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                                           REG:        MEDICAL@PROGRAf4

                                                         COMMITIREE:@

                                                               Rockville.     Mlirylan
                                                              :Thuksday     4  May  1972

                                          ACE - FEDERAL    REPORTERS,   INC.,@

                                                   Official RepQrters,
                                                 415 Second Street, N.E.
                                                                                      Telephone:
                                                  as
                                                 W hingt6n, D. C. 20002.         (Code 202) 547-6222

                                               NATION-WIDE COVERAGE


  @ra-@t/Renzi  I             DEPA.RTI,'X-,NT OF HEALTH,, EDY,@CAI-rION PND T,@TELFAPE
    CR "D876
                2                         PUBLIC HEALTli 'O'ElIN7ICE
   0            3         HEALTH SERVICES AND MENTAL HEALTH ADM@T-NISTRTTION
                4                      REGIONAL MEDICAli PROGRAMS

                5

                6                            Review Committee

                7

                8

                9

                                                      Conference Room GH
               10@                                    Parklawn Building
               11                                     Rockville, Maryland
                                                      Thursday, May 4, 1972
               12
                              The meeting convened at 8:45 o'clock a.m., Dr.
               13
                  William Mayer presiding.
               14
                   Council Members Present:
               15
                              Dr. Gladys Ancrum
               16             Miss Dorothy Anderson
                              Sister Ann Josephine
               17             Dr. Gerald Besson
                              Dr. G@ V.  Brindl.ey
               181            Dr. Effie  0.  Ellis
                              Dr. Joseph Hess
               19             Mr. William   Hilton
                              Dr. John   Kralewski
               20             Dr. William Mayer
                              Mr. Jeanus Parks
               21             Dr. Leonard Scherlis
                              Dr. Alexander M. Schmidt
               22             Dr. Mitchell Spellman
                              Dr. William Thurman
               23             Dr. Philip White

               24

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                                                                                     2

                                                 C 0 N T E N T S

                  2    nda I                                                        a@e
                  3  Coriments by Harold May,,.-yi:i -"Les . . . . . . .0 . . 0 0 * .  .3
                  4  Future Meeting Da tes . . . . . . . . . . . . . . . .      * 0  37
                  5  Comments by Dr. Herb Pahl   . . . . . . . . . . . . . . .       39
                  6Peral Program - Dr. ilinman    . . . . . . . .   4 .    . 0 0 .   69

                  7Consideration of'Appli--ations:
                  8      Oregon . .                                                  94
                  9      Ohio  . . . . . . . . . . . . . . . . . . . . . . .         137
                  10     Northeast Ohio   . . . . . . . . . . . . . . . . . .        167
                  11     Nassau-Suffolk   . . . . . .   0 *  . .      0 *I . a *  *  209
                  12     14ebraska  . . . . . . . . . .                              242

                  13

                  14

                  15

                  16

                  17

                  18

                  19

                  20

                  21

                  22

                  23

                  24

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                                  P R 0 C E E D I N G S
                2          DR. MAYER:  I think we might begin.  As some of you
                3 are aware, there are four of us who will not be with you at
                4 the next meeting.  And I note that all four of us are rigorously
                5 in attendance and on time.  And as a consequence of that, I
                6 thought we might commence and pick up the others as we go

                7 along.
                8          Hopefully, because of the changes that are here and
                9 that we have laboriously worked at and staff has laboriously
                10 worked at, maybe we might be able to get through without workinc
                11 all night tonight and without starting at 7 or so in the
                12 morning but at a reasonable time. '
                13          A great deal has happened since the last meeting of
                14 this committee. Harold kindly did send us an interim report and
                15 try to keep us up to date on it.  I would have to say that MY
                16 grapevine suggests that even since that interim report, a
                17 heck of a lot has happened.  And I thought I understood what
                18 a rapid rate of change was. Harold, but I must admit that I
                19 am developing a now perspective on how rapid that change is

                20 and the degree of that slope.
                21          With that, let me turn it over to Harold.Margulies

                22 for comments.

                23          Harold.
                24          DR. 14ARGULI"@S:  Thank you very much.

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                25          The title of this presentation is "Present Shock.'


                                                                             4

                 I  There are a number of things I would like to go over with you,
                 2 but before I do and at the risk of saying the obvious, I would
                 3 like to comment on the fact that the end of the period of
                 4 activity of the 'Lour,people who have been serving on the
                 5 review committee is a point of real concern for all of  us.
                 6 I was just talking to Bill who confessed to something like,
                 7 six years and six months with the Regional Medical  Program
                 8 which should represent some kind of a badge of honor, purple
                 9 heart, or something of that kind or purple heart for each
                 10 year, but it is going to make a big change.  And it is going
                 11 to be a notable loss when we see these very,, very effective

                 12 people leave the coiami-Ltee.
                 13         And it does not-.xnean,of course, that we won't
                 14 anticipate being able to call on them regularly as we  have
                 15 with others who have served on both committee and  Council.
                 16 And we don't expect to let them leave the program that

                 17 effectively.
                 18          I would like to bring you up to date on a series of
                 19 events which are not necessarily related, but all of  which
                 201 have a heavy impact on our activities and on  the  Regional

                 21 Medical Programs.
                 22          First, let's start with the  current  legislative
                 23 interest which suddenly built into a point of great concern
                 24 and people realized that the Regional Medical Program

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                 25 legislation along with just abotit every major  legislative


                                                                                  5

                  I  program, legislative act, which siippor4,--s progr@-us in Health
                  2 Services;and Mental. Health Aclrainistra-tioii was up for extension
   is             3 during the coming fiscal year.  I think there are at least
                  4 14 major health legislative acts which have to be renewed by

                  5 June 30 of 1973.  Pj4P is one of them.
                  6           1 don't believe that the Administration has estab-
                  7 lished a clear position on the wl-iole range of them,  but  it  has
                  8 made it clear in the first response to Senator Kennedy's
                  9 bill that it hoped to address the legislation this time in a
                  10 much more inter-related  fashion  rather  than  having  a  separate
                  11 extension of Acts which have  come  to  have  a  relationship  with
                  12 one another, but were created at a different point in tiiii-3
                  13 without that relationship clearly spelled out.
                  14          What did happen  is  that  when  Senator  Kennedy  intro-
                  15  duced his bill on Health Maintenance Organizations, he added
                  16 to it for purposes of  opening  the  discussion  the  extension  of
                  17 several of the legislative Acts.  And Title IX for Regional

                  18 Medical Programs was one of them.
                  19          I believe that hearings   are already underway and
                  20 will continue. I don't know  the  format  in  which  they  will  be
                  21 carried out.  There have been discussions inside HEW simply
                  22 leading up to what the legislative  form  of  the  RMP  should  be.
                  23 The coordinators independently have suggested certain legislative
                  24 bases for Regional Medical Programs so that this will have a

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                  25 very clear-cut influence on wha..@ we do in the future.


                                                                           6

                           The issues are all those which you have discussed
                2 here in the review co,-mtittee.  They raise the questions of
                3 how RMP relateds to comprehensive health planning.  They
                4 raise the question of the relationship of the National Medical
                5 Programs to educational activities, to the implementation of
                6 planning, to the categorical devices which have been a part
                7 of P14P since its-beginning, and to a number of other organiza-
                8 tional issues which will probably carry-the debate until well
                9 after the election.  I would be surprised if there is any
                10 final action on our legislation until sometime after the next
                11 Congress meets.  But, of course, it is conceivable it could
                12 be done in the present Congress.  It is conceivable, but very

                13 doubtful.
                14          I also don't know how much the House and Senate
                15 committees are going  to call on other people to provide
                16 testimony.  And it is perfectly possible that if they have
                17 not already, they may ask menibers,of this committee to testify
                181 regarding their recommendation on Regional Medical Programs.
                19          While all that is going on, of course, there are
                20 appropriation acts.  Ile have had hearings before both the
                21 House and the Senate Appropriations Subcommittees.  They have
                22 made every effort this year to complete the appropriations
                23 actions prior to June.  I don't know where the Senate stands
                24 at this point, but the House has completed its actions.

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                251 What now is necessary is for the two chambers separately to
                  I


                                                                            7

                It

                I reach an agreement on what they believ,-- the appropriations
                2 shouldhe to get those through the Fiouse and the Senate,, then

                3 to reconcile any differences'.
                4           The request on the part of the Administration for
                5 PIIP was, as I think we have already indicated at the last
                6 meeting, one which would allow the Regional Medical Programs
                7 to maintain their present level of grant support which is
                8 in the general range of about $98 million.  They indicated
                9 during the testimony before both chambers that there would be
                10 no special funds set aside in the coming fiscal year for
                11 health maintenance-organizations out of the RMP budget and
                12 made it quite plain that the funds used this year for HMOs
                13 were all that they had expected to use out of the RMP

                14 appropriations.
                15          They also indicated that the construction funds which-
                16 we will talk about in a moment for a cancer facility were one-
                17 time funds in the Regional Medical Programs.  And there would
                18 be no further request for construction funds.  They prefer to
                19 keep those under other kinds of administrative authorities,
                20 especially Hill-Burton.  And I would assume some under the new
                21 cancer authority and possibly some under the educational
                22 institution support programs in the NIH.
                23          There was an indication also by the Administration
                24 that they wanted to raise the level of support for emergency

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                25 medical services from the current $8 million to $15 million in


                                                                               8

                I the next fiscal year and that this would be all that would
                2 be requested for special demonstration purposes which  I  will
                3 refer to again in a moment.

                4           There was no real discussion of the Area Health

                5 Education Center concept during the appropriations deliberation!,

                6 but we will talk about that in a moment also.  So that I would

                7 anticipate some'final action on our appropriation level in
                8 the relatively near future which means one would guess by

                9 midsummer which is far better than we had been doing during

              10  the past several years.

              11            Now, there is a word of warning  on  that.  Although

              12  the appropriations action was completed last year by  August#,

              13  there was no final disbursement of funds until well  into  the

              14  well, it wash't-until after the beginning of the  next  fiscal
              15  year.  So completing appropriations action in Congress is not
              16  enough to assure us that we will ]-,now our actual level of

              17  funding. And as you will be hearing, this  has  produced  some

              18, specific problems for us during the present fiscal year,

              19            Now, I have got several other items, but if there

              20  are some questions about that, perhaps I should stop.  That is

              21  really fairly mechanical up to this point.

              22            DR. MYER:  Harold, would you translate the appropria-

              23  tions into dollars for RMP grants?

              24            DR. 14ARGUL). S:  What has happened this year is that

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              25  with the final resolved ion of caryyover and so forth, we ended


                                                                           9

                  up at about $98.3 million for PAP grant support.  And that is

                  what we anticipate for the next fiscal year.

               3            DR. I&YER:  other questions?

               4            DR. SPELLMAN: You said the emergency medical
               5  services grant funds are being increased to $10 million?
               6            DR. MARGULIES:  The emergency medical funds are going
               7  to be increased -from the $8 million of this year to $15 million
               8  next year, but that gets a little bit more uncertain  because
               9  during the discussions of budgetary process, since that money is
               10 being utilized not as an RMP activity but rather as a
               11 HSMHA-wide activity in the current fiscal year and probably will
               12 be next fiscal year, it will very likely drop (3ut of our
               13 budget and become a separate item. So it will not  be  carried
               14 as a part of the RMP budgett but this will not affect the
               15 basic level of grant support for RMPs which will remain at least
               16 constant. This is on the assumption that  the  Administration
               17 recommendations are the same as Congress'. In the  past,  they
               18 have not been.  Congress has regularly increased the level.
               19           DR. BESSON: To what extent does that apply  to  the

               20 current $8 million, that same suggestion that you just

               21 raised about the $15 million being HSMHA funds for  emergency

               22 medical services.

               23           DR.  @IARGULIES:  I will get to that in a moment.
               24 But the question that is raised is how the current $8  million

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               25 for emergency medical services is being handled. And  that  is


                                                                                10

               I  being managed as a HSMIiA-wide emergency medical service
               2  activity with contracts out of the office of the Administrator.

               3  It is not being managed by the Regional Medical Program..
               4             DR. BESSON:  Is PLAPS then not allocating money

               5  separately for EMS activity?
               6             DR. MARGULIES:  I have that on my agenda to discuss.
               7  This is as good a time as any if there are no otlier questions

               8  about that.
               9             All rightt let's talk about the  emergency  medical

               10 systems activities.
               11            When the President indicated in the state of the
               12 Union message and subsequently that he wanted  to  raise  the'
               13 level of investment in emergency medical  systems,  there  was
               14 at the same time a decision made to do this in basically two

               15 ways in HS1411A.
               16            one of them was to develop some major emergency
               17 medical systems demonstration activities with the emphasis
               1 8on it being a total system and to do this in such a manner
               19 that the various emergency activities which are fairly
               20 widespread in IISMIIA could be well coordinated at one  point.
               21            There is, for example, in NIMli suicide prevention and
               22 crises intervention emergency activities, maternal and child
               23 health services, general pediatric and poison control centers.
                 iThere is a Division of Emergency Medical  Services  in  HSMHA,
               24
  Ace-Fedetal Reportets,  Inc. etc., a whole range of emergency activities. In order to bring
               25


               I   the full effectiveness of these together and to produce some
               2@  major demonstrations, what was established was a central
               3   coordinating group which includes Regional Medical Programs.
               4   And I sit on the general group and on the small executive
               5   body which decides the basic management and contract processes

               6   for these activities.
               7            The determination, thent was that there should be
               8   in this fiscal year five major demonstration activities which
               9   would be funded by contract.  And these contracts were invited
               10  in a request for a proposal which went out sometime ago which
               11  had an initial deadline of April 15, then extended to April 21.
               12  So that all of the proposals arc@, now in and are Linder review.
               13  That is a discrete separate a,ctivitv.
               14           I would assume that next fiscal year, if there is
               15  another $15 million added to the funds available that it would
               16  be carried out in essentially this fashion, but would allow
               17  us to also at the same time establish a centralized data
               18  gathering and evaluation activity which the initial investment
               19  is probably only going to gtt started rather than fully

               go  develop,
                            At the same time,, it was felt that all of the existinc
               21
               22  emergency activities in RMP and in the other proSrams should
               23  be continued, but in such a way that they were consistent with
               24  and whenever convenient supplementary to the major contract
  Ace-Federal Reporters,  Inc. demonstration programs so that we did in RMP, to make sure
               25


                                                                            12

                It

                1 that these demonstrations did not simply  be  demonstrations

                2 with no effect, which is too often the case, initiate and
                3 encourage the development of emergency medical activities
                4 to the RMPs as a ser-.@arate grant activity eligible for
                5 supplementary grant award. And we have done  that.  And  so  the
                  Regional 14edical Programs have received and are  responding
                7 to a description of a well-coordinated total  emergency  medical
                8 service to be supported by grants vihich,is complementary to
                9 the contract activity.  And in fact, we exchange day to day,,
                10 data between what we are doing in grants and what we  are  doing
                11 in contracts with the hope that when the whole thing has been
                12 completed, we will have a total body of knowledge and of

                13 action which is effective in order to carry out  that  emergency

                14 medical activity.  As I think-you know, we have set up a
                15 separate special review body which is going to look  at  the
                6 responses to our invitation to  submit  supplementary  grant

                7 requests.

                18           DR. MAYER:  This is within RMP?
                19           DR.  MARGULIES-.  This is within RMP.
                20           DR. MAYER:  And separate from the contract?
                21           DR. MARGULIES: Quite distinct and separate  from  the
                22 contract.  The contract activity is another issue entirely.
                23           In order to give enough time to the RMPs to
                241 respond and to develop something %,Yhich is meaningful, we have
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                25 given them a fairly tight, but reasonably broad period of  time


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                I  in which to work.  The grant requests, applications, are
                2 at the present time all in.  They reach a fairly formidable
                3 level, and they will have to be reviewed on may 15.
                4           hhat we have done, in order to set up an effective

                5 review mechanism for a kind of special action, was to ask

                6 Dr. Besson, Dr. Toomey, Dr. Scherlis, who will act as
                7 chairman from the review committee, Dr. MdPhedran and Dr.'Roth
                8 from the Council to act together for these two bodies and  'for
                9 the RMPS in making a review of the E,,nergency Medical
                10 Systems grants requests.  When that occurs, we will g ve
                11 them full information regarding the status of the contract
                12 proposals so there is no confusionIbetween the --wo.  And He
                13 will try to keep then, as discrete as possible.
                14          We would anticipate that the Emergency Medical
                15 systems activities would continue beyond this year.  We have
                16 not set aside a specific sum for that purpose, and I  will  get
                17 into the funding aspects a little bit later.  But you might
                18 want to ask further  questions about the Emergency Medical

                19 Systems.
                20          DR. SPEI,Ll4AN:  When you say that the grant awards

                21 will complement
                22          DR. MAYER: Mitch, could you use the speaker?
                23          DR. SPELLMAN: My qnestion is  in  making  one  of'the
                24 qualifications of grant awards for Emergency Medical  Services

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                25 projects funded by RMPS, does this mean then that the grant


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                It

               I  awards are in effect supplements of cont-actse or does the
               2  coaplerentary process occur in a way in which the contract
               3  and grant awards are two different things, different

               4  institutions or entities?
               5            DR,  MARGULIES:  It is complementary in a conceptual
               6  sense.  What we are saying is we don't want to develop
               7  contract activity which would represent a total approach  to
               8  a system and have some grant awards which have a piece of
               9  equipment here and training program there. We want  both  of
               10 them to represent an effective approach to organizing a  total
               11 emergency system.  But with the RMP activities, I think we
               12 have some laterality which may not be true of the  contracts
               13 because we are dealing with a Regional @ledical Program in that

               14 case,
               15           Being very specific, if a contract is awarded,
               16 contract this time is awarded, for an Emergency Medical System
               17 to a unit of government in a community, it will be with  the
               18 understanding that this is a very time-limited and  emergency-
               19 related activity. It has to do with the moment at  which  an
               20 emergency is identified until the point of resolution of  what
               21 you do with that emergency in the emergency room or  whatever.
               22 And beyond thatl the contract activity doesn't apply.
               23           It doesn't. for example, go to in-hospital
               24 emergencies, to referral activities.  It has to be that
  kce- Federal Reporters,  Inc. discrete.
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                            We will be interested in @,e Regional Medical
                2 Programs in this being more tlii n an EMS carryout effectively,

                3 but in addition to that being something which has an
                4 influence on the rest of what that RMP does and on the rest  of
                5 the system which is around it such as the other  ambulatory
                6 care, the referral services. And, of course, with  our  special
                7 interests in heart disease and in stroke, we would be
                8 particularly sensitive to how effectively they include competence

                9 to deal with acute infections, acute strokes and so on.
                10          DR. 14AYER:  Two questions, Harold.  One is you are
                11 talking next year in terms of that move from $8 to'$15  million
                12 of the operation being there to start to develop centralized
                13 information. Is it the intent to expand on  those  original
                14 five contracts, to extend it to more or to expand on  those
                15 original five?  What is the intent in terms of next year?
                16          DR.  14ARGULZES:  It is to expand it to more new
                17 contracts, I am quite sure, because I believe what we will do
                181 -- and this depends in part on the demand -- I just looked@at
                19 some of the contract reports, submissions, yesterday --  is
                20 contract in such a way that we obligate funds which will  carry
                21 them over the full period of the tliree-year contract so that
                22 they will be full funded contracts and the ones which we
                23 would be looking at in the next round, therefore, would  be

                24 new contracts.

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                25          DR. 14AYER:  Jercy.


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                            DR. BES-C)N:  Yiaybe I can ask any question in a
               2@ different way.  How much ,noney would you anticipate would be
               3  allowed for the five contracts?

               4            DR. MARGULIES:  The five contracts will for the most

               5  part consume the $8 million.
               6            DR. BESSON:  Thent the moneys pertinent for RMPS-EMS

               7  are outside of anything in --

               8            DR. MARGULIES:  Yes, they are separate.
               9            DR. BESSON: And the only reason they are  not  being
               10 considered by this committee is because of the lateness of

               11 submission of the grant proposals.
               12           DR. IIARGULIES: We have the same problem with  those
               13 and with the community education activities which I can get to

               14 in a moment also.
                            DR. BESSON:  You previously have spoken of RMPS
               151
               16 money as maybe not being allocated, but somewhat sequestered
               17 for kidney activities or other activities.  Is there any
               18 thought in RMPS about how much of the --
               19           DR. MAYER:  Can you hear him in the back?
               20           They can't hear you, Jerry.
               21           DR. BESSON: Is there any thought in RMPS as  to  how
                  much money would be allotted from RMPS funds for other
               22
               23 activities?
               24           DR. MARGULIES: There is some thought about  it,  and
  ,%ce-Federal Reporters,  Inc. I will get back to that, Jerry, but it is wrapped up in several
               25


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                I  things in our final 4'undi.ng level and the change in our
                2 review cycle which is not too complex, but it is interlaced.
                3 And I would rather go over it all at one tine, I  think  it

                4 would be clearer.
                5           DR. BESSON:  Well, perhaps I can indicate why I am
                6 a@king the question.  In describing the five contracts vihi.ch
                7 are going to be let for what you refer to as broad  systems
                8 for Bmergency Medical Services contracts, the way RMPS would
                9 approach it, the implication is that we are interested in
                10 finding out on a demonstration basis how to organize geographic
                11 areas for the provision of a total system.  But IOIPS has
                12 served a somewhat different functio@i historically in relating
                13 to the various health institutions in a community.  And I am
                14 wondering whether it might not be a more appropriate stance for
                15 RMPS's interest in EMS, rather than fund:-demonstration
                16 programs to fund what I might call seedlings and spread 4-ts
                17 moneys as wide as possible rather than concentrating them on
                18 single large, grandiose activities.
                19          This is peripheral to the review coimittee's
                20 activities, but since I have been immersed in the 60 pounds of
                21 reading material I received the other day, I have become very
                22 much aware of PJAPS's emerging role in EMS. And I  wondered
                  whether it might not be appropriate that we give consideration
                23
                24 to being very lenient in funding some of these 35 proposals
  A,ce-Federal Reporters,  Inc. that are being received from the point of view of encouraging
                25


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                  the development of E14S thinking and development of F14S
                2 activities without necessarily following the straight criteria
                3 that we have laid out in the past for grant requests, hewing
                4 very closely to a certain set of criteria and either being very
                5 meritorious and therefore having priority or being somewhat

                6 lower merit and therefore being passed over.
                7          I am just wondering as to how we can most effectively
                8 spend whatever dollars P14PS considers they are going to allot
                9 to this aspect of their new activity.
                10         DR. 14AYER:  Harold, would you care to comment on that'
                11         DR. 14ARGULIES:  Well, I don't think you need feel
                12 bound by the size, the scale, the specific requirements of the
                13 contract activities, Jerry.  We would anticipate- there would
                14 be a fair range of potentialities in the grant requests.  And
                15 what we are really talking about is the avoidance of funds
                16 expended for unifocal interests like training 16 ambulance
                17 drivers when there isn't anything for them to drive or heavy
                181 investments in radio equipment when there isn't anybody at
                19 the other end.  That is really what I am talking about.
                20          1 think in looking at requests for grant awards in
                21 the PJ4P, one merely needs to make sure there is quality or
                22 potential for quality.  And it doesn't have the same kind of
                23 rigidity that the demonstration does.  But at the same time,
                24 we are hoping it represents a method of pulling the system
  kce- Federal Reporters,  Inc. together rather than dealing with only one segment of it. And
                25


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                I  that is really the only issue.

                2           DR. YJAYER:  Additional comments on EMS?

                3           (No response.)
                4           Vihat would be the intent next year in terms of MAP

                5 activity in EMS?
                6           DR. MARGULIES:  I think this is going to depend
                7 pretty much on the total influence  of the current round.
                8 And there are really three things involved.

                9           one is our general appropriation level.
                10          The second is the f@,nal decision on what will be
                11 done with the additional emergency medical activities in the

                12 $15 million zone.
                13          And the third will be some judgment about how ready
                14 we are to do more emergency activities.
                15          1 told you I thought the $15 million would go in
                16 that direction, Bill, but it really hasn't been formalized yet.
                17 It is perfectly psssible the role of P14P in the EMS activity
                18 will be redefined either by legislation or by something else
                19 during the coming year.  But assuming everything I have said
                20 is true, I would anticipate we would continue to show a high
                21 level of interest in the support of Bmergency Medical System
                22 activities in the next fiscal year as well.
                23          DR. MAYER:  Under RMP?

                24          DR.MARGULIES:  Yes.

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                25          DR. MAYER:  Under separate kind of review effort?


                                                                                   20

                 1            DR. MARGULIES:  Not we wouldn't do it separately
                 2  because this was a matter of duress.  At that point, we could

                 3  enfold it into the regular review system.

                                                         is an importan@ concept for
                 4            DR. MAYER:  I think that
                 5  this committee because it is the bits and pieces issue.
                 61 Slowly but surely you dissect everything off.
                 7            DR. MA:RGULIES:  Well, let me deal with that issue now,
                 8            DR. MAYER:  Before you do, let me make a comment@as
                 9  someone who is absolutely and irrevocably addicted to
                 10 nicotine that as all of you are aware, the Secretary of this
                 11 superb organization known as HEW has indicated a mandate which
                 12 has come on down through t,',iiz-. T think everyone is on tl-iej.Lr
                 13 own in relationship to wheth(zr,they feel the lightning bolt
                 14 coming down from downtown or not in regard to that issue.
                 15           I say that in preface to I have already made by
                 16 decision.  I want to leave tomorrow, not today.
                 17           DR. MARGULIES:  That statement is part of the
                 18 confidentiality of the meeting.
                 19           I think it might be easier for us to deal with the
                 20 budgetary issues because they keep coming up rather than with
                 21 such things as the area health education center concept.  What
                 22 has happened in this fiscal year has been the appearance of
                 231 a funding pattern which might  have embarrassed us badly, having
                 24 us reach the  end of the fiscal ,rear with more money than we had
  %ce-Fedefat Repoftets,  Inc. anticipated and no way to spend it or the appearance of that
                 25


                                                                             21

               I amount of money with us very well ready to spend it as  we  are

               2  or no additional money whatsoever which might yet occur.

               3            Now, in that range of possibilities here is  about

               4  what happened:  We did not get a clear statement about our
               5  total funds for this current fiscal year until after the end
               6  of  January.  Even when we had received that information, there
               7  was uncertainty about the funds which would be spent for Health
               8  Maintenance organizations,, some $16.2 million, and the funds

               9  which were set aside for Area Health Education %--enters, some

               10 $7.5 million.
               11           Furthermore, the $8 million which had been identified
               12 for Emergency Medical Services Systems had not yet been  set
               li aside as they are now as I described to you for contract
               14 activities.  And so we had this range of uncertainties.
               15           There was from the preceding fiscal year, you  may
               16 recall, approximately $44.5 million which was not released  in
               17 that fiscal year which we had been promised would be  released
               18 in this fiscal year.  It was released, but only in part.
               19 So we got to about.March knowing that there were several
               20 possibilities which gave us a range of difference in the month
               21 of JUne which is turning out to be true of about $22.5 million

               22 uncertainty.
               23           Well, with $22.5 million uncertainty and the
               24 desire to be able to use it effectively, you have  to  develop
  @ce- Federal Reporters,  Inc. some footwork. And so we developed some footwork. This
               25


                                                                            22

                It

                I  included the decision to support Emergency Medical Systems,
                2 decided on rather late when it became clear how the other

                3 EMS activities would be, that we would decide educational

                4 activities which were like, but not the same-as, an Area
                5 Health Education Center which had to be decided late for  other
                6 reasons which I will get back to, and we would at the same
                7 time to cover our potentialities decide now to change the
                8 review cycle from 4 to 3 a year.  That became the pivotal@-
                9 point in the whole budgetary romance because ;what we  had  to
                10 do was to make a decision to go from 4 to 3 a year, thereby
                11 change fiscal yearsf and thereby give us the opportunity to
                12 use funds either in fiscal '72 or 173 according to what we
                13 had available and in the process of doing that anticipate  the
                141 level of commitment for fiscal 173 and 174 so we didn't  over-

                15 extend ourselves.
                16          Added to that was the uncertainty of whether the  HMO
                17 funds would actually be totally used. And as time goes  ono  it
                18 appears to me personally more and more likely that they will
                19 not be totally used.  So this adds some more potential fLunds

                20 to the program.
                21          While all this was going on, the $7.5 million  which
                22 had been set aside for Area Health Education Centers was
                23 kept back and remains back. So we still have  the  uncertainty
                24 of whether we will have available $7.5 million for  educational

  %ce-Fedecal  Reporters,  Inc.
                25 activities, whether some of the HMO money will be returned to u


                                                                              23

                  and whether we will have funds available at  varying  levels,
                  depending upon the grant requests from the  Regional  Medical

               3  Programs in fiscal 172.
               4            What we decided on is a rather simple  maneuver  to
               5  give ourselves maximum flexibility.  And the way it is going to
               6  work out, we will be able -to expand all our funds no  matter
               7  what the decisions are.  We extended the fiscal years of each
               8  of the programs in this review cycle, but we did not give
               9  them grant awards to cover the whole period of  time.  So  if
               10 an Rmp went from 12 months to 16 months, the  grant award was
               11 for 12 months.  And what we told them was, "Show us what your
               12 rquirements are for the full 16 months. And  if  you  require
               13 X level, you can be assured of getting that if that is an
               14 appropriate level. But we can decide  with  you  whether  you
               15 need it this fiscal year or next  fiscal  year."  That  meant that

               16 in the majority of the program
               17           DR. MAYER:  In terms of  release, Harold.
               18           DR. 14ARGULIES:  In terms of release, yes.-
               19           It covers the same period of time, but  this  meant
               20 that up to June 30, we had a liability just  in  grant  award
               21  for basic RMPs of something in the range of $8 million which
               22 could go in one fiscal year or the other and produce the same
               23 result.  This is the only year we will ever be able to do that,
               24 but it is also the year in which the uncertainties appear to

  Ace -Federal Reporters,  Inc.
               25 be maximal.
                  I


                                                                            2 4.

                            That last statement, don't believe that for a mor@tent,

                2 but the flexibility is maximal.

                3           (Laughter.)
                4           So we are really trying to play these varying kinds

                5 of games.
                6           If you say in the middle of that, "Exactly how much
                7 is it you are going to have for EMS and how much for  educational
                8 activities," I can just add to the fringe of interest by
                9 telling you about what we are thinking about.  We hope that we
                10 can talk-in the educational activities in the general range
                11 of about $3 million.  And in the EMS, we have had a greater
                12 level of  uncertainty because it has been awfully hard to
                13 predict what might actually come in.  But I would not be
                14 surprised to see us working in the same general range for the

                15 Emergency Medical Systems.
                16          Now, this depends on an action which may be taking
                17 place today, I am not sure. Part of it does.  And  that  is  that
                181 we have gone through, and I will have to complete this,  Bill  --
                19 I am sorry that this gets complex, but, damn it, all of it is
                20 complex.  It has been like that.  We have gone through an-
                21 interesting tango -- you can't tango with four partners
                22 we have gone through an interesting square dance on the Area
                23 Health Education Center activity trying to decide who does
                24 what.  And it has at least reached a point of some definition.

  Ace - Federal Reporters,  Inc.
                25 And that is that in the opinion of the office of  Management  and


                                                                               25

                  budget and of the Office of the  Secretary,  something  called

               2  an Area Health Education Cento-i: is related to the  Carnegie

               3  Commission model which is essentially  an  activity  conducted

               4  primarily under the auspices of a  university  health  science

               5  center with the Area Health Ed,-ication Center  a  satellite

               6  thereof. And this with some  embellishments  is  the  concept.

