frank have something to say on that9 MR. COLBURN: They have been very close working staff, three programs, tri-state who has New Hampshire and Maine end Vermonto all of New England. The New En@land pro@ram, an epidemiologist used 19 to go to Maine quite frequently and he has helped the Yiaine pror,ram, has capitalized on what was done in Vermont with re- gara to coronary care networks,,safety program, Now they are movino, into the area of establishing Guidelines and standards within the corona,ry care network foi- treatment. And I thitiK r,.n-is is capitalizing on the success of that ty@ of activity in Vei- mont just as an example of the exchange that takes place be- tween those three pror,-rams in the upper part of New EncLand. i CD MR. B.APRCIEIS: If the titles of the Project,are at all valid, the direction of the program seems to be excellent, very much on tar&et. DR. HEUSTIS: There isn't any question in this par- ticule,r program where there has been great leadership, at least material available to me, by the proo-ram staff. They haven't tried to sit back and say, 1%, hat would you fellows like to do and we will fit it Into an overall pattern." They have come out and said: This is what we went t6 do; would you be willing to work along that? That is the kind of regional program that I think is carryinc,- out the real mission. DR. McCALL: They list their new projects, continuing CP projects, list those they are requesting no further RI-@IP funds for, exceeds-- either they have finished their mission or have other source of funding. DR. TESCHAN: I want to ask about the CIIP relationship, 20 I am not quite clears there are no functional (b) Is, Chattergy has not done anythinu with the (b)fs to try to CD get them going or he has and they aren't functioning, or-- I an, not quite sure, or can you tell? DR. HEUSTIS: I cannot answer. MR. PETERSON: There are four orfive. MR. COLBURN: Five. MR. PETERSON: Functioning, there are five funded, be (a). (b), (c). DR. TESCHAN,. He is getting no statement of prioritie: objectives? DR& HEUSTIS: None from (b)ls. All I could say was there was really insufficient data presented on what the (b)ls were contributin- to come to any value judgm-.nts,at least on my part how the cooperation was. MR. PETERSON: Again, I think Spence or Frank will have to help me with this. I do not recall that 14aine is a region where the CHP comments either were negative or pointed a direction, but perhaps I am wrong. I,M. NASH: Spencer, didn't he invite the (b)ls in and have them sit around durinc, the discussion of these applica- C> tions? DR. HEUSTIS: Excuse me, may I I misspoke a moment, ago, I looked in the wrong column. HOOVER REPORTING CO, INC. 320 Massachusetts Avenu -@ N.E. W;oqftinc,ton D-C. 200OL' 2 L DR. McCA LL: He, rea 1 ly me t w ". th them ahea,C of t iriie, the (b) a-encie@-- even care into the R@ review I think. DR. HEUST@LS: I have down "@tended cooperation and coordination with the CHP is good. Hivhest possible effectiVE relationships are good. Joint activities are satisfactory." I misspoke; I was looking at the next column. Sorr I misled you. DR. TESCHAN: Trying to get a feel, DR. McCALL: It seems they did. 1,C .BA RR O@,S It would be awfully difficult for us I to pull dollar figures out of the air for reconLnendation, but would it be feasible for us to say break these down into groups of fives and the preferences we think they should share in the bud@et? It sounds, for instance, this should be one of the top ones. MR. PETERSON: I an. not sure when you say break there,' down into aroups of fives, what-- MR. BARROWS: Top -- DR. HEUSTIS: Aren't you thinking of this overall assessment activity? MR. BARROWS: If that is what it Is to be., then, then fine. I thought we had to come up with some financial recolln- mendations. NR. PETERSON: We do need to come up with sorw HOOVER REPORTING CO, INC. 32OMassachusettsAvenue,N.E. n f, gf)niig 22 d recommendations. It is obvious if the recommendation excee the total supply of money, there is going to have to be some adjustment. But perhaps I can answer your question in part. At least it was our hope that as a result of the-review dis- cussion and the rating sheets that had been ab,le at the time we get the two groups back together, be able to sort of display literally what the two groups had come up wi h separa ely and probably failing out into not unlike a bell-shaped curve, 1 there were some at one extreme considered among the better, some at another extreme that were considered poorerp with parenthetically the amounts recommended for them, and I think, perhaps triparte -- again I don't-- but this w ha ope to be able to do. Because I think it is difficult, because some of this indeed is comparative. DR. McCf,.LL: -And we are goinr,, to come back and look at what we have recommended here. MR. PETERSON: That is our intent. DR. McC.ALL: Set maximum rating, I would like $2 million requested. DR. HIRSCHBOFCK: How do they deal with their fund- ing? They don't get as much as they have? DR. McCALL: Yes. It has been In use all alone, one has been in use and is effective. DR. TESCHAN: Do you recommend two? NR. N-ASH: It is target figure, bear that '@n mind. 23 DR. McCALL: I didn't when I put my $2 million down, I didn't see the target figures and it exeeds it by over half a million dollars. DR. HESS: I would like to introduce another element in this discussion. What is the population served by that EMP? IvE. PETERSON: Slightly under, one million if my-- DR. McC.ALL: -About a million. MR. PETERSON: The State of Maine has a little less than a million people. DE. HESS: I think that factor has to modify, put into Considerations. Now, another factor is what, within that document-- apparently they have done a better job than most in term of outlining the health needs of the population. In my own mind I don't think of Maine as a-- well, It is a rural, but com- prised o4 at least my image is of pretty hardy self-sufficient people who, you know, can take care of themselves pretty well. And that may be a reflection why they have oot such a vood application, I don't know, leadership there. It bolls down ultimately to a handful of people. But be that as it may, I think we have to -aodify ourl thinking about how the needs, of the people in Maine compare with the needs of people in Mississippi or-Alabama, or, you know, other areas of the country. And look at the HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.E. Washin2ton. D.C. 20002 24 i relationship between funding recommendations, the'size of the popuLetiono and what we know about the health nee6s of that particular region. If they have got a million people, just to give us a rougher Index, and @y2 million application, roughly '@2 per capita, RMP funding for that; at the other end of the scale t erE are lil4P's that come out with something like 25 cents per capi a. And I am not su,7cresting a, capita thing except I think we do have to keep In mind the needs of the population, how lar@e i the population and the amount of money that is goinc, in. CD There ought to be some kind of rational way to rationalize that at that level as well as just how good the program is. DR. McC.ALL: I totally agree with you, having come from a region that had 12 million people. And under ,ny great leadership was reduced to .