I II, II I 'Illi @ i 11 * "I@Qll@iii l@iiii, ICAL PROGRAMS C/LMC DIVISION OF REGIONAL MED AD HOC REVIEW COMMITTEE PANEL "A" 6 7 8 Conference ROOM-G/Hr Parklawn Building, 10 5600 rishers Lane, Rockville, Maryland, 20852, 11 Wednesday,, May 22, 1974. -121 131 - - - 14 PRESIDING: 15 CLEVELAND R. CHAMBLTSS, Acting Deputv Director. 16 PRESENT: 17 MRS. FLORENCE TIYCKOFF DR. PHILIP WHITE 111; DR. WILLIAM VAUN MR. ROBERT TOOMEY 19 MR. JOHN THOMPSON - DR. ROBERT SLATER 20 MRS. JESSE SALAZAR DR. WINSTON MILLER 21 DR. ALEXANDER McPHEDRAN DR. ROBERT CARPENTER 22 2:1 24 ER RLPUKTING CO. INC. lasuchusetis Aveniie, H-E. ICAL PROGRAMS C/Lmc DIVISION OF REGIONAL @IED 2 AD HOC REVIEW COMMITTEE 3 4 5 PANEL "A" 6 7 8 9 conference Room G/H, Parklawn Building,, 5600 Fishers Lane, 10 I Rockville, Maryland, 2OBi52, Wednesdayl May 22, 1974.@ 12 13 14 PRESIDING: 15 CLEVELAND R. CHAM13LTSS, Acting Deputv Director.. 16 PRESENT: 17 MRS. FLORENCE WYCKOFF DR. PHILIP 1,MITE- 18 DR. WILLIAM VAUN MR. ROBERT TOOMEY --i4R. JOHN THOMPSON DR. ROBERT SLATER 20 MRS. JESSE SALAZAR DR. WINSTON MILLER DR. ALEXANDER McPHEDRAN 21 DR. ROBERT CARPENTER 22 2:3 24 2;-j ER RLYURIING CO, INC. lassachusetts Avenue, N.E. . A @Ann) ColiTr.,IITS, qional 17 3Alabama Re. 27 4 Motion for ne-coni@ndalion 5I\r)-,an-3as TteL-r:Lonal ilIncltcal Program 32 43 t!otion for Reco-.@an(lat-ton 7 '51 Bi-v,ta,Le Regional i@(lical Prorjr,@- 8 tlotion for reco"noildatioll .9 Colorado-l-lyominG Be@bion.ll..dical Program 60 10 klotion for Recommendation 77 11 Georgia Regional I-ledical PioGram co 12; Motion for recommendation 87 331 rlorida,ll-ion-cil 1,10 dicai ri,oGrILini 14 notion for recoiniiienCntion in, 15 Dledtc-il lyi,(;i,rtlim In(Jiana II(-,-gional r) Motion for recori",if. 1',Ition 17 I.Icdical- Prorram 'llisconsin Regional .Motion for recomiiien(-lcition. l@ns-,is Regional IliedicLil PrLry,,-iin 21) -ition Motion for fccomin@,n(l, Inter-tlountain Ilegiotial Progr-,Im 22 notion for recorll-.l,:!tifl"41tiorl 2:t Michigan Ilegion,,il rroCI"lm 24 @lotion for rcco,!il,;@,ri, 25 (cont,-Inii,,,(' oti nc,@xL- pace) CO, INC C 0 N T 13 N T S 2 PAGE 3 klisolosippi Regioiial I-ledic',Il Pro 4 klotion for recommendation 192 5 Illinois Region,,ii I."o-dical Pro(;rim I ")3 -A I-lotion for recominencll",tion 215 7 Louiciiana Ilegional I,,Ic(lic,,il P-rogram 21.7 8 n@l a t-. io n motion or recomme 22-( 10 12 13 14 15 17 20 2 1 22 23 P R 0 C E E D I N G S 2,1 all MR. CHAMBLISS: Let me take this opportunity to c 3 Panel "A"to order and welcome you here to this particular 4- work group. 5 -think u should kn that a we get int our yo ow s 0 6 procedures for the next day or so that I will have at my right 7 and at my left two operations Branch chiefs, Mr. Lee Van: 8 Winkle,, who is the operations-chief for the South-Central 9 Operations Branch of@the Division of operations and Develop- 10 men t, and Mr. Mike Posta,-"who is the operations Branch Chief for the Mid-Continent Ooerations Branch. 12 I think the panel should know that we had expecte 13 as Dr."Pahl mentioned,, Mrs. Silsbee to have chaired this panel 14 and it's-.-due-to her illness that I've been asked, just in the' 15 last-few hours, to chair @e panel, Dr. Pahl and 1, as he mentioned, have been looking 17 at other things over the last eighteen months and especially 18 these matters having to do with OMB questions,,With answering questions from the Department dealing with the congressional relations, all the Questions coming from the Congress having 20 21 to do with the phase-out and the status of the program, the inter-agency aspects of operating the program, and both of us 2- have left all but entirely the operational aspect of operating 2;1 the division to Judy, who has, I"might say,, served with great 24 distinction. [ER RLPUKIING CO, INC. chusetts Avenue, N.E. 5 When the annals of RMP are written, she will truly 2 be one of the strong people of Rmp, a great person, a great i 3 lady, a prodigious worker, and a good friend to all of us. .4 Hopefully she will be here while these proceedings 5 are underway, but Mike and Lee will provide me with lateral 6 support, and at the same time we will have support from 7 members of the operations Staff and also a representative from 8 the Grants Management Staff in the person of Mr. Larry Pullen. 9 1 think the committee is well-aware of the fact lo that we are operating under a court order and I will only say 11 one additional thing: Dr. Endicott said that things are a 12 mess; I agree. I will only add my word of wisdom, if you can 13 -call it that, and that is, we have lived in a chaotic c-omu- 14 nity over the past few months and this,, in a way,. culminates some of the trials that we have undergone by reviewing the 15 1(; applications from the regions that came in on May lst,, their application for funding beginning July 1, 174. 17 I think, as we get underway,, you should know we will 18 be operating under the Mission Statement that we all know so well. We are operating under no restrictions as relates to 20 the program activities of the RMPS. 21 And maybe I at this time should call upon Lee 22 Van Hinkle to just set forth in highlight fashion some of the 2.3 review guide procedures that we'll be utilizing. 24 Lee, won't you 2.:-) HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.E. n t' )nnn,) MR. VAN WINKIX: I just primarily want to call your 2 attention to the review guides that you have, and I know that 3 Dr. Pahl said it earlier, but I think it should be repeated that I think this group has to focus on the over-all program 5 of the Region and the proposal as submitted rather than on a 6 technical review of the individual projects, and we do have 7 the criteria listed. 8 I think the only other thing that I want to mention 9 at.all is the review sheet that Vou find attached in there,. 10 We will expect the two reviewers to fill that out and we'll 11 collect those as we go along. 121 DR. MILLER: When do you want them? 13 MR. VAN WINKLE: Sir? 14 DR. MILLER-. When do you want them? 15 MR. VAN WINKLE:. We'll give you time to complete them 17 MR. CHAMBLISS: At the end of each review as we sit j8 here. 19 DR. MILLER: At we sit here? MR. VAN WINKLE: Yes. Before we go to the next 20 21 application, we would like you to fill it out in talking 22 with @liss Leventhal -- and pick it up at that time. 2:1 DR. SLATER: I want to haIve some timd-to rewrite my commentary on those, so I'll get it back to you during this 24 25 session, but it won't be immediately after my oration. HOOVER KLPUKTING CO, INC. 320 Massachusetts Avenue, N.E. 7 MR. CHAMBLISS: Thank you, Lee. 2 I.should mention that, as you have probabl3, noted 3 in some of the background materials, that the focus f the review will, by and large, touch on about eight elements. 5 The first is program leadership; second, program 6 -staff; third, regional advisory group; four, past performance 7 and accomplishments of the region; five, the region's objec- 8 tives and priorities; six, the proposal; seven, feasibility; 9 and eight, and finally, CHP relationship. 10 I think one additional item of procedure may be in 11 order here, and it's a further elaboration on the fo@s for 12. review. Dr. Pahl mentioned that the policy issues would .13 simply be flagged and we would not necessarily attempt to 14 resolve them here; that the target amount should be the principal benchmark for a backdrop for the review. 15 16 Lee has mentioned that the two reviewers will review 17 and the second reviewer will simply add additional comments or 38 observations. We hope to follow the exception principle if we are 20 really going to get through in our appointed time. We also will have Staff c(xluttents as necessary and- 21 required and for each of the regions under review the Staff q2 person handling that particular region will be at the head 2:3 table here. 24 After that, a brief discussion, and we will attempt 2;-p HOOVER RLPORTING CO, INC. 320 Massachusefts Avenue, N.E. 1 at need to b' clarified, to clarify any items or matters th e 2 looking forward to the presenter giving us a recommendation 3 and the rationale for his recommendation, ending up with a 4 motion on that particular recommendation, and frcm there wLw 5 will ask each reviewer to complete the rating sheet as we've 6 touched on. 7 There are ap .plications at the back tablet complete 8 applications on the back table, for each of the reviewers who 9 will need them, and we would simply ask you-as a final matter 10 of procedure, kindlv speak into the microphone so that our 11 recorder can got all of the details. 12, Are there any questions at this moment before we 13 begin to proceed? 14 Dr. Vaun? 15 DR. VAUN: I've heard Lee refer a couple of times to 16 the fact that we're not going to.db a technical review, if I 17 understand what he's saying. However, I'd like to know how 18 we're going to reach a judgment about funding levels unless we address some of the technicalaspects of the programs. 20 on the basis of the guidelines submitted, namely, leadership, past performance, it's going to be very difficult 21 22 to arrive at a funding level. Lee, how do you want us to work this magic if weire 2:1 not going to look at the projects? 