               7            The essential ingredient is the  extension  of  the

               8  energies and interests of the university health science
               9  center.  That is not exactly what the Carnegie Commission report

               10 said.  It has become the general concept in the JWIA and the

               11 article by Margaret Gordon and in the office of the Secretary.
               12 ODIB and I believe the Office of the Secretary feel that that

               13 is fit for NIH Bureau of Education and 14anpower Training to do,

               14 not for HSYIIA RMP.
               15           There was in the middle of this discussion of Area
               16 Health Education circulated in among other  places  what  is
               17 known as the blue sheet a statement which  said  that  General
               18 Counsel opinion deleted RMP from educational activities.  That
               19 was in error.    There had been at that time no General Coiinsel
               20 opinion submitted to anybody. There  had  been  some  grants which
               21 were incomplete and which we asked them  to  complete  at  a

               22 later date.
               23            The General Counsel opinion on educational activities
               24 for R-?4P is quite clear-cut. it says that under  910(c),  we

  kce -Federal Reporters,  Inc.
               25 can indeed conduct educational activities which  need  not  be
                 I


                                                                                26

                1  confined to the categories v@,liich are concerned with improving
                2  the utilization of manpower,, expanding their capacityf but they
                3  added the comment that they fel.t clear that RI,4P should not be
                4  involved through 910(c) in the support of training activities
                5  iihich essentially changed the unskilled into skilled.
                6            And to be definite about it, they said such as
                7  training a high school graduate to be an RN,  paying  for  that
                8  or paying for the stipends or faculty for medical students and
                9  so on, and that we were concerned with tl-ie community activity
                10 which linked education to service. And  they  are  quite  com-

                11 fortable with that differentiation.
                12           Since that is basically the policy under vthich  IUIP

                13 has been operating for some time and causes us  no  concern  --
                14           DR. MAYER: Since the  beginning,  Harold.  CC  and  I
                15 wrote those exact same guidelines five years ago.
                16           DR. MARGULIES: This  is  buttressed,  then,  by  the
                17 General Counsel opinion, so we have no problems over it.
                18 So what we had done without any of these decisions having been
                19 made and without any General Counsel opinion is to run the risk
                20 of circulating to the Regional Medical Programs the description
                21 of a program community based education activity  to  which  we
                22 invited their attention and for which we are going to provide
                23 supplementary grant awards.  This is parallel to the Emergency

                24 Medical System activity.

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                25           We could not put this out with any term.  that  said


                                                                              27

               I  "Area Health l@,ducation Center.ft  lqe were not even sure at
               21 that point anyone would allovi us to do it because this fall's
               3  draft opinion was floating around.  But anyway, we did it.
               4  And this meant we had to wait until the last minute,  hoping  to
               5  get some clarification.  We got no clarification so we went
               6  ahead and circulated throughout the country a description of vihzt
               7  we meant by some-kind of a community-based educational and
               8  service consortium. This has led to a careful  review  by  the

               9  RMPS.

               10           Ile do now have in hand a number of submissions  for
               11 grant awards. They will be reviewed on May 20  to  21  because
               12 some of them are still coming in from both Emergencies and
               13 Area Health Education Centers.  And the ones involved in that
               14 review process which will be carried out at the same  time  as
               15 the Allied Health Conference from the review committee  will  be
               16 Hilton, Anderson, Kerr, and Hess, with Perry as chairman,
               17 and from the Council Tony Komaroff and Bob Ogden.  And  we  have
               18 asked Al Popma formerly on the Council, former RMP coordinator,
               19 to join the group so that we will be taking a review action
               20 en bloc on these educational activities at that time.
               21           There was justno mechanism by which we  could  conduct
               22 this under an orderly review process. And as  one  more  feature
               23 to it, it is likely --  Well, let me stop at this point because
               24 the additional feature gets complicated.  The rest of it has been

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               251@ easy.


                                                                             2  8

                             Leonard.

               2             DR. SCliERLIS:  Have yo u distributed to  the  members

               3  of this committee the same information you sent out to the
               4  various regions as far as their coming in for EMS or these

               5  educational centers?

               6             DR. MARGULIES:  Yes.

               7             DR. SCQERLIS:  We had that?

               8             DR. MAYER:  No.

               9             DR.  MARGULIES:  Didn't this go to review committee?
               10            I am sorry, it should have gone to review committee.
               11 I thought  it went to review committee and  Council.  That  was

               12 an error on ou-- pa--t, then.

               13            DR. SCHERLIS:  Perhaps we can have those.

               14            DR. MARGULIES:  We can get them to you today.

               15            DR. SCHERLIS:  Fine.
               16            DR. MARGULIES:  Let me add one more feature to it
               17 which gives you an idea of some of the  special  procedures  we
               18 have to carry out regarding these two categories of interest,
               19 the Area Education Service one and the EMS.  If  we  get  funds
               20 released yet this fiscal year, and I think it is likely, which
               21 the office of Management and Budget does not intend to have
               22 in continuing appropriations, we will have to provide evidence
               23 that that money can be spent to support activities in RMP
               24 without raising the level of commitment to individual programs.

  kce-Fedeial Reportefs,  Inc.
               25            Now, that can be done,  It can be done if we handle


                                                                               29

               I for one clioice the EMS activity as a discrete  activity  in  a

               2  program.  If the program coires in and says,, "We have a  well

               3  knit Emergency Medical System activitity, it will take three

               4  years to complete, it will cost X amount of  money,,"  we  can

               5  award a grant based upon their total  needs  for  three  years

               6  and reach an agreement for them to carry that  as  a  separate

               7  item in their budget.  At the end of those three years, that

               8  activity will-have been completed and will not be part of

               9  their basic commitment.

               10            I think that the Office of Management and Budget will

               11 accept that procedure.

               12            DR. tl).AYER: WI-&th the convaitment, how,@ver, for the

               13 three years coining out of -- let us assume $3 million -- that

               14 original $3 million.

               15            DR. MARGULIES-. That's  right.  It  is  essentially

               16 forward funding for the line item in their own budget.

               17            DR. MAYER:  In other words, the corrlmitment that would

               ]Bi be made, let us say.

               19            DR. M,-kRGULIES:  We would release all the funds now.

               20            DR. MAYER:  There would be only a million dollars of

               21 annualized commitment that would be made at this time, is that

               22 what you are saying?
               23            DR. MARGULIES:  Yes, we would release the $3 million,

               24 but at the end of that pe.-iod.

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               25            DR. MAYER: It would be  spread  over  three  years.


                                                                               30

                             DR. tIARGUI,TES:  'rt would be spread out over three
                                              .L.
                 2 years.  If they were smart, they  would probably handle it
                 3 through some kind of a contract to keep it separate.  At the
                 4 end of the three years, their commitment level  would  be  whatever
                 5 it had reached at that time exclusive of that $3 million which

                 6 then disappeared.
                 7           DR. SPELLI-,IAD!:  You would make the three-year award

                 8 at one time, one sum?
                 9           DR. MARGULIES:  To get the funds obligated...

                 10          DR. SPELL@IAN:  014B will commit them?
                 11          DR. MARGULIES:  We don't know yet.  That is our plan.

                 12          DR. SPELUIAN:  it is extraordinary.
                 13          DR. 14ARGULIES:  It is not so extraordinary.
                 14          DR. MAYER: They have  been  doing  that  in  construction

                 15 for  years.
                 16          DR. MARGUTJIES:  The reason they have to do that is
                 17 ibecause they are committed to releasing all funds.  It is
                 18 their -- their being downtown, whoever is downtown, it is always
                 19  they, all those people downtown with responsibility -- so the
                 20 fund was not released, and tl,aey have to @evise a method of
                 21 releasing it and making it effective.  I think they had
                 22 assumed we would not be in a position  to  respond  as  effectively
                 23 as we can.  And we can do it because we will have reviewed
                 24 and approved and identified actions on that kind of a base

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                 25 because I guess it was staff wisdom 8 months  ago  this  is  exactl


                                                                           3

                 1what would happen now.
                 21        DR. MAYER:  O.K.0 otl-ier questions.

                 3          (No response.)
                 4         That was the easy part.  Have you got the hard

                 5part, Harold?
                 6          DR. MARGULIES:  Let me just run over two or three
                 7other things quite quickly because they might take some further
                 8time.  We can come back to them because this gets to be quite

                 9a long unifocal dialogue.
                 10         DR. IAAYER:  We are listening.
                 11         DR. MARGULIES:  The Cancer Center proposal which was
                 12 reviewed by Council last time represents for your recollection
                 13 the investment based upon Congressional action of $5 million
                 14               struction center in the Northeast part of
                  for a cancer con
                 15 United States.  That was reviewed, and there has been favorable
                 16 action with certain requirements attached to it by the Council
                 17 for a cancer center in Seattle called the Fred Hutchinson

                 18 Cancer Research Center.
                 19          There were specific requirements by the Council and
                 20 some that we imposed which had to do with such regulations
                 21 as are in the legislation in State regulation, certificate of
                 22 need and so on.  They appear to be moving quite well to
                 23 complete their requirements.
                 24          We said that we would release the funds only when

  Ace-Federal  Repoitefs,  Inc.
                 25 all of these requirements were met.  So that the award was made


                                                                           32

                I  by Councilt but we will not make the aaa-d a formal award
                2 until all of these requirements are not.  And Council will have
                3 an opportunity to look at it again at least informally to see
                4 if it satisfies their needs.
                5           Probably the key issue for some members of the
                6 Council was the plan to have patient beds in the research
                7 center which is-connec-@ted with Swedish Hospital by a tunnel,
                8 but which is not a part of the building itself.  And some
                9 members of the Council felt very strongly that this might
                10 produce a good research environment, but they worried about the
                11 adequacy of regular, around-the-clock medical care in that

                12 circumstance.
                13          DR. MAYER:  it is going to be physically linked
                14 to Swedish, is that it?
                15          DR. MARGULIES:  Yes.  And they have responded showing
                16 us ways in which they are going to give assurance of good
                17 medical care. @.d it is going to be up to the Council to judge
                  whether that assurance is adequate.
                18
                            DR. SPELLMAN:  Those would be the only beds, I take
                19

                20
                21          DR. MARGULIES:  For research purposes, yes.
                            I don't really know how much to get into this next
                22
                23 issue because we could spend a lot of time speculating on it.
                24 I would be glad to speculate with you, and it is an election
  Ace - Federal Reporters,  Inc. year, and that is the popular thing to do, but this has to do
                251


                                                                           33

                I  with the iieaiiing of the emergence of the now cancer
                2 authority and of the now heart disease push in the form of
                3 two major forms of legislation.  You may recall that there was
                4 new cancer authority passed to produce a special center for
                5 cancer research and control.  And there is a parallel bill for

                6 management of heart disease.
                7           This, -of course, raises the question immediately of
                8 what relationship either of these activities may have to the
                9 Regional Medical Programs which are identified with the same
                101 diseases.
                11          It also raises the question of whether there will be
                12 a continuation of @iis  kind of special interest and special
                13 disease categories, perhaps rejuvenation of interest in
                14 neurological diseases or some of the others.  I don't know

                15 about that.
                16          What has happened, however, has been a desire certainly
                17 in the cancer bill to produce a consistent pathway from the
                18 cancer laboratory research area to the delivery of good care
                19 tothe public with prevention, diagnosis, treatment, rehabilita-

                20 tion.
                21          This could be done by establishing or re-establishing
                22 the control programs which were carried under the Di-vision of
                23 Chronic Diseases in the past.  It could be done by other
                24 mechanisms.  It could be done by the National, Cancer Institute

  kce -Federal Reporters,  Inc.
                25 managing the whole thing from ttie research end to the delivery
                 I                                                                I


                                                                            3 4

                I end.  Or it coul,d b- done by             which they work

                2 out with programs like the Pegional Medical Progr,-tln-,.
                3          There has not been a decision made at present about
                4 what our actual working relationship will be either with the
                5 National Cancer Institute or the National Heart and Lung
                6 Institute.  Tomorrow I am to go over and talk with a group of
                7 people in the National lbart and Lung Institute about heart
                8 and stroke activities which we might be able to carry out in

                9 common.  But I think the negotiations are taking place
                10 currently between the office of the Administrator and with
                11 Bob Marston at NIH to decide how best we can work this out.

                12          What I hope for is v. union of the special cancer
                13 interests and special heart and lung interests which represent
                14 NIH's major interest and constituency with those in the Regional
                15 Medical Programs.  And what nany of us hope for would be if
                16 there is a re-emergence of the control program that this be
                17 designed in such a way that it improves the delivery system
                18 rather than operating in isolated segments thereof.
                19          But we will probably have a clearer answer to

                20 that at some time in the future.
                21          in the meantime, interestingly enough, just to
                22 add to the confusion of the picture, when .@anator Kennedy
                23 extended our legislation, he dropped the categorical designation
                24 out entirely and put his total emphasis on education, manpower,
  kce-Federat Reporters,  Inc.Iand the improvement of delivery of health services. So we are
                25i


                                                                             35

               I  in a continuing Period of ti.me  of struggle between these
               2  issues which, if you had thougl,.t would disappear with anticipat.,nc
               3  events is not likely to occur in the next few years.  I do not

               4  know what final arrangements will be carried out.
               5            In the meantime, it has caused us to look again
               6  more sharply at how much of our activities are  dealing  with
               7  heart disease, cancer, stroke, and kidney disease.  And  they
               8  still remain a preponderant part of Regional Medical Programs.
               9            W-iat we have difficulty with, and it is distressing
               10 that we do, is the idea thatyou can by improving -- well,
               11 we talked about it earlier -- total emergency medical services

               12 Liiake a contributioi-i *-,o tlio cor.-I@-zol of li@zart dise That
               13 never emerges from the kind of data which are  put  together.
               14 If you are talking about a categorical disease activity in the
               15 way most of the people looking at it at the budget  end  like
               16 to look at it, it has to be exclusively for a specific disease
               17 within that category.  If not, they can't recognize it.
               18 If you improve basic primary care services iln a rural  area,
               19 the assumption is,.l guess,, that somehow you do that and
               20 exclude heart disease, cancer, stroke, and kidney disease and
               21 related diseases when in fact that is an absurdity.
               22           If you try to tote up what you ve doing in some kind
               23 of  dollar terms to improve management of these diseases, it is
               24 very difficult to do..  And we are in that kind of a dialogue.

  kce -Federal Repof ters, Inc.
               25 I have no answers for you,


                                                                           36

                1          DR. IVIAYER:  O.K.      con,,-teiitse Harold?
                2          DR. MARGULIES:  one other, and some of these others

                3 will come up again.
                4          We have issued the new kidney guidelines very recentl,),
                5 and they are available to you. And I think rather than  go
                6 into detail at the present time, since we have been over qu3te
                7 abit of ground already this morning, that we will bring up the
                8 details of that at a point where you are actually going to
                9 deal with the subject. Or we can do it now if you  prefer,

                10 Bill.  It is up to you.
                11          I have a more significant issue to deal with, though,
                12 for the tire being.  And that -is the nonpayment of consultants.

                13 All I can do is read you the note.
                14          What happened was that the central payroll converted
                15 to a new system.  An old consultant timekeeper number was
                16 used which resulted in many consultant checks not being written.
                17 Research has been conducted to double check on the consultants
                18 not Paid and to clear up other errors.  Hopefully, all work
                19@ will be completed-and checks written for the May 23, 1972, pay.,
                2o day.
                21          in other words, we operate our pay system when we
                22 change from an old system to a new system just as others do --
                23 ineffectively.  So that those who have not been paid have not
                24 been paid because they had wrong addresses, wrong  numbers

  Ace -Federal  Reporters,  Inc.
                25 which the switchover managed to produce.  And we will, if we


                                                                                                                                                   37

                                1   can get the machine to listen to us, make sure evc,,,,:ybody gets

                                2   paid as he should have.
                                3                      Some people are in arrears clear back to last

                                4   October.
                                5                      DR. SCHE@TIS:  It has been speculated that is a

                                6   source of          funding for your expanding EMS.programs.
                                7                      DR. MA     RGULIES:  As a matter of fact, we linked it up
                                8   to another failure in another subscriber system.  And if you
                                9   don't get paid, you are going to get a 10-year subscription to

                                10  the National Geographic.

                                I 1                    (Laughter.)

                                12                     DR.  MAYER:    Otlier  conui@ents?

                                13                     (No  response.)

                                14                     Thank  you very  much,  Harold.
                                15                     At  the  risk  early  in  the  meeting of  fixing  dates,
                                16  I would  like  to  turn  to  the  calendars  wh4Lch  are  contained  in
                                17  your  notebooks  under  the  first  tab which  is  labeled  simply
                                18  "Calendar"  in  an  attemot  to  get  the  link with  Council  or  closer
                                19  link  to  Council  at  least  temporally    if  not  philosophically,
                                20  we  need  to  pick  two  dates  out  of  the  following  three  weeks

                                21  in  the    subsequent  year.
                                22                     If  you will  put  a  circle  around  the  September  17-23
                                23  week,  a  circle  around  the  January  15-19  week  and  a  circle
                                24  around  the  May  14-1-9  week,  what vi-e  need  to  do  is  pick  two

    Ace -Federai Repo@tets,  Inc.
                                25  days  in  that  period  of  time,  ca,,-h  of  those weeks,  that  you


                                                                                                                                              3 8

                               I would like to schedule for m@,eti.n(-T. And this is part of that
                               2 goi.ng from four cycles to three cy6l,e year.
                               3                      Preference  is  in  Sept@er?    We  are  now  on  a
                               4 Thursday-Friday  go.    Is  that  good,  bad,  indifferent?
                               5                      How  about  the  21st  and  22nd  of  Septainber  as

                               6 possibilities?
                               7                      Going -once,  twice,,  all  right,  gone.
                               8                      In  January,  is  the  18-19  appropriate?
                               9                      All  rights  other  time  during  that week?
                               10                     DR.  AN-CRUM:    Any  day  except  that  Friday.    I  have

                               11 to be  back  in  Seattle.
                               12                     DR.  MAYER:    O.K.,
                               13                     DR.  ANCRUI@lo.    That would be  fine.
                               14                     DR.  MLAYFR:    How  is  that,  O.K.?
                               15                     17-18,  then,  of  January.
                               16                     And  in May  17-18  of may?
                               17                     DR.  ANCRUM:    The  third  Friday  is  out  for me.
                               18                     DR.  MAYER:    Then what  about  the  16-17?
                               19                     DR.  ANCRUM:    Am I  the  only  one  that  has  this

                               20  conflict?
                               21                     DR.  MAYER:    I  don't  hear  anybody moaning  about  the
                               22  other  cycle.    There  is  no  magic  about  Thursday-Friday.
                               23                     O.K.,  then  the  16-17  of  May.
                               24                     O.K.,,  then what we  have  said  is  21-22  September,
    Ace-Federal Reporters,  Inc.   17-18  January,  and  3.6-17  May,  as  the  next  three  gols.
                               25


                             would like to turn now to sol,-te other additional
                 2comients which I think are very pertinent to the review
                 3process itself as we go through the review process from Dr.

                 4Pahl.

                 5          Herb.

                 6          DR. PAHL:  Thank you, Bill.
                 7          First'of al'L, I would like to mention for you that
                 8there is the dinner this evening at the Flagship Restaurant
                 9close by here to the Parklawn Building.
                 10         And, Bob, perhaps you can give detail arrangements
                 11 later.  But this is something that we are looking forward to
                 12 because we do have several of -the members of the coiuaittee
                 13 leaving.  And we believe that the other members of the cogLmittec
                 14 together with-staff would like to meet together informally and
                 15 have an opportunity to socialize and wish those who are
                 16 departing well, althouch we do hope we have close and continuing

                 17 relationships with each and every one.
                 18         I have just a very few comments because I think Dr.
                 19 Margulies has indicated the complexities that we have been
                 20 going through.  And you will again obviously have a very full
                 21 agenda of information items in September because the program
                 22 does continue to change.  However, my remarks are much more

                 23 mundane and specific.
                 24          Specifically, I would like to indicate that the

  Ace -Federal Reporters,  Inc.
                 25@ staff anniversary review panel is continuing to function very


                                                                            40

                 I  well and that this time they had an tuiusually heavy task
                 2  before there. because the appli,ca-ions tllztt came before them
                 3 had not received initial priority ratings.  Ther,eforet there
                 4 was in this period along with all of the other specialized
                 5 activities the need to review in depth these particular
                 6 programs and assign priorities.  These priorities are indicated
                 7 to you in the applications in the book.
                 8          There are some few programs which are behind the
                 9 blue tab in the book where you are not required to take action.
                 10 Those applications are being brought before this committee
                 11 for information purposes only.  The other applications for
                 12 one reason or ano--her do require certain kinds of action.
                 13         liov7ever, I do want to make it clear that the committee
                 141 does have the opportunity and privilege of raising a question
                 15 about any priority on any application that the staff anniversary
                 16 review panel assigned regardless of whether that application
                 17 is before you for action or for information only.  And we
                 181 will be asking you to formally concur in those priority ratings
                 19 or to mod,-&fy th,--m,as you see fit.
                 20          Should you have questions about any priority rating,
                 21 we will have the chief of the operational branch responsible
                 22 for that region prepared to present to you the basis on which
                 23 those ratings were assigned.  And you should know in this
                 24 connection that the branch chief for that region was not a

  Ace-Federal  Reporters,  Inc.
                 25 member of the voting team for that application so that he
                   I


                                                                           41

                1  would be p--esenting a su@tary, if you will, of what the staff
                2@ anniversary review panel concluded relative to the application
                3 to reach that assigned priority.
                4          You will also note that we have introduced certain
                5 new formats in the paper work which has come to you both at the
                6 time of site visits and in terms of primary and secondary
                7 review of the applications.  And I believe you will see very
                8 readily that the purpose of this has been to try to tie into
                9 our analysis of the application in question the review criteria
                10 which have been developed and are increasingly being used not
                11 only by RMPS, but by the RmPs themselves as they view the

                12 p-Logress of their programs.
                13          There will be an opportunity provided to this
                14 committee at the end of this meeting tomorrow to comment upon
                15 and make constructive suggestions for modifications in these
                16 new kinds of forms and so forth which we are using.  We hope
                17 that the information is being organized perhaps somewhat better
                18 for you, particularly for comparison purposes between and
                19 among programs-since by having the items organized along the
                20 lines of the review criteria it is more possible now to review
                21 one program in comparison to another and look at the similar

                22 items of information.
                23          Internally, there certainly is not complete agreement
                24 that this is the ultimate way to present information.  We do

  Ace -Federal Reporters,  Inc.
                25 feel,, however, that there is an opportunity here to improve


                                                                             42

                 I  matters.  At the same time, we feel eiat the information as
                 2 we are now reco@ving it and prsenting it to you does contain
                 3 perhaps less narrative and more pithy substance on the particular
                 4 points in question.  However, we do look fonTard to your
                 5 comments at the end of the meeting as you have had an
                 6 opportunity to use these new forms.
                 7          DR. MAYER: I might just interject,  Herb,  each  of
                 8 you, I think, at your desk had a long sheet which does  have
                 9 the May-June review cycle, SARP recommendations on it which you
                 10 need to have for referral as we go through.
                 11         DR. PAHL: And it is the five  applications  at  the
                 12 bottorA of the sliect Viich are being brought -,,;o you for
                   infor1rat4on purposes only and are included behind that blue
                 13
                 14 tab in the back of your book.
                 15          In terms of the NIS printouts, in just a moment  I
                 16 would like to ask Mr. lettinoviski to present very briefly for
                 17 you what the printouts are designed to do.  And he has
                 18 distributed these large binders for you.
                 19          There is no intent to have you try to look  at  or
                 20 absorb any such information here at the table.  Rather, those
                 21 Of You who have been assigned primary and  secondary  review
                 22 of applications have already received the appropriate printout
                 23 packages.  And this merely represents a compilation for
                 24 each application before you today so that you will have some

  Ace -Federal Reporters,  Inc.
                 25, appreciation of how  the  NI.S, National Information Systemo is


                                                                                  11.3

                 I  being utilized more and more to bring information to your
                 2 site visitors, and the National Pdvisoril  Council,  and  to  be
                 3 used more effectively by our oAn staff  as  we  go  through  the
                 4 review process and analysis of regions.
                 5           I would indicate again that we look to this committee
                 6 and to our non-committee site visitors for constructive
                 7 suggestions as to how to bring to you those kinds of
                 8 information and present them to you in some organized fashion
                 9 that will be more effective in accomplishing both site visits
                 10 and the anlaysis and discussions of the regions' programs.
                 11          Now, with that slight introduction I would like to
                 12 ask 1-ir. Ichinowski to take a fGw minutes and rev,.e-a for  you
                 13 not any specific numbers within  these  pr2.ntouts,  but  rather
                 14 what the nature of the format of each printout is designed to

                 15 do for you.
                 16          And,, again, I will appreciate as well, particularly
                 17 at the end of tomorrow's meeting or  at  any  time,  of  course,
                 18 that you so desire suggestions as to how this kind of
                 19 activity can be improved to se-eve your purposes better.

                 20           Frank.
                 21           MR. ICHINOWSKI:  Thank you, Dr. Pahl.
                 22           We put together a number of printouts on each
                 23 region that is going to be discussed here today and tomorrow.
                 24 And these packages were  previously  sent  to  the  primary  and
  Ace  -Federal  Reporters,  Inc.  ,-        those regions that they ha
                 25 econdary reviewers for                               d =der their


                I  responsibility.  So maybe they are not completely new to you.
                2          We have, thenr all 14 regions here with the excerption
                3 of the new Ohio RMP.  we have six printouts for each WIP.
                4 And if you would be so kind as just to take your big black
                5 binder, maybe we could run through for a minute or two the
                6 kinds of things we have there and perhaps how you could use

                7 them in your determinations.
                8           First of all, they cxe all alphabetical, the ILMP,
                9 starting with Kansas, Missouri, and so forth.  We have
                10 reduced the printouts, as you know, from the large size which
                11 we found somewhat unwieldy to this reduced version that you

                12 bee in front of you.
                13          If we could use perhaps the Ya-Tisas P2,IP as an example
                14 and run through the printouts, maybe that would be of assistance.
                15          The first printout is a funding history list which
                16 identifies for you for each RMP all of the projects that
                17 were ever supported by RI,4PS funds and then in each column by
                18 year the moneys that were put into that activity.
                19          For example, in the Kansasp you see there they have
                20 it awarded for five years.  So the first five columns are the
                21 moneys that were awarded in each project and total at the bottom
                22 for each of those five years.
                23          To the right of the asterisk column are those
                  ,Ttoneys that they are requesting at thi s time for subsequent
                24
  Ace-Federal Reporters, Inc. years, In the case of Kansas for years 06, 07, and 08. Again,
                251


                                                                           45

                  at tl-ie bottoirp the totals that are bei.ng requested.
                2          O.K.  For the ne,,ct printout, you flip over behind
                3 the number one tab.  The breakout of request which identifies
                4 for each RMP by type of support being requested, whether it is
                5 continuation within approved period of support, which is the
                6 first column, continues beyond the approved period of support
                7 whichis the second column, and so forth, those moneys that are

                8 being requested for a particular year. ,
                9           Each page is a program period.  The first page for
                10 Kansas is their 06 year of request.  The second page will be 07,
                11          At the right  of the page, you not only have the
                12 direct cost being requested, but also the indirect and total

                13 dollars.
                14          Now, behind the nu@er 4 tab, under Kansas, we have
                15 an  identification of the PNY).PS funds that. are being requested
                16 as a percentage of other sources of support.
                17          Now, in the financial data record that the RMP
                18, submits to us on each project, they identify if they are going
                19 to be getting other sources of support for that activity.
                20 And we have displayed this in terms of identifying in the first
                21 column after the title the RMPS funds that are requested.
                22 The second one is those funds that they have indicated will be
                23 coming from other sources, with the total then in the third
                24 column.  And in the fourth column is that percentage of money

  Ace-Fedefal Reporters,  Inc.
                25 that RMPS would be contributing.


                                                                                 ik    ri

                             In the case of Kansas, as you can see, they have
                 2 not indicated any other sources of support for any of their

                 3 activities.
                 4           We can go, then, behind the number 9 tab of Kansas,
                 5 And these are printouts that come from the descriptor summaries
                 6 that had been submitted to us by the IU4P.  We have this

                 7 broken down into,three major groupings.
                 8           The first groupings are operational components.

                 9 in the case of Kanasa, on the top left-hand corner, you can
                 101 see that they  are  requesting  12  operational  components  which
                 11 total $693,243.  within each of the 12 major groupings of
                 12 descriptor categories, we have brok-c-ii tl-iose dean to  identify
                 13 for you tlic- number of componei).ts that relate to that  specific
                 14  element, the dollars that are related and then the percentage
                 15 of those dollars that that money identifies of the amount that

                 16 they are requesting.
                 17           There are four  pages  for  that  particular  printout.
                 18 And then right behind the little yellow @ , we have a similar
                 19 type of display for the ple-xxning studies that they have
                 20 identified in their application which runs the same pattern, --
                 211 the number of programs that they are requesting and the amount
                 22 @of dollars.
                 23           And the third batch are the program feasibility
                 241 studies and  central  services  again  in  a  similar  arrangements
  (kce-Fedetat Reporters,  Inc.
                 95 and array.


                                                                             47

                           The next printout Londer Tab No. 11 is a repeat
                2 of their page 7 of their application which identifies equal
                3 employment opportunity data they have submitted to us.  There
                4 are four major columns, the first being core staff, again
                5 broken down into professionals technical and secretarial
                6 and clerical the same breakdown for project staff.
                7          The th."&rd major column is the regional advisory

                8 group,
                9          And the fourth one other committees.
                10          The rows, I believe, are self-explanatory.  The top
                11 row is total which are members.  Then you have the breakdown
                12 bet@7een male and femF.-.1e.  Thr@ii you h,--t@re the breakdo,@ under
                13 minority groups, total minority, and those that are
                14 appropriate to blacks, Indians, Spanish, oriental and others.
                15 This is a direct take-off from page 7 of their application.
                16          The lst printout we have provided for each RMP
                17 behind Tab 14 has been derived from the financial data
                18 records where we have identified for those objecf@-s of expenditua
                19 that are on page 16, moneys in each component that have been
                20 reported to us.  Each coliLnin is a particular component, the
   0            21 first being core, the second one developmental, and then the
                22 component numbers.  The total in each object of expenditure
                23 for each PIIP would be the furthermost right-hand row of the
                24 last page. In the case of Xansas, the last colunun on page 2.

  Ace-Fedetat Reporters,  Inc.
                25          Now, there is one other set of printouts that we have


                I  prov4-ded which is helpful for those of you who want to do some
                2 analysis.  And that is at the veL-Y back of the book, there is
                3 a tab that is identified as miseell,@ieous printouts, if we can
                4 flip back there under the No. 10 tab, there are four different
                5 printouts in this series.  And what these printouts identify
                6 are those RMPs that are in this revielvi cycle broken down accord-@
                7 ing to the number of years that they are operational.  So you
                8 can see that there are four RmPs that are in their first year
                9 of operational, one in the second and so forth.
                10          If we can use the Kansas e@ca,.,nple which is the second
                11 line from the bottom that we have been following through, you
                12 can see that Kansas has been operational. for five years.
                13          Nowe what we have attempted to display on this
                14 printout is a comparison of the moneys that they are requesting
                15 in column 3, $1.7 million, as a percentage of their currently
                16 budgeted dollars in column 2, $1.3 million.
                17          In the third coliznm request is the percent change fro
                18 current.  You can see they are requesting 19.9 percent more
                19 moneys in total direct cost than thay are currently being
                20 funded for.
                21          In the subsequent columns in that page, we have also
                22 given you a comparison for you to see in terms of the history
                23 of that FLMP, the percentage change that occurred in that RMP
                24 between years 1 and 2 -- in this case 177.7 percent.  And then
  Ace-Fedeial Repotteis,  Inc. the second column would be between years 2 and 3, a plus 27
                25


                                                                             49

                  percent and so forth down th.@,@ lirAe.
                           Now, there are four printouts to  this  series.  The
                  first page 'chat we have gone over is total direct cost.  The
                4 second page has to do for core contpoients, the third one for
                5 project and the fourth for those that apply developmental

                6 components.

                7           Yes, Sister.
                8           SISTER ANN JOSEPHINE:  I am interested in this five

                9 years.
                10          DR. MAYER:  Sister, could you use the microphone?
                11          SISTER ANN JOSEPHINE:  in this five-year operational,
                12 as you look at Kansas and Missouri, and you look at the current
                13 budget and requested, immediately the question comes up what
                14 is changing there?  Because it is changing very rapidly.
                15          MR. ICHINOWSKI:  In the case of Kansas, they are
                16 requesting $1.7 million.  And they are currently being supported
                171 at the $1.3 million level.
                18          SISTER ANN JOSEPHINE:  I am talking about Missouri.
                19 As I look at these two, they are being funded at $1.9, and
                20 they are requesting $4.4.  There are some significant changes

                21 taking place here.
                22          MR. ICHINOWSKI: In Missouri?  I  believe  you  will
                231 discuss that at the time the Missouri application is to be

                24 presented.

  Ace-Fedetal Reporters,  itic.
                25           SISTER ANN JOSEPHINE: This could  highlight  these
                  I


                                                                              50

                   of things I suppose one would l,ool,, ;;,,t.
                            MR. ICIIINOWSKI:  That is the intent of my covering

                 3 this.
                 4          SISTER ANN JOSEPHINE:  I keep hoping vie ask the right
                 5 questions because if we don't, we work on the wrong answers.
                 6          MR. ICHINOWSKI:  Are there any other questions?

                 7          MR. HILTON:  Yes.

                 8          DR. MAYER:  Yes, Mr. Hilton.
                 9          MR. HILTON:  Is the current plan to have these
                 10 printouts replace much of the reading material we have in the
                 11 other book?  Is this the idea?