@1.2 million funds. D So that is a very important point that I am very sensitive to, and my only reason for taking this hi@ii level at this point is to say we don't know where these others are r--oing to shake out. If you are goinv to come back when these things are C> finally looked at in terms of the total dollar available for quality, needpopulation served, it would be final figure, this program comes throu@h at such high quality to me I would like to see us not start low and not be able to give them the maximum they should get when you look at the overall. EFORTING CO, INC. 320 Massachusetts Avenup, N.E. Washington, D.C. 20002 DR. ILESS: These folks sound to me like peop.Le -viro can make efficient effective use of money. DR. HEUST@LS: Thio is really what came through to i MP-* DR. McCALL: They are going to function if we don't give them a dime. I think you shouldn't penalize them for thv,,@. MR. 13ARROWS: That is important;as a taxpayer I hate' to see these bucks spent on the basis of need without produc- tive use of them. DR. IIEUI@.,TIS: I recognize need, but in these troubled times it seems to me efficient productive use of money might be things that would impress the Congress rather more than taking another program that I reviewed that has a.,Iar@e need and a large problem and not as L7,ood a program. DR. HESS: I am not recommending puttinLT a lot of i money into a poorly managed program, but to carry this argu- ment to a ridiculous level, if they could use @"5 mill-Lon, woulIci you give @laine '4@)5 million just because they are a top-notch pro,rre.,,n you see? DR. HEUSTIS: I think you have to balance relative--I DR. McCALL: Fine thing, I am not sure I would even recommc-znd- @2 million. MR. BARR(I-@S: I wanted to bring this down, bring another factor into the decision. DR. McCALL: It might ,@ake it easier for you to try o i r,'- to make some better jucic,,r@.ent of all these thinvs at this p La ID CD MR. PETERSON: I think, you knows our judgmental process which is collective and right now bifarcated, I am not goinv to intrude too much on that. CD Let me only mention one thing, Maine is requesting sli@htly over '@'2 million. It is one of the few re-ions which has indicated to us tais is their total package, so their ,@2 million is not goinv to be a supplemental or additional, or CD further request in July. Their target figure, column C, was rou-hLy @1,4 million. I think that again looking at it in terms of some rough per capita, Maine indeed exceeded the national norm at an earlier point in time by virtue of the fact that it had been considered a good program at the tirmvie were steering towards selective funding. I think what I have heard is a range from @2 millionj and somebody said they are goinrT to continue whether we give them a dime or not, so we have got@.between a dime.atid Q@2 Would somebody Like to put somewhere between those two points, perhaps lay a recommendation as to an amount on tell floor? 14R. BARRA-IS: That Is the thing that bothers me. We do not have a target budget for our whole business. If we i had something like this and then could say classify them,;and then cut the melon when we get them all through on-the amount Ho REPORTING CD, INC. 32OMamchusettsAvenup N.E. WashingtQn, D.C. 20002 of money to be spent, it would be a lot easier. Just picking fioures out of the air, I am afraid our results will be very fortuitous. MR. PETERSON: I didn't mean to. DR. HEUSTIS: It seems to me you have on overall assessment five categories. MR. PETERSON: Right. DR. HEUSTIS: In all good conscious, more data is available in Maine about previous funding than any of the others I reviewed and there was just insufficient data about background and use of money and about progress to really make C) a valid fundinT judgment on the basis of the written material that they --athered together with all of the constraints. I feel very strongly the same as you do, perhaps the best w.e can do is to say that this is an interior program and it is entitled to maybe better treatment if the need Is there and-- of coutseo if there are two superior programs and both have needs, I would agree with you. Some of these things on the basis of more infornativi,i we could come up with dollars. MR. BARR(IIS: Even divide them into groups, the plus oroupr average group and minus group, and cut it Like that, MR. PETERSON: Let me see if I can heLp.us out of this. Since we will in one sense be operating against a HOG ER REPORTING CO, INC. 320 Massachusetts Avenue, N.E. Washinaton, D@C. 20002 28 benchmark of a target firfure, vill-at I hear. the group say.I @,D CD is that it would like to make a recommendation vis-a-vis Maine -- correct me if I am wronc, -- that says here Is a region that, in our judgment, without giving a specific amount@ it should perhaps be 9,bove the tartc.-et-figure, whatever that Increment is. I think we, again, as staff, Dr. Pahl is the Director, in the final analysis, who is going to have to divide $109 million or A@LL4 million up, certainly is going to be influenced I think by virtue of the fact that this whole re- Vi -ew process is ooeratino, with a great deal of lack of infor:,.,a tion and the like, -Ard that the pluses or minuse-.- will be in-@i dremp-ntal rather than order of magnitude. it is more defensible to say let's cive this region CD 20 percent or 10 percent more, as opposed to 100 percent more or less. Because I don't think any of us feel comfortable with that process. I wonder if in those terms sombody would DR. McCALL: @laybe to help you have tte figures,, the sense is there in what you are saying, I think we all recoc,,.--- it, with all the constraints and time) we have to come into focus. We really can't go back and write all the imbalances i and 'inequities that my exist. Maybe@pl.@, million reconraendati 'n C', does that, it is a little abov requested, It reflects its e super.Lor rating. If there are others, that is the' sense. -And it would take into consideration per capita needs and other things as well as their quality,. DR. TIfURd,4AN: Second. MR. BARR(aiS: Their request Is $2 million, DR. McCALL: Yes. MR. PETERSON: You are saying recommendation of $1,5 million? MR. C OLBURN: I was going to say in the past,the previous procedure was to make a recommendation regardless of the availability of funds. Then you know the distribution of funds would be based on total recommendations. MR. HASH: I think Dr. Pahl wanted some sort of recommendation. DR. HESS: I think it would be helpful if we go through and we come to grips with a specific figure on each project, and then come back if we want to adjust it at the end of time. DR. McC.ALL: This is what I am integrate nT into the $1.5 million. MR. NASH: I think that gives us a benchmark to woric with as we move along. DR. HEUSTIS: I wou Id have great d If f ic u Ity on anything except political orounds of recommending that you approve anything except the reqoest. I can-- if-you asked me to make a technical decision, the prouram is worthy of support@@ H REPORTING CO, INC. 320 Massachusetts Avenue, N.E. Wash;ngton, D.C. 20002 30 If you ask me to make a political decisions there is not enough moneys then it seems to me the political decisions at least as I see It, ought to be made at a higher level than which I have said at the present time. SISTER JOSEPHINE: I would like to say I made a site visit to Maine with Dr. Brandon and Dr. Vaun, who is in the other i7roup, end I guess in 1969 or 1970. It was at the time when theyviere first be(,-inning to get their resources together. CD -And I had an opportunity to stay several days and so-a couple of us went around and we visited in different places in the state. And in response, Dr. Hess, to the number of people, you know, I am so impressed with the distance, the distances, the scattered population -- really, the total lack almost of services, you know, that were available. I was also impressed as we sat end talked with the peoples with the fact that, you know, they had already been ir,- volved in the process, the people'viere listening to what they need. And the program that has been developed, you know,, I would be reasonably sure has been developed in response to needs that were really identified, and I don't feel that is tyUE of all programs. DR. HESS: No, I am not questioning the needs were identified. I think that has been well done. 14R. BARRCFWS: Introducing the equi y, If we adopt this thing, what we are sayin(ci then is EPORTING CO, INC. 320 Massachusetts Avenue, N.E. Wastiinp.ton. D.C. 20002 we have concluded our formulas as an outstanding programy and E,,et 75 percent of what they asked for. DR. THURlilP.N: No. Not at all. I think what we are sayin,7 is can any group operating at $1.5 million leap to $2 million? Now,.i,in seconding the motion, I am not proposing we give 7!) percent. I think this ib a re-ion that gets results. I rather doubt if it would be able to leap -to 'qk?2 million. MR. BARR(7.,@@S: You are brinoino, up a very valid con- sideration, do they have the capacity tp do this job; in effect, they are askinr,- for two times present bud@et. CD DR. THURTA.,:AN: The other thing we have to consider is,i there has never been a human being who wrote a grant who didn't add something to it. DR. HEUSTIS: I disagree, but go ahead and make your point. DR. TH@l,!AN: That is my only point. They knew they! might as well ask for everything they could c-et. But I don't believe it is possible for them to spend $2 million in a reasonable way. DR. HESS: That is a 100 percent increase. DR. HEUSTIS: Mr. Chairman, the thing that bothered me was the fact the only fi-ure we have on this sheet is this 32 currently annualized level of what they are getting. This doesn't take us back to what they did before they were out, and not having that information and not having the informa- tion on how well they had spent their money before they were cut, I am just wondering -- IM. NASH: That figure, Doctor, does not include a large supplemental award for EFS or HSA activity out of 1972. -Actually they have been operating at a level over .@l million. Spence, do you have MR. COLBMN: I am trying to recall DR. HEUSTIS: I am just saying on the basis of one year of restricted allocation MR. NASH: You are talking about ability to handle a large group ofmney and this actually isn't that. @IR. PETERSON: There are, as Frank points out, in a number of regions, @laine isn't the only one, where the current annualized level which is really the present six-month award times two, It is that simple, is perhaps misleading -- not in all instances. In some ways the column C figure, which reflec,,c a percentage of the immediate pre-phaseout level is more indic@. tive of the kind of annualized level, approximating the kind of annualized level that lvlaine and nearly all the other were operating on prior to January 1973. But a,--lain, in-the interest of moving the discussion H REPORTING CO, INC. 320 Massachuse!ts Avenue, N.E. Washington, D,C. 20002 along, we have got a situation here now where two reviewers one in effect has laid a recommendation on the tabl@e for $1.5 million, I heard -Al indicate that he would have problems with anything less than the full amount requested. I think simply in terms of the order in which those two figures were mentioned, I would ask if Charlie regards his $1.5 million as a recommendation to that effect? If so, if there is a second? DR. THURIIAN: I seconded I MR. BARRO/TS: Did you say a real Index of their pre-crisis fundi ng was this targettea available thing. IYM. PETERSON: That target figure is an extrapola- tion from that and it more clearly approxiiiate8 the level of activity in the re,-,ion than necessarily the first column which doesn't reflect in some instance rather significant supplemental funds. Maine, for example, had a good deal of actiVity fund for a couple of years which,now does turn up again in some of these projects. MR. NASH: Actually at one time they were managing $2,872,000 in one year. DR. TESCHAN: I would like to make the point, Frank, If we would be able to have that kind of figure, at least ready during these discussions, that would answer that kind of question. MR. PETERSON: I think we do. EPORTING CO, INC. 32OMassachusettsAvenue,N.E. Washington, D.C. 20002 MR. STOLOV: For every region we have computer funding printout. MR. PETERSON: Is there any other discussion? Again, I think I have heard a motion, a second,for i $1.5 million, and I think if there Is, I would put the question to the group. Those in favor of the motion? MR. BARROleIS: Is the $1.5 million based on what you just said is not a significant increase in the level of activity they have been carryinc,? IvM. NASH: No. In fact, it is a decrease from one prior year. DR. HESS: But they have also cut back in staff probably. MR. NASH: No, they maintained basically pretty well staff even through the phaseout. They lost a few, but basically it is pretty much the same staff. MR. PET@SON: I wonder if I could ask the question., Thix e in favor of @@1.5 million? (Shoii ofhands) 14R. PETIMSON: Oh, we are,going to have one of these'. No, divided -- all right. No, It isn't divided. I am sorry, Sister, and we have r,,-ot nine people; Iwas looking at the ei@ht, four for a n ri 35 five a-ainst. IC. BARROIIS: Could we p Ll t the z'PL.5 ml ILion on the hook.and come back to it? DR. HEUSTIS: I think we should do this, Is this motion lost then? MR. PETERSON: Yes, it has. DR. HEUSTIS: Is not column C the amoutn of money available for 'Lunding ',.his fiscal 1975? 14R. PETERSON: That was our estimate at a time when we weren't even as sure as we are now* DR. HEUSTIS: So it may or may not have any rele- vance to the previous fundin,7 levels of tile prograiio') YLR. PETERSON: Oli, I see. The column C does have relevance to the previous funding levels, Al. We took pre-phaseout levels, annualized levels, and calculated a percentage thereof. -At the time-- it still does, it adds up to '@114 million. At the time we did that, that was our best -uestiiote of rouc-hLy what we were CD CD going to have, and we were trying to give regions a target. It so happened that we are going to, in all likeli- hood, end up with either '@'109 million or $114 million. DR. HEU,@,TIS: lilay I suggest If we have to make what I Call a political decision, could we Lay the funding amounts for each of these programs on the table until after we have had a chance to look at them all, and then we can look-at the HOOVEP REPORTING CD, INC. 32OMassachusettsAvenue,N.E. request, we can look at what you have got down here and then we can go through and decide what can we do to com@ out soirie- where within the available money and be fair. DR. TESCH-AN: I think we could easily Indicate that Maine is in the top, divide the regions into approximately three big groups and with the details of the population, and the kind of other comments we have had. Ard then begin to adjust after we see the total group. MR. PETERSON: Is that the sense of the group that we lay recommendations as to funding amounts aside until Thursday afternoon, Friday morning? IC, BARR(I-IS: No, we could strike a tentative figure, but I personally don't feel that we are doinc, justice to these by just picking a figure out of thin air. I have no way of knowing whether 6pl.5 million is better than @l,,450,,OOO or @ol,750,000. To me it Is just picking a figure out of the air, DR. HIRSCHBODCK: We have to deal with this proble-rft, those who are not applyin- for July Ist money. This is exactly the significance here. If we do not take that Into consideration, we might be short chanuing them considerably. 