24 MR. VAN WINKLE: Well, I think that you do have to 25 HOOVER REFURYIN(I CO,' NC. 320 Massachusetts Avenue, N.E. Washington, D.C. 20002 9 look at the projects because that's a part of the total pro- 2 posal that came in, and if what you see in here is not 3 related to the goals and objectives of that region, then I -4 think you have real cause for concern, and certainly if there 5 are items included in here that are strictly against policy 6 of the Regional medical Program, that also has to come out. 7 But I think you have to look at what they've sub- 8 mitted, the individual pieces; but as to getting into the 9 individual technical aspects of a particular activity that's 10 what we're trying to avoid. 11 DR. VAUN: Okay. 12. MR. VAN WINKLE: The actual makeup of that activity that you're looking at. 13 14 MR. CHAMBLISS: Let me just add one additional piece 15 of information so that we have something of a framework. The panel will have a total of 28 applications to review with a requested amount of $65.5 million. There's one continuation 17 request; there are 23 continuati on and new activity requests; 18 1,) there are 24 additional applications expected from this set of 20 regions in July. 21 Twelve of the regions that you will be reviewing have had -- twelve of the twenty-eight have had new coordi- 9.) nators since the phase-out was announced. There have been 2:3 limited site visits. However, there have been Staff visits to 24 nineteen of the regions in question. Two have had review 2;-w HOOVER REFORTiriG CO, INC. 320 Massachusetts Avenue, N.E. 10 I certifications; six have had management surveys; and twelve 2 others have had technical assistance.visits. 3 So there is a body of intelligence residing in the 4 Staff as to how the regions are functioning and operating., I 5 thought you would like to have that just as a backdrop. 6 MR.- VAN WINKLE: Can I add just one thing? 7 MR. CHAMBLISS: Yes 8 MR. VAN WINKLE: Dr. Vaun, I think what we're seek- 9 ing here is the development of a level of funding and not a 10 funding level level of approval, if you will, not funding 11 level, and the funding level actually will be determined some- 12 where within that level of approval. If you come in, let's say, with a leval of approval 13 14 on one program at $2 million, the actual funding level will be' made up to that figure, it won't exceed it, and it may be less 15 .than that. 16 DR. SLATER: Could I 17 18 MR.. CHAMBLISS: Dr. Slater. DR. SLATER: May I make a point? 1, like you, have been trying to get a grasp on this in comparison to the old 20 21 days and, furthermore, in the light of what Mr. Rubel is talk- 9.) ihg about, and I have the same concern that you have, that while not really examining these projects which are presented 2:1 in variable detail from one region to another, I'm attempting 24 to make some kind of an assessment, really, to give you, in a 2.:-) HOOVER RLPOftTING CO, INC. 320 Massachusetts-Avenue, N.E. sense,, professional backup as to what kind of funding these 2 regions should have. 3 Coming through to my mind all the time is the fact .4 that since we're apparently going through such major changes 5 in the next few years in which RMP will be recast in some way 6 or the other that what we're here to-do, really, is to just 7 I look for the most obvious problems or errors which you as 8 Staff have'to correct in order to justify the expenditure of 9 these funds and that we're not going to varv, really very 10 much from the figures you have here, because the mos 11 important role w e have to Play now in this interim p,riod is 12; to stabilize those staffs out there in order that one has a .13 group of People that are well-trained and indoctrinated to 14 move ahead in some fashion in the years ahead. 15 So I must say I don't have too much difficulty I(; making assessments. I'm having to rely so much on what 17 they've already decided to do there, that I think we're 18 really here just to provide professional extramural moral I!) support more than anything else -- obviously, there Are going 20 to be some holes in that, but, generally speaking, that's how I read it. 21 MR. CHILMBLISS: I assure you we need that, too, but 22 we do need your professional judgment. 2;@ DR. SLATER: I agree. 24 MR. CHAMBLISS: And we need your views and we would 2;-p HOOVER REFURTING CO, INC. 320 Massachusetts Avenue, N.E. 12 like you to work on the exception principle. If there are 2 matters that are exceptions of policy issues, then we would 3 like to have your judgment on them. 4 DR. SLATER: I'm not trying to be soft, but whatI 5 am concerned about is that with the stability of thelstaff and 6 the projects and all they mean out there is perha s the most p 7 1 important element in the survival of the whole pattern of activity that was started eight or ten years ago. 9 MR. CHAMBLISS: Mr. Thompson. 10 MR. THOMPSON: On the interface with kidney, EM 11 emergency medical services, and PSRO, did the Staff through 12! and edit any of these in any way, identify those pr ects that .13 are obviously in conflict with kidney, emergency, and PSRO? 14 MR. CHAMBLISS: We have in fact gone through all the 1.5 requested project activities and have seen -- attempted to 16 determine if there was a conflict with the policies of another 17 program. We have also had discussions with the key staffs of 18 the kidney program, the emergency medical services program, I!) and they will give us-some assistance in these reviews where 20 we find conflicts. 21 A number of these activities, the regions have been into actually before some of the legislation was passed -- 9.) quality assurance, which borders very closely to PSRO, and.so 2;1 on and those activities are )5eing continued. 24 However, in the case of EMS, you should know that it HOOVER REFURTING CO, INC. 320 Massachusetts Avenue, N.E. W2thinotnn DC-20002 13 is a program decision and a matter of statute that the RMPS 2 or no other program will enter into EMS activities so as to 3 build a system of emergency medical care. -4 Our regions have had facets of a system and, theie- 5 fore, with the understanding that we have between EMS and RMP, 6 those activities are permissible for funding under this set of 7 applications, so their basis they are not'designed to 8 produce total systems. 9 MR. THOMPSON: But maybe the problem is that if vou 10 put money into those nobody will ever be able to design a 11 total svstem because those pieces will be out, you can't pick 12. them-up- 13 MR. CHV4BLISS: Well,, at the local level the CHP 14 aaencies have been coordinating to see how the RMP proposal 15 fits into the total need"a@.the local level, so there has been i(i a degree of coordination and cooperation there to make sure 17 that the pieces that we support have sane relevance to what 18 else is going on. MR. THOMPSON: But I detect something in the appli- '20 cations I read$, which, although it is not in direct conflict 21 with the PSRO organization, it is obviously addressed to the 2,-' tactic that hospitals, if they have any brains, have suddenly 23 got to realize that they've got to get their own quality assurance program, optioning (phonetic) subbing it out to a 24 PSRO or do it themselves, and some of these projects are 2;-) HOOVER RLFORIING CO, INC. ,VO Massachusetts Avenue, N.E. 14 asking for money to let hospitals build up their own quality 2 assurance programs so they can eventually do this for PSRO. 3 I object to it for two reasons. one is they should .4 have been paying attention to quality a long time ago --'ail 5 of a sudden they shouldn't have discovered the wheel. But 6 this isn't related to PSRO 7 MR. CHAMBLISS: Indeed it is. As a matter of policy 8 Council policy, we have stated many times that the RMPs could not become involved in PSRO development per se; they could not 10 use their funds for the operational aspects of a PSRO. 11 DR. McPHEDRAN: They could be involved in develop- 12; ment? .13 MR. CHAMBLISS: They could not be involved in the 14 actual development, but that if there were studies, data 15 collection or peripheral.-activities related to quality i(i assurance, that they could be involved in that using RMP funds. 17 MR. VAN WINKLE: I'd like to add-one comment. As j8 far as th e Staff comments you find in here, they have flagged I!) items for your attention, items that they felt were of concern 20 that they wanted to be sure that you looked at. 21 Now they haven't made any recommendation on those 22 to the cri,iiittee. Thevlve left that up to the committee. 2:1 And in looking at the criteria that you're going 24 through as far as leadership, RAG, and all of these items, I want to assure you that the Staff have looked at all of those 2;-) HOOVER REFURTING CO, INC. 320 Massachusetts Avenue, N.E. items, too.. and if you see no ccmmentr it, doesn't mean that (sic) 2 they haven't looked at them and are satisfied with what they 3 see, but if you have any question, we'll be glad to have the 4 Staff respond to it. 5 MR. CRAMBLISS: Mr. Posta. 