                 12         ViR. ICIITIIO;,JSKI:  Yo
                 13         MR. HILTON:  Is there  some way to make this printout

                 14 clearer7 Some of these figures are --
                 15         MR. ICHINOWSKI:  Yes.  We have just in this last cycle
                 16 made the decision to go from the large printout to the reduced
                 17 printout.  It is an internal problem with the use of a Xarox
                 18 7000 machine in the building here.  And if we can get #to use
                 19 the Brun!.ng or one of the other machines which we are negotiating
                 20 for right now and get it perhaps printed rather than xeroxed,
                 21 we can improve the quality significantly.  And I believe by
                 22 the next  tire these printouts are presented to you, you will
                 23 note the difference in the quality.
                 24          DR. MAYER:  That is extremely helpful data.  When I

  Ace-Fedetat Repoitets, Inc.
                 251tried to dissect out that "new" Ohio program, I would have


                                                                           5%

                  my eye teeth for this data.  Arid I have just asked to try to
                2 get some comparable data for that one because there is literally
                3 no way you can view the thing in a total picture over time
                4 without some feeling of this kind of data displayed.  There is
                5 just no way if you haven't been involved, at least that I can
                6 capture, without this kind of information.  It is absolutely
                7@ essential.
                8          MR. HILTON:  Perhaps this is a question for Dr. Pahl.
                9 I notice some new colors in the form.  Is there a color coding
                10 formula somewhere?  Does it mean anything?  or are we just

                11 more decorative, surplus paper?
                12         DR. PAHL:  Well, to answer your question, I wil@l try
                13 to go through it with Lorraine Kyttle here.  I am sure she

                14 will check my accuracy.
                15         The Staff Anniversary Review-Panel acts on only
                16 certain types of applications, you will recall.  And when they
                17 do, the report of that panel is given on sort of this pink

                18 sheet.
                19          DR. MARGULIES:  It i-s good you asked him.  I am

                201 color blind.
                21          DR. PAHL:  A yellow sheet indicates that this is a
                22        cument for use by the committee and the Sta.F4'
                  staff do
                23 Anniversary Review Panel has not acted.  Therefore, this kind
                24 of staff summary is coming to you as an initial consideration

  A,ce-Fedetal Repofters,  Inc.
                25 without prior review by an iiite-&nal staff panel.


                                                                                 52

               I              And the whites are generally the back-tip information.
               11             And Lorraine, do we have another color?
               3              MRS. XYTT.TJE:  No, sir, only one little thing that
               4    jarred us, and that is that tl,,e printer contracted out and,
               5    therefore, we have several shades of the  same  color.  A  pink
               6    is a pink, no matter what its shade is.  It depends on what

               7    contractor printed it,
               8              MR. HILTON:  V7hat is a salmon'.
               9              MRS. KYTTLE:  Mr. Hilton, the salmon indicates materi@.l@
               10   generated by staff or the initial review of the Staff Anni%rer-

               11   sary Review Panel.
               12             DR. IIA@RER:               that is the link.
               13             MRS. KYTTLE:  We are a.11 swixring upstream.
               14             DR. MAYER:  other comments
               15             DR. PAHL:  I do have one or two points of information
               16   for you,  And then I have something to state about the kidney
               17   proposals. So let me take up the first  two  point@.3  relative
               18   to information at this time.
                              There has been over many  months  now  an  increasing
               19
               20   need by Pd4Ps for a clear statement from RMPs relative to the
               21   responsibilities and relationships of the grantee, the RAG and
                    the  coordinator.  And ri,.any months of staff work have now gone
               22
               23   into a statement which has been looked at by the steering
               24   committee of the coordinators and  has  received  the  approval

  Ace -Federal Reporters,  Inc.
                    of the HSMHA grants         office.  And we will be getting out
               25


                                                                               53

                 It

                 I hopefully within the next week or two weeks a statr-,-tnent on

                 2                                     0- IIAG, grantee and
                   responsibilities and relati.onshi@)s

                 3 coordinator.

                 4           Now, we are aware thal- by making this statement
                 5 and it will be policy, there will have to be some modifications
                 6 in some of the RMP regions' by-liN,.,Ys and relationships.  But 3-n
                 7 general this is 'what the director and HSM.HA and the steering
                 8 committee of the  coordinator  believe  is  appropriate.  And
                 9 since it is rather lengthy, I won't read it into the record.

                 10          We do not have it for you today.  We have been
                 11 working intensively to make such a deadline,  but  have  been
                 12 unable to get the HSMIIA clearance in ordex, to do so.

                 13          The value of this, I         will@ be that for once
                 14 there will be an opportunity for both the regions and their
                 15 organizational groups and ours to have a common document to
                 16 look at as we discuss problems which do arise in the various

                 17 regions.
                 181         In general, the key statement which has been itself
                 19 so easy to read and has taken so long to get clearance on, I
                 20 would like to read into the record because I think the rest of

                 21  it amplifies this statement.
                 22          The grantee organization shall manage the grant of
                 23 the Regional medical Program in a manner which will implement
                 241 the program established '--Jy the Regional Advisory Group in
  4,ce-Federat Reportets,  Inc.
                 25 accordance with Federal regulations and policies.


                                                                               54

                            And then there are a         of it@.oz describing in
               2@ detail the role and responsibilities of the grantee, the
               3   Regional Advisory Group and the coordinator who in this document
               4   is also identified as the chief executive officer.  And it
               5   represents, I think, a major step fonTard.  And there will be
               6   some specific, isolated problems, but most of the problems
               7   which have arisei are because of misunderstandings and lack

               8   of agreement as to a common theme..
               9           So we do,hope that this results in better unders4.--andin@,s
               10  and relationships.  And over the course of the year, I am sure
               11  the few specific problems will be able to be worked out on a

               12  negotiable basis.
               13           MISS @4DERSON:  Pre you going to include the make-up
               14  of the RAG and definitions of what consumer is?
               15            DR. PPJIL:  Not in this document.  As we have- brought
               16  before you at earlier times, there is a  requirement  by  the
               17  Department that more aspects of all HEW programs be put into
               18  regulations. This is a mandate  by  the  Secretary's  office,
               19  and we are proceeding as we develop these documents to tlen
               20  couch them in broader, more general language in terms of
               21  regulations. We are tnring to  kecp  the  formal  regulations
               22  as broad as possible to provide maximum flexibility to both the
               23  regions and ourselves and to use these statements to make
               24  explicit what is understood and Intended and IISMIIA  policy.

  Ace-Federal Reporters,  Inc.
               25            But the points you ,mentioned are not in this


                 11                                                          5  r,

                I documi2@-rit and prc)l)r@@ly will be the! ':;LPb-iect of @@urther Work.

                2 These take quite a while to get everybody to come to some

                3 agreement on.

                4            DR. 14AYER:  When will these be released, Herb?

                5            DR. PR-XL: It has been cleared by  HSMHA.  I  would

                6 expect in  the next two weeks we would be able to begin

                7 mechanically getting them printed and out.

                8            The second point I would mention is that  HSMHA  has

                9 now established a policy effective April 11 -- and this is only

              10  for your information -- which now makes it a requirement,

              11  places it as a requirement, on all IISIAHA programs to  inform

              12  the appropriate regional health director of anv proposed  gravity

              13  or contract to be r,@ie@de by L@IMSIIA in that II-RW region and to give

              14  to that regional health director the  opportunity  to  comment

              15  upon prior to the final decision either grant or contract.

              16  He is not required to submit comment, but he  trust  be  provided

              17  the opportunity to make comment.
              18             It also is a requirement that once  the  disposition

              19  has been made, either approval or disapproval  and  award  level,
              201 this information must be given back to the regional health
              21  director. Obviously, this is in the  interest  of  keeping  him
              22  better informed about all activities, whether  they  are  managed
                 Iin his office or not, but which come from HS@IHA.  And we have
              23
              24  already implemented this relative to our grant activity in that
  ce- Federal Reporters, Inc. we are soliciting for current applications to go  to  the  June
              25@


                                                                                56

                 I Council, EIls apr@licaticn, the corc,,@,tiinity-ba-:.;ed educational
                 2 applications, mid also the ones  before  you.  if  there  have
                 3 not been comments, we are so not.4.fy4-ng the regional  health
                 4 director in providing him that opportunity to submit them

                 5 prior to this Jime Council.
                 6           And then we will be implementing this in an effective
                 7 way for the contract activities which the office of the
                 8 Director of PZIPS does engage in.
                 9           Now, I would like to turn  to  the  last  item.  And
                 10 I am sorry there are so many things, but this is relatively
                 11 important.  And with your permission, I would like to read to
                 12 you the importe-Tit aspec-tri because   has not bc--@-n given to
                 13 You-  And it is difficult for you to select out those

                 14 important paragraphs.
                 15          As Dr. Margulies indicated, we have now issued the
                 16 revised guidelines and local and national review procedures
                 17 for the kidney disease activities of RMPS.  Dr. Hinman will
                 18 pick up where I leave off and will then lead into a general
                 19 discussion of these guidelines.  But I would like to go over
                 201 the review process with you and as a matter of information for
                 21 you and also as part of our record read  to  you  those  parts
                   which are pertinent to the review process  and  leave  to  Dr.
                 22
                 23 Hinman to then discuss the more general statement about the
                 24 kidney program objectives and specifics relative to th4-s
  Ace-Federal Reporters,  Inc. meeting and kidney applications.
                 25


                                                                                                                               57

                           I                  There            bc-on a xvel-y grca@,t z@,-notxn,@- of effort in
                           2   trying to develop this  issuance  and without going into that,
                           3   let me read to you,  then,  what  the siimaary of the  review
                           4   process at the local and the national level is which is
                           5   effective now and,  therefore,  pertains  to the activities  of

                           6   the meeting of this  committee.
                           7                  StartiAg off with the technical review process at
                           8   the local      level and forgetting about initial discussions which
                           9   may occur      between the region and MIPS  staff  as  a concept  for
                           lo  a kidney proposal develops,  but starting with  the  technical
                           11  review process  at the  local  level,  the  issuance  reads:
                           12                  Prior i-o st2.bm3-tti-.ng applicc3.tion  for a renal
                           13  disease program,  the  W4P is expected to obtain a  technical
                           14  review of the proposal by  a group which has not participated in
                           15  the program's development.   The technical review group must
                           16  be comprised of at least three  renal authorities  from outside
                           17  the  geographic area served by  the region.    Payment of the costs
                           18,1 of such  consultant services will be made by the  requesting MAP.
                           19                  The region may obtain  the names  of consulting renal
                           20  experts by calling the  appropriate Operations Branch  for
                           21  assistance.   The Division of Professional and Technical
                               Development maintains  a list of  renal  consultants,  and is
                           22
                               responsible  for coordinating their assignments   Should  the RI,4P
                           23
                           24  desire to choose  its own review panel,  the names  and curriculum
   Ace-Federal Reporters, Inc. vitae of prospective consultants must be  cleared with the
                           25


                I Division of Prolless4Lonal and Technical,

                2           Technical reviews of renal px,ograNts need not
                3 always be made by consultant site visits,, but may be accomplish d
                4 by mail when appropriate. The RYX will negotiate any  compromise
                5 needed should conflicting technical advice be given by the

                6 technical reviewers.
                7           Forviarding Froposals - only those proposals which arE
                8 recommended favorably by the local technical review group
                9 shall be eligible for consideration by P.MPS.  In addition,
                10 an opportunity must be provided prior to consideration of the
                11 proposal by the RAG for review and comment by the appropriate
                12 CIIP @,genc@,, or agencies as reqi-,.,4,red by Section 904(b) of the

                13 Act.
                14          The RAG shall consider any CHP comments and comment
                15 on the ability of the IULD to manage the kidney project without
                16 hindering the development of the overall  MIP program, and the
                17 reasonableness and adequacy of the kidney budget proposed.
                181 The RAG is responsible also for indicating how major issues
                19 raised by the local technical review group will be resolved.
                            Since kidney proposals are reviewed separately at  the
                20
                21 national level, the RAG need not give priority ranking to
                22 kidney proposals in relation to other nori-kidney PIIP operational
                23 activities.  Kidney proposals shall be considered by RMPS in
                24 relation to national priorities.
  kce - Federal Reporters,  Inc. The complete comments of the members of the  technical
                25


                                                                              59

                I review col,rl.,,rtittee,azid any CI-IP @c;c@ncy com@nc-,nts, must be included

                2 in the forwarded proposal.
                3            R,:4PS Staff Review - the initial review z;t RMPS shall

                4 include:
                5            a.  The contribution of the project toward kidney

                6 program objectives.
                7            b.  The completeness and nature of the comments of

                8 the RAG.

                9            c.  Comments of CHP agencies.

                10           d.  The preferred met-.hod of fiLnding.
                11           Pj4PS Review Committee - PLAPS staff will summarize for
                12 the PU@,PS review coriun-I.-tt,,ze avc,4.1ab e information as to how -each
                13 kidney proposal- proposes to support the National Kidney Program
                14 objectives, and the substantive points developed through local
                15 review processes by the Technical Review Committee, the RZTG, anc
                16 the CHP agency.  For those applications for which the RAG;
                17 CHP a @ cy; director, RMPS, or RMPS Review Committee has
                18 indicated a concern apart from the technical merits of the
                19 project, the RMPS-Roview Conutiittee will be asked to make a
                20 recommendation to the National Adviso271 Council.
                             The R14PS Review Cor          'fically will not
                21                              .@r-ittee speci.
                22 review on a technical basis the merit of the proposal, or
                23 establish formal numerical ratings for individual proposals.
                24           And, finally, section 6, Council Review - all kidney

  Ace-Federal Reporters,  Inc.
                25 proposals shall be submitted to the National Advisory Council


                                                                                   6  0

                I   for f;-nal recom,.itendition,  in keeping with the categorical

                2   nature of the kidney disease pro@ra,.@,t within Ri@iPS, the  Council

                3   will review  and  recommend  funding  levels  for  kidney  proposals
                4   separately from the  funding level of the specific RMP.  Kidney
                5   program funding will be in addition to other PMP program fundin(,,,
                0              Now, those are pages  3  and  4  of  this  issuance.  And
                7   I would like  before  we  entertain  discussion,  because  I  think
                81  this is not in the complete framework, to have Dr. Hinman
                9   have distributed to you these which were just issued and perhaps,,
                10  comment on some of the  other  features  of  this  --  namely,  the
                11  framework of kidney program objectives.
                12             DR. PJAYER-. Before we do that, cov.,3.d we  talk  about
                13  the specific ..ro"&a of this ;,-aview committee

                14             DR. PAHL:  Of course.
                15             DR. MAYER:  -- to make sure we have got     that   under-

                16  stood?
                17             DR. PAHL:  Of course, Bill.
                18             Perhaps what I should do is    indicate to you that the
                ig  review co@mmttee responsibilities are    on page  4,  item  5,  and
                20@ if we can have Dr. Hinman come up perhaps the two of us
                21  can try to respond together with Dr. Margulies to the

                    questions that may be raised.
                22
                23             DR.  I-IAYER:  I guess my problem relates   to how we
                24  deal with  this.  We are not dealing with the technical aspects
  @ce-Fedeial Repofteis, Inc. of it. lie are dealing  with  its  presumed  relationship  to  the
                25


                                                                                                                                               6 1

                                                                                                      tlia-@- col7r,-@ct@?
                                1   rest  of  the  regional  act
                                2                   I  am  trying  to  get  a,  feel  for wha,@-  is  our role

                                3   vis-a-vis       the  kidney  projects.
                                4                   DR.  Pr-iHL:    Wellp  this              issuance  came  about  as  a  result
                                5   of  the  extended  discussion  at  @  last  committee  meeting  and
                                6   at  the  Council  subsequent  to  that meeting.    And  perhaps  in
                                7   order  to  abbreviate  it,  Dr.  Margulies  can  reiterate,  I  think,
                                8   what was  a  statement  to  the  committee  that  afternoon  of  the
                                9   second  day  and which  has  been embodied  in  the  principles

                                10  enunciated  here.
                                11                   So  let  me  ask  Harold
                                12                   DR.  PI-IYER:    I  need  to have  a positive  statement,
                                13  perhaps  with  examples  of  concerns  apart  from  technical  merits
                                14  which  is what  it  defines  as  this  and what  kind of  range  is  that
                                15                   DR.  MARGULIES:    I  think  the  most  important  issue  here
                                16  is  the  one  that we wrestled with  over quite  a period  of  time.
                                17  And  that  is  the  relationship betueen  a proposed kidney  activity
                                18  which  may be  technically  satisfactory  and  a  Regional  Medical
                                19  Program which  may have  some  problems  with  it.
                                20                    At  one  time,  we  had been  operating with,  at  least,
                                21  the  iniplici4@-  assumption  that  an  PJ4P  which  was  in  real  trouble
                                22  was  probably  not  a  very  good  site  for  the  establishment  of  an
                                23  effective  categorical  kidney  program.    That  appeared  in many
                                24  ways  to be  as  a  general  principle  unacceptable  ,aid  unworkable.

     Ace-Fedeial Reportefs,  Inc.
                                25  So what  we  would  ask  the  revieNq  conmittee  to  do with  that  kind


                                                                                62

                 I of a question is essentially to opT.@rcite on review of kidney
                 2 activities by exception .-- by           mF--anirig when you see
                 3 a kidney proposal which has gone through technical review and
                 4 is acceptable, but it is in a Regional iledical Program about
                 5 which you have some doubts, review committee  should  on  that
                 6 occasion raise those doubts and make some kind of decision
                 7 about whether it is appropriate for that r@P and not ask itself
                 8 to carry out a technical review, to second the technical review
                 9 which has already been completed.  So it really is action by

                 10 exception in those circumstances.
                 11          DR. MAYER:  I guess my problem is I can conceive of
                 12 a Y,)oor IL@IP, if I can use that ter,-fl, having a superb, not only
                 13 technical, but superbly organized  kidney  effort.  %  I  have
                 141 got that problem. And I am going to comment  that  that  is  a
                 15 miserable RM.0, and they have got a great kidney proposal in it.
                 16 And the PI-,IP ought to grow up to be as good a cooperative
                 17 arrangement as that kidney proposal.
                 18          Now, what have I done?  I am having a tough time
                 19 dealing with what.is the role of this review committee in that
                 20 process and  how do we get ahold of the data to deal with that

                 21 role?
   0                         DR. 14ARGULIES:  I tl-Aink it is an extremely difficult
                 22
                 23 problem. We have gone at it two ways.  In both instances, we
                 24 have felt uncomfortable with izhe result.  There are at least

  4ce-Fedetal Reporters,  Inc.
                   in our experience to date two possibilities in those circumstan c
                 25


                                                                             63

                I And that is exactly the kind of sitt@atic)n we are talking about.

                21
                            one of them is a possibility -that the kidney program
                3 will be the only thing in the activity which is any good.
                4 it will be relatively large,  it will not involve the Regional
                5 medical Program in any kind of regionalizing activity and
                6 under some circumstances, based upon your judgment of those

                7 circumstances, might serve as an excuse for the P14P to go on
                8 doing a bad job because they are doing something good with the
                9 kidney activity, in which case you might decide no matter how
                10 good the kidney activity is,the total result for the whole
                11 region will be made worse rather than better.
                12          The alternative probe,-bil2'.ty is that % kidney program
                13@ which is put together which is truly regionalized and which is
                14 designed to meet the needs of the population in the best
                15 possible way may p@-ove a good vehicle in a weak program for
                16 learning how to do things in c-m integrated, effective fashion,

                17 and might be an additive stimulus to it.
                18          There aren't any specific rules on that,  Those are

                19 the kinds of events you have to examine cn an individual
                20 basis.  And it is exactly that kind of dilemma which the review
                21 committee, I am afraid, is going to have to deal with.  I don't

                22 know any sharp rules for it.

                23          DR. MI@YER:  Sister Ann Josephine.
                24          SISTER %,NN JOStv,@DHINE:  I call anticipate another Problc-

  @ce-Federat Repofters,  Inc.
                25 l@ where the consultants do not have to examine the project on


                                                                              64

                I  site on a site visit, but can jl-;e con@,tiltc-d by I.,,i-ione or mail
                2  or however.  And I am becor.,@ing more exid more avia--e of the

                3  fact that sometimes what is i,@,ritten and what actually
                4  is quite different.  And I c@,iii .,ee that the validity of a
                5  technical review could be in question inder those conditions.

                6  land I can even visualize the conditions.
                7            DR. MARGULIES:  These consultant visits will have to

                8  be on site visits.  We are act going to accept the paper

                9  review'.
              10             DR. HIN14AN:  Harold, that is not what it says.

              11             DR. MARGULIES:  It doesn't?

              12             SISTER P@ill
              13             DR. MAPGULIES:  WI-,Il, in that case, we have to reach
              14   full agreement because I can't see just a paper review of it
              15   either.  There has got to be some site visit involved in this.
              16             DR. HINI,@N:  As the committee can tell, there has
              17   been considerable amount of discussion, both within RIAPS and
              18   between various committee mei-Lbers,, Council members, RMPS,
              19   and various people in the field.  And it was not until
              20   Tuesday there was a final decision on most of these things,
              21   the thought being on the ability to have a mail vote.  And we
              22   have in hand some technical reviews in which in Seattle at the
              23   ASAIO meeting which was convened, a review committee on a
              24   proposal for five members that were present there, and they

  kce-Fedefat Repofters,  Inc.
              25   discussed it thoroughly, but they had not site visited the
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                                                                              65

               I  the region, whel.:ber this would suL'fice or not.
                            It is very similar in the anniversary applications.
               3  This body gits in review without hearing physically gone to the

               4   region to site visit.
               5            DR.  PAHL:  Sister Pnnl I believe that both of the
               6   questions that have already been raised and those that will
               7   come up, you really have the answer couched in this statement
               8   by exception which is as broad as we could conceive it to be
               9   and yet be helpful.  And that is, %.:here the RAG, where the
               10  CHP agency, where the Director and his staff, or where the
               11  review committee has a concern apart from the actual technical
               12  iftf--r-Lt of the prop,-salo then this rc,.r-'"evi corun.4.ttee is asked to
               13  review the data and to mal@ a reccwm---Yidzition,
               14           Now, the concern can be on any point.  We felt there
               15  were occasions when it would not be necessary to make a full
               16  site visit because of recent actions by staff or Knowledge.
               171 And we were trying not to bind every applicant into a specific.
               18  We would imagine that most activities would involve site
               19  visits, but we wanted to be free on that.  But if there were
               20  1a  concern by any party to this review process that it weren't
               21  an adequate, valid review, this committee is given the full
               22  responsibility for raising that concern, having full information
               23  from the staff, and making whatever recommendation it so

               24  desires to the Council.
  Ace - Fedetal Reportets,  Inc'I
               251           It doesn't solve it poin.t by point, but that is the
                   I


                                                                              66

                 1 heart of the @,jhole i@sue in safeguax,diiig cit the national level
                 21 abuses that inadvertently may arise through local actions end
                 3 not seeing the total picture as the review corariittee might

                 4 here.
                 5           DR. SCIIERLIS:  I am curious as to why the device is
                 6 used permitting the region submitting the kicL-tey project to
                 7 select its own technical review members.  I would think that
                 8 if we carry that to the extreme, we should allow RMPs to
                 9 select their own site visitors.  I think this gets t,,Ie
                 10 national Pj4PS in a position if they don't like a  technical

                 11 review member to be in an embarrassing position to  say  no.
                 12 @vhy cc-ai't you just maintain your @,?n techriic4,a reviews?
                 131         I would think a local group could Utilize this
                 14 mechanism in ways which I think should not be part of the
                 15 national policy.  I don't see the reason for...havi-ng them
                 16 initiate their own technical review when it should be done, I
                 17 think, through R-T-@,PS,  Isn't that the responsibility of Pd4PS?
                 18          DR. 14AYER:  Harold, before you answer, let me
                 191 amplify the question as I read it and as I heard it.
                 201         It is my underst nding that the major component of
                 21 the burden of technical review belongs to those local technical
                 22 reviewers who are brought in by the region from the outside.

                 23 Is thatnot correct?
                 24          DR. DL@RGULIES:  That is right.

  Ace-Federal  Reporters,  Inc.
                 25          DR. MAYER:  Then I think Loonard's question is a very


                                                                             67

               1  pertinent one.
               21           DR. MPRGUL'L'ES: I thin k i4l-- is a pertinent one.
               3  The difficulty we find ourselves in in following your
               4  suggestion is that we are still trying to maintain some reasonallc
               5  balance even in the categorical activities between a centrally
               6  controlled activity and one whicti is locally developed.
               7            You might raise the same question  about  technical

               8  review for all activities  in a Regional Medical Program.
               9  The basic plan for non-kidney activities is the technical
               10 review is carried out under the purview of the local Regional
               11 Medical Programs selecting its own specialists and its own

               12 con@ul,4-,ants, its own advisers,.
               13           The -eason we have iRz-tdo an exception in the ki(Liev
               14 activity is no more complicated than the fact it is almost
               15 impossible to get technical review by people within the  RIIP
               16 without involving those who will be in fact in  the  project.
               17 And all we are really aiming for is to make sure  that  those
               18 who are not actively personally interested are involved in the
               19 review. And so long as they select competent people, the
               20 individual selection, it would seem to us, is reasonably
               21 left in the region as it is with all other technical review.
               22            DR. SCIIERLIS:  Then you are particularly exempting
               23 any technical review by this committee, are you not?
               24i           DR. 14ARGTILIES:  That's right.
  Ace-Federal Reporters,  Inc.
               25            DR. SCHL.RLIS:  I gLess I have to wrestle with that


                                                                               6 8
                 It

                 1as our cha-i2--m@ doer,,
                 2          DR. 1,14YER:  Let re M<A',E@ a suggestion, and I am not
                                                           t4
                 3sure what your time is and Dr. I-I.i,,rman's  xte, but k,7e ha-ve. been
                 4at it two hours in terms of time sequence.  And I have a
                 5feeling we are getting a little heaNry sitting.  And let me
                 6suggest we take a 15-minute brea)-, at this point in time and

                 7then come back. -
                 8           (Whereupon, a recess was taken.)
                 9           DR. @IAYER:  Could we take our seats, please?
                 10          We would like to go back to pick. up where we were
                 11  on the kidney proposal issue and see if there is furt e--

                 12 discussion about that.
                 13          Yes, Phil.
                 14          DR. WHITE:  It is with some degree of pleasure that
                 15 I can make this comment without fear of the future, but it
                 16 has been interesting to %,iatch the gradual emasculat4@6n process
                 17 that goes on in the sense that we were never allowed to drink
                 18 coffee in these conference rooms, some short time ago,
                 19 we were told not to look at projects today we are prohibited
                 201 from smoking,  7md in view of the new guidelines, it probably
                 21 will be unnecessary for us to make any decisions in the near

                 22 future.
                 2           I hope that the remaining members of the committee
                 24 can be comfortable with thi,@ g"adual process.
  Ace-Fedefat  Repoitets,  Inc. DR. SPELLI.4.,Pll:  It is emancipa4.-ion,, tha-. is what it i
                 25


                 1           I wanL-e(i to ask a          1-jow many      corssultz:Lni s
                 2 are there to draw fro:,,i? I asked becavse I got the impression
                 3 the numbers are so small, so-called qualified ones, that it
                 4 ends up in a sense of a kind of round robbin in which the
                 5 same persons are repetitively looking at them.  And I ask
                 6 that because then it would bring somci reality to the  question
                 7 if, indeed, the 'region can mlect its own consultant and
                 8 there are precious few of them, what liberty is this in the

                 9 final analysis?
                 10          DR. IIAYERI.  Does someone have information?  Ed. do

                 11 you have information on it?
                 12          Did you all hear     question?
                 13          DR. HIIIIA.AN:  The quest--ion revo'Lved around the nur.-L@-,er
                 141 of consultants we would keep available, the names we would
                 1
                 15 keep available here to assist the region.
                 16          At the      that decision was made to E,;roceed in
                 17 this direction, we mailed out requests to approximately 55
                 18 different experts in the field we felt could be of use in this
                 19 activity.  I don't-know exactly how mc-.tny responded yet, but
                 20 vie would anticipate having a lis-- of about 50 people regularly
                 21 who could be used by the regions in the review process.
                 22          I would like to address this issue of the reviewers
                 23 a little ,more since it was the subject-- upon which the  coffee
                 24 break was taken. l@u io sort of  appropriate  the  coffee  break

  Ace-Federal Reporters,  Inc.
                 25 was taken during the kidney discussion.   I assume that a


                                                                                 70

                   bladder b,,-eak is in-volved, too.
                             The issue of who does the tecl-,,,nical review is  one
                 3 that has been of major concern.  The poiiit that I)r, Spellman
                 4 just raised about the number of consultaxits was the reason that
                 5 prompted us to insist upon there being people from outside
                 6 the region. Because if you emi imagine within  any  one  PI.-IP,
                 7 the total nurnber'of consultants that  could  be  available  and
                 8 would have the competency to do the kind of review we are
                 9 looking for is such that they almost undoubtedly will be

                 10 involved in the projects initially.
                 11           DR. MAYER:  Or if they aren't. were concerned about

                 12 it.
                 13           DR. HINMAN.:  That's r;-ght.  Or if they are not, it
                 14 is because they are from another medical school and have
                 15 the scratch-each-other's-back approach.
                 16           So what we were concerned about was attempting to
                 17 assure there will not be a casual or cavalier approach to the
                 18 technical review. So the  dec4-sion  was  made  to  insist  upon
                 19 three people from outside the region.
                 20           Now, it is impossible for us  to  keep  up  with  who
                 21 might qualify on a montlily bar-is or semi-annual basis.  And th4@r,
                 22 was the reason why there was the freedom for the region to come
                 23 to us and -,ay, "May we constitute our review committee from
                 24 someone other than those on your D.st-?"

  Ace - Fedetal Reportets, Inc.
                 25           To date, the regions that have called in and said,


                                                                            71

                1 "viho is On Your list we cai-i c@,.!I, " they not proposed

                2 ringers fror,.i the outside.
                3          The criteria we would be concerned about is  that  it
                4 be someone who has technical knowledge in the area, i.e., if
                5 it would be a pediatric naphrology type of application, one
                6 dealing with children only, I would be very distressed if  the
                7 technical review'were done only by physicians treating  adults
                8 only because the problems of children with kidney disease  are
                9 different than those of adults with renal disease.  So we do
                10 have@the right to say that this is not   adequate review

                1 1cor.,nittee.
                12          We also have ad-3@ed tl,.,-a       thp@-t tJ-ie written
                13 reviews be sent to the national level, be available for
                14 perusal either by this group or advisory council or by  staff.
                15 This will tend to limit again people giving a very superficial
                16 review, I would think.  Pnd it is conceivable some people would,
                17 but again the number of potential consultants being, as I
                18 said, in the 50 to 70 range, the number of potential applications
                19 being in a similar range, possibly if each region had
                20 applications in, again I would be surprised if someone who
                21 is potential applicant from Region A would gloss over  a  poor
                22 application oil Region B because he in turn is going to be
                23 submitting an application somewhere along the line.  So I think
                24 it will be somewhat of a pol4@cing activity.

  Ace -Federal Reporters,  Inc.
                25          Of the reviews that @llave come in so far since the


                                                                                      72

                  1 word began to leak out of the change -- iL i,;,-is in tl-xc Cov;rtcil
                  2 minutes last round of some of the change,, how it-. w,:is  going  to
                  3 occur -- I halze been surprised, d that even when the review had
                  41 started locally and they were people from within the region,
                  5 there have been some fairly gro,,ie questions raised about the
                  0 adequacy of some of the proposals  that  have  come  in  by  pL@ople
                  7 within the area since they know it is going to be a written

                  8 review.
                  9            The staff role in preparing applicatioxis that come
                  10 to you or to the  advisory  council  will  be  to  assure  that  there
                  11 has been technical review, not to  say  whether  the  guy  is  Z-.ight
                  12 or @,7-"ong, but assure there has been tn7c-hiic,;-tl,  ev!,-ew.
                  13           In the various             of the document that @,,,-ent
                  14 out, that particular sentence was left out under the staff
                  15 responsibility.  But  in  two  of  the  applications  that  are  going
                  16 to be discussed this morning, the local technical revieu,
                  17 recommended  mpjor  changes  in  the  application,  the  MIP  did  not
                  18 heed those recor@mtendations and forwarded the application anyway.
                  19 It is our re-.ommandation that these be disapproved.
                  20           We see our role  as  being  a  watchdog  to  assure  that
                  21 Ithe process has goyie on as defined.
                               DR. MAYER: You are going to feel free to comment only
                  22
                  23 on process, not on content.
                  24i          DR. I-IINMAN:  ConcFz@iit if it is dispa.-ate from the
  Ace-Fedet@nt Reporters, Inc. national priority. This is one other area, thank you, that 1
                  25


                                                                               73

                 Ihad forgotten to mention,   In t-he I)eginnA,.ng of the doc,,urcznt, --
                 2@ I have lost ray copy here -.- on the first page,, the sentence
                 3under curreitt Ri,'ir-S prog--ara, emrhe,.-.-@s for kidi-ic-,,y disease, it
                 4sort of casually refers to a panel of regional authorities.
                 51 We have two plans, and we don't know which is going to have.
                 6to go  into effect because there are changing decisions.
                 7          Kidney-is no different from the other P14P progiaits.
                 8At one time, we were asked to submit some recommendations for
                 9expansion of kidney activities.  If this was to occur, part of
                 10 this would requ'p_re the constitution of a formal advisory
                 11 group advisory to Dr. Margulies on kidney disease which would
                 12 have regular scheduled raatings to determine Priorities.
                 13 that does not occur, we will anyway constitute  a  group  of
                 14 authorities to come in and suggest priorities to look at how
                 15 well the regionalization of treatment facilities is occurring
                  and whether there is a program that is knit to,-ether.  And
                 16
                 17 their findings will be submitted to the region so they will have
                 181 them, the RAG chairman and the consultants, this list of
                 19 consultants, so when they go into a region th,--y will  have
                 20 something to judge by.
                 21          In turn, when it comes here, if staff  looks  and
   0              sees if it see,-as to be missing the target, this would be one
                 22
                 23 of the occasions we would bring it to your attention and the
                 24 Advisory Councills attention.  It does not seem to fit into
  @ce-Fedetat  Reporteis,  Inc. the needs as determined by this outside  group  of  experts. So
                 25i,


                1 we would         on con-k6.ent in             Dr. Mr...yer.