14R. PETERSON: Charlie. DR. McC.A LL: I am concerned, as we had reviewed, on the whole, the gaps, the changino- situation, and we are Ho R REPORTING CO, INC. 32OtAassachusettsAvenu,;,N.E. W2,hinott)n D C. 20002 cominc, here In the last chapter of this p' tur roo-ram, the struc @laving-been designated, very fine people still here, but @qina.Li in nLunbers, overworked, mechanism torn asunder. And even when is I it-was there, we knew there were some inequities and son)e things that needed correcting, we were wor ng on, It seems we are really taking on something that really doesn't make sense. To think with all those limitations we are not-- as last gasp, use some sort of judgment, start a new bench- mark, write all of this in terms of population and everything else. Not that I am not for doing those things; it seems to me this is not the point in time at which we are armed wi-thi and able to do that any better than takinc- all of the problems and our disagreements about them, the former benchmark, and usin- it as where we start, and then ,noclify up and down in light of what comes in here rather than tryin@ to go back and go throu,,,h all of these and now come up with --,ome sort of new-- MR. BARRCJ@IS: I wrestled with that in my own mind ano- came up with this generalfeelino,-, whether right or wrong, any--,, body can say, but I felt we had a responsibility to preserve reasonable stability of the procram. But we should take away from programs that didn't appear to be able to use this one-ti.,Tie money effectively within reason and give that extra money to the programs that are doina- the top-notch job. DR. HEUSTIS: Great. MR. BARRO,@IS: 1-Thether that is good policy or not, that Is the way I came out with it. DR. HESS: Ancl you do that purely on the quality of the job and setting aside any other factors about the region? I,,IR. BARRO@IS: Well, one factor, the population inequities being on historically, and I don't think we can dramatically change that now in this short time,. DR. HESS: It is not a matter of changino, it. But to my mind it is not a matter of carrying that to excess. MR. BARR@,iS: I would keep a reasonable stability sa-y-- int- treat the averace in one way, cut down a little bit on tie pro-rams that are not too effective andpive that money to the pro-rams that are. But not make violence with 30 percent to 190 percent. DR. THUR@N: I hope we won't have this emotional kind of discussion with each application. A lot of us would like to have more information than we have to make a decision, yet we have never had enough information at any time in the past to make any better decision than what we have been asked to make ri(xht now. I don't see any difference as we sit here, except the understanding the proo-rams as they exist have.gone through 4D Living hell as far as from an organizational standpoint. But EPORTING CO, INC. 320 Massachtisetts Avenu N.E. Viashington, D.C. 20002 .i @ I either they have had the relationship and capability of doin@ it, they have known their state, they have known their capability -- but the only rationale -- I don't mean that in a, derogatory concept. The only rational comment was Sister's tD because she was there. To me I am not the least bit concerned about reach- ln,-@, into midair pulling out a figure in May of 1974 and I C> was concerned in June of 1972 doing the -same thing, with the .same kind of program. So that I think we are trying to find an excuse for our lnabi I,-ty to approach something in an irrational fashion when we have always approached it in an irrational fashion. So that I just-- this sheet doesn't mean a damn tii@Ln@ pardon me, ladies -- doesn't mean a damn thing to me, becalt: Ise here is a program, the people have come in, excellent .7rant w ri ters I two reviewers have been snowed -- ar,-ain, I don't mean that derogatorily -- been snowed by this preparation, Sister has said that the people in @ia,ine are interested in lt.i These peoole have 9,sked for $2 million. They have got one year of self-sufficiency for a small population. -And then they have @.ot to carry these proc,,-rams without us. What more do we need to make a rational decision tlic,,n those facts? 14R. BARRA[S: I don't say this is going -to be without us, the succeeding programs contemplated by Congress C3 will absorb at least some of this? DR. THURI@,IAN: Let's see,if yoti and I knew the answer to that, we would be the world's greatest -- DR. TESCHAN: What i-s the punch line? MR. PETERSON: What is the figure? DR. HEUSTIS: l@,Lr. Chairman, I @7OUld offer a motion. MR. PETERSON: Fine. DR. HEUSTIS: To bring this to a head. Motion was for @PL-5 million, request is $2 million; I'll be rational and split the difference. MR. PETERSON: Is that a motion for $1.75 million? DR. HEUSTI,'>': - @i)1.75 million. MR. PETERSON: Do I hear a second? DR. TESCIIPN: I will second it. MR. PETERSON: Second to get a vote. Any other comment? Question: How many would recommend -- and I thin we do have the sense that all of these are tentative plus, min,@s kind of motions, it is again a rough motions It Is again-- how many would concur at '@@1-75 million for the Maine R14P? All those that do,show their hands. (Show of hands) 14R. PETERSON: That motion is voted down also I think, four toflve again. E TING CO, INC. POR 32 assachusetts Avenue, N.E. Washington, D.C. 20002 (202) 546-6666 I dontt know whether we are moving in the right d lrec tion. Do we have another motion? DR. TESCHAN: Let me fly this one., 10 Percent more of recommendation to Dr. Pahl that he consider llaine in the top group; secondly that he consider funding at more than the approximate ratio that he has dealt with before, on which these fio-ures were completed, say some thing like 10 CD Percent or so more then that, on up to the totalamount of the application, depending on availability of funds. DR. HEUSTIS: I @fill support that. That sounds good to me. l@. BARP,,UiTS: C) DR. HESS: Cop out. DR. TESCHAN: Sure, it is a cop out, DR. HEUSTIS: As I understand your motion, you are leading us to put these into ranking things, so that some will be financed more than before, some at about the same level and some at less than figure to be decided after we have all of the evidence* I think this gets me off the hook from making political decision for which i do not feel qualified. I am perfectly willinc- to make a political decision. DR, HESS: I think that Dr. Pahl wants from us a figure end that for us to avoid the need for making that recor,,;- mendation, difficult thou-h it may be, even though it feels like we are rolling dice@ as we like to Pride ourselves in, you bei-ng very logical, rational people, but ;then if', comes right down to it, you h ave to take a Leap and make some judt- me tit s. I would say I think we ought to not avoid the re'- sponsibility that we have been asked to assume and do it even thou,7h we are uncomfortable about it. CD With that preface, I would like to offer a motion for @L.6 million. 