6 MR. POSTA: I would like to make a ccmnent concern- 7 ing, for instance, EMS activities. Many of our states are 8 making applications to HSA for various EMS activities. Dead- 9 lines in certain areas have been April 15t@h. 10 We have other opportunities in,area research for EMS 11 that are going to be funded by another bureau and we have, 12: from a Staff standpoint, made it clear that whatever we -- meaning RMP, DRMP -- will be funding will be double checked 1 14 with the other agencies to avoid duplication in these type of 15 efforts. 16 MRS. WYCKOFF: Is that what you mean when you list -- 17 well,,- four EMS projects under concerns, that you're going to 18 check them with these other to see if.they should have applied I!) somewhere else? 20 MR. POSTA: Right. And to see also if they're 21 flagged whether or not the amounts of money requested in this 22 application is, in essence, double that of what has been approved for the first six .months of the year. So we do it 2:3 24 both ways. I-le keynote an expansion of an activity moneywise as HOOVElt RLPORIIMG CO, INC. 320 faasuchusetts Avenue, N.E. 16 well as 2 MRS. WYCKOFF: I see. 3 MR. VAN WINKLE: Continuations here aren't of 4 concern in terms of the new legislation. Continuations are 5 not of concern insofar as the new legislation. Only new start- 6 UPS. 7 MR. CHAMBLISS: All right. 'Are there other 8 questions? If not, I think we should begin our review and our 9 listing shows that the first-regional medical program to be- 10 reviewed is Alabama. 11 and Mrs. Salazar, and the The review is by Dr. Vaun 12 Staff person, who is already here at the head table, is Mr. .13 Joe Jewell. 14 will the first reviewer make his or her presentation? 15 17 18 20 21 22 2;3 24 HOOVER REFORIING CO, INC. 320 Massachusetts Avenue, N.E. 17 ALABAMA REGIONAL MEDICAL PROGRAM 2 MRS. SALAZAR: Alabama has always led this parade 3 MR.@-CHAMBLISS: Use the microphone. 4 MRS. SALAZAR: of the reviews, and I'm afraid I 5 fell-into that trap and I may get carried away, but I hope not. 6 The present fundina of the Alabama RMP is $687,000 in the third year of a triennial status, with-the year ending April 30th, for a total of four operational years. 9 The activities that were reported in the application 10 are related to phase-out pursuits,.rescinding of phase-out, 11 reactivation, retooling, in response to the off-again/on-a4ain 12' syndrome that has bedeviled the regions all across the country .13 this past year. 14 In view of this, the Alabama application,. to me, is 15 somewhat astounding froma number of standpoints. 16 First, after the phase-out orders in February of 17 1973 only two projects were approved for partial support and onlv four which were funded through contracts were continued beyond June 30, 1973. 20 Two: the Regional Advisory Council elected to remain 21 intact the RAG is called RAC there -@ it retained its work- 22 ling committees, and, indeed, throughout such troublesome times 2:1 iof adversity it grew in strength and.wisdom, guiding and sup- porting the RMP efforts throughout the region. The RAC has met 24 1 ,four times, reviewed proposals, set priorities, implemented new 2.7i HOOVER RLPUI(LIPG r-0. INC. 320 Massachusetts Avenue, N.E. W2thinuinn 1) C 2OW2 18 by-laws, counseling and opening avenues of communication in 2 their respective geographic areas.of the region. 3 Vacancies that have occurred on the staff have been 4 filled very promptly and attendance at all meetings has 5 averaged better than 66 Y)ercent. 6 There is a nine-member executive board of the RAC. 7 It has met six times, average,attendance at 75 percent. The 8 chairman is a member of the State Health the State Board of 9 Health Department. 10 The third astounding feature of this application, to 11 me, has to do with the ability of the region to seek and 12 obtain local support for twelve out of sixteen of their con- 13 tinuation programs, twenty-one out of the thirty new proposals, 14 Spoken or stated another way, in addition to the $2,648,000 15 they are requesting,, $1,922,000 almost $2 million will i(i be supplied by state, local, and other federal monies. 17 or still another way, 73 percent of this application, 18 will generate other grant-related support, resulting in A total of $4,500,000 for the Alabama RMP is that correct, Joe? 20 MR. JEWELL: That's correct. 21 9.) MRS. SALAZAR: The Review Committee and the EMS Com- mittee have remained active, with the latter forming the 2:3 nucleus of the State Advisory Committee to the Governor and 24 the State Board of Health. 2;-) HOOVER RLPORTING CO, INC. 320 Massachusetts Avenue, N.E. Ml' qnnn,) I 19 The.membership of the RAC is adequately represented 2 by providers and consumers from each of the 10 CHP B agencies 3 and it includes the Director of the State CHP A Agency and a 4 representative complement of health educators and providers, 5 officials, and the like -- there's a mayor, too, as I recall. 6 The University of Alabama in the Birmingham Medical 7 Center serves as the grantee and the present Executive 8 Director of the Alabama RMP is on leave of absence from the 9 university at 100 percent of time. Maximum'resource support 10 from the university is accorded the Regional medical Program. 11 The present Director has had extensive experience 12: with the Alabama -PJ4'-P, having served on its first Regional 13 Advisory Committee in 1967. She has been a member of various 14 committees for about three years, has served as a part-time 15 Associate Director professional She has also been a member of the faculty of the School of Medicine for over 25 years, 17 and for the past twelve years as Assistant and Associate Dean is for Continuing Medical Education'. She is active in medical affairs throughout the state., The Deputy Director has been with the program since 20 October 1970 and the Assistant Director for operations has 21 22 been employed by the Alabama PLIP for seven years. The position of Associate Director for Health Care 2:1 Serviceso which will provide liaison with health providers 24 throughout the region, is open. Recruitment is un erway. HOOVER RLPORTING CO, INC. 320 lAassachusetts Avenue, N.E. Washington, D.C. 2DO02 20 This unit is pursuing PSRO efforts and will provide 2 an appropriate channel for.emerging national health insurance 3 information. 4 An Assistant Director for Multimedia ActivLties And i 5 an evaluator round out the professional staff and bring the 6 total to its approximate prephase-out status. 7 There's a sense of optimism and enthusiasmlthat 8 comes through in this application. It communicates a feeling 9 of confidence in the competency and the wisdom and the motiva- 10 tion of the staff. 11 The region appears to me to be on target in meeting 12 its goals and objectives as revised in 1971 to meet @e chang- 13 ing national and local priorities. 14 It is quite apparent that enormous staff energy went 15 into'creating four of the initial six B Agencies in the state and it is still wielding a great'influence on theemergence.6f 17 the other four. The Director of the CH P A Agency is a-member of RAC 18 and several members of the Area Health Councils are also RAC members. B Agency members frequently attend RAC meetings. 20 There is excellent communication among all groups. 21 22 The endorsement of the Alabama Advisory Council for CHP A Agency is quite guarded, and there are some stated 2;3 24 reservations concerning the duplication in sponsoring agencies, but for the most part these are fairly superficial. 25 HOOVER REFURYING CO, INC. 320 Massachusetts Avenue, N.E. W-thinafnn n r. gnnog 21 As far back as 1967 the Alabama Regional Medical 2 Program proposed in its first planning grant the development 3 of six cormunity-based health education centers to serve 4 regional needs for health manpower education, service, and' continuing education for all health professionals in the 6 region. Eleven programs are now ongoing, coveting all geo- 7 graphic areas of the state, and one it emerging in.the 8 resource-poor southeast section. 9 There is an,exciting program that is entitled I 10 "Project HELP' which emerged from.a tripartite agreement among 11 University of Alabama, Birmingham-Auburn.' and the State Health 12@ Department for health education of the public. It utilizes the services of the Agriculture Extension Service at Auburn 14 University and county agents and councils in every county of 1.5 the state. This program,will receive future funding through i(i state education funds. 17 The present Application, as I said, generates a 18 feeling of optimism in the reader. Cooperative arrangements have been achieved. Staff of -both CHP A and Bs are actively 20 involved in RMP affairs. Projects, both_proposed and ongoing, are timely, relevant, and appear to be viable. They are par- 21 9.) ticularly applicable to the region's@health nee ds, but also in line with national emphases, such as PSRO and quality and cost 2:1 24 controls of the health delivery system4 These are all spoken HOOVER REFOXIING CO, INC. 32OMassachusettsAvenue,N.E. 22 Flor'the July submission the region is preparing 2 additional projects in neonatology and one to develop a rural 3 community health task force. it is significant, I think, to note that the 5 Regional Advisory Council incorporates in its committee 6 structure the CHP B planning agencies. These areawide 7 advisory bodies formulate policy and approve plans pertinent 8 to health issues, not only project proposals from Alabama RMP 9 but others requesting federal and state funds that affect 10 their geographical areas. 