                2           DR. MAYER:  Let me      one more, and I will stop.

                3 And that is the concern -- and this is a,-t issue I was  trying
                4 to get out but doing it poorly before the break, let's  see  if
                5 I can do it better after -- about the issue of regionalization

                6 process,
                7           One of the things I commented on is a good region

                8 that is going through that proress or a poor region that
                9 isn't and a kidney program that is. And my problem  is  who  is
                10 looking at that regional4-zation process? In other  words,  you
                11 can have the greatest technical competence in the world across
                12 the 2@-@ect frc)m one      v@l-io ar.not interr,7.,lati-ng in a

                13 regionalized effort in kidney
                14          Now, I guess I need to have a feel for who is looking
                15 at that.  Pnd if I ax, not out there to sample that and if that
                16 is a part of the responsibility of this committee, somebody
                17 has got to be out there to see about that issue.  or is it
                18 a responsibility of technical review? Who  has  that  responsi-

                19 bility?
                20          DR. IIINMAN:  The basic responsibility for regionalizal.
                21 tion rests in the hands of the regional advisory group in
                22 each P14P.  We see our staff role, my staff sees its role,
                23 here to again watch behind this.  As you know, there are the
                241 regular review processes, verification review process, which
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                25 goes on which attempts to look rt these issues of regionaliz,,:Atici,


                                                                                                                                                 75

                               I     as  well  as  in  things  other  than  jusl--  kidney.    But ry  staff
                               2   feels  t4lic@  major  responsi.b@-lit-,r  in  @ooking  at  the  question  of
                                                                                       .A
                               3   whether  there  is  some  con  @@t  tlia-t  at  some -poin*.  in  tipie  every
                               4   citizen  in  the  country  would have  access  to  a  kidney  flow
                               5   system.    And we  take  this  responsibility  to watchdog  the
                               6   regionalization  and  again  bring it  to  the  attention of  review
                               7   committe  and  council  if  it  is  not  followed.
                               8                    DR,  MP.YER:    So  is  that  part  of  technical  reviei-i or
                               91  is  that  part of  staff  effort?    In  other words,  I  feel  free
                               101 to  comrtent  about  the  regional  advisory  group  locally  in  terms
                               11  of how  are  they  functioning  in  terms  of  the  regionalization

                               12  process.
                               131                  What    I  thought  I  heard  this  morninq  was  that  there
                               14  is  a possibility  that  there  is  good  regionalization  in  kidney,
                               15  bad  regionalization  RLN@'.    I want  to know who  is  looking  at

                               16  regionalization  kidney.
                               17                    DR.  HINY,-kN:    I  am going  to bring  an  example  of  that
                               18  to you when we  get  into  the  specific  applications  because we
                               19  have  a  region  in which  the  kidney  program  is  becoming
                               20  regionalized  and wishes  support  to  finish  the  process.    And
                               21  it  is  not  the  strongest  RIIP  as  a vil-&(:;le.  And we  are  bringing
                               22  that  to you  for  advice  and suggestions,  comments,  this  morning.
                               23                    DR.  L@LNYER:    Well,  O.K.
                               24                    DR.  PAIIL:    Bill@  let me  t--y  a  statement.    I  think

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                               25  1this  will       be  a  continuing  staff  concern  because  it  is  one  of


                                                                                76

                 1 the basic the,-ties of MIPS is -L-c)                        I.Ch--
                 2 responsibility Ilo;-- carry.;.Tig oul,-, recl.-I.onpli,--ation lies within
                 3@ tho local PMP, but this woii.16. be HA point @hat staff would  be
                 4 looking at and comes under the point-. ctf if the Director, RTIPS
                 5 has a concern apart from the technical  merits  of  the  project,
                 6 it comes to this conmittee or if anyone  on  this  committee  has
                 7 such a concern. 'so that I don't think it is pinpointed to
                 8 just staff.  But certainly it would be a responsibility of
                 9 staff to look at this and bring info-@,ation to this committee.
                 10           DR. MP.YER:  Bill, you had a cowirent?
                 11           DR. THUPJUill:  i,et's take a very specific example,
                 12 one you @,,-ere recently on w-,-th us. 'P,@,.d t,4@lat vyas the Gre,:Atc,-@,r

                 13 Delaware Valley.
                 14           Going back to Bill Mayer's question, that regionaliza-
                 15 tion was not approved by  the  @.G.  There  are  good  facilities
                 16 across the street from each other which don't need to be there.
                 17 Who does have the responsibility  for  looking  at  the  Delaware
                 18 Valley?  Is that supposed to be eie RAG?  And if so', it certainly

                 19 doesn't work.
                 20           That is what Bill is really asking in a way.
                 21           DR. @lZ@RGULIES:  This is a very key question.  It
                 22 involves the whole change in structure.
                 23           One of the things that we have done in the process of
                 241 changing the review cyc--Ip. from fo-,ir to three is free a

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                 25  considerable araount of staff time from the review process and
                                                                                       I


                                                                               77

               I  sl?end inorc- tiioe in  region.
               2@           The answer to your question is this  is  an  explicit
               3' responsibility of staff to loo)r. alc what we cannot depend
               4  upon technical renologists to do. I think  it  is  quite  clear
               5 ia man can look at %.ihether or not dialysis, transplant,
               6  can be done effectively.  And he may try his best to be

               7  regional minded and may not be.
               8            The rest of it which we will not for the moment
               9  call technical review, but call regionaliza@@ion review, is
               10 something which staff will be looking at.  They will be in that
               11 region before the application is in, while it is in.  And
               12 Iciiis wil'L be b-.A-ought to your attention as a part of your
               13 understanding of what is beixtg dome in that p ogram.
               14           DR. THUPj4AN:  l@lhat is the role the committee plays?
               15 I guess we are back to that question one more time.
               16           DR. W-.RGULIES:  Not technical review.
               17           DR. THURMAN: And not  regional  review  as  you  have
               18 just defined it. So I am not  sure  what  role  this  committee
               19 plays if it doesn't play those two roles?
               20            DR. 1%9,,RGULIES: You know, a few minutes ago  there
               21 was sore Mention made of emasculation.  And  I  would  like  to
               22 respond on that because that is one of thc,,reasons we are
               231 increasing the number of women on the review committee so we
               24 won't be too deficient.

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               25            That really isn't a very good word you used before.


                                                                            7 8

                I           DP,. I,,VYLR-.  You should hii,.Pe            That

                2 goes eith(-,r sc-x.
                31          DR. MARGULIES:  That's a little broader.  it is a

                4 little better.

                5           (Laughter.)
                6           There is no evading -the fact thr@t when you are
                7 running a program as wa are which is dealing 95 percent of the
                8 time with Ragional Medical Programs and the way in which they
                9 function that you cannot at the same tima use the same processes
                10 on what is a narrow categorical project )@ind of activity.
                11 find there is little doubt but that the review co7i-nittee's role
                12 with ]-.idnc-y revi.ew dces not he@v@,-,@ t.1-ie penetration and the
                13 same Meaning as it does with triw;inual review, anniversary
                14 review, and total attention which it gives to Regional
                15 Medical Programs.  And we have been saying that now for some

                16 time.
                17          What we are asking you to do is to look at the kidney
                18 proposals in terms of the Regional Medical Program when
                19 appropriate, but not ask yourselves to be technical revie@i
                20 people and not ask yourselves to be fiscal people in determining
                21 what the actual budgetary level should be.
                22          DR. MAYER:  Leonard.
                23          DR. SCHERLIS:  I guess having started the problem
                24 this far as the discussion of consultants, I v@-ould like to

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                25 pursue that further.


                                                                              9

                 I                          listen4-iiq to yoii, Dr. Hinniar., I

                 2  see no reason for
                 3          DR. MA,VER:  Jerry, could you hand him the microphone?
                 4          DR. SCHERLIS:  l@fter listening to your comments as to
                 5 why the --egions c-hould select their own consultants, I can't
                 6 really discern the point you made.  The ni,-,re fact that the
                 7 lists change, they chaage locally as well as nationally.  Pnd
                 8 I would think if a technical review is indeed to come to us
                 9 with all of its finality, as we hav,e been told, that I  would
                 10 much prefer that the technical review be done  by  consultants
                 11 wh are indeed selected nationally.
                 12         1 see no reason for hav4-ng local option on the
                 13 Selection of consultants.  P-rd I would indicate that if the
                 14 review committee -- vihat is our responsibility?  Do  we  have
                 15 any at all?  In other words, if it goes from here to the
                 16 AdvisoLy Council, is it arsumed that,: we have made some action
                 17 upon it or do we just sort of ignore the fact there is a

                 18 kidne.v nro-posal?
                 19          The point I am going to n@ake is if we have any
                 20 action Whatsoever on this, I would find it impossible to make
                 21 such action unless the consultants are indeed appointed from
                 22 the national office and not selected  locally.  I  would  like
                 231that point pursued in soine detail.  I have rather strong
                 24 feelings about it, and I ..7ould like to either have them altered

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                 25 by your comments or carry it further to an action by the


                                                                             so

                 I  iTi i t
                 2          DR.  @@yliYER: Mac6  you  are       on thi,c, issue?

                 3          DR.  SCHMIDT:    Yes.
                 4          It seems to me there is an inconsistency in x,.,hat 1
                 5 have heard about the reason4-ng for the local people to select
                 6 technical review locally and yet have them approve somehow
                 71 at national.  There are national constraints to be placed
                 8 on the technical review process.  There,are few people to be
                 9 called upon.  They have to be expert, I would think, not only
                 10 in th-- technical aspects of the renal programs, but also hope-
                 11 fully at least something also concerning Regional Medical
                 12 PrograiT@.s and itz. purpo c@.-; in fiirdirig these.  The site visitors
                 13 have to bf-- educated at least to soxre extent be3rond simple
                 14 technical aspects of the renal program.
                 15          And the policy would be far more consistent and
                 16 understandable to me if regions could ask for people to be
                 17 placed on a national panel and Plus the national panel broaderc,l
                 18 by nominations, if you like, fro,7ci regions of experts that they
                 19 would like to see-and t"han have the technical review team
                 20 picked nationally and sent to a region.  This would be a
                 21 consistent poli@l,, at least, and @,,,Tould meet the desires as
                 22 I have heard them expressed.
                 23          And I believe as written up here, it is inconsistent
                 24 at some point.  So I wo.-ilt ask for comment.

  Ace-Fedeial Repofters,  Inc.
                 25          Againr I would like somebody to explain to ine the


                   Is,@@cond pz,.rei.grarh c.@.n 4, PL'I-ticiil@-rly villat is Iackc@nt by
                   2"Sirice kidney proT--@sais are wed s?,p@..vately at the national
                   3level," and @Linallyt '@Xic3ney proposals sliall be considered by
                   4Pj,,,PS in relation to national priorities."  And I would like to
                   5know by whom that is to be done.
                   6        DR. MAYER:  'two issue@s. let's deal with --he issue
                   7of the selection of th3 panel.
                   8        1 guess the concern that I am,hearing is a concern
                   9that is expressed on the potentiality of packing the courts,
                   10 so to speak, if the selection is made by the individual group.
                   11 I am not sure how much energy is involved in setting up the
                   12 option of the sort c-.r     -aart being arrr.,aged centrally
                   13 in the marrier %,,Thicli Leonard and Mac ha\Fe suggested.  It would
                   14 seem to me that that -rs not too great a process, and it
                   15 t@s away -- I am not saying that it Liill or will not improve
                   16 it -- at least it takes away that potent4-al question that is
                   17 going to be raised by p--oplef I think, consistently about

                   18 this area.
                   19        DR. RINI.IAN:  I have no problem @-:ith that if that is
                   20 Dr. Margulies' decision.  It would not be a major problem to do
                   21 what Dr. Schmidt suggested.
                   22        DR. MARGULIES:  I think this is a very interesting
                   23 and reasonable idea.  And if it expresses what the review
                   24 committee viould prefer, we will -Certainly bring that recoyi@rtenda-I
   Ace-Fedetat   Repotters,    Inc.
                   25 tion to the council @id discuss it with them.  I don't see it
                   I


                                                                                      82

                 I                    Fi. thing to           A.T),d 1 tl,ii.nk your points

                 2  are iiell taken.

                 3             DR. @MYER:  Jc@.

                 4             DR. BESSON: If  we  can  formalize  that,  then,  and
                 5  bring it to Council so we c&m have an opinion rendered by
                 6  Council on that question, I would like for us to do that,
                 7  Because I would like to enlarge the question from that speci-r--
                                                                                      .ic

                 8  point to the fact that that particular point is one manifesta-
                 9  tion of a much larger question that I think we should be dealinc

                 10 with. And that is somewhere  along  the  line  we  have  got  to
                 11 look at the ;,,,hole concept of RAG re@,,Yiow and local review  and

                 12 wonder whet'@-*er      isn't so,lae kind oil a buil.t-in bias,
                 13 a kind of a Parkiiison's law of m-al!.irig sure that  cxything  that
                 14 you mbmit has local RAG  ap-rovai  that  tends  to  remove  this
                 15 committees fmction of risking some larger decision about
                 16 prioties. that I see  in  the  rhetoric  everywhere,  but  the  word
                 17 "emascu:Lation"is Ivory appropriate. I  thin],,  that  function  is
                 18 being removed f.-om this  com,,nittee's  activities.  lhd  I  wonder
                 19 whether anybody is.  assuming  responsibility  for  it  other  than
                 20 someunknown,  nameless,  faceless  people  who  are  called  vague.
                 21   1  -     Maybe we ought to dispose of this question first,
                 221 Len, and then get to the larger  question  that  I  think  is  a
                 231very important part of it.
                 24            DR. II.AYER,: Would someone c@ii-e to fr@irrie a ir,,,.jtion

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                 25 relative to -- I gather the key issues are that the experts tllat


                                                                               a 3

                   are brou@,ht 4-nto the techri.4.c@.1    revic@--,q iFit -the loc,--.l
                   2level be selected by RI@IPS rather   by the individual region.

                   3Is that the essence of it?

                   4        DR. SCliE@,IS:  Yes.
                   5         I would move that item 2 on page 3 be altered as

                   6follows:
                   7         DR. 14hYER:  I think pz@ob,7@ly it is a recommendation
                   8to Council'that vie are ma-king, then.
                   9         DR. SCHERLIS:  Yes, to Co-ancil be altered as follows:
                   10 That the technical reviaii group must be comprised of at least
                   11 three renal authorities from. outside the geographic area
                   12 served by the region, said           to be appointed by

                   13 pt@IpS.
                   14         Is there a second to that?
                   15         DR. TIIURMAli:  Second.
                   16         DR. VLAYER:  Further discussionof that motion?

                   17         (No response.)
                   18         All those in favor?
                   19         (Chorus-of ayes.)

                   20         Opposed?

                   21         (No response.)

                   22         O.K.
                   23         DR. THUPJAM-.  At the r2.sk of being called dense,
                   24  could I ask Dr. Margu2,4-es to say o@-ic more time wliat our

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                   25  responsibility is.  Because I didn't catch it when it went by.


                                                                                                                                             84

                                                   DII.  F-p@RC-UL'.@ES.,    Th@,'@                                          th-%s
                               2   technical  review  is  primarily  by  exception.                                  Since  it  is  a
                               3   technical  review,  it  will be  b-,--ougl-xt  to  your                           attpntion  Lhat
                               4   a kidney  x,c@@j,3.ew  has  been  covtnleted.    if  the  reco,-LLvt@indation  is
                               5   that it meets with the national priorities which are described
                               6   in  the way  t-liat Dr.  Hinman  laid  Vnera out  and which  go  back  to
                               7   an  earlier  document which  is  e,.n  effort  to have  a national
                               8   network  of  kidney  dialysis  centers,  if  all  the  technical
                               9   requirements  are met  and  the  Pagional  Medical  Program is  a
                               10  good,  sound  program  end we  bring    to  yo@-ir  attention  the  fact
                               11  that  the  regionalization  aspec-@s  are  adequate,  there  really
                               12  isn't any need Lor you to t@-.6 &,,ct@-,.or,, cn it.
                               13                   I,,,Ihen, hoivsver, these things are not tri.-..e or
                               14  there  is  a  challenge which  is  brought  up  at  any  point  in  this
                               15  range  of  activities,  then  you  do  come  into  action.
                               16                    DR.  SCHMIDT:    Is  it  iroplied  by  that  that  this
                               17  committee  cannot  raise  an  exception?
                               1811                  DR.  MARGULIES:    The  committee  can  always  raise  an
                               19  exception.    That  is  in  the  document  .
                               20                    DR.  SCHERT-IS:    It  specifically  states  on page whateve
                               21  it  is  --  4  --  "Those  applications  for which  the  RNGE  CHP  agency
                               22  Director  IU@,PS,  or  PJ,4PS  Review  Committee  has  indicated  a
                               23  concern  apart  from  the  technical  merits  of  the  project,  the
                               24  @,@@IPS  revis-nil  Committee  .illl be  asked  to ivake  a  rec6mmei-,dation."

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                               25                     So  since  technical  is  not  clearly defined,  I  would


                I ass@ir@@- th(;,sc,,, area very   eL@ifin,,.tions of that term

                2 as far as rciisiiig e,-,i oy@-iection,
                                         .-4
                3          DR, 1,4ARGULIT-'S: @,le would think tha';- probably
                4 whole committee would not want to debate @.@hether one form of
                5 dialysis or another is betterp but you certainly want to got
                6 into the question of whether what is being proposed is going

                7 to meet the regional needs.

                8           DR. MAYER:  Jerry.
                9           DR. BESSON:  Perhaps, then, if we disposed of that,
                10 we can get to the larger question of emasculation.  And it is
                11 interesting, Phil, that at our break, I used practically the
                12                 in            @@4ith Len F.,,.bou,t i   o-f
                13 this revie@t., committee.  So I gu--ss as incorii.iig me-l-@@bers emeriti
                14 of this committee that our thoughts are not too far apart.
                15          I would like to pursue this question if this is

                16 an appropriate time.
                17          DR. 14AYER:  Could I suggest, Jerry, that that is
                18 a major, broad issue vihich I think is going to lead  appropri,--ttcl-
                19 should lead, to half an hour or more of discussion.  And what
                20 1 would like to do is to red flag it, see how we are progressing
                21 in terms of time, in terms of meeting our goals, and then come
                22 back to it, if I could.
                23          DR. BESSON:  Sure.
                24          DR.VAYER:  To get a very real red flag on the agenda

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                25 to deal with it.  Because I -,'zl-ii!,ik it is an important issue.


                                                                             86

                 I  We discussed itt as you know, at some length at the last
                 2 meeting and I think left feeling @ had made  so-me  progress
                 3 in understanding that issue.  Obviously there are still
                 4 concerns, and I think they ought to be discussed.
                 5          O.K., other items on the renal issue?
                 6          DR. HINMAN:  Dr. Schmidt had raised another question
                 7 that was never answered on page 4, the second paragraph.
                 8 And what it was referring to was the fact that other.parts of
                 9 the P14P applications are looked at as a whole and considered.
                 10 In other words, when you review any one of the ones that are
                 11 here today, the RMPS discusses as a whole, but the kidney is
                 12 notdiscussed w.-6th t"%a-I.- application.  And that is what those
                 13 two sentences refer to -- the first sentence.
                 14         The second  sentence refers to the attempted process
                 15 to prevent having an application that is.technically
                 16 meritorious passed in by a RAG, but does not reach toward the
                 17 goal of regionalized kidney resources throughout the country,
                 18 i.e., several regions are further along in provision of
                 19 treatment facilities than other regions.
                 20          It would seem that the regions that do  not  have
                 21 these facilities should have a higher priority than a screening
                 22 program, for instance, in a region  that  already  has  the
                 23 treatment facilities.  A treating program may be very meritorious
                 24 but it is one of the ones that are not a topic of priority

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                 25 list until we have the country better covered with facilities


                                                                           87

                I  for the treatment of end staga renal disease patients.
                2          DR. 14A'IMR:  Other comments on the renal issue?

                3          Sister?
                4          SISTER ANN JOSEPHINE:  May I ask a question?  I
                5 notice on page 3 at the botto@-ii v.,hich says, "Forwarding
                6 proposals," it indicates the technical review committee and
                7 then the RAG and,then the CHP agency.  Would there be any merit
                8 in having the Division of Internal medicine of the Medical
                9 Association in its appropriate committee make some comment on
                10 this?  If the majority of the renologists were in the Medical
                11 Association and in practice and werenlo@- with the particular
                12 group who were svbn;,,itt4-rg tli,-a proposal, I would thank that
                13 their input would be rather significant in a case like this.,
                14 And this  would be by exception, probably.  I don't know.
                15          DR. HINMAN:  Sister, the proposals dealing with
                16 transplantation, dealing with children, would not fit under
                17 internal medicine.  Proposals in which a large element is
                18 public education, again., there would be other groups that would
                19 feel they should have the sair.- right to comment if it is
                20 given to a single part of the Medical Society group.
                21          SISTER ANN JOSEPHINE:  I would like to tl,-inlc that
                22 all the children would be the same, just by pediatricians.
                23 But this is truly not the case.
                24          DR. THURMAN:  The majority are not.
  @ce-Federal Reportefs, Inc. SISTER  ANN  JOSEP.HINE: Realistically, they are not.
                251


                I          DR. I.IAYER: other cop.Lzr;zints?
                2          DR. HIN@IAN:  I would like if there are no comments
                3 about kidney in general to get down to kidney specifically.

                4          DR. 14AYER:  All right.
                5          DR. HINMAN:  There are nine regions that have
                  applications containing some element of kidney involved in
                7 them, eight of which are in your folder and one which is
                8 outside, There are two types of applications before the blue

                9 tab and after the blue tab.
                10         Before the blue tab, the first region having an
                11 application is Nassau-Suffolk.  Nassau-Suffolk has submitted
                12 t@io requests for ki(L-isy activities.
                13          The first is a donor program.  And the purpose was
                14 to  procure cadaver kidneys from at least 24 donors each year
                15 from seven named hospitals in vihich there is a physician

                16 committed to the program.
                17          The application further states they are working with
                18 Metropolitan New York and New Jersey in an effort to design
                19 a tri-region 910 application for organ procurement for the
                20 entire area, but that pending the negotiation between the RAGS
                21 and the staff and the individual RmPs, they would like to get

                22 started.
                23          The total amount requested was $27,060 for the first
                24 year.  This would be used to develop and train procurement

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                25 teains.


                           DR. IIPYER:  Let's sCO if I am clear on where we are,
                   2Are we going to 90 through the renal applications separately
                   3at this point in time?  is that the intent?
                   4       DR. HINMAN:  Yes, sir.
                   5       DR. MAYER:  All right, I guess I need to be referred
                   6to what kind of material and where is it in the mass that I
                   7may be making reference to.
                   8       DR. HINMAN:  Well, there-are some comments in the
                   9Nassau-Suffolk on a white sheet, I believe, not having a

                   10 folder.
                   11       They are there, I see.  It is right behind the yellow

                   12 one in Nassau-Suffolk.
                   13       DR. MAYER:  Could I juc-t make sure the Committee has
                   14 where we are?  Nassau-Suffolk, white tab, March 31, 1972t

                   15 Post-Mini SAU
                   16       DR. HINMAN:  Of the nine regions with kidney request,-=--
                   17 using the general guidelines Dr. Margulies had laid down,
                   18 eight of them are for your information.  One of them is for
                   19 your advice and recommendations.
                   20       Nassau-Suffolk is in the- former group.  In other
                   21 words, my comments are informational to the review committee.
                   22        Unfortunatelye as I also indicated a little earlier,
                   23 some of these decisions were arrived at during this week so
                   24 @Lhat the supporting -,iaterial is not at the level that would be
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                   25 desirable either by my staff or by the review committee.  We


                                                                             90

                   1are still going through what has been Icnov,;n for the last
                   2several months as the transition period.  And I would hope that
                   3by the next L-neeting of this groupt there will be tabs and
                   4information that are easier to refer to than what you  have

                   5today.
                   6        This part of the renal, organ procurement  program
                   7              . locally and approved by the RAG.  The staff
                   had been reviewed
                   8revieo concurred in the reviews and is recommending approval
                   9of this part of the application.
                   10       The second part of the application, a home dialysis
                   11 training program, the stated purpose was to develop 50 validated
                   12 modular single concept lessons for home dialysis.  And in loolci g
                   13 at this part of the programme the investigators did not seem
                   14 to be aware of the fact that there were several home dialysis
                   15 training programs throughout the country that  had  already

                   16
                   succeeded in doing this quite t@iell. They were  requesting
                   17 $31,200  for this, and it was the recommendation that this be
                   18 disapproved and not funded and strong advice back to the region
                   19 which, incidentally, had been given to the region nearly a
                   20 year before,, that in home dialysis training programs names of
                   21 individuals who knew how to do it and advice to them as to how
                   22 to go about it, and they seemed to have ignored this.
                   23        DR. BESSO'ii:  Mr. Chairman, are we going to be talking
                   24 about these individually or are we talking about Nassau-Suffolk

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                   25 now?


                                                                            91

                 1         DR.IIIN14AN:  No, Sir.  I w,-,,s requested to present
                 2 @ sequentially in an abbreviated fashion the nine kidney
                 3 proposals that are in this review cycle.
                 4         DR. BESSON:  Will tli,ey be reviewed as part of thr--

                 5 regional @---eview?
                 6          DR.  HINMAN:  The reason for bringing them up ahead
                 7 of time is so when you did get -Lo Nassau-Suffolk, for iLstance,
                 8 you would already be aware of vThat the recommendations were

                 9 on it.
                 10         DR. BESSON:  They might be a little bit more in
                 11 context. Excuse me, Dr. Hinman, but I find myself not really
                 12 listening to what you are saying because it is totally out of
                 13 context with what our job is @,yhich is to look over individual
                 14 areas in the context of everything that is happening here.
                 15         Now, maybe that is rwl own inadequacy.  But I just
                 16 mention that.  If this is the procedure that is going to be
                 17 established, fine, we will do it.
                 181        DR. HIN14AN:  Whatever you all want.  I have no

                 19 vested interest. -
                 20         DR. BESSON:  I would rather look at Nassau-Suffolk
                 21 in context so we would know what is happening there.
                 22         DR. MAYER:  Yes,, Mac.
                 23          DR. SCHMIDT:  Bill, I believe strongly that castrated
                 24 is as castrated does.  I support Jerry and believe these should

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                 25 be looked at as we look at the regions.
                   I


                                                                            92

                            DR.  14P.YEI':  C).K.  is that t-lie constlnstiS of the

                 2 committee
                 3          I would feel more colifortr@le. That is why I  asked
                 4 the question what is it that we are doing at this point in

                 5 time.
                 6          DR.  HINI@,.N:  Before I relinquish the chair --

                 7          (Laughter.)
                 8          -- my staff assures me these items I  distributed
                 9 during the break were indeed mailed to the committee members.
                 10 one of them is a package dated February 25, 1972, and is the
                 11Iguidelines for the EDYS applications that Dr. Scherlis or Dr.
                 12 Bc-ssoii, I am not sure    -.,.eferred tr@.
                 13         And the other is a series of three documents, oiie
                 14 dated March 13, one dated March 15, and one dated April 7,
                 15 that were sent out concerning the community-based manpower
                 16 development program.  This was mailed just Tuesday night.
                 17 That is why many of you probably did not receive it.  We
                 18 distributed that a little earlier.
                 19         DR. 14AYER:  I would be delighted to talk to whoever
                 20 your staff is who has got some validation that this  material
   0             21 was mailed.
                 22          DR. HIN14AN: Believe me, as confusing as  things
                 23 have been, I cannot be certain.  T'nat is why I gave them back
                 241, to you.
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                             DR. PAIIL: Well, we r)n the committee apologize  if
                 25ii
                   11


                                                                              ci

                    I         materials v;er@z! not i,.iLiiled or- ,i.@,.ren't !rufficien@cl.y
                    2identified.  And all we can p-Iead is that it has been somewhat
                    3hectic.  But if you havenit received it, it is really
                    4inexcusable.  So we do apologize.
                    5        DR. MAYER:  Other items, Herb, that need to be
                    6brought to the corz-ni-ttee's attention?
                    7        DR. P-&(iL:  I think the only one point which Dr.
                    8Margulies wanted me to mention which is,a very pleasant duty
                    9is an appointment which has been made between  the  time  that
                    10 you last met and this meeting.  And that is that Mrs. Judar Silsleo
                    11 is the Deputy Director of the Division of Operations, working
                    12 closely with tir, Chai-,bliss. Aind in the press of all of the
                    13 business we have been discussing with you, I think we forgot
                    14 to mention this pleasant duty.
                    15        So Mrs. Silsbee has changed hats and is functioning
                    16 as Deputy in the Division of operations these past few months.
                    17        Nothing other than that, Bill.
                    18        DR. THURMAN:  Is she to be congratulated or pitied?
                    19        DR. PML:     I almost prefer not to ask her.
                    20        DR. MAYER:  I need to have before we move forward
    0               21 an Opportunity to comment on the order in which we take these
                    22 because of people's presence, absence, etc.  Two problems that
                    23 1 am aware of relate, fortunately, in  what  is  an  un-unholy
                    24 alliance, and that is Northeast Ohio and Ohio, both Sister Ann

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                    25 and myself.  I am not going to be able to be present tomorrow,


                                                    ic@@iinq Oll'of 1 would like to
                   1so sometime todayt s4nce I am rcv
                   2have the opportunity of taking that onp- up as primary reviewer.
                   3And that is very intimately linked -- well, that  is  the  wrong
                   4statement. It ought to be, but  isn't  intimately  linked  to
                   5Northeast Ohio.  But the discussion ought to go on back to back,,

                   61 think, on those two.
                   7         Are there olcber specific problems?
                   8         John Kralewski will be in  hopefully  this  afternoon,
                   9and Dr. Brindley ought to be in this afternoon  to  pick  up.
                   10        is there anyone else with problems?

                   11        Phil?
                   12        DR. VJHIT-Q:  I must leave' by noon tomorrow.
                   13        DR. 1411,Yl,;R:  Hall, if there are no other major
                   14 conflict time scheduling problems, then what  I  would  propose
                   15 to do would be to start out with the tri enniali.  ceview  of
                   16 Oregon wh.,.ch has been site Visited which Dr. White does have

                   17 responsibility for.
                   isl        Phil, it is all yours.
                   19         DR. WHITE:  One is supposed never to preface comments
                   20 with an apology so I shall not, but I  would  like  to  explain
                   21 something to you as ray presentation may be less than sparkling.
                   22 It relates to an experience which was somewhat distressing
                   23 which has left m distraught and discombobulated.  It is a
                   24 comment on our health care system which perhaps  P,14PS  may

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                   25 eventually influence.