14R. PETERSON: We have a motion of $L.6 million. Do we have 9, second? DR.McC.ALL: Second. 1,4R. PETERSON: Question, DR. THUP14AN: Call for the question. PETERSON: Call the question. DR. HESS: -Pre you asking for? MR. PETERSON: Yes, for those in favor, @1.6 miiiion,p five for and four presumably against. Okay, the recommendation of this group, by painful process and high degree of tentativeness, is $i.6 million. DR. THURIAAN: FulLy with the understanding we may come back. DR. HESS: We may come back and revise this. This is kind of a breakinc-in process.. MR. BARROVIS: We are cutting the melon without H*OEPORTING CO, INC. 320 Massachusetts Avenue, N.E. Washington, D.C. 20002 1-@@, I., I'll knowing how many shells we want to cut. DR. TESCHAN: Bic)-ht. PETERSON: Dick, you had wanted to say somethin@. NR. RUSSELL: Yes, I was a little bit disturbed and concerned durin@ this discussion. It seems to me we are get- C) ting two issues mixed up. One is the role ai this group in terms of making recommendations for funding leveLs; the other, as Dr. Heustis talked about, was the political part of the decision Dr. Pahl and the Administration will have to make in nia,kin@ the funds actually available What I heard in this discussion -- I have no vested :Lntere.-;t 'Ln llaine whatsoever -- here we have an application that apparently is ,iell put together, the projects do fit the goals and objectives; historically this program has been very strono'. -All the pieces fit together. I think it is that type of Information on which th@i-s group should make Its decision. Now, In terms of the target figure where we have programs that don't come across as stronr.,,I think that is goin@, to be important to look at that, so you do have to take that into consideration. But I really don't think it should be whether or not the actual funding made available will come out as your recommendation You do have a chance-- DR. TESCHAN-. But, Dick,, you are not helping, you EPORT[f,'G CO, INC. 320 Massachusetts Avenue, N.E. Washington, D.C. 20002 i4 '4 are at variance with the imperatives to come up with a number.@i I am comfortable with that kind of ambiguity, say "hoorah for Yiaind and leave it at that. But if we are under an imperative, maybe we should settle the question, are we or aren't we. If we are, we have to go beyond where we are,, MR. PETERS014: Herb PatiL's decision in terms of de- cidin@ signid- agrant award, statement for Maine with a figure, CD that is Toin.- to take place after the Council meets. I think with a Council that insisted upon a review committee, kind of restructured review process, 13 new members that while it is true that the Council is in a sense the formal recommender, I think they are going to have more diffi- culty coming up with numbers if we don't provide some bench- mark for them, I think, Dick, at least in our skull sessions, in the precedin-- daysi you know, I think we can belabor a-nd overdo the numbers game. And I am speakino, personally, not as your chairman. I think we as staff, and Herb -- you know if there are no numbers, we aren't all that helpful. MR. RUSSELL: I am not saying-- I think you need numbers ultimately. IAR. PETERSON: Right. 1,4R. RUSSELL: But the viewers have a chance to rate the RMP'S. DR. ,McCfii LL: I think there may be some Abstaining. MR. PETERSON: I am sorry. DR. HEUSTIS: Mr. Chairman, I object to this. lyle spent already too much time on this. DR. 14cCA LL: I don't mean -- I am talking about the future. I am not talking about calling for Y@ine. In the future. I don't want to go back and do thati on this one. DR. HEUSTI.S: I have the very strong I like what, you said and-I like what you said and it seems to me even though we have done it before, and I wasn't a party to it, I may have gone along the same as you did. But it seems as though if we give him the arnnunitic4 if we have extra money, this is what you do with it, this Is who you give more and thiis is who you take away, that is our primary function. DR. TESCHAN: I feel better about that, DR. HESS: He is not bound to use these figures. DR. HEUSTIL@i.- Not bound but as he makes the political I decisions, I don't know the gentleman, but being a politician probably to better or lesser degree, and sombody questions it@ he says, "But, haha, the Ad Hoe Co@@, ttee, -Advisory Council, this Is what they recommended." And he justifies in some instances where it is convenient, he justifies it. And he is no different from any governor or any legislature that tries to EPORTING CO, INC. 320@assachusettsAvenue,N.E. Wastiington, D.C. 20002 (202) 546:6666 t his budget so 'that he doesn't havel get a, protTram person to cu CD to mt-,e-the political decision. is DR. HESS: Al, just let me comment on that. If I understand the purpose of this ad hoc review, it is to brino- some additional perspectives to bear on these CD very complex issues and so to ask this group to weigh in our best we can all the various dimensions that should goi mind,.-, -as into decision making about, you know, this national program on a region by region bqsis. And that the most preci.se re- flection of the summation of those judgments is in dollars at this stage of the game. And that the role that the Directo.,' iLrid Council are not bound in any way, shape or form by those recommendations, but nevertheless that is the most concrete translation of 'udgment that we make. MR. BARRO,4S: Pete, let me make a. proposal that may simplify this whole problem. We clearly have two distinct philosophies on this thing and we are going to be tallcinv about that all night. Could we do this, could we let these numbers come out of the air from the frequent revelation from the record or 1, wherever, get them altogether, take a look at them when we are all done and go over them and do-- MR. PETERSON: We propose to do that. 14R. BARROWS: Do our equity on it. MR. PETERSON: I feel less concerned about spendinc.- H*REPORTING CO, INC. 320 Massachusetts Avenue, N.E. Washington, D.C. 20002 ,qnn% rAC tzrgg 47 a Little time with the first few applications, because I thi ni,c this is where we are gol.n,, to have to wrestle with some issu@@; and set some guidance to ourselves as to howue operate. It seems to me there are at least three things that, will go to the Council and Herb Pahl, at least there are three inputs from this uroup. There Is a, number that may be e CD softest and least offensive. There may also be in most instances some kind of half quantitative rating based on several people; and thirdly,i there will be the o,-eneral sense which I hope staff will be able to reflect accurately and which in the case of Mainequitn apart from more or less, that there was a. general, general sense consensus that this was, n.ll things considered, a com- paratively good stron- program that had %,Iaine stability durlnc,i the period of the last 18 months. And I think, you know, it is not as if the number is the only thing we are go ing to feed him. I think we need to keep that in mind, So we are triano-u!