11 From the very limited information to be gleaned from 12, the resort on the HRA-T4, I believe it's called,,which is the 13 Equal Employment Opportunity breakout and my previous 14 knowledge of Alabama, it does.appear to me that the Alabama 15 Region has made progressl,in its Equal Employment Opportunity 1(; for minorities, but, I believe, still has a long way to go in 17 achieving adequate representation of these minorities on their 18 committees, particularly in the professional and clerical staff, as well as membership of planning groups and committees at the community level. 20 I'll cite you one example: the Regional Advisory 21 9.) Council membership is fifty-eight, only four of whom are blacks; the total professional staff is sixty-three, with 2:3 24 eight blacks. I will withhold my recommendations, Mr. Chairman, 2;-) HOOVER RLPORTING CO, INC. 320 Massachusetts Avenue, N.E. Wa,.thinoton- D-C, 20002 23 until the other review. 2 MR. CHAMBLISS: Thank you. 3 I will now call upon the second reviewers Dr. Vaun. 4 DR. VAUN: I'm not going to address attention exten- 5 sively to the background because I think Mrs. Salazar has 6 covered that well, and in a discussion that the two of us had 7 initially, we agreed that she-would address the background and 8 I would talk somewhat about the projects. 9 I will start exactly opposite. I will address-first 10 and foremost my recommended level of funding, and then tell 11 you how I arrived at that in analyzing the project. 12! I have recommended that their request of $2,648,439 13 be reduced to $2,028,389 -- this may be backwards? but this is 14 my approach to this one with the background you've gotten on 15 Alabama. I think they've done a good job. I think the 17 projects that they've submitted are congruent with their 38 stated objectives, and I saw one thing that came glaringly 1!) through in the Alabama application, and that is that they gave 20 me a feel for priorities, both from the CHP point of view and 2.1 from the RMP point of view, and I hope this doesn't act to 22 their detriment because it was really a splendid job and it's 2;3 part of the way I arrived at the reduction. Also I arrive4 at the reduction,on the basis of 24 2;-j some experience with like projects and observations about the HOOVER RLPURTING CO, INC. 320 Massachusetts Avenue, N.E. 24 successes of like projects. 2 For the core operation of the Multimedia learning 3 skills, the only reduction in core was $10,000 from that 4 specific aspect of their project and not from project staff 5 itself. 6 From the continuation projects -- and I re lly won't 7 go into the details unless you want me to -- I have arrived 8 at a level of funding reduction.of $107,753. From their 9 $565,005,@ I have come down to $447,,252, and there is@only-one 10 project that I really didn't feel warranted funding it all and 11 that was the No. 82, which is entitled 'Audio-'OisuallAssist- 12 ance in Educating Hypertensives.' 13 I don't know,, I feel that there's so much of this 14 around now that spending $7,000 on it in another,area just 15 doesn"t seem like it was worth the effort4 16 The other $100,000 came from reduction of funding of 17 several of the projects. As I say, I'd be delighted to submit j8 my recommendations to Staff or go over them here, whichever you wish. MR. VAN WINKLE: I think it will probably depend on 20 commendation is. 21 what the final r DR. VAUN: Why don't I go through the rest of them? 22 MR. VAN IIINKLE: All right. 2:3 24 DR. VAUN: From their'new ProJects, they submitted $1,422,440; 1 would recommend a reduction of $492,297 to bring 25 HOOVER RLPUKTING CO, INC. 320 Massachusetts Avenue, N.E. Washinoton. D.C. 20002 25 their new application award to $930,143. 2 I was a little concerned again, although the pro- 3 jects are congruent with their stated objectives -- I think A $11,000 for trophoblastic disease left me a little cool at' 5 this stage of our development; immunofluorescence for renal 6 biopsies in the State of Alabama also left me a little 7 concerned at this point; a rather sizeable sum of money for 8 cervical cancer screenings I reduced substantially. 9 And then the PSRO which was $151,000i and a few odd 10 dollars, thought should be substantially reduced by 11 $100 000. I just didn't feel this was appropriate. 12 So you have my recommendation in the light of Mrs. 13 Salazar's background, and I wonder if that couldn't set the 14 pattern. Don't you think it would be wasteful for both 15 reviewers to spend a great deal of time presenting the back- ground? Couldn't we arrive at some agreement and one person 17 take-one task and the other person take another task and, 18 hopefully, come together on it? MR. CHAMBLISS: Certainly I would await the judgment 20 of this committee on that point. I think it will tend to expedite things. 21 9.) MR. THOMPSON: So moved. 2.@ DR. WHITE: I take exception to it and object, in the sense that many of us have done work already admittedly 24 scanty but it might be somewhat difficult for us to recast HOOVER REFURTING CO, INC. 320 Massachusetts Avenue, N.E. n r- )Ann,) 25 ourselv es in roles which we hadn't been expecting. 2 DR. VAUN: In the light of consultation amongst the 3 two reviewers 4 DR. WHITE: If time permits. 5 DR. VAUN: maybe one would have spent more time 6 on one thing than' the other, they could agree on a presenta- 7 tion@ 8 DR. WHITE: If the two 9 DR. SLATER: Mr. Chairman, I think it's quite easy 10 to draw up background. Anybody can do that. But I think if 11 there has been a fair amount of time spent in looking at the 12 projects and considering them in the terms of the criteria you 13 want, I think the individual reviewers have,to go into this. 14 There won't be that much duplication except as to background 15' history. That seems redundant. MR. CHAMBLISS: I se@'to get a sense from the com- 17 mittee that you would prefer to hold to the original approach. 18 DR. WHITE: I think everybody has to play his own role, and.if you don't like the way I do it, you can holler at 20 me, 21 MRS. WYCKOFF: I tried to follow this thing, wh ci is quite different 9.) MR. CHAMBLISS: You are seemingly suggesting that 2:i we have the clock before us and"we can always call tirqe,.., 24 All right. Can we get a motion, then? 2;-) HOOVER RLPURIING CO, !NC. 320 Massachusetts Avenue, N.E. W.@hi..fnn n r. ?nnn2 27 DR. VAUN: Mrs. Salazar hasn't made her recommenda- 2 tion yet. She was going to withhold her recommendation. 3 MRS. SALAZAR: I defer to you as the principal 4 reviewer. 5 DR. VAUN: Again',, Bob,, I'm new to this. Do I make 6 the motion, or does somebody else? 7 MR. CHAMBLISS: You can make the motion if you 8 choose, Doctor. You've already given us a level of funding 9 that you have recommended and the.rationale for that level.. 10 If you will put that in the form of a motion, the chair will 11 entertain it. 12. DR. VAUN: I will move that the request of the 13 'Alabama Regional Medical Program be reduced from their 14 requested-amount of $2,648,439 to $2,028r389' 15 MR. CHAMBLISS: There's a motion on the floor that the recommended level of funding-for the Alabama Regional 17 Medical Program be placed at $2,O2Op389 DR. VAUN: $2,028,389. MR. CHAMBLISS: $2,028,389. 20 Is there a second? MR. TOOMEY: I second it. 21 MR* CHAMBLISS: It has properly been made and 22 seconded. 2:3 Ts there any discussion on the motion, please? 24 Dr. Miller. HOOVER RLPUKIING CO, INC. 320 Massachusetts Avenue, N.E. W.q-zhino,tnn DC-20002 1 DR. MILLER: To what extent do we need to pay atten- 2 tion to these motions for dollar levels in terms of the 3 relative relationships of the various RMPs on this list? This 4 motion places Alabama at a level that -- does it or does it 5 not -- it exceeds the targeted available funds item, and with- 6 out any consideration to the probability of what their state- 7 ment was, an estimate of $1.1 million application to be sub- 8 mitted in July-. Are you goina to count them out, almost surely 10 from much of anything on July lst by this level at this time? .11 MR. VAN WINKLE: Dr. Miller,, again, this is just an 12, approval level. That's what's being recommended, an approval 13 level. It does not necessarily mean that when it's actually 14 funded that's what it's going to come out to be. DR. MILLER: Could I ask, then another question? 15 What happens if this co@tee ends up with an approval.level 17 of $114 million this time; then you decide who gets what, right? 18 MR VAN WINKLE: I suspect Council will MR. CHAMBLISS: Council will then make its recom- 20 mendations based on the findings of this committee. 21 22 DR. WHITE: I think that's quite appropriate. T e 2;3 fact that someone here has seen fit to suggest that Alabama deserves more would be taken into consideration even though 24 11 @ they may not get that amount they migh get more in 2;) HOOVER BEFURTING CO, INC. 320 Massachusetts Avenue, N.E. Washington, D.C. 20002 l')A')% rAC rtZrIZ 29 proportion than some other region. 2 MR. CHAMBLISS: That's quite true. 3 DR. WHITE: It's simply aguideline. 