I I!illl liii IEI iiiii i@ll@l l@ll lit, -x i- 00 t 7' T IY4.OOVL"R CO-NIP -1@ 6 -,66 I!" 3 DE'PART@T,,"@T Or T-,DITCATIOTL A@ID @17ELPARE P7@"PTI@@IC7 01' AD HOC CO,'@'iStjLTA.\ITS PT-,VIE@'7ITIC, MRDICA.L PROC@P"! APPLICP-TIOTTS Conferenc.e Roorn 11 Parkl.a@@7n Ptiilc9.incT 5(,OO risliers La.ne Rockvill(-, @.4c-;-ryland 202-52 ThursOa-,I, !-4ay 23, 19'74 Panel B conlieneO at 8:40 o'cl-ock, a.ir.. 14r. 'Peterson ChEii.rr,,an, nre.-,iclincr. TI'ATIT'T, (,As licretofore notrO.) C 0 't I T @l, @l T c.; c--.i rT e -.Ian for Orcgon 11) 5 Pr7 Motion for recommendation 204 RerTi.ona,l 'Dlan for ('aliforn-ia 2 0 5 @iotion for recornmen0ation 212 Motion for recororen6ation 232 P,r,-qion,-il Pie(.ical Ill.an for 'DLic-rto Pico Motion For recoTnT,,c--no',ation 23") P,e,crional T'lan for the "oi-intain @)tc7.i-of3 2 4 2 l@ot;-on -rnr rccorr-enOaticn ?19 ',,Ioti.on for rccol,-,rnc-l-,f,,ation r) 14 or !@'@@.-@cal -lan -.For 2 r-,, 0 1) P, A. @lotion for r-,3cor-,-3nOati.-on @ioti-on 'cr 2 5-.7 ','@'.oticn for r@co-rrenrlaticn 2pp@ T.Zcc-ionz,.! @lan i'or 'IeTir Ter@o.-t, 2 ci Motion for recorrendation 29r) f-lotion for re-cori-,cncl.ation 30 5 P..eqional- I-ledical nlp.n for Pcchester, vorl-, 307 Motion --For reccnuien(lation 3ii P.,P-@ional Ili@(lical ',?)-an for @,'7@ishinrTton an6 Alaska 312 I-lotion for recor@renrlation 31@5 I,-!otion for rcc-.oT;.iir-enrlat-'@(.)r) 322 lr@'4 - A C 0 T,'@' T T@7 T (Continued) AFq'ERI-10011 Sr@913IO,'l -I 7 ,"P-(Iical Plan for l@7est(@-rn renn-,Yl.v,-inia 336 P,Ioti.on for r(?cc)rimendation 3 50 Virc@l-i-nia. R(--gional- @4eOical TrocTrar. 355 !,!.Otion for rccorT,-.,en(Ic-Ltion 36 7 .ecormc;nc,e.. Teri-i. c F- I T, I- F- n F o r t' -i e the I,ake-, @.reci 3 r. 9 !notion -f(@-- .-ecor,.--enea.tion 3n2 Motion for )-occTmp-n('.E,-.i-c)n 40r) TrocTra.m for the Peci-n-nal -e. r, i c a'. f'@tate of ila.rvlzinc7L lic)tion 7or reccml-nn@-z;.tic)n H7W Reaicnal kle@ica'L @l.an for tho D-L.-,trict of Columl)ia @25 I'@loticn for rc-,co-nTnen(lation 4 31) I-T-'-r@,,7 Pegional "leeical '?]-an for LoncT Islan@, @,-7e@,7 vork anO @Tassau- Suffol-% Counties 443 @,@otion for recoTmpneation @55 TIPI,T RecTional !,,eO-4.cal !'Ilan for Susauchanna N:al-lev 461 @40tion for recoplj,-en0ation 4 72 7t 1 p R 0 c E E D I A G s iurs [Th(,, B '2-iTicl @.7as called to order at 8 it-0 a.m. !Dy n a. L@. T-leterro,-i, ttic, C'@@a.irman.] PETERSI@)'@i: l@,7e are still missing, a coiinle of peonle. I took some stuff home last ni( is .jlit and this just to! Clive vou an idea of -vihat .@7e did Yesterday. [Indicatinq the blaclcboard,l, on %7hich was inscribed Rec 77und- Overall Item ing in l@s %!Zca % Tar&e+-- Alban-,,- (1) SU.? 3.0 1.066 @100 70 T,Iaine S u-@) 2.9+ 1,600 8 0 12,0 AA S 2.5 700 67 5 C,D Valle@@7 2 . 5 2 30 0 82 61 C-@-I York Aug 1.8 615 77 Ai-ta 1.8 70 70 ,.la,,.7aiit 1,109 Ariz (1) Bi% 1.7 860 64 50 Conn BA Poon 1.6 510 80 22 $8,751 c 80 70 It seemed to me t',Lie realons fell out- into al:)otit four nice cTroups. The first column indicates that sort of overall ratin-r that revie@.,,crs aave "Sun,2rior", ".@bove AveracTe", "Belo%.7 Averaa(--", or "Poor. !4o%.i the second colur,.in is sort of an itemization. You Still -recall that you i@7cre asked to chec'i', "Cood", "Averacje t 2 "Bclo%q Avera,7e" -- and I sort of ,,Yc-,i-cThtc@ that as 11311, "2" and t count in where pcon)-e said there i.,7as insufficient and diciii' basis for judgment. And again, it seems to me those sco res, that itemized kinO of scorin(T is rouqhlNi consistent with the verbal score. And then I indicated i-.71-iat your recommended fundincT levels Caere, in thousands. @.nd the last tN,'70 columns are the percentc-,ige- of that recorn-r.ene,ation vis-a-vi.s the request in the first column; and vis-a-vis the overall target fic-ure or level for that ret73-on. So i,7e do have in,:irled disparities II,ai..ne, -for if ,ou -,.fill recall, theirs i-s onl,;, comiTic in now (1) Connecticu@@ is at the very @ottori of the list. -@@s it ',Ianr@-cned, heir initial request was really quite modest co,-,'Oared to what .je were exnectina. But this is noti'lin,,T authoritative or final, but I thougi-it vou mig',--It be interested in just -,ort of seeing one a,,,r of .--u+-- k@-incT, ho@-i things care out yesterday. It did seem to r,@e the-,7 sort of fell out into four ec,,ual cirou-)s, rather than t,@170 -,mall ones and then the middle -- we don't have a bell shamed @urve ,@ihich I guess is something that educators are ex- treriel,7 interested in. DR. TESCE@-'I: That's because tliev are saving taoney or the nroqram. 187 3 1-71-7E CIIAI@TI.I@TT: Well --yes. Those are- rouc.Th np-rceii,@-aCTC C@ at ti'le 'i.)ottom. You r-cco@tmended about 80 Percent of the requests in the acgreqate, and about 70 percent of the tarQct figures -- on the eicTI-it recTions we looked at yesterday. Well, I'm not sure that we rcallv ira.nt to wait on ,,',ill and Toe. We @.!ere aoin(7 to take up Puerto @,ico first, and' both of those are Puerto Ri-co people. DJ.'. ,-.cCALI,: llo,,.7 about taking @,lest Virginia first? TIIE Well. or otherwise You haven't had your coffee vet, Sister Ann, would you mind if we qo to 17cst Virginia? Otherwise, I was aoina -Lo@ 0 to Oregon. S'-,ic was the orlv o-crson @,7e didn't cret tovasterday 9 -- and, T.,,ell, that wasn't entirely accidental, there was a little collusion with the chairman. It was -part of the ecumenical T-iovei-.c,.nt. [Laualiter. I,,,'h@,7 cbn't we start !..,,i.tli T,,Te s tVir(-inia, then, -@nd let Sister -@.nn drink her coffee -- and ma@7be then bv that tirie Bill Thurman and L-Joe @,7ill be here. if they aren't, they'll have two Y)laci-, marks apiece thevlve alreadv qot one. (Laug'lt(--r.] And on latest Virginia, @7c have Paul Tescl'lan and ,--hari-s and vou Pe .-.cCall oT)le have colluded -- or do vou @@7an,@- to flin 7 acoin? DR. T@SCTIAN: 11@o. I I I vield the floor Author )r. jl,,'cCall, pleasure to my senior colleague; from -Le.@as. 188 A "'HE CIIAI-T-@7'Z: No@.7 if we are going to ,jet into these Senate tvpe protocol, Caere not going to aet fourteen regions done-todav. [Laught@r.) DR. !@','cCALL: I'm not sure whether I accept the floor under those circumstances. I'm sorrv Bill is not here. I wanted to point out to him that I find another "SuT)erior" region, but that I'r. not one that came in ,.7ith t,,.7o volums of elaborate amplification Y)er Se -- but just the onoosiLe. k quarter inch, non- i bound, non-color, bl.acl@ and.@7'n.Lte aD-Dlication that is one of t'ie simplest, clearest, i,-iost conci--e aT)nlications tiiat I've read and it's siri-c)le for a lot of reasons: One, is the state, itself, and the the-,7 i-iave v developed the nroaram, bulk-- also because this application is 0 a recTuest for support for staff, and onlv tio continuation projects !.ii-th the plan to come in for all of their neT,,7 programs in Julv. And that is clearl,7 as stated here, it is a reaion that came in rather late in terms of the overall 56 that ultiratr--lv -,,,as our peak -- so that tl iev came in, developed their T)roQram based on the neeris of the region, developed theix priorities, stucl!-. with then, haven't had to shift them they have a strong staff and region advisory grouT) leadership and an integrated proaram that has been consistent, right along. 189 t 4 And I have alreadv mentioned that i.tls reallk,, a staff @ge 4A [3roposal, Primarily, -- just t@,ro continuation projects just continued in other funds. I think the feasibility of their accomplishing, in the lirTht of @7hat they say here. vihat they have done in the -past, is excellent and @,7hile there is not a lot of information on 7P,-P relationships -- there is nothing that indicates there is nrobl---ii nO'@7 there, at all.. They are reauestincT, no-,,7, 663,132. The onlv thina I -qould noi.nt out there is that there is a significant indirect @ost in this that has come up before, about 130 some odd -- or 136,663 which -,.ias indirect cost but that is an establi-s'-ieCi 'I--hi@ng that @,70 couldn't do an,ithinq ai-)out at this point in time. 1 merely call it to ,7our attention. 1,@nci I think I'll sto-o there. The @7.,ea4-onal -@@dvisor,7 Groun is a little heav@7 on thc. rofessional T,"e-wershin, but it's t@iere -- I don't think it's a ;erious oroblem. Pciul? DT.Z. r."ESC',I-@l: T,7e have no reason to disagree -.,7it@l an,7- -hing that has been said. It's a pleasure to read a program I --hat has not onlv ',:)een able to carry -- not onl-,), been able to ,accumulate funds currently, and arrange ongoing funding -- lut i,,,hd is able to accumulate funds concurrcntlv in multiples -- .e., -,,7here they @@7ill put in half a million and they @.?ill be igo running about a ti.:o to three million dollar program 5 that @.7hcn P2-IP was going to -)hage out, the Governor and the State Government were ready to take the staff on. It looks as if they are as far along bccominct the follo@,i operation of PIIP as anv rcqion that %.!e have come across. I-.le have kno@-in Charlie, in operation of West Virginia, because it's a mer-loership in the Southeastern CROUT) and @?ye have been a@@.lare of this development in the general direction, un to no@i. ,hev seen to accorqnlish more interaction, and startina of more services and devel-o-oina of manpower, @,Titill fe@ver dollars t-@lian almost any group @.7c,- are aT@iare of. So mv recommendation -- if I can nree-mot the dignit7;, of r,,.y T)rce,eccssor would reco!-.-Lnend f tinO incT as rec:i:tested. I'll second that. THE O.Tz'. Before we opera that u-o as Charlie did indicate, this is a verv, in one sense, a verv modest application a continuation of nroararq staff with fundina -- a sliQht expansion in view there and a cou-)Ie of projects so that it totals @663,000.00 in round nu,@,ers. They do anticipate comina in with a major su_oplerental@ application injulv for $1.2 million. DR. I!c,OALL: But that, added to this, would nut ther,! above the target. 