                I          Tuesday, I ar--ived in D@@-Lroit bec-,,tise n;P father-iri-1w@
                2 broke his hip. This is not why I ai7ri,ved in Detroit, it is

                3 why I went to Detroit.
                4          He was taken to a local hospital at 4:30 in the
                5 afternoon.  At 10 o'clock or shortly thereafter, he was
                6 finally put in bed.  He in the meantime occupied a corridor
                7 along with a nuir-@r of other elderly gentlemen who were also
                8 apparently emergencies of one sort or another.
                9          And I thought this was appropriate in @iew of the
                10 emergency system which is being discussed.
                11          In the course of his experiences there, he was taken
                12 iii,, tc, Y.-i:,ay, presumably because this is essential to ti-,e
                13 diagnOS4.S of a brol@en hip or at leas@t helpful.  'Klliil.e there
                14 he had an urge which perhaps relates to the renal problems we

                15 have been talking about.
                16          To my surprise, there was no urinal anywhere in that
                17 vicinity, and no one who seemed to have the authority to
                181 indicate where one could be procured.  So I went down to the
                19 emergency room myself.  And being familiar with hospitals, knew
                20 that they would usually be in a closet and procured one ana
                21 took it up.  Someone was a little aghast that someone without
                22 a white coat was carrying a urinal around.
                23          While up in X-ray, during tihich time we saw very
                24@ few people, one of the other elderly gentlemen  there had a
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                25 cardiac arrest.  And suddenly, all of the doctors which were


                                                                             9 6

                   my,-,t;erio @lv missing r.,r-,.Or to this eve,-,it appeared and very
                   2fortunately saved the man's life or at least got his heart
                   3going again, following which they stood around and discussed
                   4their triumph for the next hour.
                   5       The point of this @ihole discussion is that it was
                   6my first nersonal experience, I guess, as semi-pati.ent,  But I
                   7stood there for all those hours with my father-in-lavi.  I did
                   8not identify myself as a physician.  I c-m hopeful that it
                   9wouldn't have made any difference if I had.
                   10       Finally, an orthopedic surgeon did arrive on the
                   11 scene.  It is still a mystery to me, however, exactly what his
                   12 decisions are.  He did not deicjrs to talk to t-he fa-mily.  He
                   13 discussed it with my -F                in no position to
                                                     who was
                   14 understand the discussion, what the process was going to be.
                   15       The point of my comments, I guess, is that I hage to
                   16 see large contracts being issued for emergency care systems
                   17 which emphasize the technology without equal emphasis on the
                   18 human elements that must be considered in our emergency care
                   19 process these days.  But this has disturbed me because I am
                   20 a physician, and I don't like to see physicians behaving that
                   21 way.  And I haven't been able to get it out of my mind.  And
                   22 I will Probably write a. nasty letter to the hospital administra c
                   23 and never be able to show my face in Detroit again,
                   24        And I am not picking on Detroit, Joe.

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                   25        (Laughter.)


                                                                               97

                I            Be that as it may, in Larch we did v@41sit the  Oregon

                2  Regional iledical Program.  And Dr. Thurman was with us as well

                3 as Mr. RUssell and Mr. Moore.  And  I  understand  Dr.  Blomquist

                4 isback there today looking at their ],:idney program.

                5            There has been a turnover of  coordinators  in  this

                6 region over the years.  I think this is, what, the fourth

                7 different coordinator. And the present  one  has  been  on  board

                8 something about a year.

                9            In the past, the activities of the Oregon Regioi-ia"@

               10 medical Program were largely educationally oriented.  They had

               11 circuit-riding teams going  about  talking  about  eart,  cancer,

               12 find stroke.  They had coronary care training units and

               13 other similar educational activities.  They have run understanding

               14 of the new mission of the  Regional  medical  Program  Service
               15 and have adopted objectives and goals which seem consonant with

               16 those which have been suggested from Washington.

               17            They have involved their  regional  advisory  board,

               18 as they call it, in this planning for  the  next  three  vears.
               19 And it seemed to us that they were  deeply  involved  and  did
               20 participate. Their  staff  is  involved.  And  Dr.  Reinschmidt

               21 who is the new coordinator is a seemingly  capable  man  who  has
               22 spurred them on to changing their  goals  and  objectives  and

               23 to participating in the development of these goals and

               24 objectives.

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               25            They are, as you can imagine, related to improving


                                                                               98

               I  accessib-,-Iitv of primary health ser-vices, improving the
               2   quality of care arid containing tl,4e costs, which are  those

               3   which are relevant these days.

               4             They felt that these were in keeping with the
               5   national guidelines and goals and were  relevant  to  the  needs

               6   in  Oregon.
               7             They had different rrp-thods by which  these  goals
               8   were to be achieved.  They had different subsets of objectives

               9   and goals which related to the primary ones.

               10            We felt in reviewing this  program  that  they  had
               11  given considerable thought and were  realistic  in  their  plans
               12  and -@-n tj'ie adopl--ion of these goz@,ls arid oL-jecti-;,,-es.
               13            The one perhaps weak area would  relate  to  the  fact
               14  that their health data were weak, that there was some intuitive
               15  process involved in the development of their goals and
               16  objectives although it  would  seen  unlikely  that  Oregon's
               17  problems were greatly different from those of the rest of the
               18  country.  Nevertheless, it was recommended that some effort be
               19  undertaken to strengthen their data base so that they could
               20  indeed determine whether or not their new activities would have

               21  an impact on the problems in Oregon.
               22            In the past as I mentioned, they have emphasized
               23  educational activities.  Nevertheless, they were also very
               24  active staff people, and they were  out  stirring  up  interest,

  @ce-Federal Reportets,  Inc.
               25  developing relationships, and a highly qualified and dedicated


               I   sta@L-f had been developed.
               21           There needs to be a continuing effort to relate to
               3  the community so that the now ORMP goals are more completely
               4   understood and accepted by the community and so that the
               5   community will have c-m understanding as to how they can best
               61  use the Oregon Regional medical Program,,  This is in the
               7   planning stages.' This is in themind of Dr. Reinschmidt, and
               8   he has plans to increase the staff with this in mind.
               9            Some of the projects that have been undertaken in the
               10                             They have attempted to develop
                   past have been phased out.
               11  other funding for these, and indeed, in the acceptance of the
               12  project, there is clear               t@,h,-itl: funding, by R.IIP
               13  will be discontinued at the erd of tlirc,@e years.
               14           In some instances, at least, some of the projects
               15  have been taken over by other funding mechanisms. Some of the
               16  educational processes for example, by tuition payments or
               17  underwriting by some of the institutions benefiting from the
               18  educational activities.   Not all of their projects have

               19  continued, however.
               201           You might note in the printouts on the management
   0           21  assessment sheets that there is some sharing of project
               22  funding by other sources. In contrast to Kansas who said 100
               23  percent of the projects were funded by P@IPS money, you will
               24  note that there is a variable Percentage in Oregon,

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                             We looked at the minority interest. It is interestin
               25


                                                                          100

                                                              the niriorit@:Y
                   Ito notes however, there o-rr;nlt people
                   2  in O:cegan.  or at least those who are in minority groups don't
                   3number very large.  So it ties been difficult for them to get
                   4equal or proper representation on -Uie decision-yraking bodies
                   5in the Oregon Regional Medical ProgramL. Nevertheless, it
                   6was recommended that they undertake more strenuous searching
                   7for representatives f.-om the migrants, the Indian population,
                   8the blacks, and the other minorities to see if they could not
                   9entice them into serving on their bod4@s.
                   10      Ile wereimpressed by Dr. Reinschmidt as an extremely
                   11 capable coordinator. He seemed to stimulate his staff. He
                   12 was obviously a m@ with iraginati.on.  He was de-,re loping nei-i
                   @13 ideas. Ile was able to infect his staff Keith a certain degree
                   14 of enthusiasm. We think also that he had convinced the
                   15 Regional Adviso--y Board that new directions were appropriate
                   16 and that they should be tmdertaken.
                   17       He had developed close relationships with the Oregon
                   18@ Medical Associationt and he seemed to be accepted not only Joy
                   19 his own staff and-Regional Advisory Board, but by other members
                   20 of--bther health organizations in the State of Oregon. He
                   21 needs help, however. It was one of our re@iRtmendations that
                   22 he seek a deputy coordinator or someone to assist him.
                   23       The core staff is made up of professionals. We
                   24 reviewed each person's           We asked them to outline

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                   25 their background and      for us. It seems that they were


                                                                               101

                    1all cappl,)).e people.  They work hard.  TI@).r@,y have d-finr--,d areas
                    2of responsibilities.  And we xio,@,iced that some of the core
                    3activities may have bean limited in the past because of budget
                    4restrictions.  And Oregon shows when cuts in budget came about
                    5not to penalize their projects or program activities,  but  rathe3
                    6to cut back on core support.
                    7        So we would recommend to Oregon that if the funding
                    8is approved by this body and Council that steps be undertaken
                    9to strengthen their core, not from a quality  standpoint  so  much
                    10 as from a quantity standpoint.
                    11       The regional advisory body was represented in force,
                    12 Th----C@, wer@, a ni@,.-ber of       here who were  stal,@qarts
                    13 w.-tCi sat through the whole tx,@o days of the site visit, often
                    14 making comments but at least by their presence indicating

                    15 support.
                    16        We are told that the attendance at their meetings is
                    17 good.  They have indeed as you will note in title site visit
                    18i report dismissed certain members who attendance was not good

                    19 and replaced them.
                    201       We had evidence that the members of the Regional
                    21 Advisory Board are serving on committees, take an active role
   0
                    22 in the assessment of programs and projects.
                    23        We did note that there was a  dearth  of  allied  health
                    24 people on this committee and recoitutienr-led that they look into
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                    25 that,


                                                                            102

                 1          There are no probleris to speak of with the grantee
                 2 organization.  The University of O-ctgon School of Medicine
                 3 is that organization.  It adopted a h(c-inds--off policy from the
                 4 very beginning, acting only as the fisca.,l agent,  and I tl-iirik,
                 5 Dr. Pahl,completely conforming to the guidelines @vhich you
                 6 read to us earlier about the relationships between a regional
                 7 advisory group and grantee organization.
                 8          We did note one problem in that the salary scale o
                 9 the University of Oregon School of Medicine was lo,,ti.  Dr.
                 10 Reinsc-limidt has had some difficulty in recruiting certain
                 11 kinds of people to his staff because he is not competitive.
                   Thev are examining the              that. are available to them,
                 12
                 13 aid they may choose to go to the route of aui independent
                 14 corporation.  However, the services provided by the University
                 15 have value, and tl-,ey do not want to undertake this change
                 16 light.!-y.
                 17          We recommend that tlir-,y do give this serious thought
                   and look at the alternatives available to them.
                 18
                             During the site visit, we had a number of presentatio@ys
                 19
                 20 by other people from other health agencies, including a number
                 21 from the CHP B agencies, volunteer health associations,
                 22 Model C4-ties people, the president of the State Medical
                 23 Association, and so on.  It was apparent that there was
                 24 cooperation and participation both by the RMP in those
  Ace-Federal Reporters,  Inc. activities and by them in RMP activities.
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                                                                              103

                            The PIIP ard the Oregoii Mc-dicn,). Association are and

                2 will cont4.nue working closely together to develop a  peer
                3 review system or some other quality assessment system  that  is
                41 pertinent to the needs of Oregon. To some  extent,  through  the
                5 efforts of o@, there had already  been  developed  by  the
                6 Oregon medical Association a requirement that their members
                7 take certain hours of post graduate education in order to be

                8 eligible for membership in that body. And  indeed  I  have
                9 forgotten the exact number -- I think it was 11 -- members

                10 of  that society had been dropped from membership because

                11 they failed to meet these requirements.
                12          I--. was apparent,      tl-iE@t the ikgen(-:Les in the oregor

                13 region c,-:;.).lccl upon the OIUIP for e@cperti,se and --dvicc-, and

                14 assistance, although perhaps there was a need for them  to  more
                15 clearly understand what ORMP was all about.  And we recoranended
                16 that there should be further elaboration of ORMP's role  to  the

                17 other health agencies in the area.
                18          There are comprehensive health planning  agencies  in
                19 Oregon. There is a CHP statewide organization. Not  all  of  the
                20 B agencies are functioning well.  However, there is a close
                21 relationship between what does exist in the CHP and  the  ORMP.
                22 They abide by the policies which require joint review and

                23 comment where applicable.
                24          I referred earlier to the fact that there was a

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                25 relative lack of hard data in ter-ins of health needs. And  they


                                                                            1 0

                   unders6,--and this.  Thev ha-,Fe established what is called a
                 2 needs assessment uni-t as part o'@ their new organi-.ational
   Is            3@ structure.  And this presumably in coop.@2@ation with the
                 4 health resources unit in the CHP agencies where they exist in
                            'll be undertaking some studies of what is necessary
                 5 @ie area wi
                 6 in Oregon to develop a quality health care system, not just
                 7 only from the standpoint of defining where there is a lack of
                 8 anything, but perhaps more from the standpoint of the provider
                 9 defining what needs to be done, what process should be under-
                 10 taken, to meet the needs.  This needs assessment committee
                 11 will overlook and guide the development of, they tell me,
                 1 217 di-f fe,-,ent gro@ps acourkd tJ,,e Stat,(@- c)f r@hysici,,ins,
                 1 3  I think 12 or 14 nurse groups of a similar type.
                 14        They  will be directed by coordinators.  It will be
                 15 their responsibility to determine and define what is required
                 16 in a particular area of the State.  We felt that this was a
                 17 healthy change of direction.
                 18@        We have little or no question about the quality of
                 191management of this region.  The staff was good.  As I mentioned,
                 20 the fiscal agent was good.  We found no evidence that there was
                 21 any problem with the way they managed their funds or kept a
                 22 handle on what was going on in the region.
                 23          However, related to this was the evaluation process..
                 24 1 guess there have- been som3 problems here in the sense that

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                 25 with budge%-. restrictions, Dr. Yagi was put on half-time rather


                                                                          105

                                                   -vy, Ile wi 3
                I than @eul'L time as an eval-.vator.  No   .L be goi.r@g b ck
                2@ full time, presuming this contmittects favorable review.
                3         Pnd we suggested that they need to look at some
                4 other kind of evaluation.  They haNre been looking at process
                5 evaluation rather than evaluation as to v7,hether they have
                6 achieved their goals or objectives.  znd I guess as somebody
                7 has said, they have an H & H type of evaluation process, a
                8 head count and a happiness index sort of evaluation.
                9          Dr. Yagi, hov-ever,- seemed a capable sort of person,
                10 well organized, disciplined man, and we are hopeful that
                11 something more will come from his full-time employment by the
                12 Oregon Regional 1-4adi-cal Prograill. Wa are continent tllat- e
                13 will develop the technic,;,,ic-s a,-pnrol)riate to assessment of
                14 their achievement of goals and objectives.
                15         Well, the action plan, I need not go into a great
                16 deal more because I think I have covered it to some extent in
                17 lay previous comments',  They are developing projects Vnich will
                18 be pro-ramroatically oriented. which will be consonant with
                19 their goals and objectives.  They are, indeed, looking at some
                20 of the needs.  They are, I thinlc, action oriented.
                21 @       We did have one question about action, and I giiess
                22 that relates to funding.  You may note that in their request,
                23 they have asked for growth fvmds. We had a little bit  of
                24 difficulty grappling with this because I wasn't clear in my

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                25 mind at the onset of the difference between growth funds and


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                I  developmental funds.  t-,;nd I @ul        little uncomfortable

                2  about tliist but it ap
                                        @pear.@,3 th-at they- have projects and activities
                3  in mind which were not at the tiiTe of this review fully
                4   developed and, therefore, they we,,-e not aware of the specific
                5@  budgetary needs which would be relevant to these projects
                61  which they will undertake.  They are asking for growth funds
                7   to support these'specific types of projects,,vzhereas the
                8   developmental funds are those which can@meet needs which
                9   cannot be clearly defined at this point.
                10            They feel that the growth funds would relate to their
                11  being -.bl-e to develop prir,.iary entrance clinics in rural and
                12  renw-c areas, fc-jqily pract4-ce cl4                  d   remote
                        .1                                  iii urLdc-r-,erve
                13  areas, and a television riat@viorl,,.  11 ving had some experience
                14  with television networks, I was not terribly enthusiastic
                15  about in a sense giving them a blank check.  But after
                16  discussing this with them, they did seem to know that  there
                17  are drawbacks to television networks, that they are'not  the
                18  an                                              o ld  iew the
                    zlitome of educational processes.  And they w u      v
                19  television networl-@, in Oregon as more of an informational
                20  exchange mechanism which would permit doctors in remote,
                21  inaccessible areas to communicate back and forth and to
                22  demonstrate their problems with patients to more knowledgeable

                23  or resourceful people.

                              It in y
                24                    be a rr,.e@Aod v,,-hich we have -tr-@p oved -n other

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                25  areas for getting expertise into remote region by a


                                                                           107

                 I technological p,k:o@-ess ra-th-@r tl7tan by -tr,@.-iisi)orting the

                 2 patient or the expert.
                 3          The fam4,ly practice cliiiic was also a little bit
                 4 nebulous, I felt, in the sense that they were presuming that
                 5 with appropriate financial unden; riting, they could establish
                 6 f  ily practice clinics in areas vihere doctors had not
                 7 previously chosen to practice.  @ reminded them that Sears
                 8 Roebuck had not had favorable experiences along these lines.
                 9 They felt that perhaps this was more than just building a
                 10 building for someone to practice in; that they were going to
                 11 make an effort to develop teams to locate in these areas.
                 12 @id if -lai4-s is       t@@ian thiL @-jould seem to ba appropriates,
                            You may recall thirAt in t,:ie Journal of Medical
                 13
                 14 Education a few months ago, and I can't remember the citat on
                 15 specifically, there was a study of why people left practice
                 16 in rural areas.  And it was clearly related to the fact that
                 17 doctors feel lonely when they are by themselves and that they
                 18' do  need some kind of health professional team about them.
                 19 And if the oregon.Regional l@tedical Program can indeed generate
                 20 teams in remote areas, it might be a worthwhile experience.
                 21          So it is with reference to these sorts of activities
                 22 that they have asked for growth funds.
                 231         We feel that the Oregon Regional Medical Program is
                 24 strong.  We feel that with some of these projected activities,

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                 25 the development of the needs assessment unit and the health
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                   Iresourl-l-l@-s unit, that the         of @@ core, there will
                   2indeed b-- improvcy,-ex t in thc-,-Lr proarc,,ms and projects.
                   3        I shall not, i t,hir@%-, go further at this point and
                   4simply indicate that in general the team was iinnressed that
                   5this was a good region and that it was.iT,,aking attempts at
                   strengthening regionalization, that iti@is trying to reach out
                   7into the totalit@ of the State in spite of the fact that about
                   870 percent of the population resides in Willamette Valley.
                   91 Pnd I would like Dr. Thurman to make some comments at this
                   10Itime if he wishes to do so before we talk about the funding.

                 -11        DR. MAYER:  Bill, comments?
                   12       DR.THUI@i2Ui:  Thc-r-e. is little to sciy.  I agree Keith
                   13 everything that Phil has-said. I thirk one of our major
                   14 concerns was that core staff is too small to do particularly
                   151 with the new thrust job that they are trying to do.
                   161      We were all impressed with one new man that they
                   17 had added recently and how much tim-. he is spending on the

                   181 road and bringing things in.
                   19        I would underline one po,%nt that he made and that is

                   20 that their coordinator is so strong that if he had a coronary
                   21 tomorrow, they might be in trouble really because there is
                   22 no depth.  So that all of us brought over to him again the
                   23 business of needing a deputy coordinator to pick up some of

                   24 these th.i.ngs.

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                   251       I think the oi,".'-y other two points I would underline
                   I


                                                                                              109

                    it

                       about  @.@hat  Phil  said  was  that  thc,@y  really  don't   understand
                    2 1 what consumers are or have not understood what cc)nE,,-Ilmc-.,Cs are
                    3  and had not made a truly honest effort despite the fact that
                    4  one of their core staff was specifically assigned this
                    5  responsibility.   I believe that our site visit was very
                    6  useful to them from that standpoint and that they understood
                    7  what  we  were  trying  to  say,  they  thought  we   were   sayinq   it
                    8  reasonably  nicely.  And  I   believe   that   they   intend   to   move

                    9  on  with   that   relationship.
                    10            The  other  point  was  the  one  he  made   about   a   fair
                    11 amount of their money goes to help develop programs for
                    12 other agencies.  And despite tJiatt      .there are a great many
                    13 people who do not see any visibility foL- the Oregon Regional
                    14 Medical Program.  Dr. Reinschmidt recognizes this.   I am not
                    15 so sure that he ),.nows how to correct it.   I am not so sure that
                    16 anybody knows how to correct it.  But it is interesting how
                    17 well he has done with his money in helping other people get
                    18 their programs off the ground.  But it has not provided the
                    19 visibility  for  IU4P.in  Oregon   that   it   might   have   otherwise.
                                   I  close  all   tha         ing I was very im,
                    20                               t by say                        ,Dressed with

                    21 this     program.
                    22             DR.  MAYER:    Mr. Moore, do you have additional comments?

                    23
                                   MR.  140ORE:   14 o.
                    24             DR.  1-iA@YEP.: Phil, your rF-irommendatio,.i?

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                    25             DR.  IIHITE:   Well, as I mentioned, the major problem


                                                                            110

               I  was this growth fund.  You may note that they were asking

               2  in the second year for $775,000 worth of growth funds.  That

               3  is a lot of growing.  And it appears to me that this is an

               4  unrealistic estimate  of their needs.  And I think the site

               5 visitors felt that.

               6           There were things on thehorizion -- these  television

               7 systems, the family practice clinics and so on, which will be

               8 coming to fruition in the near future.  And some funding will

               9 be required, but it seemed improbable to us they would be

              10 able to spend that amount of money that quickly.

              11           We recommended therefore, a reduction in this to

              12 about $250,000 for each of the second and third  years4  They

              13 did not ask for developmental funds the first year, so we  have

              14 recommended they get what they asked the first year; that  each

              15 of the second and third years they get reduced growth funds

              16 plus their developmental components and instead of $1,588,000

              17 the second yeart we Ihave.recommended $1,063,000,, the third

                 year in contrast to $1.6 million, we recommended $1.52  million
              18
              19           DR. MAYER:  That is in the form of a motion?

                           DR.WHITE:  I would move the adoption of that.
              20

                           DR. THURMAN:  Secon
              21
              22           DR.MAYER: Questions or comments by  the  committee?

                           DR  HINMAN: Do you want me to comment on  the  kidney
              23

                 now?
              24

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               I           DR. HINMAN: Because that is included  in  that.

               2           DR. MAYER:  The only reason I didn't mention it was

               3 simply because I had heard somebody say that there was somebody

               4 out there today.

               5           DR. HINMAN:  Part of this application from Oregon
               6 includes a cadaver organ procurement application.  At the time

               7 that the CHP A agenc
                                     ,y established its health plan for the
               8 State,, kidney was a major activity and was a well-outlined
               9 plan for entry points into dialysis and to transplantation
              10 which  design was accepted by the Governor,  Parts of it,
              11 particularly the dialysis aspects, have been  implemented

              12 to date.

              13           Their application requests funding to enlarge organ
              14 procurement activities throughout the State, particularly in
              15 this valley right here where most of the population.resides
              16 and in which there is an interstate highway and a lot  of
              17 carthage on the road.  So that the availability of organs

              18 is right in this particular area,
              19           They also are requesting funds to expand  their
              20 transplant capabilities.  The VA hospital in Portland has been
              21 approved to increase its transplant capabilities.  It is targeted
                 to procure sufficient organs for the needs of all the residents
              22
              23 in the State, both the veterans and non-veterans.
                           This was reviewed locally by the RAG and by a
              24

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              25 staff group.  There was some concern about some of the budgeta


                                                                               112

                I items and recommendation was made that a  consultant  visit  the
                2 area, And today was the only day in  which  we  could  arrange
                3 to get more than one of the transplant surgeons  who  has  had
                4 extensive experience  to go up.

                5           There were  a couple of areas in terms of equipment

                6 in their planning and in some of the fee items  that  we  felt

                7 should have comment from someone outside the region'     So we

                8 do not have an exact dollar recommendation.  It is our

                9 anticipation that Dr. Belcher will recommend  that  the  program

              10  be approved as it stands, but with some negotiation of the

              11  budget items.

              12            so that in your motion, Dr. white* since it does

              13  include the kidney dollars as requested, if it is acceptable

              14  to allow some scaling down of that, depending upon negotiations.

              15  going on today.

              16            DR. WHITE: It is acceptable to  include  that  in  the

              17  motion as far as I am concerned.

              18            DR. MAYER:  I gather the site visit team   from  the

              19  comments in-the report had no concerns about the kidney proposa3.

              20            DR. WHITE:  We didn't look at it in any great detail,

              21  anticipating that someone else was going to do it for us.

              22            DR. HINMAN:  Dr. Blomquist from our staff was a

              23  member of the site visit  team and talked with the investigators

              24  before the site visit.

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              25            DR. MAYER:  Comments on the motion?


                                                                       113

               I          Jerry?

               2          DR. BESSON:  Phil, do I understand then for this

               3 fifth year, you are recommending no growth funds?

               4 -        DR.  WHITE:  Nop we are recommending growth funds,

               5 but substantially reduced from their request, Jerry.

               6          DR MAYER:  Not in the fifth year.

               7          DR. WHITE:  They have not asked for them in the

               8  fifth year.

               9          DR. DESSON:  I see,

             10           In this summary sheet of what they plan to do with

             11  their growth funds -- Oh, I seet they have just begun with the

             12  sixth, used for the sixth year.

             13           DR, WHITE:  Yes.

             14           DR. BESSON4.  In reading at least your reiteration

             15 of their goals and priorities, and you mentioned the holy

             16  trinity of cost containment,the quality improvement, and what

             17  was the third?

             18           DR. MAYER:  Accessibility.

             19           DR.  WHITE:  Accessibility.

             20           DR. BESSON:  Increased   access to care   that

             21  they have some money set aside in their growth fund for the

                 additional funding Of the establishment of a peer review
             22

             23  organization on a statewide basis.  $50,000 was set aside for

             24  the second year.  And since they are being funded currently

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                                                                             114

                1 and if these goals are going to be more  than  just  rhetoric

                2 as far as Oregon is concerned I wonder if  in  our  letter  to

                3 them explaining the action of Council, whether  it  might  not
                4 be appropriate for us to encourage them in the  use  of  their

                5 growth funds for this kind of activity..

                6           There is precious little that review committee can
                7 do.  Perhaps this might be one thing they can do.  And there'

                8 is no need to make a motion,, but I would just like  to  call

                9 attention to that use of growth funds and encourage it.

              10            DR. MAYER:   Phil, would you are to comment on that?

              11            DR. WHITE:   I am sure that they  would  welc.ome this

              12  recommendation.  They  are highly interested. in  this  areas

              13 and I think if we were to encourage them, they  would  bec!pjne

              14  more active.

              15            DR. MAYER:  Could I raise a comment   about the:

              16  growth funds and the principles inherent therein?

              17            As we move toward anniversary review, triennial

              18  review,, whatever you want to call it, it said that each

              19  program would hae the option of and  has  the  responsibility

              20  of coming in annually for an update of their requests.  It was

              21  my understanding when we did that that that provided a
              22  mechanism for requests for new project proposals of the individila

              23  regions once they have been fully formulated, fully approved by

              24  the Regional Advisory Group, to find their way to Washington.
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                                                                             115

                1 of saying,, "O.K., we are or are not going to use  that  mechanism

                2 in terms of contingency funds." That  is  what  the  developmental

                3 component was all about.

                4           I guess it is that problem of should  they  come  in

                5 next  year with additional project support identifying $250,000

                6 worth of projects that they want to accomplish with the

                7 assurance that they have gone through RAG in detail and have

                81 been approved.  I would have no problem with the annual

                9 review within the triennium of dealing with that.

              10            What is the problem with dealing with it  in  that  way?

              11  Because  Ithought that is what we were proposing   two years

              12  back or  ayear and a half back when we were moving in this

              13  'direction.

              14            DR. WHITE:  well, this is precisely the same problem

              15  that we examined on the site visit itself.  Some of us, at.

              16  least, were reluctant to accept this blank check  in  a  sense

              17  that we were giving this region.  I do think I understand the

              18  difference between how they are going to use these versus how

              19  they would use developmental funds in the  sense  that  they  have

              20  specific projects that are being  generated  which  presumably

              21  would be at an active level a year from now,

              22            DR. MAYER:  But don't they have the option of coming

              23  in a  year from now and asking for additional funds to acc  'lish
                                                                             OMP

                  that?
              24

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              25            DR. WHITE:  Surely.  I think they do.


                                                                           116

               I            DR. SPELLMAN:  It seems to me this option would be

               2  retained if they got frowth funds if you would like to

               3  consider that.  It seems to me if they are awarded growth

               4  fundst they could still do this because this would not in

               5  that sense be a supplement.

               6            DR. BESSON:  I see a subtle difference that if there

               7  is something new in RMP that emanates from the regions  that

               8  this may represent.  I see in the use of the term "growth

               9  funds" and as I read at least the summary that they mean  to

              10  use this in a slightly different way than developmental funds

              11  in anticipating that what they are going to become involved in

              12  is going to increase in scope rather than actually developing

              13  new ideas, although,they do list the number of projects that

              14  they ho e to fund with this.
                        p

              15           And I think that I remember a couple of  years  ago

              16  I made a suggestion which was unfortunately hot  accepted  by

              17  this committee or Council, that when we see a region that  is

              18  moving in the direction that we are almost impelled  to  say,

              19  "That's it,,.you are doing just what you ought to be  doing,"

              20 that-they be commended in some way,  And the only way in which

              21  we can do that formally -- I had suggested some kind of

              22  certificate -- is with bucks.

              23           I wonder whether this use of growth funds and  our,

              24  acceptance of their concept wouldn't be a way of this review

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              25  committee at least indicating to them that, yes, this is a


                                                                             117

                1 very appropriate way for Oregon to be moving in  contrast to

                2 some others that we will discuss over the next couple  of days

                3 that are going in the totally opposite direction, and  we

                4 would discourage by turning off funds.

                5           This  is a way of supplementing their request.  I

                6 like the idea.  I have not encountered it before.  But I think

                7 it is a good one.

                8           DR. MAYER:  O.K.,. further co@nts?

                9           MR. HILTON;  Just a question, really. I am going to

              10  take advantage of my newness to this committee.

              11            Is there still a distinction  bet@t-l@-this:term

              12  "growth funds" which is new to me and the developmental

              13  component?

              14            DR. MAYER:  I have no problem with that because I

              15  think that what they are saying is in terms of the developmental

              16  component that that is priming, catalytic kind of dollars.

              17  And they are saying that-growth funds if.I understand it,, Phil,

                      -dollars for new projects
              18  are

              19            DR. WHITE:  That's about right.

              20            DR. MAYER:  -- as yet not formulated in final form,

              21  but have at least come along far enough so that they can see

              22  that they are going to be in final form within a finite period

              23  of time.

              24            DR. WHITE:  That 'is essentially correct. And'thpy

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              25 justified this in a sense that in the past they have gone


                                                                           118

               1 through this process of developing an activity, a  project,
               2 but they have been unable to carry it out because of  serious

               3 restrictions on the budget which you are all familiar  with

               4 a year or so ago. And they feel that without some  kind  of

               5 a little carrot in hand, they may have trouble getting  these

               6 people who they need to cooperate with their transportation
               7 system, peer review system, the family practice clinic system,

               8 to go along with the whole idea.

               9           I can see this point. On the airplanelout,, I  felt

              10 this was a nonsensical way of approaching the problem.  I

              11 felt just like you.  once they devel oped something, they come
              12 back next year and ask for support for it,  But after talking

              13 with them, I understand their viewpoint and feel perhaps there

              14 is some legitimacy of awarding them these growth funds,,

              15 particularly since I think all of the site visitors were
              16 particularly struck with the quality of the people  involve

              17 in this area.
              18           DRk MAYER:  I guess I have to ask the question of
              19 staff as to whether this is or is not within existing pol  cy
              20 of the RAG and whether this is a policy issue that ought to be
              21 surfaced. I am not saying pro or con, Phil, in terms  of  the
              22 approach because I think philosophically, I am in agreement
              23 with the approach.  But I am not sure that that is not a-p6licy

              24 issue as'opposed to a request issue.

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              25           MRS. XYTTLE:  Dr. Mayer,

                I


                                                                             119

               1            DR. MAYER:  Yes.  Mrs. Kyttle.

               2            MRS. KYTTLE: In back of the tab  labeled  "Council

               3  Highlights" in your books is a resolution passed  last  Council

               4  that says unless the review procedures have stipulated  to  the

               5  contrary when regions enter a triennium,, the approved  levels

               6  of the first year will hold for the remaining  two  approved

               7  years of the triennium.

               8            We had to move to that because Oregon,  like  several

               9  other regions, proposing a triennium, particularly  in  your

              10  fifth year, and it catches you betwixt and between with a

              11  program that is ongoing and yet in the next year it  will  drop,

                  was attempting to establish a level for its  triennial  period

              13  within which it could move in its triennium.  That is the

              14  concept of the approved triennium.