- lating. Sister Ann. SISTER JOSEPHINE: Yes. May I say one other thing. I think the 53, out of 53 pro-rawq there are only 6 that CD are complete,as we are going to review them, that aren't goi rE" to have anything for the Cray Lst review, or the July Ist revi.F--I,,,. I think that that is a consideration also, we have to keep in mind,and this is one of them and I th ink this is very important. MR. PETERSON: Well, I would like to ask the group at this juncture, It is ten after twelve, our cafeteria is probably most crowded now; on the other hand, by the tire you a,-et to certainly 12:45, the fare starts becoming severely diminished. Not that it is all that great to start with. It seems to me we have crot to make a decision either to go to lunch now or try to wrap up and let our beLlies push us in terms of one more before we go to lunch. DR. THUR@IAN: Move for one more. Nobody here needs the fare that badly. DR. HEUSTIS: Who do we give these things to we don't need any more? (Indicn,ting) MR. PETERSON: You can put them under the table. Hand them behind you and somebody will put them back farther. RUSSELL: As usual, we will pass them on down. (Lau,hter) @M. PETERSON: I ,Ionder If we could take Albany. This Is an Instance where, by virtue of the fact of a recent last-minute cancellation, we only have one reviewer, Mr. Barrows, and move on with -Albany then, since you said you were best prepared' for lbany. EPORTIliG CO, INC. 32010a,,@chusettsAvenue,N.E. Washington D.C. 20002 (202) 546-6'666 .A LBA NY 4 9 MR. BARROWS: That is a small tribute to my prepara- tion, I assure you. I think most of us on this committee can make extended and culpatory statements of the same kind, that were made on behalf of staff, I quite honestly had difficulty in doinv, justice to five applications. I say that in advance, because if I didn't say it, you would detect it as I went along. In any event-- DR. THURI,4AN: We won't be critical. MR. BARR(NIS: No, but you would cut hell out of the budget. To end the suspense, I have a pretty good impres- sion of the Albany proolram. It is a 24-county proc-ram. The grantee is the Albany Medical Collece, These were all the figures, but 1 had to go by them. Budget request was for $i,056,000. Their present funding for half a year was $556,000 so about the same level of fundin@ they are seeking. The director Dr. Kraft, has been with the program since its inception except he has be director since January 1973. The chairman is a retired physician hospital adminis:- trator. Executive committee represents a wide variety of H REPORTING Co, INC. 320 Massachusetts Avenue, N.E. Washi6gton, D.C. 20002 Interests and remarkable -- Includes edu(-ation, labor, com- munity agencies business, and so on, Staff of 70 full time, two part-time professionals. They plan to add two more. Their survival, staff survival through the phaseout looked to me good. Variance ranges from two to eight years. Regional-Advi8ory Group 43 of them. I noted the director Is an ex-officio member of RPG. 10 I think that puts him in a This is a philosophical thino-. peculiar position to influence the whole process. -And from the looks of the staff, I think this is kind of a one-man type of programs but that is just a guess. The executive co,@4 ttee exercises planning. Basically the committee structure looks Pretty good. Logical structure, I can't say who dominates from what is reported* Past performance, the direction has been I think quite acceptable. They made a prompt effective response to the '71 change. Their track record is -ood; of 27 active projects since RMP support, but '71., 12 are continuing with 10 they are flying under other support. OnLy two have termin-i ated. Their goals and objectives are very well articulated and very con@;,ruantp as the record shows the RMP mission. i The proposal situation to ,ae better than averave compliance with their own stated objectives. I had more troub @ with that factor* Everybody states the same objec- tives in glowina terms, then they go off and do something else; but I think they stayed pretty close to their objec- tives. There is no CHP agency in their area except in Western Massachusetts, They are working with that one. That seems to be harmonious. And they are trying to get another one off the ground. So I think their CHP agency relationships are good. I think they have got a reasonable chance o SLIC- cess. 14uchp of course, is going to depend especially on these pro-rams designed to serve the underserved areas. Much will depend on future funding from a variety of sources. Icame up with a good to excellent rating for the total proaram. I summarize it this way: ARMP has retained essential strengths, Well =named and well oriented. Proposals consistent with basic RIMD mission."ReconLnend funding proportionate share of what is available, at least equal to past level. MR. PETERSON-. You have heard Mr, Barrows' review. This is one we don't have two reviewers. Check with Frank, I don't think any people around the table in their prior in- carnations had at least site visited Albany, but I am sure *REPORTING CO, INC. 320 Massachusetts Avenue, N.E. Washington, D.C. 20002 (202) 546@6666 52 there are some of youIwho have some impressions perhaps have So had some specific information about the Albany RMP. before I check with staff, I was wondering if there is any-- from the rest of the reviewers whether there is anything specific or general they want to add to what Mr, Barrows had to say? DR. TESCHAN: What Is the population? I missed it. MR. BARROIIS: 24 counties. Metropolitan area -- Albany, Schenectady DR. TESCHAN: I just ,neant millions. MR. PETERSON: We don't ha-ve a fact book, do we? MR. NASH: No, I don't know. MR. PETERSON: I will have some population figures after lunch. My guesstimate in the Albany area is probably approachin- or over a million certainly. It may be a couple C3 of million. You have Schenectady, Rensselaer, Troy -- you also have a lot of -'Adirondack, without too much population except up around the Plattsburgh area. MR, BARROWS: Pushing over a million and a-half. I have one quest2!on. Let me just throw out, obvious" ly, on th e basis of my information, it is terribly difficult for me to say what is the proper problems for relating to liother federal initiatives," that is particularly true in the i, EPORTING CO, INC. 32O MassachusettsAvenuL,N.E. Washington, D.C. 2000? case of emergencies here* there has been $L38)000 The activities for which looked to me to be fairly consistent In that they were more preparing to get ready for entering the emergency systems program than they were in doing the same things that the emergency systems program I understand is doing. I am just mentioning that as something that ran ray mind. through MR. PETERSON: do you or Norm have anything-- there were a, number of projects listed inthe summer here that reLate to HMO'S, E24S'@ et cetera. Are there any significant problems or policy issues that you see posed by these? 