1,7e're recognizing that. But I tl.'Iinl@ we are in a position to let them mal-.e igi the judgment of what 'I--hey do come in with, in their new committee. TFIE CIIAIP@,LV@l: All we knew -- this is one of the reasons -- this is one of ma@,,,be eight or ten, where the initial application is, indeed, restricted to continuation and to program staff -- and all of their new activities will be reflected in the iulv submission. O.N.,, !\Torm, are there anv comments regarding CAP or this matter I recall @,7est Virginia has at least considered, over I the years, some possibility of disassociation from the University but I'm not sure Whether that ever got much bevcnd a sort of @@iR. NOR@-L'V,-i A7-TDE:T-',SO-@4: Anv AgencN.7 Director is a ember. of the LecTal 2%dvisor,,, (,roup, and t,ic@.r did 'recor@-n@-nc3, annroval. of this particular anDlication. @,nd as- I said, it has been nreviouslv anD--oved by the aqencv, since the wor"@ is continuing on schedule. The major thrust of the urocrram we can anticipate in@i@ the next application, will be on the State-@@?ide basis, as opposed to the individual project, or community basis. Now I think it orobablv will be the size that thev will get. DR. TESCTIP,14': They have helped build PAC aaencies in an area. TIIE Tom, do you have anv particular 192 i Virginia? ,it 7 'into this as regards West MR. SIMONDS: Well I think Norm summed it up very well. That's a pretty good state. THE CHAIRMAN: Most of West Virginia is still that way,, I know. We do have a recommendation but are there additional comments,, questions, observations. MR. BARROWS: I would like to ask a question, just as a matter of my own information: What qualities, as you fellows isee it, accounts for this marvelous support on the part of Itheir constituency? DR. McCALL: The usual fact of strong, capable Ileadership involving MR. BARROWS: On the part of the coordinator, or do Ithey have a good RAG too? DR. McCALL: I think it goes on further than that MR. NASH: The coordinator, the utiversityll and the force of the medical society They started off with -- had the RAGs to start with and they haven't had to shift. They have been right on target throughout. MR. BARROWS: The university and the medical isociety &re united -- i.e. -- they both agree. Now, I didn't say the relationship was good between the medical society and lithe university, but both units support the RMP. PORTING CO, INC. 320 t@lassachusetts Avenue, tq.1. Wasfiingtof,@, D@C. 20092 193 DR. TESCHAN: There's a very important phrase about ihalf of one line in the application that says that, in working with the medical societies in the health delivery area, they have restricted their activities to their legislative franchise. And then the thing goes on. Well, anybody who reads English in the context that ,we have all experienced it, will know exactly what they mean. That says that Charley's been very careful as a non-MD, he's been very careful and he's working with full understanding with the People who might otherwise take umbrage. MR. NASH: That's right. THE CHAIRMAN: I think I've observed something this isn't just West Virginia -- it does seem to me that in those states which have, perhaps less in the way of health ,resources, institutionally and otherwise (and Maine falls into that category certainly) and during the phaseout period, they seem a little more, for whatever reasons, anxious to preserve .what little they've got, including the RMP, than some states ,Lhere there is almost an embarrassment of riches, in one sense. I don't know that that's an axiom, but I have that mpression that in places like Maine and West Virginia, they I eem to be, or to have been willing -- and I think they have i@ad good programs there, to try and preserve the RMP with I ilotate and other fuhds, moreso than had it .-joeen Michigan or H PORTING CO, INC. 320 flissachusetts Avenue, N.'-.. Wa@.ing!on, D.C. 26002 194 Illinois, necessari.ly. DR. McCALL: But I think also, in addition to that i t lthe good leadership, good program a lot of needs relative to', the resources. THE CHAIP14AN: Yes. DR. McCALL: But also, a rather homogenous noncomplext reaion, too. You know there has been a lot of competing institutions land people, so that they were able from the beginning to focus it, and then have not only the need to recognize their function' but they were productive in it -- and therefore, you can rally when the legislation gets shot out from under you. People ;come in and say: This is a worth while thing, and MR. NASH: There's a motion. THE CHAI@4AN: Yes, there is a motion, but are there any other questions or conunents? If not, we have a motion to recommend approval of the amount requested, $663,000.00 which has been seconded. I call for the question. [Approval of the amount requested was put to vote and carried unanimously.] ii PORTING CO, INC. 320 @Aass3chusetts Avenue, N.',. Wastlinzto,,i. D.C. 2@jOO2 195 wt 10 THE CHAIP-m@N: O.K., again we are still short Bill Thurman. He's got three black marks now -- but he can afford it,' he's a dean of a medical school and he's got enough major insecurities without worrying about black marks from the Chairman. [Laughter.] I wonder, Sister Ann, since Bill isn't here, if we could again improvise, and ask you to review Oregon? This is a region where we only do have a single reviewer, Sister Ann, since Dr. James is not here. SISTER ANN: There is a staff person here. THE CHAIRMAN: Yes, there is a staff person here, Dick Russell, and he's just coming up here. OREGON SISTER ANN: Oregon is presently at the $767,000. level and they are asking for $1.2 million. They are bringing in three new activities, and a total of eight projects, and they plan to come in, in the July review for a project at the cost of $200,000. The program, from what I can read, and I questioned a few people who were there on a site visit, and apparently it has been a good program over the years. From the material that is presented in the book I was able to identify a strong program leadership, with staff, with t he regional group, that has a good review process and 1apparently it functions adequately. PORT(NG CO, INC. 320 Mlssachusetts Avenue, Washington, D.C. 20002 19b The Regional Advisory Board select projects and 1 assign priorities, and they do this through three standing committees, by which this is accomplished. It was interesting to me that the coordinator of the': program is really in control of three projects with a total of $360,000. You might want to comment on this, this is rather interesting -- it kind of indicates the style of leader-' ship in this'program. MR. RUSSELL: Yes. SISTER ANN: There are eight professional staff and', there are three vacancies that they hope will be filled. Credentials could indicate that the staff is well qualified. Their job descriptions are well written, and if they operate within that framework, they should be able to do a good job. In the past, they have had adequate technical review,@ problem analysis, and documentation of need and technical soundness. They have also addressed themselves to efficiency and containment of costs and this would appear to be on an ongoing basis. The project, submitted in two ongoing projects (approved but unfunded projects due to phaseout directions) and the new activities not reviewed by the Board -- the methodology for achieving the goals listed on page 42 of the project and I won't read it if the methodology is H PORTING CO, INC. 320 Massachtisett@. Aveiue, N.',. 'Nashir,gton, D.C. 20002 198 wt 12 'Ifollowed, it's very adequate. ished The three priorities are ones that were establ !by the Federal Government the availability and accessibility. and improvement of following, and containment of reduction of costs -- it would appear that they would be able to carry out the projects in the allotted period of time. And the CHP relationslts appear to be good although as I looked at the letters and concurrence on the last project, I noticed that there was no return on about 50 percent of them, which kind of conflicted Vth some of the other impressions that I got. And those are the main things that I picked up. THE CHAIRMAN: I think Sister Ann was the only reviewer, but I think perhaps you will want to elaborate on this MR. RUSSELL: Well, let me respond to Sister Ann's questions, because I think they are very pertinent questions. The one that you didn't quite understand the 50 percent return -- was this of letters? SISTER ANN: Yes, that's right. MR. RUSSELL: 0. K. This is a matter of procedure as part of the Oregon structure. They have a CHP subcommittee and all the project applications come through that subcommittee so they do have input there. HOO EPORTING CO, INC. 320 Massachusetts Avenue, N.@. Washington. D.C. 20002 199 3 And in the applications for Oregon, I think it was only nine of those did not respond formally. But the CHP relationships are SISTER ANN: Yes, that is verv good. MR. RUSSELL: Now in terms of the staff, they do show two professional vacancies. Now those vacancies have been filled. They, you know, knowing that it is sometimes difficult to recruit just on short time, they are using interns from the Ten WICHIE program -- The Western States Commission for Higher Education. And these young men are on board. SISTER ANN: I think there were five they were going to bring in -- is that right? MR. RUSSELL: Well there were only two vacancies on page 53 SISTER ANN: Yes, but five interns were going to be hired into those vacancies. MR. RUSSELL: No, I think there were only two as I understood it, and those two are filled. Now the three projects which Sister Ann referred to which show the coordinator as project director -- which, I believe would be a CHP priority as 1, if I remember correctly. The other is an emergency medical service consulta- tion. Yet he is not project director, per se it's that 40 EPORTING CO, INC. 320 Massachusett,, Avefiue, ti.' .