              15            And yet, these regions when they map out their second

              16  and third year of the triennium are not in a position  at  that

              17  time to specify the exact projects and the exact  budget  that

              18  will preserve a level. So with last  Councills  action  that

                  unless there is a certain reason for a decreasing  level  in

              20  the triennium, the first year's level of,the triennium  will  be

              21  the approved levelf not necessarily the funding level,  but  the

              22  approved level for the remaining years of the triennium,

              23            DR. MAYER: Well,, where does that then relate  to  the

              24  annual review within the triennium? They are  saying  is  that

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              25  option now no longer possible vis-a-vis the action of the


                                                                            120

                 Council?

               2           MRS. XYTTLE:  O.K.o within the action of the Council

               3
                 establishing a level for the triennium, at the  anniversary
               4 a region may come in and propose uses of the dollars up  to
               5 the approved level by Council. And that is an  action  that
               6 staff anniversary review panel considers and reports to you

               7 about.

               8
                           Should they request the use of dollars beyond  that
               9 level,, then that'would come to committee for action.

              10           DR. MAYER.-  But that option is still available.

              11           MRS. KYTTLE: Oh. yes, indeed. They  may  request  a

              12 second year triennium budget that is over the level of  the

              13 approved level for  that year of the triennium if the staff

              14 anniversary-review panel recommends that that level be

              15 increased.  And I think last time Tri-State was one that came

              16 to committee because staff was recommending the  second  year

              17 of the triennium level be increased, but there was  no  other

              18 way for regions other than to forecast a program three  years

              19 ahead that might radically change than to either do as Oregon

              20 did, provide growth funds, you remember Western  Pennsylvania

              21 did it when they went to triennium.  They were trying to

              22 preserve a level, give you inklings of what  they would go into,

              23 But they are not yet ready to be specific about it.  And it

              24 led to the policy from the Council last time.
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              25           DR. MAYER:  I am not sure that answers the question


                                                                          121

               I  that I have raised, though.

               2           DR. WHITE:  Not I am not sure that is correct.  At

               3least my understanding is that the second and third year budget

               4  shall be not less than the

               5           DR. MAYER:  Let me try it again.

               6           MRS. XYTTLE:  I was waiting for your action because

               7  this one increases.

               8           DR. BESSON:  That's why you are saying not less than.

               9           DR. SPELLMAN:  Is that what you said?

              10           DR. BESSON:  You said it is at the same level.

              11           MRS. KYTTLE:  It would not be less than the level

              12  established for the first year unless committee sAid,, "Yes,,

              13 we want this decreasing because we don't like that."

              14           DR. MAYER:  But that doesn't answer the question wh'ict

              15 1 raised which is what is existing policy of the Council 'Ln

              16 terms of this group taking action on providing contingency

              17 funds for growth.  You know, without clear-cut evidence of

              18 what it is'going  to be used for.

              19           DR. SCHMIDT:  You are saying it is a new way to get

              20 money.  Is that what you are saying?

              21           DR. MAYER:  No.  I am saying is it consistent with

              22 existing policy of the Council and in that sense legal?

              23           DR. PAHL:  Bill, we don't have a clearly formulated

              24 Council policy on the point that you are  rais-ing.  And at this

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              25 point in time, the concept of developmental components and grow@l


                                                                            122

               I  funds which has been coming into it has not been fully assessed
               2  by staff.  This is one of our agenda items because we are
               3  getting into various ways of providing flexibility to the
               4  region.  So it is appropriate at this committee meeting to
               5  make whatever recommendation you want to the Council, and  they

               6  will be asked to establish a policy in connection with  these

               7  various ways of funding.
               8            But you are not inhibited  at this point in time

               9
                  from recommending favorable action on growth funds if you  so

              10  desire and to recommend different levels of funding for the

              I I
                  different years requested.
              12            Nothing in the Council policy that Lorraine.mentioned

              13  is
                     restrictive. Both this committee and the Council  may  set
              I.4
                  whatever levels for the individual years are decided upon,

              15  It is just thatunless s ecial action is taken by the Council,
                                         p

              16  then a level is fixed.

              17            DR. MAYER: Let me try it once more with  my  problem.

              18  My problem is I sit here knowing a year and a half of  effort
              19  and energy of a lot ofpeople went into establishing the
              20  policy of the developmental component. And I think  that  was
              21  appropriate because out of that came some guidelines that  were

              22  known to everyone in the world about what developmental

              23  component is.

              24            We are now talking about growth funds. And all  I  am
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                                                                            123

               1 not a larger, policy issue than the  developmental  component.

               2  And rather than deal with that on an ad hoc basis, I would

               3  just want to get it flagged as an issue that ought to  be

               4  looked at and guidelines established rather than doing it  on

               5  a hit and miss kind of ad hoc sort of basis.

               6            DR. PAHL: There is complete  concurrence.  It  is.

               7  just a question of priorities. We haven't had  an  opportunity

               8  to do this.

               9            I should say that although the concept-of developmental

              10  component was clear at one time which meant that there  would

              11  be additional funds as a reward, it turns out that as one

              12  moves into the triennial period and where there has  been

              13  responsibility delegated to the region for funding  projects

              14  'within the Council-approved program without doming back and

              15  looking on a project-by-project basis And where no  additional

              16  funds are being provided because the developmental component is

              17 awarded, the concept of developmental component  has  been

              18 changing. And right now, I don't think it is as  clear  as  you

              19 have  indicated it was when it was first enunciated.

              20           Many times we approve the  developmental  component

              21  without additional funds which gives them a flexibility within

              22  their program. But by now, going on to a  three-year  basis,

              23  they have practically all the flexibility that  they-need

              24  within their program. And the whole concept of  what  develop-
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                I is quite different than what it  was  under  a  rising  budget.

                2 And this is the question  that  staff  and  Council  must  discuss.

                3            And it is further complicated  by  this  new  concept  o

                4  growth funding that has come in.

                5            So we are not in a position to.say there is a

                6 Council policy or that there has  been  a  staff  analysis  and

                7 clear statement policy. These  things  have  yet  to  be  done.

                8  So you are free to flag the issuer and we will be coming to

                9 this.as quickly as we can. But  we  don't  have  a  policy  for

               10 you, and Council doesn't have a policy  that  I  know  of  at  this

               11 particular point in time.

               12            DR* MAYER:  Phi3..

               13            DR. WHITE:  I think it is worth bringing to Councills

               14  attent ion, and I think it is worth pointing out that this region

               15  and I hope allf are full of integrity and honestyr but they

               16 could have said these are  projects  we  are  going  to  undertake,

               17 that we have them fully developed  and  planned,  and  we  know

               18 precisely what we are going to dot and put down a budget and

               19 say, "This is it."  This way they were honest with us at least

               20  and said,, "We are going to move  in  these  directionst  we  don't

               21 yet know what it is going to cost,  and  this  is  our  estimate.,,

               22            Their estimate varies from ours a bit, but I think

               23 something ought to be done to deal with these sets of

               24 circumstances.

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               25            DR. MAYER;  O.K., other comments?


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                I           MRS. KYTTLE:  Just one? please, on triennium.

                2           When we first defined the status of  triennium,  we

                3 said that it declared a region as an accredited body  and  that

                4 it could move in this triennium.

                5           Now, following that, the region needs some commitment

                6 of financial stability through these three years.  And  -,iat

                7 is what is leading us to the concept of the funding level

                8 established for the beginning of this triennium should not

                9 decrease during that triennium unless there are specific reasons

              I 0 for it.

              11            DR. MAYER,*  We have no problem with that,  @Lorraine.

              12  I think that is a secon4..issue.

              13            Yes, Mrs. Silsbee.

              14            MRS. SILSBEE: As I hear it, though, I  think  if  you

              15  decide you are not going to have any growth fundst the

              16  level would automatically go down in this particular instance.

              17            And while we don't have a Council policy, the discuss3'.01

              18  of Council at the time Western Pennsylvania proposed this very

              19  same thing and the Council member who had it wanted  to  make

              20  very clear that Council knew what they were doing here,,  and

              21  they did agree to that as a concept. And  they  approved  it.

              22            DR. MAYER:  O.K., comments?

              23            Jerry?

              24            DR, BESSON: We have amotion on the  floor  to  accept

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              25  the recommendations of the site visit team,  And I wonder if


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                  I could amend that since this may be a focal point for pinpointing
               2  this question, the amendment to include something  to  this

               3
                  effect that where a region shows evidence  of  implementing
               4  policies which are concurrent with its stated goals and
               5  priorities and also consonant with national prioritiess, that in
               6  order to encourage'its expansion in this direction, growth
               7  funds may be awarded on application at the discretion  of  the

               8  Council.

               9            DR. MAYER:  And upon recommendation of the review

              10  committee?

              11            DR. BESSON:  Yes.

              12            DR. SPELLMAN:  I would agree with that in principle,
              13 And I think taking what Judy has said and what  Herb  said,  if
              14  increasingly developmental funds are being used  as  growth

              15  funds which is really what I understand you to have  said,.
              16  the flexibility is even greater than was intended.  Tien, you
              17  might just as well drop any distinctions between developmental
              18  and growth funds and call it by a single name and  let  the

              19  full amount then bear some relationship to  the  difference

              20  between the level of funding in the.first, second,  and  third
              21  year rather than that very modest increment in  develo  mental
                                                                        p

              22  funds.  Because, again, you see, if he calls this developmental

              23  funds by tradition or whatever, he is limited to  a  pretty

              24  small amount.  But by adding growth, he has an amount there

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              25  that is almost a fourth of the total level of funding.

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               1            So I think you might consider now adopting a

               2 single term and that you look at it only in terms of the

               3 increment above the first level of funding.  It wouldn't make

               4 any difference there, and that would take care of what.-everybodn

               5 is talking about.

               6            DR. MAYER:  Could the chair try to separate these

               7 two out?  They are linked, but I would like to deal with

               8 the individual proposal and then deal with the policy issue

               9 if we could.

              10            DR. BESSON:  Then I will withdraw.

              11            DR. MAYER:  Because you may find yourself in a

              12 position of having to vote against the recommendation that

              13 you might agree with because you are disagreeing  with  the

              14 principle.  And I think that would be inappropriate.

              15            DR. BESSON:  O.K.

              16            DR.  MAYER:  Further coment on the recommendation

              17 of the site visitors relative to the funding and  level  of

              18 funding for the Oregon RMP?

              19            MR. MOORE:  I would like to add one point.

              20            DR. MAYER:  Yes, Mr. Moore.

            ..21            MR. MOORE:  of the seven growth fund activities they

              22 are presentl participating in five as a  part  of  planning
                             y

              23 feasibility and core activities.  So these are not new

              24 activities per se. And the use of the  term  "growth"  that

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               1 projects in the following years, then they would be

               2  submitting such projects.

               3            DR. MAYER:  Further comments?

               4            (No response.)

               5            Everyone clear on the motion and recommendation?

               6            All those in favor say, IsAyeen

               7            (Chorus of ayes.)

               8            Opposed?

               9            (No response.)

              10            Now, the question is how do we deal With the  issue.

              11 I  think  it needs to be flagged, obviously, as a  policy  issue.

              12  And  maybe, Jerry,, the approach that you are taking is the

              13  obvious one.  I just have a feeling that the implications

              14  of that are moderately significant in terms of how people change

              15  in approach.  And having been in on that discussion on a

              16 developmental thing as many of us were, that got to  be  pretty

              17  sticky.  And I am not sure that it isn't just raising the

              18  flag of the policy issue in suggesting that an appropriate

              19  group be called upon to look at that issue and to insist or at

              20  least to suggest that representation on that group come off

              21 of this review committee as well as off of staff  and  Council.

              22            I am just suggesting that as an approach.  Maybe  it

              23  is as simple as you say.

                            DR. BESSON:  In the interests of being even-handed
              24

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                1 putting some    I will block that metaphor that just came  to

                2 mind -- but getting the review committee back in the saddle --

                3 (laughter)  -- that I would like to keep this idea of a growth

                4 fund separate.

                5           Let me reintroduce my motion. But I  would  like  to

                6 keep it separate from the developmental component  mett  oned

                7 because I think it really says something different.
                8           if there is some merit to the idea that  the  review

                9 committee by its action can tend to move this ponderous
              10  machine in one direction or another,, then the use of  growth
              11  funds can be what we used to do many years ago  in  awarding
              12  funds for projects -- encouraging those that we said  yea  to

              13  and discouraging those that we say no to. But now  we  can  no

                  longer do.  All we can do is award a lump sum and approve
              14
              15  general principles and process.
              16            But this might allow us to indicate to a region that,

                  yes, they are doing what they should be doing and  to  other
              17

                  regions that get zero growth funds, that can be a very obvious
              18

                  sign to them that maybe this review committee and the general
              19
              20  direction therefore for how RMPs should develop may be-somewhat

                  more re-established.
              21
              22            DR. SPELLMAN: I would just answer  that  by  saying
              23  that I think the differences between what the growth fund
              24  and the developmental component are going.to be used  for  in
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               1 that,, it is only 13 percent different between the first  and

               2  second year.

               3            What this means is this is just an assurance to

               4  Oregon that they have a level of funding higher in the second

               5  and third year with a wider latitude to determine what  they

               6  are going to do with that increment.  That is all it is.  And

               7  I wonder,, what Herb said, if people are already doing this

               8  with-the developmental component anyway, what is going to be

               9  done with growth funds? It just doesn't seem to.me  any  longer

              10  to have any merit by creating two kinds of instruments which

              11  in the final analysis are.used for the same thing. -That  is

              12  the only point I make.

              13            DR. MAYER:  Joe.

              14            DR. HESS: As I have listened  to  this  discussion

              15  here, I have wondered how much of this problem would have  been

              16  eliminated if they had just not put in those two words  "growth

              17  funds,,n and left those projects listed under the headings and tie

              18  money attached to it and left the developmental component  just

              19  sitting there and get those two words out of there.  How much

              20  of this discussion we had had in the last few minutes would have

              21  gone on?

              22            DR4. MAYER: If you are saying if they had  formulated

              23  projects that were there that the site visitors felt were

              24  consistent with their goals and it was clear that they had

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               1  problem with it.  But those are two big if's.

               2            DR. HESS: But what they are saying here,  it  seems

               3  to me, is these are areas in which we want to develop

               4  projects. This is not completely flexible money that  can  be

                  used for anything that happens to come along, but these are

               6  ideas that we have that are partially formulated that we

               7  think are appropriate to be in the regions that we are  going

               8  tofund.  And they are projects in proce ss which to me is  a

               9  different thing than developmental component which is sort of

              10  flexible money that could be used for something that hasn't

              11  even been thought about yet.                        1

              12            DR. SPELLMAN:  But the evidence I gather is  that

              13  the differences between these are rapidly fading and.indis-

              14  tinguishable from what he tells me. The question  is  really-

              15  two years from now whether we will be able to tell them  in

              16  Oregon what is the difference between the way they use  the

              17  $75tOOO and the $250,000'.  They may lose their definition.  Thai

              l@ 8is all.

              19            But I am in agreement with the principle that  they

              20  ought to have $75,000 plus the $250,000.  I was just suggesting

              21  that it be done in a way which in the future would make it  a

              22  lot less complicated than inventing nomenclature that is just

              23  meaningless.  It is the way of getting more money for the

              24  second and third year.

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              25            DR. MAYER:  Maybe it goes something like this -- let


                                                                                   132

                1  me try it and see if this is acceptable:  That the committee

                2  is:in@ favor of the conceptualization of the growth fund issue;

                3  that if definitive policies  are  to  be  established  relative  to

                4  growth funds and how they might appropriately be done,, that

                5  the committee expresses its desire to participate in those

                6  decision-making processes.

                7             DR. BESSON;  But they can't do it because once the

                8  anniversary review,. once you fall into that slot, then you

                9  no longer have control.

               10             DR.  MAYER:  No, no.  You are missing what I have

               11  said, Jerry. I am sorry.  What  I  am  saying  is  if  the  Council

               12  in its infinite wisdom listens to the fact that we think the

               13  growth funds are good, they think it is appropriate,, but it

               14  finally dawns on  them  that  unless  they  start:as-in.all@.things

               15  to further define what the boundaries of growth funds area

               1.6 what percentages might be appropriate, da-da, da-da, da-da,

               17  when they do that, all I am  saying  is  we  ought  to  participate

               18  or representatives of this committee in the future ought to

               19  participate in those discussions.

               20             Yes, Leonard.

               21             DR. SCHERLIS: Maybe  I  am  hypoglycemic,  and  I  don't

               22 quite know why I feel as I do about  it,,  but  I  really  think  we

               23  are raising issues that we are looking to raise in this regard.

               24  I would much prefer that the site visitors give us a

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               25  recommendation that certain  priorities  have  been  set  up  which


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               I  obviously require certain funds of money,  And it is
               2  apparent that the money will be spent in that area.

               3
                           1 don't like the term "growth" now.  we are going to

               4 have to define it as distinguished from developmental.
               5           Maybe I am the only one who has the limitation of
               6 trying to distinguish between these two terms.  I would much
               7 prefer we keep the developmental as it is and just  ask  for
               8 a little better definition of how they are spending the money.

               9           You have defined it. You said seven areas  they  are

              10 moving into. They have already moved into  five,  they  need

              11 the funds to move into the other two.  After all,, I would just

              12 say they found some money, that is what they are going to  do,

              13 and they defined it pretty well.

              14
                           I would hate to see us telling Council when they have.

              15 reached a decision they have got to come back to us, and we will

              16 discuss it further.  I don't think a decision is necessary  in

              17 this regard.

              1 8          I would move to strike out the last ten'minttes of

              19 discussion..

              20           DR. MAYER:  Joe.

              21           DR. HESS:  I think we may well be creating an

              22 issue that doesn't need to be created here. If  we  understand

              23 what they want to do, ber.-atse they happen to use a couple of

              24 words that were unfamiliar to us, let's not get hung  up  on

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                1  handled under existing policy of a region who has reached

                2 the triennial status.

                3           DR. MAYER:  There is more than just the  words, Joe.

                4 There is some substantive difference between this   approach

                5 and other approaches of definitive projects.  And  I won't say

                6 anything more about it,

                7           DR. SPELLMAN:  If it is that simple, you can predict

                8 that everybody will do that.

                9           DR. BESSON: I think everybody else  might  have  the

              10  option of doing  it.

              11            At the risk of prolonging this discussion,at an

              12  inappropriate blood sugar level time, and many  decisions  we

              13  may make are based on no more influence than that,, I  would

              14  say that I see a difference. And I think that  a  13  percent

              15  increment you referred to, implying that therefore it  is  not

              16  very different from the developmental component, I  think  I

              17  read somewhat differently heret Mitch, because I see that that

              18  13 percent increase is a result of a 24 percent  decrease  in

              19  projects and an 18 percent decrease in core, but  100  percent

              20  increase in growth funds.
              21            Now, that gives you a figure which is not  far  from
              22  the developmental component, But the point is  I  don't  think

              23  that  10 percent is adequate enough for what some regions want

              24  to do in an expansioning fashion. The  growth  fund  concept,

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                                                                           135

               I  a region that is moving in the right direction to really

               2  blossom.

               3            Right now it is constrained from so doincj@@by-having

               4  a limitation of 10 percent on it.

               5            DR. MAYER:  O.K., I guess the question I have to

               6  ask is, we have taken an action on one which does have this

               7  principle that would suggest we are in favor of it, at least

               8  as it relates to Oregonr and we have no objections to the

               9  principle at least at it applies to Oregon.  I guess the

              10  question I want to raise-is do we want to make any comments

              11  above and beyond-that of a more generic nature to Counc3l?

              12  And if we do what is it? And if we don't. then,  fine,  let's

              13  end the discussion,

              14            Mac,

              15            DR. SCHMIDT:  I believe we should comment that it

              16 seems apparent there is some change in the concept behind  the

              17  developmental component and the growth fund concept is  worthy

              18 of study in.relation to the other. And the staff  and  Council

              19  should take-this under advisement and so on.

              20            I think both of them have to be looked at in relation

                  to each other and something new developed.
              21

              22            I personally favor a single type of dollar.  And I am

              23 really closer, I think, with Leonard than anybody else.

              24            DR. BESSON: I withdraw my motion in favor of  that.

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              25            DR. SCHMIDT: I would move the sense of whatever  it


                                                                             136

                1  was I said be conveyed.
                2            (Laughter.)

                3            DR. MAYER:  All right, is that clear?

                4            DR. ELLIS:  Second that.

                5            DR. MAYER:  Further comment?

                6            DR. SCHERLIS:  You have dismounted, is that correct?

                7            DR. MAYER:  All those in favor?

                8
                             (Chorus of ayes.)

                9
                             Opposed?

              10
                             (No response.)

              11             Why don't we break for lunch?  Try and be,back at

              12  1:30.

              13             Do not forget during that 45-minutes that you  ave

              14  an obligation to  score this region*
              15             (Whereupon, at 12:45 o'clock p.m,, the meeting

              16  recessed,  to reconvene at 1:30 p.m. the same day.)

              17

              18

              19

              20

              21

              22

              23

              24

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                                                                            137

                I                     AFTERNOON SESSION

                2                                          (1:40 p.m.)

                3           DR. MAYER:  What I would like  to do  sequentially  as

                4 a  tentative agenda is go down the list  and pick up Ohio and

                5 then pick up Northeast Ohio which is in  a way linked,  then

                6 go back up to Nassau-Suffolk and to  Nebraska  sequentially.

                7 And that gives John a chance to settle in before he  has  to

                8 go to  bat.

                9           DR. KRALEWSKI:  Thank you.

              10            DR. MAYER:  And I assume that you all followed the

              11 explicit instructions given just  before  breaking-for  lunch  to

              12 use part of your lunch break to complete  the  rating  sheets

              13 on Oregon. If you did not do so,  let's  take  a  couple  seconds

              14  and do that now because I am afraid if we wait after we start irti

              15  another one that things may get a little fuzzy.

              16            What we are turning to, then, is the new Ohio

              17  Regional medical Programi.  I am the primary reviewer, Mr.

              18 Hilton is back-up reviewer on it.

              19            Let me comment in way of introduction about this one,

              20  Phil said or someone said earlier you ought not to make

              21  apologies, but I really feel that I have got to make some

              22  disclaimers at the outset on this one because  after  six  years

              23  and six months of involvement in one way or  another  with  RMP,
              24  staff somehow-seemed to have saved the toughest task that I

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                                                                             138

               1  done is given me the opportunity if you can call  it  thate
               2  without benefit of site visit or personal involvement six
               3  years after the funding of the first RMPs what is essentially
               4  a new RMP to review by guidelines which are long since  moved

               5  on to other kinds of things.

               6           At this stage in the development  we  are  supposed

               7  to be looking at total programs and not individual  projects.
               8  Yet, there is as yet no really total program existent  here.

               9           At the same time, there was a mandate from  us  and

              10  Council that they try in the Ohio Region to put two or  more

              11  of those individual RMPs together because of their Poor

              12  quality to date,, at least the three of them and they  have

              13  done that, at least with two of the programs.  our advice and

              14  counsel are to go up to the National Advisory Council,,  Wp

              15  of whom whose most sophisticated and long-standing  members,

              16  Bruce Everist and Clark Millikan, have trod this sod which  I

              17  have not trod in Januaryt and they obviously  I suspect, have

              18  some preconceived ideas about what ought to be done in  the

              19  area,

              20           If there has ever been a setup to wipe  out  itself

              21  on this one, and I can see the headlines now,, "Mayer goes down

              22  in flames on final mission.''

              23           To cap,it all off, I am not sure how  much  advanced

              24  notice Mr. Hilton had.  At least in the previous communications

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                                                                             139

               I this. And so I really think it is going to  be,,  "Mayer  goes

               2  down alone in flames on final mission."

               3            So I commence this review knowing I picked  up  an

               4  assignment befitting a chapter in "Mission  Impossible,"  and

               5  wishing that not only my instructions might have self-destructe(L,,

               6  but the whole region from Athens to Zanesville.

               7            As a background, you will know, as you  recall  in

               8  previous meetings,, we felt that although the State of  Ohio

               9  might be,the mother of Presidents,, we hardly felt it was  the

              10  father of RMPS. There were four RmPs involved  in  the  State

              11  the Ohio State RMP which was focused out of Columbus, the

              12  Northwest Ohio RMP focused out of Toledo, Northeast  Ohio  RMP

              13  focused out of Cleveland, and then the  Ohio  Valley-Kentucky

              14  RMP focused in Kentucky and including Cincinnati and the

              15  several-county area in southwest Ohio.

              16            The first three? to put it mildly, had a great deal

              17  to be desired.  And it was suggested by staff and by ourselves

              18  and Council-that we might be able to put some bad apples

              19  together and with appropriate aging come up with  a  vintage
              20  wine rather than some sour cider.  I am not sure how

              21  appropriate that decision was, but that was the  decision  we

                  made.
              22

              23            Accordingly, in the April-May review cycle  of  last

                  year when we had all of the bad apples together from  Ohio  in
              24

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               I  period from July of last year to January to provide them the
               2  opportunity to get together. This they did with  the  following

               3  results:

               4
                            It looked like the Ohio State    I think if you

               5  will take your yellow sheets, page 7. there is a map  which
               6  outlines the region.  It gives you some feel for the geography.
               7  What appeared was that the Ohio State RMP which is central an

               8        ast Ohio and the Northwest Ohio RMP were making  music

               9: together, but the Northeast RMP really was keeping out  and
              10  saying they wanted no part of those other two. And  really,,

                  the Ohio Valley RMP which incorporated the southwest  component
              12  of it wag never'really a major part of the issue,, feeling
              13  they probably were a functional RMP and it may not be.'

              14  appropriate to try to get them involved.

              15            So.we extended them for six more months from

              16  January to July after having extended them six months  from
              17  July to January to try to work that out, then extended  them

              18  another six-months and then sent the shock troops of  Millikan,

              19  Everist, and staff in on January 10 and 11 as a fact-finding

              20  activity relative to the three regions.

              21            The results of that visit are outlined in the

              22  very poignant comments of millikan and Everist on pages 27 to
              23  35 of the yellow sheets.  I recommend those to you as readingf
              24  programs tonight because I think they are classic  examples
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               1             In brief, they,-,however,, discovered the  following:

               2 That Ohio State and Northwest  Ohio  RMPs  were  making  progress

               3   towards union and Northeast Ohio in its pristine purity was

               4   having none of it. And although  they  had  invited  the  Ohio

               5   Valley-Kentucky groups to participate, they felt  that  it  was

               6   probably not appropriate to incorporate them in it.

               7             The end result was a series of recommendations that

               8   dame out of the February 172 issues of Council which are on

               9   page 2 of your yellow sheets.  And I will not go.thkough those

               10  in any detail, but essentially I think did recommend the

               11  formation of a new RMP which combined the Ohio State with

               12  Northwestern regions and that the  effective  date  of  merger

               13  be September 1 and that this application of  that  merged,  two
               14  merged RMPS, are to be brought back to this particular review

               15  cycle.

               16            Well, that is the background of this particular

               17  application. And what do we have in  it?  We  have  a  proposal

               18  then to merge previously existing Ohio State and Nor       est

               19  Ohio RmPs into the Ohio Regional medical Program.

               20            We have a request for $2,082,000 in direct costs for

                   one year activity when as near as I can figure  out  from  data

               22  which are not totally complete, they are roughly at a $1.4 mill4.o

               23  level of activity in that.

               24            The,request includes a request for  $1.2  million  of

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                1  of about $800,000 now in core.

                2           We have a request of approximately $800,000 of

                3 project funding which include the following:

                4           One,, two projects, the first and second  ones  there

                5 which have previous Council support for  approva@  for  support

                6 for an additional year.

                7           Two, a kidney project in the  amount  of  $201,000

                8 that is project three -- which will be reviewed  on  May  8.

                9 And since this is may 4t I don't know what  that  review  has

              10  in  common.

              11            And thirdly, there are 12 other  new  projects,  nine

              12  of  which are from the previously  existing  Northwest  Ohio

              13  RMP and three from the previously  existing activity  in  the

              14  Ohio state RMP. And when I am  sayin  nine  in  that  Northwest
                                                       9

              15  Ohio RMP,. I have to comment parenthetically there  has  been

              16  a considerable amount of concern that  previous  activities  in

              17  the Northwest Ohio RMP were moving towards the funding of the

              18  newly developed medical school at Toledo with emphasis on that

              19  rather than to a greater  degree  on the RMP component.

              20            And, finally, one  out  of the 12 that is  a  health

              21  careers program of Ohio in the amount of $171,000  outside of

              22  RMP guidelines.  And that is contained on page 17 of the

              23  yellow sheets as to why4

              24            In my opinions then, they have  made  progress  in

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               I  Northeast Ohio and Ohio Valley RMP.  However,, this whole

               2  application has the flavor of a new and developing  region.
               3  And it kind of has the deja vu of four to five years ago.

               4            William Pace, the Dr. William Pace at@ohio  State

               5  who is the acting coordinator, obviously has had a great

               6  impact in trying'to bring this merger about and has obviously

               7  been helpful in effecting it. Howevere he is pulling  out  or

               8  resigning on June 30 of this year, and they are looqing for

               9  a new coordinator. The reasons why Dr. Pace is  leaving  that

              10  responsibility aren't,clear, and perhaps staff may have  some

              11  comment-on that that may be helpful to us.

              12            Secondly, in terms of the review process at the

              13  regional leveli this appliation is acknowledged by them  to

              14  essentially having been nonreviewed in the kind of review

              15  process that they would hope to ultimately accomplish in  A

              16  combined region due to the newness of the effort.

              17            Thirdly, the goals and priorities of the group  are

              18  general# not specific but they do have a mechanism and are

              19  actively, I-gather, working on them.

              20            Fourthlyt the advisory council is temporary and  is

              21  in the process of -- this is the combined advisory  council

              22  expansion in organization.

              23            Fifthly,, the staff is not yet fully formulated or

              24  organized, although there is a fairly good proposal for
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                I materials. They now have, as I gathert  19  professionals  in

                2 the two pre-existing programs, 13 in Ohio State and  6  in

                3 Northwest Ohio, and are requesting 32 professionals  in  the

                4 core staff and the new development, an increase of 13.

                5           Sixthly, they have agreed on a grantee and  a  fiscal

                6 agent, the Ohio State University Research  Foundation,  which

                7 is evidently a private corporation which is  handling  the

                8 research funds of Ohio State in the amount this year of

                9 around $20 million and obviously have competency at the

              10  fiscal level to handle the activity.

              11            And#, finally, they evidently have settled,in  a

              12  positive light on a relatively strong RAG chairman in the form

              13  of Dr. Brain Bradford of Toledo.

              14            So that's where we are. And I  suspect  you  can

              15  understand'part of my problem that I tried to outline at the

              16  beginning of the presentation. When I got to  this  stage  of
              17  the report, debating about what to conclude about All  of  this

              18  in light of the newness of the activity when  most  programs

              19  have moved on in a far more sophisticated fashion, I reca

              20  John Gardner's beautiful essay on the  anti-leadership  vaccine

              21  which some of you may have read.  And it is in the part when

                  he was describing one of the great dilemmas of the  day  and
              2 2

              23  problems of today is the lack of any real confidence  in  the
              24  leaders'of today    that is, confidence in their capacity to

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                            When he was talking about it, he described  the

                2 story of the little girl in the third grade art class who  was

                3 asked by the teacher, "What are you drawing, Mary?"  To  which

                4 Mary replied, "I am drawing a picture of God."  And the

                5 teacher then saidr "But, Mary, no one knows what  God  looks

                6 like."  Mary simply said, "They will when I get through.st
                7           So what I am about to tell you is I have  no  idea
                8 in my own mind really what is the appropriate way  of  going

                9 about evaluating this activity. we have an  example  of  two
              10  regions which have a poor-track record in terms of what they

              11  have accomplished in,the past.  We have told them to merge.
              12  They have do ne that and have done that withr as I  gather
              13  reading between the lines,, a fair amount of pain, but neverthe-
              14  less have accomplished it and do look like they are beginning,

              15  to move in appropriate directions.
              16            So that is where it is.  And I guess it is out of
              17  that kind of anxiety and concern that I will blithely  go
                  ahead and give some conclusions about recommendations about the
              18
              19  activity.
              20            As I indicated before, the funding, as near as we
                  can get an estimate of the'program support of core  staff
              21
                  of the two programs together, is about $811,000 on an annual
              22
              23  basis.  I would recommend funding them at about $900,000 for
              24  the first year which is roughly a 10 percent  increase  with

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                1 that or at the roughly $990,000 level.  This does, then,

                2 at least give them an opportunity to try to take the  steps

                3 of putting th e two programs together and building  a,strong

                4 and effective core staff.
                5           They are currently funded at about $583,000 in terms

                6 of individual projects and are asking approximately $800,000

                7 for individual projects in this.  And I would recommend a

                8 level not to exceed $500,000 in project activity with a

                9 minimum of 5 percent increase in the second year.