4 DR. SLATER: I'm just wondering how to deal with' 5 this, too. I wondered how, as Dr. Vaun has, to deal with 6 dollar amounts, and I guess what I'm searching for are guide- 7 lines. I've wondered whether or not we can't find the same 8 problems that you have and indi cate that our guidance is that 9 within the framework of whatever cutbacks you have to mak6. 10 they shall not that they will have to redefine their distri.- 11 bution of funds to exclude the coverage rather than try and 12 set a dollar level at this stage of the game. 13 In other words, I'd rather find fault with the 14 thing, with the specific project, if we get into that degree 15 of detailing, and then leave them with whatever funding level 1(; is ultimately going to be made'possible, but within theIgu3de- 17 lines that they're not to spend money on those particular 18 aspects. MR. CHAMBLISS., That is correct, Doctor. 20 DR. SLATER: That gets us away from dealing with odd 21 dollars, and I don't know whether that satisfies your thinking DR. VAUN: I'm not sure I understand it. 9.) DR. SLATER: Rather than assigning dollar cutbacks 2:1 as you have, identify the concerns that you have and give 24 guidance to the Staff and the recommendation to the Council 2;-) HOOVER REFURTING CO, INC. 320 Massachusetts Avenue, N.E. Washinzton, D.C. 20002 30 that within the framework of whatever dollar cutbacks -- 2 they're asking for a hundred and thirty-six -- there probably 3 is going to be some cutback, but in whatever framework, the .4 money they receive shall not be spent on those particular 5 projects. They have to define how they 6 MR. CHAMBLI SS: Well, I think he's simply been 7 generous in giving us the dollar amounts and where, and we 8 will the Staff will certainly take that into account as 9 this goes through the review process. 10 MR. VAN WINKLE: And we would like Dr. Vaunts 11 written figures details. 12. if you have them, we'd certainly appreciate them. 13 DR. VAUN: Maybe I'd better get clarification of 14 that. Does that mean that if I submit the details that this 15 is a mandatory translation to them where they cannot spend the funds? 17 That's what you were saying. MR. CHAMBLISS: It does not. You have simply, based 18 on your professional judgment, indicated those areas of concern, and they will be passed on through the review process 20 and finally acted upon. 21 9.) DR. VAUN: But it will be up to.the region to decide 2:3 finally'.> MR. CHAMBLISS: Yes. 24 DR. VAUN: Fine. 2;-) HOOVER RLFORTING CO, INC. 320 Massachusetts Avenue, N.E. I., nil qnnn,)I 31 DR. SLATER: Your indication of dollar amount is 2 simply a reflection of your extent of concern. 3 DR. VAUN: Gut feeling. .4 MR. CHAMBLISS: Is there further discussioxi? 5 I'll call the question. Those in favor of the motion, may I have the usual 7 signal of voting? (-Ayes respond.) 9 MR. CHAMBLISS: And those opposed? 10 (No response.) 11 MR. CHAMBLISS: The motion, then, is carri6d, and 12. we have finished our first review. 13 14 15 17 19 20 21 22 2:3 24 2-7) HOOVER REFUNTING CO, INC. 32OMassachu ttsAvenue,N.E. Washin2ton. D. . 20002 32 ARKANSAS REGIONAL MEDICAL PROGRAM 2 MR. CHAMBLISS: In our next region we have,only one 3 reviewer here at the moment. That region is Arkansas. And A we will ask Dr. Carpenter if he will carry the entire load'for 5 that region. 6 Dr. Carpenter. DR. CA"ENTER: Thank you. 8 I'don't have anything like the kind of background on 9 this region that Mrs. Salazar did. My view is that the region 10 has maintained the mechanism of the regional program adequate- -.11 ly. The advisory committee remains intact; the review system 12! remains intact; and that what we have is an application pre- 13 pared by a reduced staff in an appropriately reasonable 14 fashion, but in a depressive time which has forced them to, in 15 the first place, be responsive to a large number of federal 16 initiatives, some of which I donit believe were at their 17 emotional heart. 38 Secondly, they had to respond, obviously, very 10 rapidly and they, in the process, were forced to give up much 20 of the matter of pressing for very detailed program objectives and there's essentially nothing in the application about 21 22 evaluation either of the past program or of the and no suggested specific evaluation of most of the projects. 2:1 24 And,,.so, one has -- as Iread the application, I 25 have the feeling of a regional program which is a bit at sea; HOOVER REFUNTING CO, INC. 320 Massachusetts Avenue, N.E. n i, )nnn,) 33 has no real continuing thrust that can organize Arkansas in 2 any'significant way, though it does have enough thrust to 3 contribute here and there in a kind of stopgap way, which I .4 think most regions are going to have to be content with. 5 1 believe that if I were in Arkansas I would spend 6 the next year trying t-a document -- trying to develop a highly 7 professional staff and document what its effect can be in 8 terms of a detailed project plan. 9 1 have in view the July submission. You can see 10 from your computer printout here that the present funding 11 level is $144 million; that -- as that somewhere,, if we go 12! through with their,projected application, in July we'll be at 13 a level -- which I'm having trouble reading of only 15 per- 14 cent @igher than what might be expected. on the other hand, @15 it would be twice what theylrd now spending. And I just don't believe that they've had an oppor- 17 tunity to organize a coherent program that's twice as large as the one they're presently involved in. 18 So my inclination would be to fund them at about the 20 same level now and if the July application shows progress in 21 terms of more detailed planning, then I think there's an opportunity to provide them with what will, I suspect, be a 22 large enough amount of money for them for the next year. 2:1 So I'd recommend a fuAding level of $1,450,000. 24 MR. CHAMBLISS: At the current annualized level HOOVER REFURYING CO, INC. 320 Massachusetts Avenue, N.E. W..hinatnn n (,. gnnn? I 34 al- MR.- POSTA: Excuse me,, Doctor. That current annu 2 ized level projected over a year for Arkansas is $1,848,000, 3 the first column. 4 DR. CARPENTER: My first column shows a million four, 5 MRS. WYCKOFF: So does mine. 6 DR. WHITE: Do does mine. 7 MR. POSTA: I guess it's the 17th edition. 8 MR. CHAMBLISS: We're working from the May 21st 9 edition. 10 MR. POSTA: I'm sorry about that. 11 MR. CHAMBLISS: Thanks for that presentation. 12 1 would like to ask if Mr. Posta will provide, in 131 the absence of the second reviewer, the committee with any 14 additional information that he chooses on Arkansas. Mike? 15 MR. POSTA: I hdve been associated as operations 17 officer to Arkansas since 1970. The Mid-Continent Operations 18 Branch considered Arkansas to be one of the better programs in the Mid-Continent Operatioos Branch, primarily because of 20 the coordinator who has.just resigned in February. I think that Dr. Carpenter's comments were quite 21 relevant because Dr. Silverblatt has left the State of Arkansas. There is a question of leadership. 2:t However, Mr. Roger Warner has been the evaluator 24 the monitor and evaluation chief of.that particular section 2;-) HOOVER RLPORTING CO, INC. 320 Massachusetts Avenue, N.E. W.@hin-tnn n (' 2flffl7 i 35 and has clone ' good job in this regard and is serving in an a 2 acting capacity now. 3 The Search Committee is in process of selecting 4 another coordinator. Mr. Warner is one candidate. 5 Seven of their top professional people have been on 6 board for about seven years* 7 Now, last year when they came in --.meaning the last 8 Council meeting in November of 173 -- the region responded to 9 the five initiatives which DRMP had sent out to all of the 10 RMPS; that is, "We want to do more in planning; we want to do 11 more in quality care; we'd like to get something going in 12 kidney, EMS, and hypertension." Most of their ap their thrust during .13 _placation -- or 14 that period of time was in these five areas, and in this par- 15 ticular application they,.have what they call an "umbrella concept" within the core staff of ten particular areas where 17 they have maintained.those five original ones that we've men- 18 tioned and brought in position extenders more of a program force, unified health planning and new legislative concepts more in the area of hypertension and a couple of others that I 20 can't recall. 21 Seventeen of the activities are hew; seven are con- 22 tinuing. 2:1 I might refer you to your yellow sheet in the book. 24 I think you all probably have that.' It more or less reflects HOOVER RLPUHTING CO, INC. 320 Massachusetts Avenue, N.E. 36 1 what Dr. Carpenter just mentioned with reference to staff. 2 They have currently on board 16.6 full-time people. They do 3 propose 29.6 in order to do the job that they've set out. 4 I think there's been no problems whatsoever with'the 5 CHP A and B agencies. Arkansas was one of the first regions 6 to have a complete blanketed state with eight CHP funded 7 agencies. 