@'ithese funds are controlled through the Program Staff budget Viashington, D.C. 20002 200 Advisor and all of that money will be subject to Regional y 4 Board review, and approval. You are right, the Regional Advisory Board is aware of them -- I sat with them for their four-hour meeting to look at the applications, and they have been very much involved, and it has been a very strong program. DR. TESCEPQ: How many of the new activities are going to be processed through, or managed by the University of Oregon? Just in round numbers -- one out of ten, or ten out of ten or -- there are a number of these projects who will be managed through the University. MR. RUSSELL: Very few,, if I remember. DR. TESCH@L: W@ll, when I seO-. the list here look, it looks as if they were managed somewhere else. "A hundred thousand dollars to CHP priority" was the title, and I was interested in what it was. SISTER ANN: But that, then, is when it was under [Dr. Rhineschmidt] and that -is under staff $900,000 and then there's another $150,000 somewhere it's total $360,000 under his direction, so he keeps it in the program,himse. DR. TESCHAN: What do they plan to do with that? Can you tell from that? SISTER ANN: No, I can't tell from the application, but apparently the staff-is going to address itself to the H PORTING CO, C. 320 Vasq,,husetts Aven-----, N.'-,. DC 2ilOO2 201 management of it, but I would think that CHP is going to be 5 involved in the planning, and I think the various agencies in the @area. are going to be involved in providing the services. MR. RUSSELL: What', this is -- this is, you know, in keeping with the emphasis being placed on the particular relationship DR. TESCHAN: That signal, I got. I wanted to know the content -- I can read this myself. MR. RUSSELL: And they have a number of.activities that now are in the developmental stage. These will come in as prO3ects -- go through the advisory group interview, and then will be approved and awarded to individual CHP agencies. DR. TESCHAN: I gather the decision is exactly what the content would be -- it's open ended. They wanted to get some staff resource to move in that direction and to have it earmarked for committee for that purpose, to get the signal to you all and to the rest of us on that. [Reads from the document.] what they are saying, you see, the law is that they have to do this and most CAPs or many, would say: This lin our experience has not been ready because they didn't have the basis to make the judgment. SISTER ANN: I got the impression that the majority ,of the funds for these programs, tha"L-. it's really kind of a ,Ithrust into the future as well beginning in the present, and H PORTING CO, INC. 320 Massachusetts Avenue, N., Washington, D,C. 20002 202 it really would be very difficult to kind of link these programs 6 together in the kind of a model that their Federal Government t time. talks about at the presen Is that right? Does that reflect MR. RUSSELL:- Yes. THE CHAIP14AN: Paul, with respect to the University of Oregon and the Medical School, I recently, on a flight, was I sitting next to somebody from the University of '.Oregon', and I had the -- apparently, you know Oregon is a "different" state you see in many respects. They are trying to keep people out, and they led the way in gas rationing -- but also, its University is one that they are at the end of the line in feeding at the Government trough They get less money in terms of Fe era grants percentage-wise, than any other medical school in the country. And the Dental School won't even accept percapitation grants that, you know, is almost unheard of. So it isn't surprising in one sense that despite the fact that the University is a grantee here, that very many P14P activities now, or in my recollection in the past, has been university-sponsored. DR. TESCIIAN: You really must have a first rate coordinator out there too. MR. RUSSELL: Not too long ago there was a management assessment this was by a management program -- and the best @4 PORTING CO, INC. 320 Via@chusetts Aveiue, N.,,, @Vashingtof@, D.C. 2@@)002 203 wt 17 I can remember, the only recommendation was that the grantee ought to buy some curtains for the RMP Office. MR. SIMONDS: Well, that's a little exaggeration. [Laughter.] DR. HEUSTIS: Well, while you folks feel sorry for the university, I know that they are getting $163,000.00 in indirect costs MR. RUSSELL: I didn't say I was feeling sorry Lor it, Al. THE CHAIRMAN: I seldom have bled for a university. SISTER ANN: But you know, for a university grantee, they get the lowest amount. DR. TESCHAN: What's their rate? SISTER ANN: Oh, 1 think it goes up to 60 percent in some cases DR. TESCHAN: And how low MR. RUSSELL: 40 percent for salaries and wages. THE CHAIRMAN: Well, this is an application for, again, in round numbers $1.2 million. They have estimated that they will be in with a very small supplemental, roughly $200,000.00 in the July request but this is their major request. The total of those would bet again, almost their target level figure of 102 percent by our calculation. 0 40op RTING CO, INC. 320 MassachusettsAvenue, N.1,@I Washin;,fton, D.C. 20002 204 wt 18 Any other questions, or any other comments? Sister Ann? SISTER ANN: I recommend that they get the amount i@.that they are asking br $1.2 million. Their target is just 102 percent. I believe in rewarding good programs. DR. HESS: Was that a motion? SISTER ANN: Yes. DR. HESS: I'll second it. THE CHAIP24AN: We have a motion and a second, to approve, or recommending the funding at the level requested, $1.2 million. Is there any further discussion, comments, questions? In that case, the question. DR. HESS: Let's vote. [The motion was properly put to vote and carried unanimously.] H PORTING CO, INC. 320 Mawchus@tts Avepue, Washi,i@ion. D.C. 20002 205 THE CHAIRMAN: Again, unanimous we're just continuing the complacency of yesterday afternoon. DR. HEUSTIS: I think the Chairman should find a better word than "complacency." THE CHAIRMAN: Everything, in the eyes of the beholder, Al. Well, we are still missing Bill Thurman, so we re going to continue to extemporize. DR. HEUSTIS: If they ever subpoena these tapes, I would just hate to have anybody think we were complacent. THE CHAIRMAN: Well I don't think they will find very many explicatives, or, on my part, many "inaudible" portions. As long as we are on the West Coast, and if John and Al feel up to it, we might want to take one tenth of our MP, namely, -California, which in terms of population, past funding, has roughly come out that way. Al, do you want to lead off? Or John? Again, I don't know DR. HIRSCHBOECK: No, Al does. [Laughter.] DR. HEUSTIS: You see, I have a voice problem, this morning. CALIFORNIA DR. HEUSTIS: Well, California is submitting two applications for this year, and the one that you have before you .4 PORTING CO,!4.C. 320 Ma@chu etts Aven,-,, N @E. 'Alast,in2ton, Dsc. 20002 206 11 is for approximately $8.3 million, of which about $1.6 million is for the program staff. And they would estimate that with the July application they would come to $14 million and you can note, if you care to:@ look on your white sheet that the RMP are prorated figures at $12.5 -- so there are approximately $1.5 million ahead of what they were advised to do. They served the area of California with two regional offices, both of them (note) located near major airports, one in the northern part of the state and one in the southern part of the state. The Regional Advisory Group has established siy@-goals, and six program elements, and they will implement these. The goals are to be implemented through six programs, and they have assigned a percentage of funds, and have determined their priorities in this way to each of the riajbr goals. The percentages are the largest, they held manpower at some 25 percent and the least is 4 percent -- with others ranging in between. The RAG is strong, stable, and very interested and this is judged by the attendance which has a very well- known committee structure. In addition to the Executive Board, there are three standing committees on program development, one on program lireview and one on evaluation -- and then they have what I like,' Ho*(P'ORTING Co, INC. 320 f,,iassachusetts Ave,.iue, N.',. Oiastiipgton, D.C. 20002 207 and the program element committees in each of the areas their charge is to develop programs and to monitor programs. Here, again, it seems to me that real guiddnce is provided to people that would request money, in what the money should be requested for. It came through strong and clear to me that the P14P Central Staff plays an extremely important role in actually coming up with the projects and trying to define what our RMP role ought to be in each of the general areas -- and trying to define what kind of applications they ought to address themselves to, and they actually have pretty well defined criterias for the program development and provide actual guidance and request preparation I don't know whether they actually write the requests or not, that wasn't stated. It was stated that the nine RMP Area Committees that formerly existed, had been phased out and that