141. NA SH: I th @ the HMO, I be lie ve , is afeasible study. MR. PETERSON: Within our guidelines, earlier policyi, i c,uide line so MR.NP@@H: Yes. Yes,Ild say EM activity Is continuing. MR. PETERSON: Sorethin@ started by the EM leglsla- tion. MR. NASH: Yes. MR. ANDERSON: Also pro-ram activity supports previous approved policy we had; It complements. MR. PETERSON: And I know Albany is one of those piaces that are few in number now where there is no major 54 (b) agency in the Albany area. There Is one they overlap ,with in' the Berkshires, northern Iliassachusetts. I Albany said, "Throw this sheet away" -- not-- figuratively. Albany Is a region which, again, we ha.d indicated CD target figure of about 1.5 million. We have an application here which is entirely continuation program staff and some projects continuations. They have indicated that they will be coming in with an additional application on July 1 for new starts totalinf7 about half a million dollars, This one, CD this request totals just slightly over a million. Thus our estimate at this juncture is that tlbany will be reqi@esting-- happens to be a couple of thousand less. Just about that f icure. target CD But the present application is for @l.,-'6,ooo.1, DR. TESCigiN: I wonder, management assessment, re- view verification, if there is any indication whether, In essence, the grantee is behavinu according to policy? Any evidence on that? IAR. PETERSON: Norm, we did have some problems I know some years ago, but boti, with respect to review and management, review process has been verified and found in compliance. MR. ANDERL'DON: Yes. Right. MR.NASH: Right. NR. PETERSON: Are there any recent management assessment figures? MR. SI1401iDS: That is one of the very early ones. That has been several years ago, would have no relevance today'. MR. A@TDP",RSON: We Here program staff, support what Mr. Barrows said. MR. PETERSON: Can you lift that up four decibeLs? MR. fiNDERSON: Durin- the phaseout period,, they were able to maintain pretty much the program staff$ kept it pretty much intact. The RAG did continue to meet on an every-I two-,,nonth basis. I They continued to maintain a stable level of opera- tion throughout this time period. DR. TE'",@'HAN: Would you identify the program as bei,,,@ in the big middle o,,roup? MR. BARRGJS: The big-- DR. TESCH-AN: Middle group? Would you put it at the top of everything you have seen or bottom? MR. BARROWS: I would say probably top of the middle@ group, I was impressed with something concerning which I. have mixed feelings, perhaps more than any other pro@ram CD that Ilooked at, They have Addressed themselves to the prob- lems of the underserved. That is a high risk type of activity'. So prospects of success are low. Brownie points for trying to do a good job are high. I co,@- o,,,It with a stand-off on Ui I don't know how the rest of you feel about this. MR. @MSON: Are there any more questions com- ments, observations from the review panel members? Staff? Norm? Frank? MR. NASH: No. DR. TESCHAN:. Do you want a motion? .MR. PETERS014: Yes. I was go ing to say it looks like -- much as I regret it -- novi this is a request only for *1 million. DR. TESCHAN: Yes. MR. PETERSOii: So I don't think we are-- DR. TESCHAN: I am sensitive to Sister Ann's point here, that we have to consider the later -- perhaps after considering the later-- 14R. NASH: Even if you consider what the@- Propose to come In with July Ist, they would still be a little less than the targeted figure if you give the targeted figure any force. MR. PETERSON: Yes. I think here we clearly have toi be guided, Paul, by the fact while in Albany and in many, many; others of these,we will be seeing a second request which will total X or Y amount that really our recommendation at this session, certainly the other inputs will have a bearing on tt,.e; second set of recommendations, hopefully many of the same people will be involved, that we have L-ot to look at this re- quest and make our recommendation in those terms. So that I guess I am saying DR. TESCHAN: 14otion for $ipo66,ooo then, approxi- mately. MR. PETERSON: That Is the maximum. Yes, John. DR. IIIRSCHBOECK: These request figures include tie indirect costs as weLl? MR. PETERSON: These are total costs I believe, tha is a battle I think I have finally ,on. We used to show you people direct costs whichwas very deceptive. These are total costs, direct and indirect. And that is vihat it costs to run the Albany proo-ram. DR. TESCH-AN: Do you have the indirect cost rate? MR. BARPaiS: Yes. Somewhere. MR. PETERSON: i@edical Collegeo it is probably in the neighborhood of 40 or 50 percent of salaries and wages. DR. THMIIAN: 50 percent on salaries. MR. PETERSON: That is rou@hly what you are runnin-- on, MR. ANDERSON: 6o percent. MR. PETERSON: Probably the best guess I will make in three days. DR. TESCHAN: The record ought to show that is one of the things that kills a progra m in Congress. And we ought tb raise the question as to whether this isn't-the time for the Albany group to recognize that fact, and see whether or not I they can begin the staff processes necessary to get them rea.dyi for corporate grantee. MR. PETERSON: This I don't think has ever been actively considered in Albany, has It? M. 14A SH: I don't think so. MR. PETERSON: I know what you are saying, I don't know whether it is even in our jurisdiction to recommend it or@'i to move it, or whether that is our duty; but it seems-to me if we have responsibility for the program, for the public accountability of funds, that this is one critical issue. MR, BARRO@IS: They will be doing that under any pend ing new legislation, won't they? DR. HEUSTIS: Mr. Chairman. -St Ale MR. PETERSON: Ye MR. HEUSTIS: Out of t@e projects I reviewed, it seemed to m California and I think Maine made no provision that I could see for any indirect costs whatsoever. MR. PETERSON: Thae are private nonprofit corpora- tions established essentially for that purpose, so.those be- came direct costs. DR. IMUSTIS: This is even for-- MR. SIMONDS: Both of those programs right now are in process of negotiating indirect costs, because they are managing funds other than RMP funds, so if they don't, RMP ,noney is going to be spent on the management of these oLit-I side. DR. TESCHAN: They generally pay Indirect costs to universities, but the direct administrative costscoordinators put together varies with the years, as you may remember, and 10 percent being a pretty good figure to put on it. DR. HEUSTIS* I think Maine had a policy, if I re- call correctly, of not being indirect cost to anybody* I don't know whether It is carried out and I may be in.error. 14R. =, ERSON: Paul, I think many of the thin-s you say are true, but I wonder .whether the issue of direct cost or indirect cost is something which this review group -- it mayiriore appropriately be a matter of Council. I happened to a number of years ago once sat and tried to take on indirect costs at National Foundation on the -Arts and Humanities and I had three university presidents ,-Zittina- on that Council., Princeton, fellow just left the University of Washin@ton, and Brown. I didn't realize what kind of tic7er I had walked into. I at least at that juncture acknowledge everything you say, but I, one, question whether the review group is really the forum in which to deal with it, and two, at least in the next 14 months, I can see, of some stability, whether it is a polir-y we are probably going to accept as regions take it on themselves and many have, but Albany Is not one that has made any move to disassociate itself from a medical college and sets up a nonprofit corporation. It is a cost of doing business. It may indeed have done the program harm, Again, a personal view. DR. HESS: Maybe the best thing can be done, notelin the comment, the question was raised and would be worked out administratively. 