8 The ARMP and the CHPS, along with what we call an 9 "Estes" (phonetic) program, the Experimental Health Delivery 10 System package, have been in operation in Arkansas for about 11 four'years. They have been funded with about $3.4 million of EMS activities from HSA. 12. In this particular application they do have an 13 14 umbralla.concept since the core staff did develop the EMS 15 proposal that was approved by the then-HRA agency. I could go on, 9'ut I--thi'nk I'd better stop. 17 MRS. WYCKOFF: What do you mean by "an umbrella concept"? I see this in a number of these, and I wonder what 18 does that consist of? 20 MR. POSTA: Well, within the total program staff 21 budget, they have said, "we would like to administratively break up our entire program staff into ten areas," and they 22 break out their budget Accordingly, and those ten that I men- 2:1 tioned in hypertension -- they have one on arthritis that I 24 didn't mention each of these people on staff would be 25 HOOVER KLFUKIING CO, INC. 320 Massachusetts Avenue, N.E. W.ehinufnn n r. 7nnfig 37 1 working in these particular activities. 2 Within the application, which does request,$890,000 3 in this total program staff budget, you have about 13 percen 4 of the over-all request in what we used to call a develop-- 5 mental component or, as they call it, contingency funds -- or 6 as some of us would call water. 7 But I might say in all fairness to Arkansas that 8 that is a mechanism of funding, and I dare say that @ll of the! 9 applications you see -have-. certain developmental component 10 funds,listed. MR. CHAMBLISS: All right. I wonder, at the end of this presentationoiif 12 -13 there's a motion for Arkansas, or are there further matters to 14 be discussed? Are.there further questions? DR. WHITE: Their request is for a million eight, 15 16 and that's only $400,000 more than they are getting at the present time. 17 18 DR. CARP@ER: Yes, and they're going to dome in for some more in July. 19 1 think it's very hard to set the funding level. 20 21 For me,, it was very difficult. I If you try to go by you look at the projects and try to see which.one would amount to 22 something. I just don't have any confidence in anything from 2:1 what they've described, and I, obviously, don't think we ought 24 to make it impossible for them to start any projects. I think 2;-) HOOVER REPORTING CO, INC. 'A')D M;izqachusetis Avenue, N.E. 38 1 their core needs to be protected, which I -- and, so, I sort 2 of added a few projects to core. 3 DR. SLATER: The question I'm asking is whether you 4 feel that they need to re-present what they have apparently 5 done ineffectively for the July deadline so that they in fact 6 are going to be coming back for the total amount that they 7 were shooting for? 8 I'm not quite sure what the guidelines are that are 9 associated with your suggestion for a continuation of funding 10 at the Present rate. 11 DR. CARPENTER: I was wondering about that, too. 12@ DR. SLATER: Are they just to be given the money and then permitted to cut back where they see fit? How does this 13 14 help improve their function? I feel the same way you do; I'm at a loss as to how 15 to react to them. 16 MR. VAN WINKLE: It would be too late, though, I 17 think, to amend their July 1 proposal because their RAGs are 0 meeting at the present time on that proposal I think most of them are, aren't they, -Mike? 20 21 MR. POSTA: Yes. They expect about $800,000 new 22 activities to be submitted in that July 1. DR. CARPENTER: Let me comment on that. I think 2:3 0 they do have RAG approval on these -projects, and I -- it's 24 obviously suggesting an enormous am bunt of work in an already 2;; HOOVERREFURIINGCO, INC. 39 1 overburdened staff,, but if I was to be convinced that they 2 could spend more money effectivelyy I would need additional 3 information about their -- the goals and the evaluation .4 systems for the projects that they intend, and I would think 5 it might be interesting to think whether we want to suggest 6 that some region provide that kind of information in view of 7 the difficulty of the rush (phonetic) of the projects. 8 MR. VAN WINKLE: All I was looking at is that 9 Council will be meeting and we cannot relay any information io back to them until after Council meets and their July 1 appli- 11 cation would probably almost be in the mail to us by that time 12 DR. CARPENTER: But presumably -- and this is what 'the key issue is in July if you are not going to do a 13 14 project review and you are going to have only an application that describes projects 15 MR. VAN WINKLE: it'll-be a full-blown map -- 17 DR. CARPENTER: Well,, you see, that gives you -- MR. VAN WINKLE: It'll have to stand on its own. 38 DR. CA RPENTER: Then thatt standing oh its own, 20 could say#, "Hey,, look at all the progress we've made since last time in our project plan." 21 9.) DR. 14HITE: May I ask a questio n. Mr. Chambliss? MR. CHAMBLISS: Dr. white. 2:3 DR. WHITE: This was a highly regarded region at 24 one time; is that correct? 2.:t HOOVER RLPURTING CO, INC. 320 Massachusetts Avenue, N.E. Withinatnrt fir, ?nOO2 39 1 overburdened staff, but if I was to be convinced that they 2 could spend more money effectively? I would need additional 3 information about their -- the goals and the evaluation -4 systems for the projects that they intend, and I would think 5 it might be interesting to think whether we wan t to suggest 6 that some region provide that kind of information in view of 7 the difficulty of the rush (phonetic) of the projects. 8 MR. VAN WINKLE: All I was looking at is that 9 Council will be meeting and we cannot relay any information lo back to them until after Council meets and their July 1 appli- cation would probably almost be in the mail to us by that time 12 DR. CARPENTER: But presumably -- and this is what 13 the key issue is in July if you are not going to do a 1 14 project review and you are going to have only an application. that describes projects 15 MR. VAN WINKLE: It'll-be a full-blown map 17 DR. CARPENTER: Well, you see, that gives you -- 18 MR. VAN WINKLE: It'll have to stand on its own. DR. CARPENTER: Then that, standing oh its own, 20 could say, "Hey, look at all the progress we've made since last time in our project plan." 21 9-3 DR."ATHITE: May I ask a question,, Mr. Chambliss? MR. CHAMBLISS: Dr. White. 2:1 DR. WHITE: This was a highly regarded region at 24 one time; is that correct? 25 HOOVER RLPURTING CO, INC. 320 Massachusetts Avenue, N.E. nr, )nnn,) 40 1 een a hi MR. CHAMBLISS: It has b ghly regarded region@ 2 DR. IIHITE: The question now, Bob, is that@there has 3 been a change of leadership and sane disassembling othings? 4 DR. CARPENTER: You know, it's hard to tel whether 5 there's been a change in leadership or just, no matt r how 6 good your leadership is, this is an impossible SitUaf,.LWLL, and 7 it might be possible to say well, look at this --@I don't 8 know if you'can -- but as I look at the staff, theye@e being 9 asked to do some very difficult things in terms of, irou know, io the details of the sickle cell project, for instance,, and 11 they're not able to do it, and I don't know whether that -- 12 maybe in the past they would have gotten the expert i'se they need from their voluntary groupsi For some reason or another, 13 14 they don't seem to have it now. 15 1 can't tell whether it's the leadership or the time element. 16 DR. SLATER: Your real concern here is not, 1 17 is gather, on a project basis whereby you feel that one wants to cut back there, but some sense that the program isn't as 19 20 strong, that the staff leadership isn't as,strong, and it 21 doesn't satisfy these criteria as well as you would like and, 22 therefore, it should be generaIlly kept at the present level? DR. CARPENTER: Yes; I doubt that the staff can 2:3 enforce high-quality projects of the type suggested. 24 DR. WHITE: That's a reasonable concern. 2;) HOOVER RLFUI(IING CO, INC. 32OMassachusettsAvenue,N.E. 41 1 MR. POSTA: I feel very awkward in defending the 2 region. I really do. I don't think that's my role as Branch 3 Chief, on top of that. 4 DR. SLATE,R: May I speak to that? I think it's very 5 important -- if the Staff have direct contact with the people 6 there and they have a sense of history that we certainly can't 7 pick up from one reading 8 MR. POSTA: I assure you this is not the bpst 9 application that Arkansas has ever submitted, and that's true 10 because 15 days after they got instructions, the coordinator 11 had long departed. 12 However, they do have what I consider a good, small 13 staff. Arkansas has never had a.big staff. We're talking 14 about a state that's forty-ninth in the country as far as 15 average income is concerned, They have limited providers. 16 1 think that just-as an example in this patticu- lar ap 17 plication, for the amount of other sources of support which is included in your conglomerate budget, they have state funds, local funds, and other federal support of $415,000; mainly through the RMP, the EDIS anpl ication was approved and 20 21 plans put into the CHP A agencies were likewise approve They, along with the VA, were instrumental in draft- 22 ing the proposal whereby Arkansas has a state Estes program. 