the program elements committees had replaced these, and that the they were well satisfied with the fact that the volunteers were now doing -- at least I got the impression from the work, that they were now doing a better job than the goo job they previously thought that the staff had been doing. The final budget, as requested, has been approved by the RAG, and first of all, apparently in the process the reports of the Program Area Committees goes to an Executive. PORTING CO, INC. '1120 Viassachusetts Aven,i,,. @Yashington, D.C. 20002 2o8 n of the Board, and the Executive Board recommends a divisio 2 funds among the Program Arzas -- and then the RAG makes the decision as far as the -- within that context, with regard to the applications. I think they have a really well defined review and approval process, which is adequately described and interestingly -- and before I reviewed this, I didn't know that this was exclusive. They used technical experts,, apparently from outside the region -- but the technical experts work under the supervision of the Review Committee. The one matter that I felt was defective, and yet I am extremely understanding, because California is a pretty I complex state -- and other large states have been having similar problems -- and that is: First of all, who speaks for CHP? And how do they effectively communicate what they think, to R.MP? I gathered that RMP bas, what I would consider an "arms length" relationship with CHP and that RMP was extremely strong, relatively, and CHP was relatively extremely weak and there was no described CHP development or input into the preparation of requests prior to the RAG action, except for the legal review and comment -- and that seemed as though Ilat minimal, CHP ought to in some way formally be consulted lilabout what they thought their needs and priorities were. H PORTING CO, 14C. 320 li'ia@@chusetts Avert---,,, N.',. V4ashino,ton, D.C, 2 0002 209 Of course, the whole problem may be that they don't have any need for priorities that have as yet been developed but that is rather reading between the lines rather than reading what's there. DR. TESCHAN: Well, they have had seven years time to acquire DR. HEUSTIS: The staff is well seasoned and exper- ienced, although substantially cut. They used to have approximately 50 percent of the total awards that went to staff and it's now down to 12 percent. The past results that I found, seemed to be impressive both with regard to the numbers trained and, I guess I have to interpret some of these figures, I'm not quite certain how meaningful some of this is, as far as the meaningfulness. We talked about new medical power resources created or "new medical people power resources created" and the number wasn't really very impressive. I think it was a little better than 2,000. But the access to care -- it seemed as though the two major provider systems that had been started and now were expanding with other funds -- they have given attention to urban Indians, and they have done some work with the California Council of Free Clinics all helping the under- liprivileged. fi@00'iER REPORTING CO. INC@ 320 Niasqc husetts Averi,@, N.F-, 210 The record of continuations, the projects without i ing They said that out of 76 ongo was impressive. 24 RMp funds, projects, Or a total of 81 projects that had terminated since @i July, 1960 -- 70 percent had continued with other funding sources. it said that following the RMP In the first yearr . usly been funded discontinuance the projects that had previo ot a total of RMP funds, in the amount of I over three ears f y ear of going along with other $7 million -in the first y with $4.5 million to continue what funds the people came up ressive on. I thought that that was rather an imp was going iaure. ed by all kinds of moneyl The continuations support including voluntary funds, university funds, hospital fundst State Governmental funds In the proposed program, they are trying to set up of what they call "Health Services, Educational a network Adtivities" to cover the entire state -- d yet some 14 of these formed ten of them are incorporated and four are rove the quality developing -- and these are supposed to imp of health care for coordinated state-wide system for health, manpower, training utilization and health education. And again, it mentioned that over a hundred colleges and 120 hospitals(seemed low) and clinics were involved in this with some 200 people on the boards of 211 ot directors of these organizations. In high bloodpressure control programs, they have a state-wide plan, and I thought it was interesting that of the 36 applications that had been received, the project said that sixteen were selected for funding. Then I think the others were, of course, pretty much there. Again, as I indicated before, the thing that probably bothers me the most, and yet probably shouldn't bother me too 'much, knowing what the facts of life are -- are the relationships between CHP and the Regional Medical Program. THE CHAITNIAN: Oh, I think Staff may have something to contribute to that -- we spent four days in California DR. HEUSTIS: It is very difficult for a person with just the information we have, to evaluate the real meanina- fulness of the CHP comments -- whether they are just bemoaning the fact that they haven't been recognized and want to say some things, or whether they really have a beef and maybe the staff could be helpful there. But before we get to that, as far as my assessment was concerned, I have rated on the Review Sheet, all of the items from -- on the first page, program leadership, program staff, the RAG and the performance and objectives in the ilgood" to "excellent" category. H POP@TING CO, INC. 320 flasn[ilisetts Avenue, Olashir,gtoti, D.C. 20002 wt 26 On the second page, I had to break down the three items in the proposal, thinking that they were congruent and that they were addressed to areas of emphasis, and because I didn't know about the CHP input of plans, and because there were criticisms, I rated that down to "Above Average." And then on CHP relationships, I thought these were very -- I couldn't make the determination, and if I had to vote I would have to vote that these were certainly "Poor." But the column that I checked was the "Insufficient Data" and then the overall assessment of the program was "Above AVerage." And the recommendation was made that as far as the funding level, that we ought to know more about CHP. And t en I should say after that that we need to have staff comments. THE CHAIIU4AN: Well, thank you. You have raised the matter of CHP. Perhaps I would comment on that before we ask John, and then Rebecca can complement some other things, as relates to California region. Relationships with CHP there, are uneven, but even CHP relationships one to another, are uneven. Let me explain that: There are twelve B agencies in California and I think the relationship of the California RIAP, with most of the medium-moderate sized ones (Fresno and the northern counties, Empire Valley, which is Sacramento) we met with, during the H PORTING Co, IN 320 Massachusetts Aventi-@, N.@'. Washington, D.C. 20002 213 course of our four-day visit, Rebecca and Sandy and I, met i'with six B Agency Directors and the A Agency Director. The relationships -- I would describe those agencies as Fair to Excellent." Much of this has been as a result of the Health Service Educational activities where the State is blanketed ,by those which have been sponsored by the California Rmp again, the development has been somewhat uneven, but in many instances, one finds that these health service educational activities, most of which are now incorporated as private noh- profit groups, are in a very real sense, the health planning arm, or at least an important adjunct of the local CHP agency. Relationship, on the other hand, with the three major CHPs in terms of population areas @- Bay Area, Los Angeles, and Sani)iego -- are arms length to "awful." MRS. SADIN: Well, LA was all right THE CHAIRMAN: Well, yes, LA -- at least the word we got was that LA wasn't doing anything, so that they weren't igetting into anybody's way. But some of that is a matter of personalities, I think. We found, for example, that in the Bay Area, the Director of the C8P (and that's sort of a federated CHP, as ilthere are nine counties, and each of them with one exce tion p I believe)-- DR. HEUSTIS: Yes, but it seemed to me that in PORTING CO, INC. 320 thssacht!setts avenue, N.