14R. PETERSON: Right, and I have done that. Did I hear a motion recommending the amounts request ted for this application, @l,o66,ooo? DR. HF,,,ULTIS: Somebody made it end I support it. MR. PETERSON: Okay, you seconded It. -Are there any other comments If not, those in favor of that recommended amount raise their hand. (sho,i of hands) MR. PETERSON: Everyone* Anyone against or abstaininn'? I think I saw nine hands up. All right, we have in an hour and ten minutes which comes out to 3r,', minutes per application -- disposed of two easy applications. So while I am encouraged, I don't think any of us ought to cet overly encouraged. I think It probably would be a good time to break for lunch, as I say. DR. THURMAN: Will we finish today? MR. PETERSON: If we take some class action. What would be a reasonable tirie to ask the group to, reassemble? 1:15? 1:30? DR. HESS: 1:15. MR. PETERSON: Can we try and be back by 1:15. We will start with Northern Nei,, Enrrland by virtue of the fact Joe has a three o'clock deadline. Thank you all so much. (I-Ihereupon, at 12:30 o'clock, p,-m., the meeting was recessed, to reconvene at l@15 o'clock, p.m., the same day,) ,NORTHERN NEW ENGLAN.U AFTERN0014 SESSION (1:17 P.m.) MR. PETERSON: We were goint@ to pick up with Northern New England, but I did want to mention a couple of things. Again, on the rating sheets, I am not going to,at least to the best of my abilityo let you get out of this room tonight where you have reviewed a region without lettinu me hate those rating sheets. Secondly, to the extent that any of you have,as I think perhaps llrl, Barrows did, had some notes from whence you spoke, even if they are in longhand, I would also appreciate your leaving those with us, althouc,-h I won't Insist upon that., Because there has been a f7reat deal, as you know, of litigatio about correspondence and notes in Washington of late, and I don't want to get into that. MR. BARROI@TS: What was that you were referring to? (Laughter) MR. PETERSON: I should also have mentioned this morning that if any of you need any assistance with travel andi@ the like, I think we can handle that and maybe I can ask Shirley or someone, but to the extent you have got those kinds of probl,- lemso let us have them and we will take care of that. Finally, and th!6 Is really directed to staff, I would appreciate it, for the benefit of Mrs. Chian-, that when staff does speak up for the first time, if you would identify yourself -- not for my benefit, not for most other people,.-but for her benefit. With that brieC. if not lue@,.Cil introduction could we push on for Northern New England, sometimes known as Ver- mont, Joe de LaPuente. MR. DE LA PUENTE: This is an application for the support of proo-ram staff and selected continuation of on-@oing CD projects. They will present some new projects that have a high priority in their July Ist application. The prouram is committed to addressing Community problems and the development of their solutions. By now they have developed P- cardiac care management system, a respiratory disease communications network, a high risk infant care and transportation system, and a strategy for addressing emergency C) CD medical services issues. Their present thrust will be that of encouraging ends developing coir..munity involvement in program development, in pro-r@i,m plannin--, and in program evaluation. The region -is particularly involved in the continued!, evatuation,and improvement of the medical care system, land they are doing it by developing specific guidelines and delivery of selected services. They are doinu it through the support of "Disease management committees towards 'the assessment and the! maintenance of established guidelines. And also they are doit-,@, eiri It through the support of providers enga@ed in improving 'h CD LI programs towards the maintenance of established guidelines. They have Linkages with the Department of Medicine at the University of Vermont, the State Health Department, the Medical Society, voluntary agencies, and most hospitals in the state. Community support seems to be demonstrated by the continued involvement of their Regional Advisory Group during this period of indecision. Their Regional -Advisory Group continues to be intimately Involved not only In the management of the proc,-ram, but also in the development-and support of sLib'r, stantial prooram priorities. The Regional Heart Management Committee, for examole, includes 29 standin@ members, and they have continued the,@r activities durino- the last 12 monthsL CD The present core staff Includes eivht persons, four of whom have advanced degrees. Their steffino- pattern appears CD to be very similar to that existing prior to the phase-out order. The present vacancy pattern may represent an oppor- tunity for the director to develop a sta.ffinc7 pattern more consistent with his future proo-ram plans. Their present request is for a core budget of $432,800, including i'?'292,800 for salaries and wages. Their request for the seven projects envisaged amounts to @687,000, for a total request of @'L,039,670. Thi s represents approximo.t@l 40 percent core staff activities. tinuqlly involved in The core staff, however, is con the support of disease management committees. Their present application is for $1,039,670. It-is estimated that their July I request may amount to $1,,839,670 compared with a projected availability of $lol99,300. I will not go into the cluster of projects. I was very much impressed with the type of projects that they have: a, regional end-sta@e kidney treatment program, a project o increase the capability of rural ambulance and emergency room personnel, a reulonaL proc,-ram for hicri-i-risk Infants and mothers, a regional respiratory disease program, an ambulatory', pediatric care project, a voluntary problem-oriented,health care inforr@ntion system, and a program addressing the sources of communication among school children, 1-n summary, this recion possesses a @ood track record' CD in obtainin@ community support for its activities. They want to shift their prorreua emphasis to improve primary care and CD strengthen community level organization Presently they are involved in providing an environ-11 ment where quality assurance can become a living reality. Their present request alone exceeds that of previous funding. But special consideration should be given to determine whether or,not the staffing level presently proposed is consistent, both with the activities proposed for the coming year end the level of support tha-t they will probably receivers, This is not to detract from h(y much I m,@s impressed by this reoion In terms of how precisely they develop their priorities, how the project they have forthcoming agree with those priorities. So I have a recommendation. MR. P.-bTERSON: 14aybe we should hold that, Joe. 14R. DE U, PUENTE: Yes. PETERSOlq: This is an instance where Dr. Jams was the other reviewer, but I wondered, Bill, since you had been up there either in a structured or kind of offhand fashion, if you might want to briefly address Northern New En@,land and then I will ask staff iL' they have any comment before we open it up to the whole group. DR. T'@a.URI,,@IAN:Ihad your e:-@,phasis---- first of all, since our site,visit, there test been a change of directorship.; The new per---on q-ec,-.qs to be a relatively strong leader. Tile re has been stability of a corporation now where there wasn't before, which was one of the recommendations that was made at the time of the site visit. One of the stron@ continuing strengths as Joe indi- CD cated was the RAG chairman who was the strongest person at our meeting, much stronger then the director at