              10            included in that funding of individual projects

              11  obviously is the continuing commitment of the funding of
              12  pro)ects 1 and 2 which have already been approved if they so
              13  desire.  And included in 2t is the funding of the renal
              14  project if approved by the ad hoc panel. And if it  is  not
              15  approved by the ad hoc panel, then I would suggest a reduction
              16  of that amount from the $500,000 that I recommended  above.
                            And then, fifthly, obviously excluded from approval
              17
              18  for them to spend any of their money on what would'be project 8
              19  which is outside the guidelines of the RMP.
              20            And# finally, I would suggest that we indicate to
              21  Clark Millikan and Bruce Everist at Council level that I reviewed
              22  this project for the review committee and suggest at  least
              23  that my tour of duty with RMP, at least at this point in time,
              24  at least equals or exceeds theirs, so when they get to alter
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                I whose recommendations they altered.
                2           Mr. Hiltont comment?

                3
                            MR, HILTON:  In view of the weak history of the
                4 Northwest Ohio Regional Medical Program and the  Ohio  Regional
                5  Medical Program prior to its consolidation, it might be

                6  appropriate to ask whether encouraging consolidation would
                7 really amount to lumping together weak programs in order to
                8 create a larger weak program. I think that is  the  dilemma  we
                9 are facing right now, and we don't rea lly know what with  the
              10  vacancy in the coordinator position and some of the other

              11  things that are on the horizon.

              12            However, I was positively affected by the documentation

              13  on this program. The statements of by-laws  and  very  detailed

              14  descriptions of administrative procedures which will be

              15  implemented in this new, first operational year of the new

              1.6 ORMP.

              17            The RMP recognized that consolidation really has

              18  been against the'background of its history its major accomplish-

              19  ment for @e last year. It also concedes that  it  has  taken  a

              20  good deal of time, staff time, and energy.

              21            They. face a problem, looking to this first year,  I

              22  think, a dilemma which was described in one of  the  documents

              23  I read whether they should devote themselves  aggressively  to

              24  pliqning and development activities in light of this new
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               1. a real active involvement in new projects. I don't  think  it

               2  was really an either/or position. They opted for  the  active

               3  involvement in projects which I had the feeling would not  be

               4  appropriate, And so I totally agree with Dr. Mayers' suggestion

               5  they not be funded to launch all those projects.

               6            I think there still remains to be enough  uncertainty

               7  about what would happen with the new coordinator. And  I  think

               8  we are really inviting a situation where the body controls  the

               9  head to have this much predetermined before a new coordinator

              10  could be hired.

              11            I was impressed by the participatory RAG or what they

              12  calltheir Regional Adviso    Council, Regional Advisory  Group.
                                            ry

              13  Apparently that body participates fully and actively.  And

              14  there are some innovative ways in which RAG members will be

              15  able to through task forces continually monitor  the-progress

              16  of staff toward consummation of projects that have been

              17  proposed for the area.

              18            Some of the things that worried me -- I have  alluded

              19 to one  already, and that is not knowing the coordinator and

              20  not knowing whether we are really talking now about a larger,

              21  more efficient program, more efficient leadership, or just  a

              22  larger program.  I was impressed by the efforts to keep the

              23  door open for Northeastern Ohio and even for Cincinnagi,  which

              24  seems no t to be inclined to join the group.

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                I  statistics suggest some 9 percent nonwhite population in Ohio.
                2  And for this region, this new consolidated region in particular
                3  it would probably somewhere in' the neighborhood of at least
                4  6 percent minority overall.  But on the staff, some 19
                5  professionals, there are 2 black professional staff. There
                6  are no other nonwhite minorities indicated, in  any  of  the
                7  reports.  And there are 2 blacks on the clerical staff.  I am
                8  uncertain as to the minority input into the RAG.  And planning
                9  committee, I get numbers that range from 8 to 11 in terms of
              10   participation and no clarity on the degree of participation.
              11             Nor are there any statements indicating any move at

              12   this point to act on that problem.
              13             The new projects, 9 new projects that were submitted

              14   aside from the legal point on project No. 8 seem to  have,,,
              15   been heavily designed by Northwestern Ohio which originally
              16   -covered only 12 counties.  I was concerned whether the smaller
              17   number of counties to the extent that these pro]ects might be

              18   based in those counties should dominate the entire Ohio
              19   Regional Medical Program which the other part of  it  is  49
              20   counties and really the larger part of the area in question.

              21   So I had some.concerns about that.
              22             Aside from that, I think we are put in the position
              23   that we have to accept a good deal on faith at this point in
              24   time due to incomplete information and  the  expectation  of

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                  have-'to         Mayer in the uncertainty, but I  would  agree
                          join:'-Dr.'

                  perfectly with the recommendations on funding.

                3           DR. MAYER:  O.K., additional comments or

                4 questions.

                5           DR. ELLIS:  I would like to ask a question.  Are

                6 they working very closely with Comprehensive Planning A

                7 agency? And how are they working with the  section  in  north-

                8 western Ohio?

                9           DR. MAYER:  Well, I gather from the information that

              10  there is a very direct linkage with the B agenciesi  I missed

              11  where that link was with the A agencies.  In other words,

              12  they are actually planning to subregi6nalize the area in accord

              13  with the B agency geographic boundaries and linked to the B

              14  agencies. That is part of their  whole  organizational  chart.

              15            You all got it.

              16            DR. ELLIS*-  I just wondered what you thought about it.

              17            DR. MARGULIES:  Could I comment on that?  Because

              18  Ohio is a rather unusual situation for CHP.  The  director  of

              19  Comprehensive Health Planning is Sewell Millikan who is on

              20  the National Advisory Council. And he has played  one  of  the

              21  key roles in trying to carry this merger through and  in  fact

              22  in trying to get what we initially were trying to achieve which

              23  was a merger'of all three of the programs which was so far

              24  ineffective,  So that the relationship with the A agency is

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               I            And then added to that is the fact that the director

               2 of'the State Department of Health is John Cashman who was.

               3  formerly the head of Community Health Services in HSMHA and

               4  has had unusually strong interest in uniting these activities

               5  in Ohio.

               6            So that we are favored regardless of where they are

               7  at the present time with some unusually strong elements  to

               8  pull them together better than they wou ld under ordinary

               9  circumstances.

              10            DR* MAYER: What they have  programmed,  they  have

              11  programmed a major build-up in the core staff of the  total

              12  region. They have developed two subregional groups  with  the

              13  pre-existing ones, but with small staffs there, two people, I

              14  think,, in each one.

              15            And they are proposing then they branch out  from

              16  that. For examples the Northwest Ohio Region covers  two  CHP

              17  B agencies.  And they are actually going to put their staffing

              18  in those two B agencies. And the proposal is that  there  are

              19  five 9 agencies relative to the.Central Ohio one with a  link

              20  to those five agencies.  Actually it is right on the

              21  organizational chart.

              22            Now# how far they have gone,, Idon't have a feel for.

              23  But they are at least thinking about those issues.

              24            MISS ANDERSON:  Do they have A Competent deputy

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                1           DR. MAYER: Well, all I can comment  is  what  I  read.

                2 And the opinion evidently of Millikan and  Everist  was  that

                3 the Northwest Ohio existing coordinator was not very effective

                4 and that Pace had proven to be  moderately  effective.  And  the

                5 problem is that they are now looking for a leader.

                6           And this is one of the reasons why I personally

                7 suggested that two-year funding for them as  a  mechanism  of

                8 at least providing an option for a guy to have two years of

                9 assurance of a chance to build a program.

              10            John,

              11            DR. KRALEWSKI:  Are they actively looking for a

              12            DR. MAYER:  Yes.

              13            DR. KRALEWSKI-. Everyone that is  there  knows  that?.

              14            DR. 14AYER: Yes.

              15            Does staff have  any further information?

              16            MR. VAN WINKLE:   They have a  search committee,  and

              17  they actively now have 42 possible candidates for that position,

              18 a sum of 42. Some of them  are  existing  coordinators  in  other

              19  RMPs who have shown an interest, one being an ex-Ohio State

              20  or graduate of Ohio State, I might say,  And I believe he is

              21  an Ohio boy.

              22            They have hired, it is not really a deputy coordinator.

              23  They have a 'three-pronged organizational  chart  there.  And

              24  they call them associate coordinators.  And  they  have  just

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              I  under the Rhodes administration.  And I believe Dr. Ellis

              2  is quite familiar with him.

              3         DR. ELLIS:  Yes, he is good.

              4         MR. VAN WINKLE;  He is quite an effective administra-

              5tor.  And he is due to come aboard the first of June,

              6        .And Dr. Pace's reason for his stepping out is that

              7he said that he had 21 years commitment to Ohio State

              8University, and when it came to making a decision as to

              9whether we were insistent upon 100 percent coordinator,, he had

            10 to go and stay with Ohio State rather than stay with the PZT.

            11 It was his election that he do that.

            12          DR. MAYER;  John, I think their problem is no one

            13 in their right mind until the Council takes some sort of

            14 action in this sequence, I think would dive into that.  Because

            15 the message that is there is that there have been two weak

            16 programs, and we have told them to do something about it in

            17 terms of merging them.  But they don't have any answer back

            18 about whether we think there is a chance.

            19          So I.think what is done as action in this next step

            20 is important.  And this is why I put the emphasis on core

            21 staff support as part of the planning and build-up of the

            22 region as opposed to individual project-,support.
            23          DR. KRALEWSKI:  That funding that you are suggesting,

            24 what does that allow them to do?  I am sorry, but I didn't

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               I            DR. MAYER:  What it allows-them to do, they

               2 currently have about $8OOtOOO in existing core staff  at  the

               3 expenditure level4 My guess is that they are  going  to  lose

               4 some of those people because of the changes that have occurred.

               5 So that there will be some shrinkage and freedom  that  will

               6 be as a result of that.

               7            I am suggesting another $100,000 interms of  core

               8 staff support for them. 7nd I am  also  suggesting  $500,000

               9 in project support if the renal disease program  is  approved.

              10  If the renal disease program is not approved, I am recommending

              11  only $300,000 in project support.

              12            Now, if the renal disease program is not  approved,

              13  that produces an operating budget for next year of about

              14 $1.2 million as opposed to an existing operating  budget  of

              15  about $1.4 million.

              16            Now# of that $1.4 million, a significant hunk  of

              17 that are projects which are due to be phased  out.  only  two

              18 of those that are there are previously existing projects.

              19            You are caught on the horns of a dilemma.  You provide

              20 a significant increase for two regions who have  not  achieved

              21 on the hopes for the future. And I guess  what  I  am  taking

              22 is a middle road which says provide them approximately what they

              23 were getting as two separate regions to move forward into the

              24 future to see if they can do something with it.

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                I           SISTER ANN JOSEPHINE:   I think it is  significant

                2 they are looking for a coordinator of the  Regional  Medical

                3  Program.  And I think there:are several other programs that
                4 are probably in that same position. And I think  it  is  not
                5 unrealistic to expect it is going to be difficult from here
                6 on out to get good coordinators of programs .  There is going

                7 to be a lot of interprogram pirating.

                8           And so I think that the national trend that we are

                9 seeing in mergers and consolidations certainly  should  hold
              16  on a State level.  You know, in California, we could be looking

              11  for eight coordinators.

              12            DR. MAYER:  other comments?

              13            (No response.)
              14            Any additional comments of staff who were  on  the

              15  site visit in aanuary?
              16            DR. SPELLMAN:  Is it appropriate to include in the
              17  level of funding a sum which includes the renal project given

              18  the guidelines we have just had set?  Can we do that?
              19            DR. MAYER: Well,,.it was included in  their  total

              20  tab.

              21            DR. SPELLMAN:  O.K.
              22            DR. MAYER:  Since that $200,000 was a part of the
              23  $800,000 requested for projects, I dealt with it in that

              24  context.

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              25            DR. HINMAN:  Do you want any comment on the kidney?


                                                                            156

               I            DR. MAYER:  Fine.  I would love to have some comment.

               2            I had assumed because it was being dealt with  on

               3  the 8th

               4            DR, HINMAN: Just to set the background,  all  the

               5  kidney documents did not arrive here until Tuesday which is

               6 why it is being-dealt with on the 8th.'

               7            But Ohio in January of 1971 established a planning

               8 group on renal disease that is statewide.  It includes

               9 representatives from Cleveland as well as the major cities in

              10 the new merged area.

              11            They have had adult type kidney doctors, and they are

              12 appointing, either have or will be appointing, pediatric
              13 type doctors as well.  And they are starting an organ sharing
              14 program within the various centers that will be in the State' of.

              15 Ohio.

              16            There are three applications in for reveiw at the

              17 present time.   One is to support a pediatric nephroldgy

              18 program.  That lost its pediatric nephrologist, and it is

              19 basically geared around acquisition of said pediatric

              20 nephrologist and funding him.

              21            The other two are organ procurement and transplant

              22 expansion programs, one for Toledo and one for Columbus,

              23 Those two organ procurement. programs have had very critical

              24 technical review.  Interestingly enough, one of them, the
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                                                                              157

                1  and the applicantion as submitted has incorporated the critical

                2  review, the things that needed to be straightened out.

                3           The other does not.  But it does begin to address

                4 theissues of dialysis and organ procurement throughout the

                5 State as a whole.

                6           DR. MAYER:  It does, you say?

                7           DR. HINMAN:  It does begin to, yes, sir.

                8           DR. MAYER:  Including-'.the troops in Cleveland?

                9           DR. HINMAN:   A little bit.  They are still pretty

              10  independent in Cleveland.

              11            This overall planning group has the sanction  of  the

              12  Governor's office.  He in turn delegated to the Commissioner

              18  of Health, Dr. Cashman, to pull the  committee  together.  And,

              14  it appears as if there would be some State  legislation  sought

              15  by this group.  And they are beginning to talk together.

              16            DR. MAYER:  Other comments

              17            (No response.)

              18            Is everybody clear on the recommendations?  Staff

              19  clear?

              20            All those in favor say, "Aye.01

              21            (Chorus of ayes.)

              22            opposed?

              23            (No response.)

              24            I would recommend to you that it might be worth taking

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                                                                                  158

                1  in the yellow sheets of the Millikan-Everist comments about

                2 the situation that exists there,

                3            DR. SCHERLIS: Pertinent to that,  who  is  now  head  of

                4 their RAG? Is it the  physician  Dr.  Hudson  who  was  mentioned

                5 or who is his latest successor?

                6            DR. MAYER:  No,  Brain Bradford who is evidently

                7 a physician in Toledo who I gather from their comments and

                8 other comments of staff is showing some    fairly dynamic

                9 leadership to it,  In fact, the comment was made-he knew

               10 more about what was happening  than  the  coordinator  which  was

               11 an interesting comment.

               12            DR.  SCHERLIS:  One  other  comment.  Suppose  elsewhere

               13 in Ohio  a regional program  comes.in for funding.   Is  there  any

               14 potential  for a technical review group  or  that  group  charged

               15 with "regionalization" saying that there.-has  to  be  an  entire

               16 Ohio renal program. and not a particulated one?

               17            DR. HINMAN:  You mean as far as the statewide committee

               18 that is

               19            DR. MAYER:  Noi, as fir@a's RMP is concerned.

               20            DR.HINMAN:  The local RMP or RMPS?

               21            As far as the local RMP is concerned$,  they  have  been

               22 an  active supporter of this Ohio Renal Disease Planning

               23 Cc)mmittee as I believe is its formal name.

               24            Technically speaking, they could address themselves

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                I  RMP.  I would assume in looking at the guidelines, the blue

                2 sheets that were discussed for a while this morning and in

                3 what I am hopeful will be further issuances coming  from  heret

                4 they will understand that the whole area needs to be looked

                5 at and not just their part of the State,

                6           DR. SCHERLIS: I hope this is  the  message@-that-this

                7 committee can help implement.   And that is that even if

                8 technical review is satisfactory, if al 1 of these areas come

                9 up with nice technical reviews, I would assume looking  at  the

              10  total national program, we would want to have evidence that

              11  this is an integrated program.  And I think this should be

              12  noted.

              13            DR. HINMAN:  The Ohio Valley RMP out of Cincinnati

              14  also has some kidney areas of concern. And  we  are  attempting

              15  to get into this total planning process as well.

              16            DR. SCHERLIS:  Of course, you are in a very fortunate,

              17  position in that you either do or do not recommend funding.

              18  And you wouldn't have to be anything more than clear  n your

              19  direction as far as regiohalization is concerned, particularly

              20  if 3pu aretalking about a national network.  is that clear?

              21            DR. HINMAN:  I would hope to be able to be specific,

              22  yes, sir.

              23            DR. MAYER:  Sister Ann.

              24            SISTER ANN JOSEPHINE:  Has Western Reserve been

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                I           DR. HINMAN: The Cleveland Clinic is  involved,,  but

                2 I just don't recall about Case Western Reserve, Sister.

                3           DR. MARGULIES: The Northeast Ohio  Program  is  very

                4 closely tied in with Western Reserve.  That is the most

                5 intimate part of their educational base.

                            When we were attempting to get a total Ohio program,

                  they were one of the principal actors in the discussion.

                8  But their area of concern involved in regionalization is

                9  not East Ohio centered around Cleveland.

              10            DR. HINMAN: The kidney  area  specifically,  though,

              11  there is already some organ sharing going on between Cleveland

              12  and some of the other cities.  Whether it is only from the

              13 'clinic or Western Reserve, too, I  just don't know the

              14  specifics.  But I think both- are involved.

              15            DR. MARGULIES:  I should tell you that the system

              16  they are using for coordinating things in Cleveland is not the

              17  same system they used for handling the poling booths.

              18            (Laughter.)

              19            DR. MAYER:  Yes, Lee.

              20            MR. VAN WINKLE: The kidney committee,  I  would  say

              21  the head of the RMPs in the State in terms of taking a look

              22  at the total picture and true regionalization, they have
              23  representatives from the Cincinnati area, the Toledo area,

              24  the Cleveland area, the Columbus are.  They are fully

  @ce-Federal Reportefs,  Inc.
              25  represented throughout the State on this committee.  And that


               I  also becomes their technical review body for any proposal

               2  that comes in to any RMP within the State -- representatives,

               3  you know, from that State committee.

               4            DR. MAYER:  On renal disease.

               5            MR, VAN WINKLE:  Renal disease only.

               6            DR. MAYER: O.K*O' I would like to move on now  to

               7  Northeast Ohio.

               8            We will need to give some thoughts to the degree to

               9  which we feel comfortable about rating or nonrating of this

              10  proposal. I am in the comparison of apples and oranges kind

              11  of issue myself which was part of my dilemma on it.  And as I

              12  go through it, I am at the one, two, three end of the spectrum

              13  relative to this.

              14            But I would have to say given the  circumstances,

              15  I don't know how they could be at other than the one,  two,

              16  three edge of the spectrum in terms of tkying to develop  a

              17  new RMP.  So the question is do we want to rate' it and what

              18  are the potential implications of that.

              19            Lorraine, any comments on it?

              20            MRS. KYTTLE:  No, sir.

              21            DR. SPELLMAN:  I don't think I could rate it if it

              22  is going to be commensurate with the decision to fund it.

              23  I don't see how to translate into this.  So I just couldn't

              24  rate it.
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              25            MR. CHAMBLISS:  May I comment there?


                                                                             162

                I           DR. MAYER:  Yes.

                2           MR, CHAMBLISS: You asked  what  are  the  implications

                3  of ratingr and you had suggested some numbers.  whereas I

                4  would not suggest numbers, I would say whatever rating this

                5  committee may place on that region would certainly give it

                6 some ind ication as to where it stands. It  would  give  it  some

                7 water line as to where it stands as a region based on the

                8 action of this committee.

                9           MR. HILTON:  Are we talking about rating the

              10  internal structures now, the internal coordinator and internal

              11  advisory committed, as opposdd to region?

              12            DR. MAYER:  Wellf I guess the question of  the

              13  committee is do you want to rate it or not.

              14            DR. SPELLMAN:  Let's have a motion.

              15            DRO SCHERLIS:  Again, I am in a dilemma in  that I

              16  don't see why we should rate it.  We are rating all regions on

              17  the basis of a lot of extenuating circumstances, some more

              18  extenuating than others.

              19            1 would think that the numbers that we come up with,

              20  and I assume you do as chairman misuse your prerogative in

              21  telling us how you rated it.

              22            DR. MAYER:   I am sorry about that,  Like  Mr.  Nixon,

              23  I occasionally forget.

              24            DR. SCHERLIS: I would think we  should  rate  it  just

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                I


                                                                          163

               1           DR. MAYER:  All right, fine.

               2           Before we do thatt I had promised Mr. Ichinowski

               3 we would comm2nt briefly about the rating sheets before we

               4 did Oregont and then I flunked again.

               5           Would you care to comment?

               6           Lee, you have another comment?

               7           MR. VAN WINKLE:  I think we are rating something that

               8 doesn't exist, sir.  This new organization that you are taking

               9 a look at is not even legal until September 1.  So are you now

              10 rating the two old regions?

              11           DR. SCHLERIS:  Then we are funding a non-existent

              12 organization.

              13           MR. VAN WINKLE:  That is an application for

              14 September 1.

              15           DR. MAYER:  Subject to.

              16           DR. SCHLERIS:  I think we hve to view the combination

                                                   valuating system   we
              17 of the two and, come up with somee

              18 reach the evaluation by the level of funding that we gave it.

              19 I assume there is something objective behind that.

              20           DR. MAYER:  Comments on the rating system.

              21           MR. ICHINOWSKI:  I have a couple of notes I would

              22 like to pass on to you which could help us as you do the

              23 scoring and some problems that we had with the rating sheets

              24 that we received from the review committee last time.

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                                                                            164

                I rating. That second column with the numbers running  down  it

                2 is the weights. And regardless of whether a  criterion  has

                3 15 points, the scoring still goes from one to five.  We did

                4 get them running up to 10 and 15.

                5           We would request that each criterion do receive a

                6 score because if you leave one of the criterion blank? .iat

                7 negates the weight.  And this causes difficulty in calculation.

                8           We also ask that you do not score, even if the

                9 region is in your opinion not worthy of but dne,-that criterion

              10  as a zero.  Because that also causes us some problems.

              11            With some of the raters last time wishing'for  some

              12  more.expansion in terms of identifying a region other  than

              13  1, 21 30 4. or 5, we notice that some were scoring 2 plus  or

              14  3 minus.  The scoring system has now been expanded to include

              15  1 decimal such that if you want to score a region 3.2 or

              16  2.5l.you can do this in each of the criterion. But  try  to

              17  stay away from something like 2-1/4 because then that  causes

              IS  another problem with two decimal places.

              19            MR. PARKS:  Would you go over again the problem

              20  azero gives you?  I really didn't get that.

              21            MR. ICHINOWSKI: A zero, when we multiply  by  the
              22  weight that criteria has just multiplies out to zero4  I would

              23  suggest if you feel a region should be given a very. low

              24  figure for that particular criterion, maybe give it a .1 rather

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                                                                               165

                I  happens to be number 2, accomplishments and implementation,
                2  which is worth 15 points, by you scoring a 0 on that element,

                3 your actual output of that is 0 times 15 or 0.

                4            MR. PARKS:  That is accurate.

                5            DR, SCHMIDT:  But we don't want it that way.

                6            MR. ICHINOWSKI: That's accurate  in  terms  of  mayha

                7  what you want to give, but in terms of then compiling it by

                8 some automated calculation technique we  are  using,  it  throws

                9 it out as a reject.

              10             DR. MARGULIES:  It is really conformity to the

              11  machinery  we are asking.

              12             DR. MAYER:  No.

              13             DR. 14ARGULIES:  Not quite, but actually it throws

              14  off the total calculation if there is  a  non-entity  in  there.

              15             DR. MAYER:  Dr. Hess4

              16             DR. HESS:  I have a question.  If I understood    you

              17  correctly, you.want some number of some sort other than     zero

              18  in every one of those boxes, right?

              19             MR. ICHINOWSKI:  That's correct.

                             DR. HESS: One of the principles  of  rating  is  that

              21  you try not to. halor and you try to be as specific as you can

              22  on every point. If you don't have data  upon  which  to  base  a

              23  judgment, you are better off not making any judgment.

              24             DR. MAYER: I thought we arrived at we would circle

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                                                                            166

               1            MR. ICHINOWSKI: What we have done in the  past  is

               2  we have circled those to indicate that the reviewer had

               3  some concern or no data regarding his rating.

               4            DR. HESS: For example, regarding Ohio,  there  are
               5  many of these categories we essentially have no information on.

               6            MR* !CHINOWSKI:  That is a tough region.

               7            DR. HESS:  It seems to me it is very unfair and

               8  illegal to make judgments on the basis of no data.  We  have

               9  data on certain of those categories, but others we have

              10  nothing,

              11            DR. MAYER:  Joet I suggest you circle them and say

              12  that the primary reviewer didn't provide you the information.

              13            DR. WHITE:  What if we should happen to say we cannot

              14  rate this? Does this make the machine angry at one  of  us?

              15            (Laughter.)

              16            DR. ICHINOWSKI:  If you do not rate the region, we
              17 have provision for excluding all your dta elements  in  that

              18  particular region.
              19            DR. SCHERLIS:  If I follow you correctly, then,

              20  if we exclude some, you are going to exclude it all?
              21            MR, ICHINOWSKI:  Or else try to come up with  some
              22  provision for filling in the blanks that seems  reasonable.
              23            DR. MAYER:  The issue is, Leonard, your opinion is
              24 probably  better than his about it even though you feel

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                                                                           167

               I            DR. SCHERLIS:  But in reality, if you get down to

               2  what we really do is we put down these numbers after we have

               3  such a forceful, lucid presentation as we just had  y our
               4  chairman.  We attempt to really extrapolate what he is thinking

               5  in terms of numerical value.  And in case we don't follow the

               6  directions, he lets.,us know what his numbers are.

               7            (Laughter.)

               8            DR. MAYER:  In advance.

               9            DR. SCHERLIS:  It proves very helpful.

              10            DR. MAYER:  Other comments?

              11            (No response.)

              12            Has everyone who intends to rate the Ohio Region

              13 'rated the Ohio Region?

              14            (Laughter.)

              15            DR. SPELLMAN:  Yes.
              16            DR. MAYER:  Let's move on to the Northeast Ohio.

              17  Sister Ann,

              18            SISTER ANN JOSEPHINE:  I have some of the same
              19  difficulties in providing information on this particular region
              20  as Dr. Mayer did.  The one contact I had with the data from
              21  the region was as a member of this committee at which time it
              22  was the decision of the group that rather than have three
              23  very weak programs, there would be advantage in making a
              24  recommendation that there be consolidation in the development

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                                                                            168

               I            However,, as Dr. Mayer indicated and the

               2  material that is in your book gives the details of this,

               3 the Northeastern groups strongly based in  Cleveland  decided

               4  not to go along with this recommendation and at the  present

               5  time are submitting a request for funding of an individual

               6  Regional medical Program.

               7            In assessing this particular program, one has

               8  to keep in mind that for 17 months . no coordinator was
               9  present during which time there was not an entire lack of

              10  leadership, however the leadership was shared by many people.

              11  And as a result, the total effort was not coordinated.

              12            more recently, Dr. Gibbons has been brought in  as

              13  the coordinator of the program. And in reading some  of  the

              14  descriptive material concerning the new coordinator* apparently

              15  he has been in the Cleveland area for many years.  He is very

              16  well acquainted with the medical community and is able to

              17  work very well with the diversified components there.

              18            However,, one of the concerns I personally would have

              19  would be with the fact that here we a coordinator who  is.76

              20  years old. And this is not saying he can't be innovative  and

              21  all these things, but certainly the possibility of his availabili

              22  over a period of time doesn't exist at the same degree as  it

              23  might if he were younger.  And besides that,, he has no assistant

              24  coordinator to work with him in this program.

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                                                                              169

                  described by the site visit team chaired by Dr.  White  in,19,70,

               2  was the-fhct that'core staff at that  time  needed  additional

               3  development.  I think the situation still exists.  And I

               4  think that in this particular area of responsibility of a

               5  coordinator in the absence of adequate core staffe we are

               6  probably going to encounter a great many problems.

               7            The operational project4f four in number, Are

               8  in no way related to the objectives that are  stated  for  the

               9  region. This was true in 1970 and  apparently  it  hasn't  been

              10  changed in the intervening time.

              11            In 1970, concern was expressed concerning the

              12  composition of RAG.  I believe some changes were made.  Additiora.'

              13  "consumer representatives" were added to the group.  However.

              14  there is strong domination by the executive committee  which-@.

              15  originates from the board of trustees.  And  in  reading  over

              1.6 the material provided,  I would get the impression that RAG

              17  simply passes judgments  on the kinds of  recommendations  that

              18  the executive committee  and the board choose to submit  to  RAG.

              19            I believe, Mr. Parks, would you want  to  give  tome

              20  of your other impressions?

              21            DR. MAYER: Mr. Parks is  secondary  reviewer  on  the

              22  project.

              23            MR. PARKS:  Sister, I concur largely in what you

              24  have said. As a matter of fact,  totally4  And,  again,  1  think

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                                                                               170

                I
                  of evaluation.

                2
                            The predicament does not lend  itself  certainly  to

                3 any of the factors which we have on our evaluation sheets.

                4 We are faced with a situation where we have  a  new  coordinator

                5 who did not participate, I understand, in  development  of  this

                6 particular application that we have here and a rather sparkling

                7 record of failure in  this  case.

                8           I know of no other way to present it accurately.

                91          My basic inclination is that assuming  it  would  be

              10  an appropriate remedy for this committee,  I  would  recommend

              11  that this program be  shut  down,

              12            The situation is tempered somewhat by some information

              13  that was delivered to us today and by some  previous  action  of

              14  the National Advisory Council which would appear to pre-empt

              15  the action by this particular committee.  And that is contained,

              16  I believe, in the papers which you have.  It is a letter

              17  dated February 10, 1972, from Dr.  Margulies  which  transmits

              18  to Dr. Glover the action of the  National  Advisory  Committee

              19  which is to-the effect that the program be retained at its

              20  present level of funding.

              21            And so it  would  seem, then, that anything  that  we

              22  might have to recommend  to  this committee with respect to either

              23  continued funding or level of funding would  be  superfluous  at

              24  this  time.

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                                                                              171

                1 role of this committee and especially in a situation where

                2 the National Advisory Council has spoken on the matter previously

                3           There was, I think, in this case as in the other

                4 Ohio situation a site visit conducted by some members  of  the

                5 Council.

                6           There are-some items about which we might particularie

                7 with respect to the Regional Advisory Group, its  make-up  and

                8 composition, the distribution and parti cipatioh that is

                9 effective participation of minority persons, the-participation

              10  of minorities on the staff, the non-application  of  priorities

              11  which are established to program activities,

              12            For example, they indicate that  their  top   priority

              13  is meeting some of the needs of the,people in the   u-rban areas.

              14  And certainly running down those four priorities,  I find  none

              15  of the operational effort directed to this.  I  find  certainly

              16  again with the exception of the Urban League director, I

              17  don't find among the members of the Regional Advisory Group

              18  or the trustees the kind of participation from among the

              19  consumer element that you would expect to find in  a  situation

              20  like this based in an urban setting such as Cleveland,.

              21            I think there is something to be said for having

              22  engaged a coordinator who has the historical qualifications

              23  that Dr. Glover presents.  Among the papers which were

              24  presented to us was a statement indicating that he has trained

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              25  the majority of the practitioners within this  region's  scope

                I


                                                                           172

                I of activity.  And it is largely through his standing within
                2 the medical profession and his personal.acquaintance with
                3 the principal actors that he is able to bring together and

                4 perhaps to effectuate some change.
                5           The papers that were handed over just momentarily
                6 I think Sister has those -- may throw some light on it as to
                7 prospective activity.  But if what we are rating covers
                8 the period in the past, I would say that this program is
                9 questionable and based on its past performance, I would say

                10 that it was of doubtful prognosis for the future.
                11          Nonetheless, we are advised, I am advised? that the
              .12 new director, despite his years,'and possibly because of it,
                13 has, I guess accentuated change and is currently developing and

                14 restructuring this particular program.
                15          But for those qualifications, I would sayt first of
                16 alle there is a very real question as to whether this business

                17 is appropriately before this committee.
                18          The second thin  is if it is an appropriate remedy
                                           9
                19 for this committee to recommend, I would be for recommending

                20 the money tor this program be withdrawn.

                21          DR, MAYER:  Could we deal with the question that
                22 is being raised?  Because I have a little trouble with
                23 substantial inconsistency of the letter of February 10, Haro
                24 in which it implies that the National Advisory Council

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                                                                            173

               I  a continuation of supprt for one year at a basis not to

               2  exceed the existing level funding.  And-then in the concluding

               3  paragraph, it says, change in review cycle will start  date
               4  for Northeast Ohio program from June to September li  1972.

               5  Therefore, the present grant period for Northeast Ohio  will

               6  extend through August 31t 1972.

               7            And presumably, this application deals with  that

               8  period after August 31, 1972. And yet presumably  there  is

               9  some kind of commitment for funding in the region through  to

              10  what    February of 1973?