[. Olashing@on, D.C. 20002 214 wt 28 addition to the B Areas, that every county had its own CHP, and to kind of sort out the comments it became very domplicated. THE CHAIRMAN: Well, the Bay area.is an interesting CHP -- certainly the most vocal, outspoken, bidder, director we ran into, that was Don Ardell in the Bay area. He was having problems with his eight County Directors, and they sort of meet apart from him. Correspondingly, those B A;jencies, and perhaps the, B Agencies in general, but certainly the larger ones -- I'm not sure it's constructive, I think there was some destructive tension going on presently between the A Agency and the area wide agencies out there. I think the RMP has, on the wh!ie, pretty good relationships with the A Agency. Now part of that may be the fact that the A Agency is, comparatively speaking, poor so that it has been getting some money from the State EMS Office, or from the RMP, to do some of the things @hat it really hasn't been able to get State funds or State positions for. But the picture is a mixed one, but certainly based on our site visit, Rebecca has thrust in front of me here both our report to Dr. Paul and our feedback letter to Paul Ward -- while we did have some recommendations about their IIOOVER REPORTING CO, INC. 320 M.,ssachtisetts Avenue, N.' . W;ithi.qotnn I) C 2OF102 215 relationships, I think there are more that have to do with 9 details, that they really ought to do a better job in insuring that the letter, as well as the spirit of the law is followed. If for no other reasons, the defensive purposes. They were kind of sloppy in logging in things, and showing that they -- you know -- somebody wants to get you over a barrel But we felt that on balance, that the requirements for CHP reviewing comment were largely being met in substance as well as technically. We did, also, have a chance to witness at the RAG meeting we attended, that there are several CHP representatives on there -- one from the State CHP and the area-wide agencies have a California Conference of CHPs -- it's kind of their "trade union" and they have a representative on the RAG and at the RAG meeting we attended an alternate member was sitting the fellow from San Diego -- and they certainly, not only spoke out, and they had some objections, but the RAG took them under advisement to the extent that they deferred -- they were going to look into the matter and either accept them in whole or ignore them -- and I think, you know, that even that slight ation suggested to us that in the RAG councils they demonstr have the ability to make themselves heard. So it's kind of an uneven picture, Al, I don't m PORTING CO, INC. 320 Massachusetts A@4enue, N.[. V@as'ninzton, D.C. 20002 216 at least from what we've DR. HEUSTIS: From what you have said previously what comes up with what I get out of the thing -- I had written down a summary of the comments that had been made, and that was marked in red -- and I admitted that the ones that I thought were important, and I had imported negative comments from six of the twelve areas at least what I thought were impor- tant negative comments of the six MR. BARROWS: I don't think we can charge them with the responsibility for resolving these intramural conflicts within the CHP. THE CHAIRMAN: Oh. no. MR. BARROWS: But we can grade them on their effort to relate to CHP -- and would you regard that effort (and this should be a positive one) as "Good" "Average" "Weak?" THE CHAIRMAN: I would have to ask for Rebecca to comment too. My judgement, I guess, would be "Atrerage" to "Good." I think there are some situations where my impressiot is that California RMP feels that it has walked the last mile. For example, when the Area Offices are abolished, that was a kind of a structured cross-over situation., When lthey abolished all their area offices and with them the area advisory committees, and came up with the Program Element Committees as a substitute -- there became a number of vacancies PORTING CO, INC. 320 MassachuseLts Avenue, N,E. '@lashinptoil, D.C. 200f.,2 217 on various B Agencies you know our slots targeted for the PDAP, we found in the Bay Area that an issue of longstanding Director wants an RMP person, but he wants the B Agency a consumer. But it just so happens that in that part of California Paul has only got some providers on his RAG, and you know, I think there is a real personality kind of conflict. But I think on the whole -- and one of the suggestions we have in our feedback letter, was that they should consider 'II the possibility of havin a fairly senior staff,person as kind 9 of a liaison with the Conference of the Aqencies -- they have met with them, and again, this is not a monochromatic picture at all DR. HEUSTIS: Have we any kind of a written agreement that has been either tried, or achieved, as to what each of them have thought they were supposed to be doing and what their responsibilities were DR. TESCHAN: The answer to that is: Yes, as I recall. Now whether it is current or not is more to the point, but I recall that there was circulated to the coordinators some two to three years ago -- and this was the first example of a written memorandum of agreement as to what RMP and CHP roles were going to be and how each would interact with them. I'm quite sure Paul Ward was .11 PORTING CO, INC. 320 @viassachtjsetts Avenue, N.' . YVashin-6ton, D.C. 20002 218 SCHAN: DR. TE I thought it was a marvel. As a 2 matter of fact, when we got around to signing a statement in Tennessee, we used that as one of the bases of ours. But I think it's uneven tli,= MRS. SADIN: relationships are Uneven. The only suggestion I could think of and we discussed this -- I think we need a Rabbinical Council you know, you 1 just need it, to mediate. I'm awfully sorry, Sister Ann. [Laughter.] You know, in the old days, they didn't need lawyers both parties just went to the local Rabbi, and I kind of thought that's what they needed. [Laughter.] They are doing, you know, the legal part of it and getting the review in comments and submitting the things, etc, etc, etc, but it's a relationship thing that's the problem, in some areas. They are now logging in, as you can see in their applications, all of the comments that are sent out and all 76 projects DR. HEUSTIS: 76? MRS. SADIN: Well 75 -- hot that's a lot of projects for review and comment -- and they just sent me another whole batch from the LA -- and this is all just LA CHP [Displaying a dossier.] DR. HEUSTIS: That came in late. H PORTINGCO,INC. 32OMa@cnusettsAveriue,N.r@. Washington, D.C. 20002 219 MRS. SADIN: Yes, that came in late. [Laughter.j 33 So it is -- you know, one of the things we suggested and this is the letter sent back to Paul Ward -- and one of the' things that we suggested is that they have a senior staff person as liaison, to spend more time and pay more attention to that problem. DR. HEUSTIS: Well I am satisfied from what I have heard, that I would change my recommendation from "Insufficient' Data" to at least a "Satisfactory" relationship. THE CHAIRMAN: Correct.me, Rebecca -- but most of the program elements committee do have a CHP representative on them. This is really their program development thrusti Now DR. HEUSTIS: Yes, it is pretty good. THE CHAIRMAN: Well, I wonder if we want to hold withhold other staff comments, and let John as a second reviewer, take a look at California -- we have spent an awful lot of time with CHP but given the fact that they are probably 110 percent of the CHP in California, also. At least, in terms of family, I wouldn't think that was far off. DR. HIRSCHBOECK: Well, I won't repeat the comments which Al made because I think they hit the target right along the linc in most instances. I am troubled in one way that in reading this over, I didn't see what really happened when the areas were dissolved" H PORTifiG CO, INC. 320 M3S&lchusetts Av@nue, N.[. in;i,zfiinutnn fJC 2tlOD2 i I 220 34 and they were put into two. Is CHP, again, is it moving into the area-wise approach here that existed with@ the regional setup? I think that because of this, maybe this is one of the reasons for some of the problems that they are encounter- ing there in relating to the CHPS. The other point that bothered me is this enormous project that Dr. White is in charge of -- it's how many millions? Altogether, I guess he's asking for a state-wide consortium of colleges and universities and hospitals and this enormous arrangement seems to me reall y going too far. At the practical level, I don't know how they are going to work this out, but if this is the way to go in California, maybe it should be allowed, but I have my druthers about that enormous approach to dealing with area- wide health education aspects. MR. BARROWS: Resolving that at Berkeley DR. HIRSCHBOECK: I guess so. [Laughs.] I have made several visits, site visits, to other agencies in the California region, and there is one for the California RMP and one in their Review Team consulting visits, and the thing that impresses me out there is that things are HOOVER REPORTING CO, INC. 32o Massachusetts Avenue, Vj.%,zf.iratnn 221 so different in different parts of the State that to try to 'WIN resolve a problem on a state-wide basis becomes extremely difficult and this is recognized initially by their setting up a CAP region. And now that this has gone, I am uncomfortable. It's like setting up a Regional Medical Program for a whole nation, and doing it in one as a sub-set of another nation. I don't think DR. McCALL: That is difficult to do. We tried it. [Laughter.] DR. HIRSCHBOECK: So that my overall evaluation is: Sure, the leadership is good. The problems are difficult. The program and staff is good. The Regional Advisory Group I might differ a little with Al on all these he has perhaps read it in a little different way. I had the feeling at least that the Regional Advisory Group- was@ not really involved in the actual process of evaluation as much as other IU4Ps are. In other words, they take the word of others very readily, without being, themselves, directly involved. Now I may be all wrong on that but I sort of sensed that a PORTING CO, INC. 320 Massachusetts A,;enue, N.