2:@ These folks have been working closely together. The Univer- 24 sity personnel is involved and definitely involved with these 2;-) HOOVER RLPORTING CO, INC. 320 Massachusetts Ayenue, N.E. Wnthinafnn n c 2onn2 42 particular projects that are in the application, including the 2 particular function, such as quality care. They have the 3 nucleus of the program in the form of a contract now going.on 4 which has set the stage for the other eleven bigger or larger 5 hospitals in the state to follow that pattern. 6 The hypertension program which was athrust from 7 us, as of last year they have carried-the ball with that and (sic) 8 have hypertensive programs going on in each of the sta es. 9 They have drastically improved as far as the 10 minority concerns-their Council and review committees have 11 had in the past. I 12, Their turnover of the Regional Advisory Group is .13 almost nil, and I feel that the ARMP,, the Arkansas RMP, is 14 much of a stronger agency when you look around at the CHP and 15 its leadership there and,,the Estes program -- in particular, .16 in the EMS portion that is being funded under Estes. They're looking to ARMP for that leadership and guidance to carry that 17 38 program in the State of Arkansas. Now, that's not to gay how much money they've come 20 in and gotten for cancer -- or have received from the cancer program or the heart program or others. 21 2-1 Now, I'm responding only because of what was said 2:; earlier with the previous region, and you're coming to a decision here. I agree that the token figure of 140 percent 24 it something to shoot for after the may 1 application is HOOVER REFORIING CO, INC. ,VO laassachusetts Avenue, N.E. 43 received, and'i really don't think your recommendation is that 2 far off, but I felt that I needed to defend this region just 3 a little bit more, because we feel, at least at this level,,. 4 that they haven't done that bad a Job. 5 MR..THOMPSON: You see, this comment is now pushing 6 us down to looking at specific projects. This is what worr ies 7 me. 8 MRS. WYCKOFF: And we can't do it. There's not 9 enough information for us to.do it that way. 10 MR. CHAMBLISS: We do not propose to look at speci- 11 fic projects, but simply the program and'the objectives of the 12 program at this particular state. '13 1 would say, based on the presentation from the 14 presenter and Mr. Posta -- I would ask -- I perceive the 15 recommendation that Dr. Carpenter has made with regard to the level of funding. I have heard a number of items of rationale 17 as to why he arrives.at that point, and I'm wondering if I could get,a motion on the floor for your recommendation, Dr. 18 1!) Carpenter. DR. CARPENTER: Well, in view of some of the dis- 20 21 cussion, let me move that we approve $1.5 rhil-lion@.for.Ar%ansas. MR. CHAMBLISS: It has been moved and seconded 22 2:@ MR. VAN WINKLE: No second yet. MR. CHM4BLISS: It has been moved that the level of 24 a million five be recommended for Arkansas. 2;-) HOOVER RLFURIING CO, INC. 320 Massachusetts Avenue, N.E. 44 Is there a second to the motion? 2 DR. VAUN: Second it. 3 MR. CHAMBLISS*- It has been seconded by Dr. Vaun. 4 Is there discussion on the motion? 5 DR. WHITE: I can sympathize with Bob in trying to 6 come up with a figure that's more than he wanted but less than 7 they asked for, but I don't know how we come to that ration- 8 ally. Is there some other alternative to this? Is there some 9 way of saying they deserve to be considered for an increase in 10 monies beyond that which they're currently getting? We would 11 not like to see, them get more than the -- what do they call 12, it? targeted funds, and preferably less. 13 MR. THOMPSON: They didn't ask for the target 14 they only asked for 80 percent of the target. 15 DR. CARPENTER:,.But they'll be up to 115 percent by .the time it's all over. 17 MRS. WYCKOFF: They want $782,000 new. That's a lot 18 of new. DR. SLATER: May I ask a question on this? on the next round that weire going to be sitting on, are the criteria 20 going to be different than this roundi or are we really going 21 to be looking at projects in the old way?. 22 2:3 MR. CHAMBLISS: The criteria will be the same. DR. McPHEDRAN: We will not be looking at projects? 24 2;-) MR. CHA14BLISS: We will just engage in the project HOOVER RLFUKTING CO, INC, 320 Massachusetts Avenue, N.E. 45 I review 2 DR. SLATER: Since this is on the floor, and having 3 known Arkansas in the past, I have to give the benefit of the @4 these situations. I doubt to the staff in Arkansas under 5 think they've been through the mill and if there is a proposal 6 that comes in that looks as if they're a little bit at sea, I 7 don't know what else to do except say, "That's the way our 8 c.ountry operates right now," and I'm inclined to move the 9 money out of here so they can stay alive in their present io state of health or at least their desired state of health, and 11 I'd like to speak in favor of giving them what they ask for. 12 MR. CHAMBLISS: Any further discussion here? DR. CARPENRLTR: I have-obviously thought of that, 13 14 too,, as an approach we can take. I @ve-in the-back of my mind, 15 I guessi something which,.is going to surface repeatedly, and .it might as well surface now. 16 I think that local planning efforts have been slip- 17 shod and we're now moving toward a time when we're going to 18 try to redo the mechanism for local planning, and I believe that one of the messages that has to get back, one of the 20 21 matters which deserves our consideration, is that-you just g-) can't reward low quality planning, and I don't see that -- you know, for instance, as this region begins to choose who its 2:3 leaders will be in the health planning businessi I think they 24 need to choose very talented people-, and I'm not anxious to 25 HOOVER RLFUKIING CO, INC. 320 Massachusetts Avenue, N.E. 46 1 lead them astray. 2 MR. LISS: Is there any further discussion on 3 the motion? ort f m et halfway 4 MRS. SALAZAR: In an attempt to s 0 e Ihe 5 between these two points of View, I would hope that t 6 message that goes back to this region is not punitive in any I 7 way. Certainly the staff must be having a pretty hard time 8 with their strong leadership having disintegratedf and I think 9 they need to be encouraged at this time rather than unished. 10 MRS. WYCKOFF: What about the kidney and the EMS and 11 that sort of thing there? Did you discount those aslthings that should be supplied from other sources? 12 DR. CARPENTER: Well, frankly, I didn't. I don't -- 13 it seems to me that the health planning leaders-hip in an area 14 might well invest some monies in assisting that area to meet i very specific goals of categorical federal programs, so with 17 that philosophy, then, I didn't get -- and from what I heard about our guidelines, I gathered that we could permit some of this. I didn't really -- I can't say I discounted those. MRS. WYCKOFF: What about this arthritis money? 20i MR. THOMPSON: That's separate. 'There.'s a @cial 21 group of people out there (indicating). DR. CARPENTER: Is that a core I think that's 2:1 part of their core activity to assist the region to develop an 24 application for arthritis funds, and develop the regional 25 HOOVER ELPURIING CO, INC. 320 Massachusetts Avenue, N.E. 47 1 system in support of that application. 2 DR. SLATER: I wonder if there's some other alterna- 3 tives available here. We've in the past been able to send .4 messages back. For instance, staff guidance. We've been able 5 to lay out visits if we're concerned -- site visits if we're 6 concerned about providing allocates (phonetic) of money. We 7 have been able to Pass things on -- for instance, hold it over 8 until the next round subject to review by an elite group. 9 Are we under sufficient pressure here to respond to. this one-time allocation? It's a survival matter, and we just 10 11 use our best judgment here? 12 MR. CHAMBLISS: Certainly we're called upon to use our best judgment, but the region will get advice as this 13 whole round of review terminates, and the concerns being 14 expressed here now will be incorporated into the advice letter 15 .going to the region. 17 DR. CARPENTER; I have a question here. When their 18 July application comes in, will it be a request for a certain dollar amount of supplemental funds or will it be a request for 20 a new funding level? MR. CHAMBLISS: It will be for both, You na e 21 in your column "July 1 Estimate" that the region anticipates 22 that it will request a sum approximating $800,000. 2:i MR. THOMPSON: Additionally. 24 MR. CHAMBLISS: That's simply a request. That does 25 HOOVER RLPOHIING co, INC. 320 Massachusetts Avenue, N,E. 4 8 because you know the I not mean that that sum will be awarded, 2 over-all limitations that we have on total funding. All of 3 this will be fitted into the amount of the available dollars ..4 that we have once the final decisions are made by-the court. 5 DR. MILLER: That $800,000 is going to be for a 6 series of projects, new projects, right? 7 MR. CHP14BLISS: Right. 8 DR, MILLER: on what basis are we going to make a 9 decision about awarding Arkansas $800,000 for a bundle of new io projects? 11 MR4 CHAMBLISS: That is only an anticipated figure. 