@. Washir,gton, D.C. 20002 222 6 Past performance and accomplishments ... objectives and priorities -- I think these are well defined. Feasibility -- here, again, the whole idea of true regionalization on a state-wide basis, I think, is Very difficult. In general, I would say "Average" or "Good." "AV3rage" would be my overall evaluation. MR. BARROWS: Let me ask a question: One of the things -- California, as you both pointed out, is not only vast, but extremely complex. One of the very unique com lexities is the strength p of the foundation movement. Now nobody has commented on how this program relates to the practices of the community which happens to be an unfortunate bias of mine -- have they been relating to these foundations at all? This is including the interplay between DR. HIRSCHBOECK: Well some of their projects are involved in the quality insurance. DR. HEUSTIS: They mentioned particularly some of the foundations have picked up the check for some of the projects which had gone on THE CHAIRMAN:: Great. DR. HEUSTIS: Now how extensive this is, I don't know H POPTING CO, INC. 320 Massachusetts Avenue, N.,'. W;t@hingtnri D@c 20002 223 or how wide. 37 MR. BARROWS: Good well boy, that's the acid test to this hard-earned DR. HEUSTIS: Whether this was two foundations or twenty foundations I couldn't -- I believe my notes are not clear. FROM THE FLOOR: Could you tell roughly how mahy grantees there are, other than their sponsoring grantees programs? DR. HEUSTIS: You would have to help me there. DR. HIRSCHBOECK: Let's see the agencies other than central staff that are handling the money -- as grantees. MRS. SADIN: They have subcontractors -- or contracted, that is, most -- for instance, all of the health service activities are contracted to the independent facilities. They are calling their shorts And almost all of what they have, when they develop a program element, they have sent out RMPS, you know, throughout the state, and in which they really outline what the'17 want and then they contract it out. They have in their access, which is going to be coming in in July, they have had something like -- from their RMP they have something like 250 -- isn't it? I think it's 250 letters of intent, which is the, way they go about -,his business., HOOVER REPORTING CO- INC. 320 tiiassa@husetts Aver@@e, 224 8 In answer to some of,your questions on the definitions of area offices -- one of the things the CHP -- or some of i them, told us -- was that well now that they don't have the area offices in California, that we could kind of take their place in terms of local input. And when-we mentioned that to Dr. Mitchell, he said ? fl "Yes, do you think this is the first time I have heard it They have never communicated this to us. [Laughter.] Some said that they missed the area offices and some of the agencies said they were glad they were gone. You know, it was kind of a 50/50 kind of thingi almost through-: out the state. The result of the definition of area offices really you know they had something like a three-months visit when HET,@,' audited them and this was the latter part of 172 -- that was a fact that one of the strongest recommendations was that they not have all of the area-- offices. And I think Paul Ward took the opportunity to follow the advice of the HEW auditors, and they now have a northern field -- it isn't just a central office, they have a northern field office and a southern field office. THE CHAIRDIAN: Yes, but these are quite different. ifrom the old areas. These are essentially administrative HOOVER REPORTING CO, INC. 320 Moss3chusetts Avenue, fall.t 225 wt 39 or for program development, and monitoring purposes. MRS. SADIN: Right. DR. HIRSCHBOECK: One.@ wonders whether they shouldn't really make two @MPs instead. MR. BARROWS: Right. From a management point of View this is too damn big for one MRS. SADIN: Right but MR. BARROWS: But we can't do anything about it. THE CHAIRMAN: I think that represents, though, a very conscious, deliberate, decision made at the time P14P came along and involving what, at that time, were a lot of the influential people in California. At that time you will remember, Breslow was the State Health Officer, and Brown was the Governor, and they made a conscious decision and they wanted a "state-wide" RMP even though it might be juggled. They came out exactly the opposite from New York, which now has six or seven RMPS. So they didn't blunder into it, and I'm sure, like any decision, it had both then and in retrospect both its plus and minus qualities. MR. BARROWS: Well, there's not much we can do about history now. What's the recommendation? SISTER ANN: I was interested in your comment where you said the technical experts work under the direction of the 40OVER REPOPTING CO, INC. 320 M3ssachusetts Avcnue, VJnthinatnn f) C.' 226 Review Committee of would this be inhibitory to the technical experts? DR. HEUSTIS: Are you talking to me? SISTER ANN: Yes, you indicated in the report, that the technical experts work under the direction of the review committee. What's the purpose of bringing in these technical experts? DR. HEUSTIS: Well, I think the purpose of bringing in the techniml experts, as I understood it from a person that made a site visit too, with me one time when we got into this discussion -- is that this is to get rid of the local bias and the local conflicts of interest and the local antagonisms between the centers from which the experts come. SISTER ANN: Then you said that they work under the direction of DR. HEUSTIS: Well, the "direction" -- perhaps if I said the overall direction or overall supervision DR. HESS: Or "they report to" MRS. SADIN: I started in on that to review particularly the manpower, and they do bring in top experts and they have to counteract the ones in California -- and I think what was meant was that the recommendations go into a review -- but it isn't DR. HIRSCHBOECK: But this is exactly the point I was tryingtd. make a little while ago. I think that'the distance 40 VF.R RFPOPTING CO, INC. 320 fla@@husetts Aver,@ e, N.','.1 nil 227 wt 41 !!between the RAG and that technical review process, is at least' at the time that I was out there it seemed to be a larger: gap than really should be. That the RAG should be much more closely involved in the actual review of the project itself and not just take the report with the badge of an expert pinned, onto it. MRS. SADIN: I don't know if they changed it since lwe ve been there, but they now have a member of that RAG present at every one of these which helps tremendously, and he reports back. THE CHAI@IAN: They have two standing committees. A review committee, and; An evaluating committee. Under the Review Committee, the technical experts operate in a panel.fashion, sort of. They look at the new projects. The Evaluation Committee, on the other hand, doesn't have that close line of the smaller committees, and they are the ones who look at and then forward to RAG. And then, both of these standing committees are RAG people, on continuation, so that they have that kind of relationship And what goes through RAG, if it's a continu- ation of the Evaluaiion Committee -- if it's new, it goes to the technical panel. So it's the overall "umbrella" supervision HOOVER REFORTIVG CO, INC. 320 @,iamchusetts A-vepue, N.cl. 228 I of the Review Committee. SISTER ANN: And then @re, too, on page 3 of the Staff Comments, they have 70 requiring surveys, four kinds of positions -- they are adding the 19 -- but one of the concerns is the proposals are not being monitored and evaluated on a systematic basis. And here, I just wondered if adding more and more people would complicate the issue. MRS. SADIN: There is some urgency to this. In fact, they have added evaluations to their staff, and they are asking -- part of the 70 is for more., But we had, after their supplemental application we sent an advice letter back to Mr. Ward. We had suggested that such a vast program would merit that they spend more time on surveillance and monitoring. And when we were there in April -- if anything, they had gone the other way. They are sending the people in the Southern Field Office to the Northern Field Office and require a monthly progress report. So if anything, they have gone overboard. So they are monitored all their people in their Field Offices are monitored -- every single contract -- and' this is the contracts mostly, so that they have a condition written into the contract. H PORTING CO, INC. 320 tlassachusetts Avepue, N@' .i '4ashingto.-,7 D,C. 20002 229 wt 43 DR. HESS: I see. DR. TESCHAN: I would like to say that the evaluation effort of what public accountability of funds really means in terms'of output benefit -- that whole concept was jelled for all of the MIPs in the country by the initiative of Paul Ward and that staff in California. And a good deal of some of the numbers you are seeing, John, and all the rest of us are aware of how that ultimately became generalized in order to get the data together, to show to various critics what the numerical impact of these activities was. I am interested that you consider that some of it became a little bit more Compulsive than others but I understand the atmosphere in which such compulsion can be generated so that I even have some tolerance for that as well.. MRS. SADIN: In terms of the H.E. Doctor, you asked a question about the manpower. When we said "supplemental funding" in July of 172 California of course as usual, got the most money in the supplemental funding for manpower control -- they started out with something like 10, plus the Central Coordinating one. They tow have something like 15 and they just about cover the state. Some are in the planning stage but most are now independents consortium with'independent,boards. POPTING CO, INC. 320 Massachusetts Avenue, N.r Washijitlon, D.C. 20002 230 It's interesting though, that at conferences like 4 the schools of Allied Health Protection -- and they have had some -- there's a national conference in Boston this year they had Dr. White speaking in some of the consortia of the directors. The people at the conference were so excited about it that they then sponsored their regional California conferences they have done some exciting