12: That is what DR. MILLER: I don't care whether it's $100 or 14 DR. WHITE: It's going to be on the sam6 amount of 15 concrete evidence-that w have today@. MRS. WYCKOFF: Exactly, DR. SLATER: It seems to me that we're going through 17 18 a problemIwhereby a traditional review committee is having a hard time learning how to opeiFate like a council, and this is 20 in fact what we're being asked to do. We're being given a 21 list of projects we are not able to technically analyze, but we're asked to look at their conherence within the framework o 22 the history of the program and the objectives of RMP. And it 2:1 seems to me that's what the Council used to do, and it may 24 well be that in the future, whatever comes out of tie HOOVER RLPOHIING CO, INC. I?n Mn@qathii.,Ptt,; Avenue. N.E. 49 1 legislation, some other kind of system will have to be put 2 together, but I would guess that we're not going to be able to 3 operate comfortably like a traditional review committee and 4 we are having to look much more at policy and staff security 5 and so on. 6 MR. CHAMBLISS: We share your discomfiture 7 DR. SLATER: I don't know how else to make these 8 decisions. 9 MR. CHAMBLISS: Dr. Vaun? 10 DR. VAUN: As the seconder of the motion, I'd like 11 to reaffirm my second of the motion on the basis of the dis- I1 12, cussion I've just heard. I don't see that this is in any way a hindrance to the group. 13 I think it would be dangerous to give them.more 14 money than the leadership can use At this point, and they have 15 an opportunity to come back again, and if there's going to be a total and complete presentation, if they get a few messages 17 on this round, there's no reason why the discussion can't be different on the next. I don't think this is a punishment or a harm to them.; 20 I think it's a rational decision on the basis of their leader-I 21 ship at this point. 22 MRS. WYCKOFF: Call for the question. 2:1 MR. CHAMBLISS: I would simply ask that those in 2A favor of the motion let it be known by the usual sign. 2;-t HOOVER REPOR I ING CO, INC@ co 1 (Ayes respond.) 2 @IRO CHAMBLISS: Those opposed? 3 (Opposed respond.) .4 MR. LISS: There are two opposed, Dr. Slater 5 and Mr. Thompson. 6 The motion is carried. 7 Did you have further 8 MR. POSTA: I wanted to know what is the official 9 motion? 10 MR. CHAMBLISS: The official motion is that it is ii recommended that the level of funding for the Arkansas 12, Regional medical Program be placed at $1,500,000, with the .13 concerns expressed by the members of the Review Committee 14 going to the region. 1.5 DR. CARPENTER:,. Particularly that they suoport that core. i(i 17 MR. CHAMBLISS: Shall we move then to our next region, Bi-State? qp 20 22 2:1 4 2 HOOVER REFURTING CO, INC. 320 M-,24sac@,,jsettsAvenue, N.E. 1 BI-STATE REGIONAL MEDICAL PROGRAM 2 ey and MR. CHAMBLISS: The reviewers are Mr. Toom 3 Dr. McPhedrant and Mr. Frank Zizlavsky will be the Staff 4 person here to give the necessary support. 5 Mr. Toomey. 6 MR. TOOMEY: I utilized the review 7 THE REPORTER: Ilm sorry, sir, I can't hear you. 8 MR. TOOMEY: for the basis of this discussion. 9 In reading the application I think the first thing that struck me was the microphone was the fact that the 10 Regional Advisory Group disbanded and turned over the respon- 11 sibility for the program to a 15-man executive committee. 12! That 15-man executive committee has functioned. However, as 13 time went on, very recently the,program coordinator himself, 14 15 Dr. Stoneman, resigned, 4nd in the material that was sent I .had, in reading it, a tremendous feeling of frustration on the 17 part of the material that was written. All of the program staff, howeveri seemed in terms 18 of their experience to be an experienced staff. I could look the figures up, but it seems to me at the present time they 20 have somewhere in the neighborhood of eleven program staff; 21 whereas their organizational program would call for about 22 nineteen. In looking at the pas@ performance and the accom- 24 plishment of the Bi-State RMP, it seemed initially in tune 25 HOOV-ER REPUHTING CO, INC. 52 1 with the heart disease, cancer, and stroke programs, although 2 it was affiliated with both WAshington University and St. 31 Louis University and these two universities were the granting .4 agencies. 5 Later in the program the major thrust was in emer- 6 gency medical services. 7 in looking at the even more recent programs, thev 8 have not substantially addresse d the problems of accessibility 9 and availability of care with the exception of the emergency jo medical services, nor have thev addressed themselves to the 11 needs of the minority groups, nor to health delivery systems. 12. In fact, they are in a very, very particularly difficult kind of situation because they're attempting to provide-a program 13 14 for t@e rural Southern Illinois and the urban St. Louis area, and I'm sure that the conflicts in terms of the needs of both 15 these areas are expressed in terms,of the variety of programs. 17 At the present time they are requesting EMS con- tinuation grants, assistance to local planning, including some 18 I!) health manpower planning, quality assurance, manpower recruit- 20 ment for the disadvantaged,, and projects related to dancer and kidney disease. 21 Now, with the exception of the EMS, the projects 22 that they propose do not in fact fall within a document which 2:@ was in this proposal which was calledf "The Health Needs of 24 Bi-State RMP Region as Identified by Joint RMP and CHP 25 HOOVER REFUN1 ING CO, INC. 32OMassachusettsAvenue,N.E. 3 1 Planning Conference." 2 In February RMP and CHP met together and they 3 selected three or four areas that they felt were necessary,for -4 the development of programs within the Bi-State area, a need 5 for improvement o4: emergency medical services -- and that one, 6 of course, they have worked on. 7 Secondly, need to improve accessibility to quality 8 health care. 9 And the third was nee d to improve the availability 10 of trained health manpower for the entire region. 11 And the fourth was need to coordinate health care 12 delivery planning. ..13 Skipping the feasibility for a moment., as far as the 14 funding is concerned my ccmment.here would be that the projectc probablv could be accomplished, but they do not seem to be compatible with the needs expressed in the joint WIP-CHP memo. 17 In terms of their relationship with comprehensive 18 health planning, despite the memo that is in the proposal from RMP, my feeling in reading the comments from CHP -- well, I noted them as being polite but restrained, and very restrain- 20 21 ed. I think I read into it, certainly, that there was not a tremendously happy relationship with that relationship. 2- As for the funding -- you can read this with me 2:1 I did not have it and I am interested in seeing it -- but at 24 the present time the present level of spending annualized is 251' HOOVER RLPURTING CO, INC- N.E. 54 1 $870,000 -- almost $871,000. The targeted available funds, 2 $1,256,000. The May 1 request which I am presently discussing 3 is $1,129,000, but there is a July 1 estimate of $410,000 .4 which places them at a figure in excess of the targeted avdil- 5 able. 6 on the basis of my own review of thisp reading this. 7 material, frankly -- and the feeling that I got from reading 8 the projects and reading the comments and relationships with 9 CHPF it would seem to me to be the unsuitability of the 10 projects in terms of the direction in which I felt RMP was 11 attempting to move itself, 12@ I recommended only $800,000 in funding for this .13 current recommendation. 14 MR. CHAMBLISS: Thank you. We will now call upon our second reviewer, Dr. 15 McPhedran. DR. McPHEDRAN: Mr. Toomey and I both were on what 17 I guess was the latest site visit, formal site visitt to Bi- State, and the program -- this regional medical program we 20 thought at that time had had a lot of difficulties with organization and there was some delay, as I recall, in their 21 2--) getting triennial approval, and I think that was true of 2:3 several other regional medical prog rams, but we were always concerned about leadership in this proc .jram. 24 They had had a great many problems,with-their 2;-) HOOVER RLPUXTING CO, INC. 32OMassachusettsAvenue,N.E. 55 relationships with the medical schools and it was perhaps a 2 blessing in disguise when the medical schools 4ithdrew, but 3 don't really think that the program leadership appears to have 4 entirely gotten -- once they got rid of what was really an' 5 incubus, that is, their relationships with the medical 6 schools, I don't really think.that they got any sort@of 7 coherent direction of their own. 8 And I'm surprised to see that the Regional Advisory 9 Group seems to have relinquished its responsibility --- I'agree I0with Mr. Toomey's assessment of that. I thought that the ii Regional Advisory Group itself was capable of providing 12. stronger leadership than that. 13 In reviewing the projects, I looked at the two new 14 ones sort of as a touchstone for what direction they wanted to 15 take -rather than, I thought, technically reviewing them. I think that the RAG or what was left of the RAG 17 when they met in February with CHP, I think that they felt that the rug was pulled out from under them when no new EMS