things. But it is a lot of money, though. DR. HIRSCHBOECK: Well, I would like to see it sometime, to see how it functioned. It sounds good on paper but I would like to DR. TESCHAN: Well, John, the thing that bothered us 0 is that each one of their nine regions was about as big as one-point-some million as most of the other RMPs we are talking about -- and to see Paul Ward, in one application, with a dissolution of area offices, just boggles my mind. And Ken s point of "management, how do you get ahold of it?" I am surprised at the HEW Audit. We know a little bit about the origin of that, or nave suspected some of the origin of it, and I'm wondering whether acceeding to it the fact that it has some budgetary require-, ments -- isn't a "giving in" to what would in Ken's view be sound management since we would have insufficient data to male 0 HOOVER REPORTING CO, oilC. 320 Piassachusetts Aver, e, 231 wt 45 or to be able to make that judgment from here. MRS. SADIN: Well, some of the things Dr. [Hirschfeld] has said -- nobody knows this is going to happen -- they had more than a norm -- they recognized that -- perhaps not DR. HESS: You are dealing with a state of some twenty million people, and $2 million for health, education though it seems a lot in one lump sum, is not a disproportionate amount for the population. THE CHAIRMAN: Al, you've been trying to DR. HEUSTIS: Yes, I've been trying to push and I would like to make a motion. THED CHAIRMAN: Fine. We have a request here for a little over $8 million and we have an indication that California will be in -- and this is a request just for continuation and program staff. Roughly, they are at the $6 million level for all new activities in July. That would total, if my figures are correct, almost $14 million. DR. HEUSTIS: If you would then look at another colLLTn you would note that if they did that, they would then come to 111 percent of the amount that you requested for them. And because both John and I have rated this as "Above Average" it seems as though, in conformity with our HOOVER REPORTING CO,:,ic. 320 Massachusetts Avep,,t N.,. LjV;;thir,iinn F) c 2ilf,02 232 6 ill policy of rewarding the people that do well, and taking away i from the people that don't INDEX I would therefore, move that it be funded at the MOJMION requested level, some $8,170,374.00 [The motion was properly seconded.'] THE CHAIRMAN: All right, we have had a motion to approve at the requested level of $8.170,000 DR. HEUSTIS: 374. -- it's a separate item. THE CHAIP14AN: $8,170,374. Are there any further comments, or any additional questions? SISTER ANN: Excuse me. Are there any things that you feel we should look at, or that you think should be looked at, serious enough that by reducing this funding (since they are coming in in July) might be an impetus for them to look at the funding? Are there any points or things that bother you about the region that maybe could be looked at? DR. HESS: But the point is, there is no time for them to look at anything. DR. HEUSTIS: I guess the answer, as far as I'm concerned, Sister, is th at I thought it was a good program f with good management and that the CHP situation bothered me H PORTING CO, INC. 320 M3s chlsetts Avpnue, Wastiip,2Lo,,i. D.C. 20002 233 but that has been resolved satisfactorily for the moment they still ought to work on that, but at this time I think I would say "no" to your question. SISTER ANN: As I read those notes here and the Staff Summary, I'm not all that impressed with the good management, and I think part of it is because it is-such a difficult region -- and as I have heard it reviewed from time to time, and the management hasn't been its strong point. But as Dr. Hess says, there is nothing that can be done about it now except@- in terms of a recommendation. MR. BARROWS: I feel as you do. We can't reverse history. I would certainly not recommend this as a model program for the new House Resources Agency it's too monstrous. SISTER ANN: Well now I would think thatwould have to come through -- it would make me much more comfortable if that came through as a -.--recommendation. MR. BARROWS: But I don't know what it's bigger than both of us. MRS. SADIN: The target that's figured though, you know, which is, I guess, less than what they -- less than the $14 million they have communicated over the telephone and they have allocated percentages to each program analysis -- and' lof course if that came down to -- say $12 million instead of $14 million -- the man had written 25 percent of 12, etc HOO'IFR REPORTING CO, INC@ 320 faas@c[iusetts Avenue, ti.1-@. @]nKhii,.oinn THE CHAIRMAN: They have pretty well -- you know, I wt 48 assume there is some ability to make adjustments at the tail ;,end of the process. But they have gone through a process lby which the RAG has said in effect: One way of expressing lpriorities is that we'll put essentially 25 percent of our money into the access program -- now whether that is X-plus $2 million lor X-minus $2 million -- so I do think we have a notion lboth here and looking at a new application, of what the or where the cuts would come. DR. THUP14AN6 Yes. Question. THE CHAI@.N: All those agreeing with the recommend- ation to fund at the level requested indicate. [The motion was properly put to vote and passed by a vote of 6 in favor and 3 opposed.] THE CHAIIU4AN: In that case, I guess thatis by default. I can't think of any better solution. There should be one, but I canOt think of it. O.K. for California. RTING CO, INC. H p 3,'*Ch@osetts Avenue, N.L Washin@,top, D.C. 20002 (202)5466666 235 THE CHAIRMAN: O.K., Bill, since you guaranteed uS, last night, that you could dispose of Puerto Rico in ten minutes, we'll take you up on that. And then after Puerto Rico, we'll see if the group wants to take some coffee. You and Joe -- I'll call on you first, since you are on the site visit -- well Maybe you were too, Joe, were you? COMMENT:@ No. PUERTO RICO DR. THURMAN: Just a reminder of the fact that a site visit was asked for by Council, as to whether or not Puerto Rico would get any money at all -- whether they should be discontinued. Mr. Nash was on the site visit with us and the most important thing about the site visit was that we had a multi- lingual team, and I think that resolved all our questions because in our meeting with the Puerto Rican group the Coordinator now, he was the Associate Coordinator before he has the respect for the program and control of the people. They continue to have real translation problems, even during the site visit and even though we were multilingual. Some of the concerns that came out were only handled by a girl who was even more fluent than the Site Team was. The RAG is very strong. It's very representative despite the differences involved with Puerto Rico, and poor N PORTING CO, IN' .. 320 Massachusetls Avenue, Alas,hiii,Mo@i, D.C. 2@002 236 wt 51 transportation and despite the phaseout as concerned that ipart of the program in toto, the RAG has continued to work quite well. The real strength of the program as far as the future is concerned, is that 70 percent of all health services in the' island are public, and the grantee being the University of Puerto Rico which is also a public agency has forced the staff to flow from agency to agency, but neverthei-esst has iworked quite well. I think the most eloquent thing that we heard was several testimonials that came from cnnsumer groups about what Puerto Rico and the medical program had meant -- the delivering of health services to the underprivileged groups in the continuing organizations. Ther-rojects were just superb, when you really under- stood them (which is not true on paper, and this has been our problem the whole time.) They have an operational VSRO which is phenomenal in every sense of the word. They have a ver y good plan for their EMS and they are working hard at the geographical spread. I think that this program, having gone down there thinking it wasn't worth supporting for another day -- the Site Team came away totally satisfied that it was an excellent liprogram, and I would recommend approval of their request. HOOVER REPOPTITIG CO, INC. 320 fiasL@chus2tt@ Aveiue, N.c,. 1) r9 @,-l Cil 237 DR. TESCHAN: Second. THE CHAIRMAN: Joe. MR. de La PUENTE: Well I have many good things to say about them. I have discussed with friends of mine who lived there and who have been living with the government structure, which is quite monstrous -- and they speak of Puerto iRico RMP as "La cr6me de la cr&me" as far as entered into our conversations -- with living over there. And under the circumstances I have written -- I wrote a lot that has already been said, but in summary, "Ithis application represents tenacity in the face of austerity in that a viable program is being presented. It is possible to enhance the staffing pattern with the introduction of a physician who possesses some training in the field of epidemiology, and this is tremendous. It is apparent that the Regional Advisory Group has continued their efforts towards program development and review. Their track record in terms of the number of programs that are eventually adopted by the community appears to be better than average. Most of the present priorities appear to coincide with the needs of the Island. Special attention should be paid to assuring the dissemination and application of findings for additional sites lin Puerto.Rico. HOOVER REPORTING CO- INC. 320 fliassac husettsAven,-.,N.E. 238 But I c 3 ertainly, strongly concur with the present recommendation. THE CHAIRMAN: Thank you. Yes, Al. DR. HEUSTIS: I am impressed by what was said. lIn fact I was so impressed by what was said that I looked over Iinto the next to the last column on this tabular sheet, and I noticed that Puerto Rico is one having the honor or distinction (or otherwise) for requesting the lowest amount of the allocated funds, for any group. i THE CHAIRMAN: Yes, the lowest percentage of that so-,; called target figure. DR. HEUSTIS: Yes, the lowest percentage. THE CHAIRMAN: Yes. DR. HEUSTIS: Now, with the obvious need, and I say obvious" need, it's from what you have said after a one- week visit -- and when I was there under different circumstances and not for RMP and quite sometime ago Is this because they were tired, or because they were@ discouraged, or because there was a lack of understanding on the part of what RMP was looking for? Why this low figure? DR. HESS: I don't think that's a good measure, I i lat all. .io.@PORTING CO, INC. 320 Massachuetts Avenue, Viashir,gion, D.t,. 20002 239 nd to th DR. THURMAN: I think I had better respo at. I agree with you, 1 don't really think it is. It's not a matter of being tired, it's not a matter of being fed up, or anything else. This program has been going and again, we didn't understand how well it worked with all the other health affairs and activities. Now they have wanted to avoid an outward appearance of affluence, and that's why they were so well accepted, as Joe points out. Again, I would just emphasize that -- not in talking to people who are getting anything out of it, but in talking to the little people -- and these people were able to speak in Spanish to the people involved -- it really is the cream of the program and they felt that they can use this money wisely and not jeopardize the future of anything else -- and they would only ask for the money they think they can use well. DR. HEUSTIS: Now in view of this, do you not wish to retract the statement that you made yesterday about the people "always asking for more than they need?" DR. THUPJMN: No, these people have asked for more Ithan they need. I would never retract a statement, like that. [Laughter.] N PORTING CO. INC. 320 Ma@mchucetts Avinue, N.,. Washinpton, D.C. 20002 24o DR. HEUSTIS: For the moment I thought I had you, ,lie but I couldn't go further DR. THURMAN: No, I am going to defend the sheet, a little later on, with the fact thatI think it's useless, so I only bring that up No, the only place that -- the place that I would criticize their budget, if you still look at the core of the staff program as to what was indicated earlier -- they just pick up all the staff, and they didn't really, physically pick them up, they just moved them to other budgets within the medical science campus, and try to find a place for them and then they kind of flow them back. And that "flow" is very worth while for the very reason you bring up -- that these people will be able to do an awful lot with a very little bit of money. So that we are approving more money than they can truly use right now, because they are funded through other mechanisms. So that I'm not defending my very dogmatic statement too much. [Laughter.] DR. HESS: The point is: How many people are there in Puerto Rico? DR. THURMAN: Higher than New York City per square H POPTIfiG CO, 14C. 320 Massaf@usetls Avpni,,,, t4.E.1 Wastiington, D,C. 20002 241 foot it's the most densely populated region in the United 11 States. MR. NASHii About 2.5 million I guess. DR. THURMAN: But a higher density than New York City, per square foot of ground. And yet the most of the island? you couldn't set foot on if you wanted to, because of the trees and the water. MR. NASH: Dr. Heustis, that figure may change 69 percent -- depending on what comes out of their application that they will submit. DR. HEUSTIS: I didn't care to exp lore that any more but it just seems as though where there was need was there a language problem. But I think my question has been satisfactorily answered. MR. NASH: All right. THE CHAIPJA-AN: We do have a motion, and a second, on this one -- to approve in the amount requested, which is $696,862.00. Is there any additional discussion? All those in favor [The motion was regularly put to vote and carried unanimously.] 14 PORTINCI CO, INC. 320 Mi@chLsetts A@@e nue, ,iv3sh,!;Igton, 242 THE CHAII"J.@l: O.TL,@., it's ten o clock. I-,Thcit is the Pleasure, of the c.frou[)? !)c) we eiant to take on another one or do %.7e want to break for fifteen minutes and have a. cup of coffee? Do @.7e have anot"Llcr ten minute one? How about the- Tlountain States of Idaho, T',Iontina, 1,7yoi-iincT, and Nevada? COI@l-!'F-NT: Is that al@,7ays that same four states? It's al@iavs been a little unclear in m,7 mind'. T,-Ihat -f Ive r(--@irl now su(-(gcsts it's sort- of a northern It half of ,,'4"7ominc-@ -- it doesn really make much difference 3 T.7 a %,-,Iol:lina has been @l-llPs "Poland" -- there are three R!I,Ps to plot over; in the mountains: Colorado, I.,7yoming, and the mountain states THE !IOU',-,4TAIN STATES DR. 1,TcCALL: They have aot a table of staff and a priority croun, and a nriori-tv setting on a nri-oritv basis, they have handled that in a hiah, medium, and low qrouninc, in this application -- which is a good application -- clear and I think it presents a picture of the recion pretty .,7ell. Tllev have had rouion review certification visit and manaae-@ient assessment visits which came out as, I think iorettl;, r,.u ch all "T)luqes" from that rcaion. Assessment of their past performance and accomolish-1; ment has also been prettv aood. 13 21 -Vyt 58 The current proposals seem to be in accord @@7ith their stated objectives and priorities, and I think they are feasible. m .Lhe CIIP there are four A Agencies and seven B r@lgencier, that have to be dealt iiitla by this Regional "-Iilcdical Program, and thev have received in this anplication, comments from all four A t%(4cncies, and four of the seven B 7@gencies are included. The Ida@o 71@ t%cfencv disapproved one of the projects I the ',?Iivsical assessment field -- nurses -- and the B Acfency had neqative conT..cnts on @ibout four nroj(-cts -- but i.@cr(z! no an in Jcpth study or criti-cTuc of t,iose -- it ,.,as just one sentence co@n@%ients. I state that to sav that I don't I-lave anv to evaluate the aualitv of the CliP revie@q and relations',i4-ns therei but these there -- the c:,,,tert of the necative t-,,,.oe col-l@T-@,ontc, @L-'iat !;"Ould nece,. deali-na %.,Titi-i b,, the @j@P -- and from the a-,)-olications, I Tiould -feel r(-,asonz,)ly comfortable, although I %.7ould Learn the Staff to corimt--nt on these if they @.7ould wi-s.@'i to deal ,@7ith the-,i. This anolication contains 27 nrojects. 11 of these Are for continuation, and 16 are new,-- making u-,o in dollars an eleven continuation of about $1.5 million; and the si--.teen new ones, at $640,000 -- the stal'f buduct being some quarter of a million dollars -- the total recuest $2.4 million. 0 244 They intend to applv for asapplement of some $220,000.00 in iulv. I rated this ",70DOve Averaae. THE CITAIP-T.@-:I: Thank vou, Charlie, and Joe. DR. IIESS: T generally concur with that. it is evidence to me that the T)eople i-ilio nut this -ioplication tocTetl-l r thi.nj,. clearl-,7, ly, and are i,7ell organized, and. are concise usinrT a-c oroce0ures. They have atterinted to reach a n,,j r on r i L out and provi@to cood service to all four states, and they hav,--l offices in each of t@ie four states, and seem to have aood @7or'i-.incT relationships .,iith the state governments, and the CTIIP and so on. Just to co.=Lent on ti ,@iat one oroject that @,le have ne-,ative coruTcnts on -- aiven a little priority in the so i think that mav be a result of the C12,,'.T) Tlcvie@,7. I think'the Cl,"@D comments on that narticular one were relevant but that Has taken account of. The onl,,- real (,iur-,stion I had a@.)out bu(Ic-et @.7as the rather larce amount of mone@i qoinq into EIIS from -?.IIP. I liav@, no doul:)t t-'!,at in that area of vast distances and so on that an @','!S system is an important element to aet organized and Qoina. stantial increas in -I!.IP But there has !)ecn a su..) money goiiia into that and I SU'OT.)OSC that it @.7ould be ap,?ro,,oria@-L@ to sort of flaa that as an issue and as]-, then to take a close 245 look at that when thev pet their Qrant a@iard. )R. TI"CCALL: la- @T 7bc, it Tioul.d be aTDproT)riatc-, to have a staff comment on that. DP,. IIESS: Yes, I was going to say, that somethi,,-l,, I meant to point out -- and because of the di-stance, of course@ it miaht well be justified, but vou can't tell. CI'IAIT@L@l: Yes. Some of the -- while a good Dart of this is con'L--inu- ation, sor,-- of that continuation is really e@,.nansion, and it's largely in the E',!S area. Dick, T don't 1-no-.7 whether ,iou .,ould want to cor.=.cn@- on this, or -,,ihe4-"Iier t'ii,-re arc any nolicv issues. I I . nTiTSS@LL: 2@t this point there are no noli-C,17 there r-Io,@s not to ',oc any police,, -but @.,7 (-I ha-,,e flagged this to make doul,)I.,l sure. In terms of the E"S program in the 'fountain St--.-nltes area, all of these -oroarar,.s startc(f@ out l@7it,i assi-str-ince- c"tates in i@-erms of vcr-,7 small contracts. Like, '.Icvada, for instance, started out v,@,,itli ',17,r,),DC. and as a result --,7ou can sec. I.Ilontana, is t,ie same i,.7a-,I. Idalio. So this is one of their big major program we do have some concerns about that larger DR. TIT,SS: This is one of the thincrs that im-,)ressed 246 me about their management teclini(-iticls; and that is that they ,ic contract ii(:-,c@lanis-i as a device for getting thina.,3 used t, dona that they have identified and Perceived as a means and ,-@ave im-mcoiatelv talr(--n the initiative -