              11                       d the issue you are raising because I can't
                            I understan

              12  see it.

              13            DR. MARGULIES:  Whatluppened earlier when we reached

              14  the same conclusion you did about the program which is  that

              15  both Northwest Ohio and Northeast Ohio were of such doubt  u

              16  quality that there was serious consideration about whether they

              17  should be continued at all, we did put considerable  pressure

              18  on them to make some basic alterations.  we, in fact, limited

              19  their funding during that period of time to six months  and

              20  then gave them an extension of six months to see how effectively

              21  they could work out their plans.

              22            And when they reached a tentative agreement  which

              23 required the Council to act on whether or not they should continue

              24 the decision was made they should have funding for  one  year,

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                                                                             174

               I  thereafter.  And so if you were to make a recommendation here

               2  that this program should no longer be continued, it would be

               3  a matter of phasing out their activities with existing funds

               4  and then closing it down.

               5            MR. PARKS:  When would be the date that their

               6  current funding would terminate?

               7            DR. MARGULIES: Their current funding under  this

               8  one-year extension -- I will have to ask for some help on

               9  that.

              10            MRS.-KYTTLE:  August 31.

              11            DR. MARGULIES: August 31 of this year as far  as

              12  I know, 172.

              13            DR. MAYER:  Except there is an implied commitment by

              14  Council until February# at least one year from February 10,'

              15  in your letter.

              16            DR. MARGULIES:  Well, I am sorry because .@'le  etter

              17  was confusing.  That referred to the six months and then

              18  six-month extension so that so far as I know the  are funded
                                                                 y

              19  only through August 31 of 172.

              20            DR. SPELL14AN: Was one of the clear alternatives

              21  merger or abandonment,, so to speak?

              22            DR. MARGULIES:  No.  We did not require them to merge,

              23  What we did was lay out to all three programs their deficiencie

              24  and recommend they give merger serious consideration.  And
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                                                                             175

               1  progress they had made.
               2            The efforts to consolidate were partially effective.
               3  So you see two programs instead of three. But we  still  have
               4  the problem of Cleveland and the rest of Ohio.  And the
               5  viability of the program is one to be judged At the present

               6  time.

               7            SISTER ANN JOSEPHINE: This morning when I  said  we

               8  have to be sure we ask the right questions, I was thinking
               9  in terms of this report.  And I personally don't feel that the
               10 question is at what level shall we fund them.but I think  the
               11 question is should we fund this program. Should  we  continue

               12 to fund,this program?

               13           DR. MAYER:  Comment, Phil?

               14
                            DR. WHITE:  I don't understand this concern in

               15 reading this. Some of the comments by Drs. Millikan and
               16 Everist suggest that in spite of his age, Dr. Glover seems  to
               17 have some leadership qualities.  What has happened since that

               18 time?  Has he made any move?
               19           Is Dr. Hudson still a thorn in their side?
               20 Has there been no progress at all since that visit by Dr.

               21 Millikan and Dr. Everistr or has there been?
               22           DR. MARGULIES:  Do you want to comment on this?

               23           DR. MAYER:  Mr. Ashby, comment?
               24           MR. ASHBY:  Actually, Dr. Glover is able to contain

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                                                                            176

               I           And, yes, he has been very busy..  The program staff,

               2  at this time,, morale is much higher.  They seem to be working

               3  harder, although it is just observation.  Everyone that has

               4  met him seems to be impressed.  Even though he is 76,.he is

               5  a young 76. He realizes his age is a limiting factor as  far
               6  as being able to be around in that program for a long period

               7  of time.

               8           He impresses me as a mover, and I don't believe  he

               9  would have taken the position at all if he hadn't thought he

              10  could do something with the program.  He was one of the

              11  biggest critics the program had prior to his acceptance as

              12  coordinator.

              13           DR. WHITE:  I gather Dr. Robbins

              14           DR. MAYEA:  Phil, we couldn't hear you.
              15           DR. WHITE:  I was asking if Dr. Robbins, the dean

              16  of the school, was in favor of RMP.
              17           DR. MAYER:  That to me is one of the great unknowns.
              18  Fred Robbins, in spite of his research background and his
              19  Nobel-laureacy is really committed to community health action
              20  efforts.  And yet here sat that RMP all this time without
              21  movement.  And I can't put those two facts together  n my
              22  mind.  If anybody can help me with that out of staff or

              23  elsewhere

              24           DR. ELLIS:  I can.
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              25


                                                                             177

                1           DR. ELLIS: His philosophy was a little  bit  out  of
                2 line  with that of the rest of the people at the  time.  And  I
                3 think  the Midwest is pretty conservative.  And  this  accounts
                4 probably for the fact that it would take a little while to get
                5 the show on the road.
                6           DR. MARGULIES: Fred has been  very  deeply  involved
                7 in the efforts to rebuild this program. When  we  first  tried

                8
                  to have a merger of all three, he was one of the leading
                9 voices for a true merger.

              10
                            The problem$ on the other hand,  getting  back  to
              11  Northeast and the question of why didn't it go,  Bill,  so  far
              12  as I could tell, it was the inability of the people in

              13  Cleveland to resolve their own internal differences.  It   is the
              14  old  issue of Western Reserve and the Academy of Medicine  and

              15  the  local politics.  And about the time he would make a
              l@6 move in one direction,, he would run into Charlie Hudson coming

              17  from the,other-direction. And he has not really  been  able  to

              18
                  overcome some of the resistance.

              19
                            I think if he had had a free hand and if  there  had

              20  been a coordinator -- You may remember when  this  program  was

              21  first developed, the coordinator was a  fellow  named  Barry

              22  Decker who was a very vigorous, imaginative,  hard-working  guy

              23  who got the program through the planning stage and promptly

              24  was recruited away.  And they then were unable to get a
  ce-federal Reporters, Inc.
              25  coordinator.  And I think the main reason they couldn't get one,


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               I  and this is the real stalling point is because they couldn't

               2  reach a resolution between the vying medical-political forces

               3  within the Cleveland area.  They would get somebody, and if

               4  it was all right with Western Reserve, it wasn't all right

               5  with the Academy. And sometimes they would say, "Maybe  we

               6  better go out of state to get somebody who is neutral."  And

               7  they were really hung up on their own internal differences

               8  while Fred was trying to get something reasonable accomplished.

               9           He is still actively interested. He  still  gives

              10  strong support to the new coordinator.  I don't know that they

              11  have resolved those problems.

              12           SISTER ANN JOSEPHINE:  The question that arises

              13  in my mind is would it be and it would seem to me that it might

              14  well be to the interest of the total State to take a stand

              15  that might give a little more encouragement to this merger.

              16           DR. MARGULIES:  I quite agree.  What we have said

              17  is that we accepted the present arrangement as a tentative

              18  one, but we insisted they continue to work toward a final

              19  resolution of a total State system.  But that is sort of good

              20  advice.  I don't know how strongly it is accepted or how much

              21  meaning.it-has.  They are meeting together.  They will talk

              22  with one another more and more, but it is not quite what you are

              23  talking about.

              24           DR. MAYER:  Yes, Leonard.

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              25           DR, SCHERLIS:  Do I read correctly the printout their


                                                                             179

               1 budget essentially is divided between  the-four,  the  hospital

               2  librarian, coronary care unit training  strep  culture,  and

               3  strong rehab?  Is this the total program?

               4            SISTER ANN JOSEPHINE:  It is really not.  It is a

               5  very difficult program.  They call it program.

               6            DR. SCHERLIS:  That comes to something 1 ke

               7  $800-some thousand.

               8            SISTER ANN JOSEPHINE: Actually, I  think  we  are

               9  describing a planning component and calling it an operational

              10  program.

              11            DR. MARGULIES: We have had  repeatedly  from  that

              12  program whenever we have leaned on them  hard,  particularly

              13  about the coordinator, the complaint that there is  so  much

              14  national instability in the Regional-Medical Program  that  it

              15  is impossible to get a coordinator.  And we keep telling them

              1.6 it is like arguing that you lost the ball game  because  it

              17  raihed. The other team is in the  same  rain.  other  programs

                  have developed, have had strong coordinators, have replaced
              18

              19  them and got good people,, and they haven't been able to.

              20  But they have used this as a kind of a defense for  not  doing

              21  anything.

              22            When you look at how long that program  has  been

              23  without a coordinator, it has been ever since  they  became

              24  operational up to the,present time when they have  gotten  Dr.

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              25  Glover in.  And that has only been within a matter,of a few


                                                                           180

               I  months.  I think he came on board in Janu

               2            DR.MAYER:  Yes,, Joe.

               3            DR. HESS:  It seems to me we have to look, if we

               4  accept Mr. Parks' and Sister's --

               5            DR. MAYER:  Could you use the mike?  We really

               6  can't hear you.

              .7            DR. HESS:  If we accept Mr. Parks' and Sisterl's

               8  feeling perhaps the thing to do might be to recommend the

               9  phaseout of this programt then we have to look at what ha     ns

              10  if that actually is taken.

              11            I think we would be in a better position or at  least

              12  I would feel more comfortable about being in favor of that if

              13  the Ohio program were in a more stable state itself. But I am

              14  jutt wondering if that wouldn't add an additional burden to'

              15  two regions that are already trying to merge and a  coordinator

              16  that is only there 'for another month or two. And how  much  can

              17  it take?  What are we going to do to PJ4P in that whole State

              18  if we do this all at once?

              19            Maybe one way out of this dilemma is perhaps delay

              20  this for a year and give the Ohio RMP a chance to see what it

              21  is going to be able to do and then take another look at it.

              22  And maybe merger would be appropriate at that time.

              23            But I must say I am worried about wiping this one

              24  out and saying merge with Ohio right now in their current state

  :e- Federal Rdpottvs,  Inc.
              25  of flux.


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                1            DR. MAYER:  Sister Ann,

                2            SISTER ANN JOSEPHINE:  I wonder if in line with this

                3 February 10 letter which could well give us a position that we

                4 could continue the funding until February  of  173  which  would

                5 be nine months and say by this time, you  know,  we  would  hope

                6 you would be able to work out these  differences,  that  would

                7 provide that leeway in keeping with something that we made

                8 some kind of a commitment to.

                9            DR. MAYER: Well, what  would  we  expect?  I  guess.I

              10  need to have some feel in terms of the new  cycle,  what  that

              11  would mean.  Presumably, that would mean that would have to be

              12  reviewed in January which says that  whatever  new  application-

              13  would have to be inhouse when?

              14             I am trying to get a feel for what kind of time  is-.

              15  that.

              16             DR. MARGULIES:  November.
              17             MRS..KYTTLE:  I think we ought to look at Ohiols

                  schedule more than this rdgion's schedule.  IE  we  want  them
              18

                  to think about effecting a merger within  a  certain  period  of
              19
              20  time, should we not be looking at the place with whom they
              21  will merge rather than this place?
              22             DR. MAYER:  I am not sure I was hearing a clear-cut
              23  call for merger. I think what I  was  hearing  was  a  clear-cut

                  call for turning it around or else.  That is what I was hearing.
              24

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              25             SISTER ANN JOSEPHINE: No. I  think  we  are  moving


                                                                              182

               I  toward merger in this.

               2            Really, it is very difficult to motivate any other

               3  way in some cases. I mean, it is a matter of really  the  funds

               4  are the strong point you have.  And as I read all this, it is

               5  not just an arbitrary decision.  It is really in the best

               6  interests of the total program for the people.

               7            MR. PARKS: With respect to merger, if you allow  this

               8  program to survive, I think the question of merger is an

               9  appropriate local decision.  I think it is an especially

              10  important one.  I think we should be careful not to get into

              11  a posture where we begin to dictate what ultimately ought to be

              12  a local decision because we also would be the ones who will

              13  come along and evaluate them. And we may have forced them  into

              14  an unnatural situation.

              15            And I would certainly hope that even though that  may
              16  be something of a tactical guess as the appropriate  direction,

              17  I certainly would dissent from any decision that would indicate

              18  to them that we expected or would expect.as a factor of

                  evaluation to have these programs merged into a single unit.
              19

                            Ithink more important that we have an effective
              20
              21  unit that meets with your broad national priorities. And as

                  long as it is operational and if you can ascertain that it is
              22

                  moving effectively in tha t direction, if you can find a mechanism
              23
              24  to close the book on a bad chapter and rate that chapter for

  ,e- Federal Rtporters,  Inc.
                  precisely what it is and then the next time you take a look  at
              25


                                                                            183

                 I it, measure it from this time forwardt I am not so sure I
                 2 would want to be in a position of this place and with the
                 3 information that we have indicating to them that they must

                 4 merge or else.
                 5          I really don't have the information to make  that

                 6  decision.
                 7          SISTER ANN JOSEPHINE:  I agree.
                 8          DR. MAYER:  Let me see.  To meo it seems like we have
                 9  roughly three options given the kind of tenor of,the discussion.
                 10         One option is that we say effective August 31, they
                 11 are out of business,  And they can come back in and,reapply
                 12 for a new RMP if they want to do that in some form at some
                 13 future date, That's one step we can take.
                 14         The second step we can take is extend them  to the
                 15 February period and say that by November you must have  a
                              here developed for review or you will be out of
                 16 program in
                 17 business effective February 28.
                 18          or, thirdly, we could say, all right, we are extending
                 19 them at some level from now, from August of this year,  to
                 20 August or September 1 of next year with the same kinds  of
                 21 constraints on it.
                 22          Now, those to me seem to be the three  options.
                             SISTER ANN JOSEPHINE:  And if we did Noe 2, what
                 23
                   would be our expectations at the end of that time?
                 24

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                 25          DR.  MAYER:  That is up to us, the committee.  And we


                                                                             184

                1  need to have those laid out more precisely.

                2           Yes, Joe.

                3           DR. HESS:  In connection with your third option,

                4  might we consider recommending what in essence would be
                5 reversion to a kind of a planning phase? Phase  out  many  of
                6 these activities and ask them to take a good, hard  look  and
                7 come in a year  from now, fund them for sort of a planning year,

                8 come back in with a better plan which reflects some very
                9 serious rethinking of where they are going to go and how they
              10  are going to get there.  And this would keep them in phase with
              11  the Ohio, and that would provide an opportunity for  them  to
              12  1ook at this question of merger as well as to look at the

              13  strengths they have to pull the program toget er.
              14            Is that possible?

                            DR. MAYER:  Sister Ann, comment?
              15
              16            SISTER ANN JOSEPHINE:  Is Ohio in a planning stage

                  now, planning phase?
              17

                            DR.MARGULIES:  No.
              18
              19            SISTER ANN JOSEPHINE:  It is operational?
              20            DR. MAYER:  Except that the recommendation we made
                  vis-a-vis the new Ohio RMP was most of the dollars in the core
              21
                  staff to support that planning group and evaluation group that
              22
              23  they are proposing for the two combined regions with very
                  little money in terms of o eration.  The money that we
              24                            p

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              25  suggested was roughly two to one, three to one, in  terms  of

                I


                                                                              185

                I  staff as opposed to projects which is the reverse of the

                2 usual situation.

                3           So in that sense, we have moved them in that

                4 direction.

                5           SISTER ANN JOSEPHINE:  Then, what Dr. Hess is

                6 suggesting would enable us at the end of the year to

                7 evaluate the region@s capability of planning and ability to

                8 become operational or not.  Is that what you are saying?

                9           DR. HESS:  Right.  Cut them back, phase out the

              10  project funding or reduce it substantially.

                            SISTER ANN JOSEPHINE:  And it might even be that

              12  during this period of time, they could begin to look toward

              13  maybe working more closely with the other Regional Medical

              14  Program in the State.  Maybe that is the way they can take their

              15  first step.  Maybe it isn't the most desirable way to go.

              16            And then if their planning stage, if at the eh  d of the

              17  planning period, the group felt that they were ready for

              1 8 operational funds, then we could move in this direction.

              19            Is it just one year for planning?

              20            DR. MARGULIES:  Technically, we would not put them

              21  into the planning stage because that has too many legal

              22  complications.  Functionally, in a planning stage, which works

              23  out the same way.

              24            The only comment I would like to make regardless of

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              25  Your decision is I think this extraordinary attention to the


                                                                          186

                 program is well deserved*  if they get through the present
              2  period of pressure and emerge as Northeast- Ohio feeling
              3  that they can now feel as though they are on sound,ground, they

              4  will be making a very bad mistake, and so will we.  Because

              5  what has come out of it is anything but satisfactory up to the

              6  present time.
              7            But we do feel the potentials are there.  But potentials

              8  aren't enough.

              9            DR. SPELLMAN: Which means at the end of that  year

              10 they would if they had not merged or had not made progress,
              11 you would have to phase them out.  That would have to be clear.

              12 Otherwise, you would just be repeating the same.

              13           DR. MARGULIES:  That's,right.
              14           SISTER ANN JOSEPHINE:  And the success that has been
              15 subscribed for this program rather recently is all bound up

              16 with one particular person, not a program.
              17        - DR. MAYER: Am'I clear that their current  level  of
              18 direct cost funding is in fact $690,000? I am looking on,  I
              19 guess it is pink.  I am not sure whether it is pink or salmon,
              20 but it has an asterisk and says "Does not include 24-month
              21 extension for 01 year of $2,376,000."  I don't understand it.
              22           What level of funding are they currently at?
              23           LeIt me make a suggestion in terms of staff.  At least
              24 what I need or.what I needed when I reviewed programs is to
  %ce- Federal Reporters,  Inc. have a fix on what the current annualized, most up-to-date
              25


                                                                             187

               1  operating costs are of the program as it is then functioning.
               2            Now, maybe we have got in here that data,  but  if

               3  somebody said to me what are they currently  functioning  on

               4  an annual rate basis in terms of core staff and in terms of

               5  project -- that is the information we need to have in terms of
               6  where they are.  I don't know where they are.  They are somewhere

               7  between $2.3 million and $690,000 on an annual basis.  I don't

               8  know where they are.

               9            Can staff help?

              10            MRS. KYTTLE:  We don't have their current expenditure

              11 rate in here because we don-It have it.  We  get  expenditure

              12  rates 120 days after a program year is ended.  And  then  they

              13  are negotiated and audited.  Pnd it is quite a while before

              14  the review system gets that information. By the  time  we  get

              15  it,, the review system has traditionally felt it was so  old

              16  that it was not applicable to the year that we are considering.

              17            DR. MAYER:  Let me ask the question a different way.

              18  We must have some idea of what their  anticipated  expenditure
              19  is from September 1. 1971, to August 31, 1972, which  is  when

              20  the thing runs out.  or don't we even have that?
              21            14RS. KYTTLE:  Their anticipated expenditure?
              22            DR. MAYER: How many dollars have they  got  to  deal

              23  with?

                            MRS,.KYTTLE:  You mean their award?
              24
  ce-Federal Reportefs,  Inc. DR. MAYER: Yes.
              25


                                                                               188

                1            MRS. KYTTLE:  This region had so many extensions

                2 that it had a 24-month 01 year. And  their  690  is  a  12-month

                3 proration of that 24-month money.

                4            DR. SPELLMAN:  That 831?

                5            MRS. KYTTLE:  lihere  is Vernon?  Did I say that right,

                6 Vernon?

                7            MR. ASHBY: No. it is  not.  The  $786,187,  they  are

                8 funded now for an 8-month period* I  was  trying  to  figure  it

                9 out here.  It is 5 something,  And it was divided by 8 and

               10 multiplied by 12 to give you the figure out  here  on  the  right-

               11 hand column.

               12            DR. MAYER:  So the ball park is $786,000,   then.  That

               13 is the level they are functioning at.

               14            MR. ASHBY:  Yes.

               15            DR. MAYER:  O.K.

               16            DR. SCHERLIS: May I  have  some  other  clarification

               17 on funding? We have used the  terms  growth  and  development  and

               18 found that somewhat confusing.

               19            Doctor, looking at the record, would you  give  me  a

               20 guess as to what you would think a reasonable amount of funds

               21 that a region of this size with a core  of  $540,000  to  allocate

               22 feasibility studies     that is somewhat  development  and  growth

               23            DR. MAYER: I..don't understand the question,,  Leonard,
               24            DR. SCHERLIS:  I guess what I am driving at is

  ,ce- Federal Reporters,  Inc.
               25 looking at their summaries of core, the $539,000 for core


                                                                            189

               I activities, they spent $246,000 for feasibility  studies  which

               2  core activity in an area that has had so much difficulty  with

               3  looking for programs seems to me an excessive amount of money,

               4  particularly since their entire project support is less  than

               5  that.

               6            What I am making is obviously the one I don't  know

               7  how they manage it.  Is there any review of RMPS of those

               8  expenditures as they go on?

               9            SISTER ANN JOSEPHINE:  I don't have any data.

              10            MRS. SILSBEE:  As a member of SARP, we looked at

              11  the money they were spending for those kinds of things  under

              12  core as being the only hope for this program.  It was small

              13  studies that were going on under the core staff.

              14            DR. SCHERLIS:  It must have been a lot of small

              15  studies.

              16            DR. MAYER:  Dr. Hinman.

              17        - DR. HINMAN: One of these  feasibility  grants  was  to

              18 the Youngstown Warren area which is one of  their  regionalized

              19 areas and has developed into a community-based manpower

              20  development proposal which will be reviewed on the  21st.  But

              21  the planning group and the concerns of the group seem most

              22  appropriate in Youngstown and Warren. So there has  been  some

              23  payoff for these dollars.

              24            SISTER ANN JOSEPHINE:  Were they specific about what

  ce- Federal Riporters, Inc.
              25 the payoff was?


                                                                            190

               1            DR.  HINMA14:  Well, I visited with them in one of

               2 their planning sessions, and they had brought  together  the

               3 people from the three counties in Ohio and the two in

               4 Pennsylvania that were contiguous that are in  this  medical

               5 trade area -- consumer representatives, medical society

               6 representatives, education representatives -- to sit down and

               7 talk about whether or not they wish to try,to  do  something

               8 together along the model of either the  Carnegie  Commission

               9 mental health education center or the RMP defined  community-

              10 based manpower development.

              11            The total dollar investment, I think, was in  the

              12 neighborhood of $12pOOO or $14,000. And it was  basically  in

              13 the salary of Mrs. Baird, the area coordinator, who was

              14 spending the time and effort in developing this program.

              15            DRi SCHERLIS:  It was $26,000.

              16            SISTER ANN JOSEPHINE:  One of the strengths of this

              17 procrame if I were to try to identify a strength, has been the

              18 ability to get different groups together. You  know,  without

              19 going into this as a feasibility study.  At least this would be

              20 my feeling.

              21            DR. MAYER:  Well, let me go back.  I think we have.

              22 got the three possibilities. And then under those  three,  we
              23 have to-arrive at a level of funding with some principles
              24 hooked to it that people can understand and rationalize,
  ce-Federal Reporters,  Inc. Yes.
              25


                                                                           191

                            MR. GARDELL:  I just say the funding, then, is
               2  $781,000 we are working with. we had no Counqil  level,  approve@

               3
                  level, of record because that was the end of its program  period,

               4
                  And so we were just working on an extension basis.  That was
               5  the level prior to the cut in 171.  And it is the figure we
               6  have been working with all along.
               7            DR. MAYER:  The $781,000 which has roughly $500,000
               8  or $600,000 of core and a couple hundred thousand of projects.
               9            MR. GARDELL:  I don't know what the breakout is.

               10 All I know is the total figure.
               11           I also should say to you we don't have any expenditure
               12 reports from that year.  We are still extending that'71 grant.
               13 And it is running 26 months.  And you don't get an expenditure

               14 report until 120 days afterward.

               15           DR. MAYER:  Leonard.

               16           DR. SCHERLIS:  I would  suggest that they spen  some
               17 of their feasibility funds to learn how to write grants.  I
               18 could make absolutely no sense out of that document.
               19           What you are telling me about the length of  year  one,
               20 I have always looked at year one rather conservatively as
               21 being roughly 12 months, as I understand it.  I don't accept
               22 220 percent year one unless it is clearly stated in.th6

               23 record.
               24           And to pick-up that blue book, I want  to  congratulate

  Ace - Federal Reportefs,  Inc.
               25 the two of you who reviewed it for making any sense out of it.


                                                                              192

                I  I find it completely lacking as far as any history or what

                2 went on.  Was I short-sighted when I looked at it or were there

                3 pages that were missing?  Because there was absolutely no

                4 history. And I tried to figure out how  they  did  everything

                5 they did in one year.

                6           How they can get this bad a record in one  year  is

                7 something 1 could not figure out. It was a  rather  long  year.

                8           DR. MAYER:  Dr. Schmidt.

                9           DR. SCHMIDT; I don't think it  would  be  appropriate

              10  to close them down.  And I think what we ought to do is approve

              11  them for a period of time that would be approximately a year

              12  or whatever it would be to get the end of  their  time  matching

              13  the end of the time of the Ohio program, whatever thatis.

              14            DR. MAYER:  That is, I gather, August 30.

              15            DR. SCHMIDT: And they should be  instructed  that  the

              16 options at that point would either be that they  make  the  case

              17  for an independent Northeast:.Regional Medical Program or  they

              18  are merged or they will be shut down and that the level of

              19  funding be someplace around $500,000 or  $600,000,  something

              20  that will get them down so that they have to  start  shutting

              21  down their projects and enter a planning phase and come back

              22  up again., And the funds should be limited to the  extent  that

              23  this will force this, maybe $500,000 or $600,000 to  do  that

              24  with the instructions stating in effect what we are  asking  for
  ,.e-Federal Riporters,  Inc.
              25  is a plan for this Regional Medical Program that we  would  look

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                                                                              193

                1  at and evaluate.

                2           They have either got it or have to throw in with the

                3 other one or they have got to quit.  Having the end point

                4 being the date

                5           DR. MAYER: Which is August 31, 1973,  which  is  what

                6 it would be.

                7           DR. SCHMIDT: If there is a sense  to  that,  I  would

                8 so move,

                9           DR.-SCHERLIS:  Second.

              10            DR. SPELLMAN:  This August or next August?

              11            DR.  MAYER:  This August there is no way they can

              12  comply with what he is asking.

              13            DR. MARGULIES:  He is talking about 173.
              14            DR. MAYER:  So what Mac is talking about is recommend-
              15  ing funding at a level which is kind of fuzzy, and we will
              16  have to sharpen that up, from September 1. 1972,to August 31,
              17  1973, which is one year and does include  12  months,  Leonard,
              18  with explicit instructions that at the end of  that  period  of
              19  time, they ought to have inhouse a grant application which either
              20  justifies their continuation as an RMP, as  Northeast  Ohio  or
              21  merged or some other effective thing or their funding is going

                  to be discontinued.
              22
              23            DR. ELLIS:  May I ask a question?

                            DR. MAYER:  Yes, Effie.
              24
  re-Federal Reporters, Inc. DR. ELLIS: I want to ask one question.   I  want  to
              25


                                                                              194

                  ask Dr. Margulies do you think if staff works with them more
                2  closely as they are set up, they will improve and their

                3 horizons can broaden? If you could get  a  younger  person

                4 with newer ideas to work under Dr. Glover if he  is  going  to

                5 be there for a few years or more or something  like  that,

                6 this would be helpful.

                7           It doesn't sound to me as if merger would be possible

                8 that is, a real sound merger -- within the period of  a  year

                9 or even two or three. Perhaps it would be better  to  say  move

              10  toward that if this seems likely.

              11            But I don't know if they are going to be able to

              12  do too much unless they-do have someone kind of really helping

              13  them and monitoring verk.closely what they are  doing  and

              14  suggesting a way,

              15            DR. MARGULIES:  Well, so far as  staff  capacity  to

              16  improve the program is concerned, I guess my best response

              17  is God willing. They are there. In  fact,  I  think  probably

              18  staff in that part of the RMP, bOD, has spent mote time on the

              19  Ohio programs than any other. And the major  benefit  has  been

              20  in the other part of it where a merger has occurred.  Aad in

              21  the process of. merger, some real new thinking has gone on,

              22            Staff at the present time,  as I indicated, has  some

              23  hope for the Cleveland end of it doing well.  But I think it

              24  will not do well unless the kind of very specific action which

  ,e-Fedefal  Repoitefs,  Inc
              25  you are talking about does come out.   So they don't think that


                                                                             195

               I  this is justa mild gesture, but it carries with it  not  a
               2  veiledo but an open threat, fish or cut bait.  I don't see any
               3 other way in which,staff will have the backing to  have  an

               4  impression on what goes on.
               5           MISS ANDERSON:  Somebody mentioned their relation-
               6  ship with Pennsylvania,  is that a reality?  Could they

               7  possibly merge with that group?
               8            DR. MARGULIES:  Nol this was just on the local basis.
               9            MR. HILTON:  I was just going to ask simply on the
               10 discussion stage on this motion, I wondered if there is  a
               11 possibility or the danger that this action might be interpreted
               12 by those on the receiving end as indeed somewhat vindictive

               13 on the part of RMPS

               14           DR. MAYER:  Somewhat what?
               15           MR.  HILTON:  Vindictive, punishment for them for
               16 not     Because it seemed there is no concept  of  merger.
               17 The seed has been planted already even in that February 10
               18 letter. It has been suggested, and they have  heard  that.
               19 And they recognize that as A product.  And would this action
               20 coming when it does not come off as being a little bit  of
               21 we are punishing you already kind of thing?  And possibly the
               22 suggestion that Dr. Ellis raises of having somebody work inter-
               23 nally to bring about change might represent a more meaningful
               24 alternative than bringing down the guns quite that firmly.
  Ace-Federal Reporters,  Inc. I just raise it as a suggestion in terms of  the
               25


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               I image of RMPS with regard to the local autonomy of  these

               2 programs.

               3           DR. SCHERLIS:  I would like that to be made very clear.

               4           DR. MAYER: Mact would you care to  sharpen  your

               5 thoughts either in consultation with Sister or how do you want

               6 to arrive at a level of funding or do we suggest that  you

               7 might all do that tonight and plug in that blank  tomorrow

               8 morning?

               9           DR. SCHMIDT:  Either $500,000 or $600,000.33.

              10           DR. HESS:  To resolve that dilemmas I would like to

              11 make a suggestion.

              12           On page 4 of the pink sheets here, the summary sheet

              13           DR. MAYER: Page 4 of what sheet is  that,  Joe?

              14           DR. HESS: The summary sheet, table  of  contents

              15 Northeastern Ohio anniversary application, page 4 that has the

              16 figures on it, financial summary, if you add up out of the

              17 column "Current Year's Award",, one operation year, and I am

              18 assuming that these are 12-month figures, if you add  the

              19 $48lpOOO for core, $55,000 for subcontracts and then  add
              20 approximately $70,000 for the  phaseout of operational
              21 activities, you end up with $600,000.  And I think that falls

                 in the guidelines, shouldn't hurt them unduly in terms of staff
              22
              23 and planning activities, give them some money for phaseout, and
              24 still the message should be there.

  ce- Federal Riporters,  Inc.
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                I            DR. MAYER:  O.K.

                2            DR. SCHMIDT:  The mover will accept that.

                3            MISS ANDERSON:  I second it.

                4            MR. PARKS:  I would think if we are planning to

                5 extend this operation, that some consideration be given to the

                6 recommendations from the staff which are on this, what did

                7 you call the other color -- on these pink sheets -- which

                8 do contain some very valuable suggestions, both  on  the  first

                9 page under recommendations and on page 2 of the critique which

              10  calls, really, for certain kinds of overall guidances and,

              11  certain kinds of technical assistance and support.

              12             I think,, for example, if we are going to allow this

              13  program to continue and    expect Dr. Glover to produce, it is

                                                                             inds
              14  then encumbent upon-RMP@to prov'de him with all of the k

              15  of support that would give him at least  a  chance  to-succeed.

              16  I think that  ought to be considered in light of the money,, for
              17  example, with $600,000 that has been recommended and also with
              18  regard to the time period within which he is expected to

              19  perform,
              20             That ist to disengage him entirely, whatever has
              21  transpired in the past, and try to give him some freedom of

                  movement,
              22
              23             SISTER ANN JOSEPHINE:  I think, too, it would be very,

                           rtant if staff can to find this assistant for him,
              24  very 'mPo
  ce-Federal Reporters, Inc. an adequate assistant, because to fill  this  role  effectively
              25


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                I is going to require a lot of hard work. And it is  going  to  be

                2 a very tiring thing. And I think without  an  assistant  and

                3 without the ability to delegate, you can almost predict  it  is

                4 notgoing to work.

                5           DR. MAYER:  Yes, Mr. Ashby.

                6           MR. ASHBY: Dr. Glover, I don't think  he  intends  to

                7 stay  more than two years. And he is actively  looking  for  an

                8  assistant to train. And as I said before, he has  one  of  the

                9 biggest critics of this program. And at the  same  time,  if

              10 you consider the new coordinator, they have  been  without  a

              11 coordinator for 17 months. And then  you  limit  their  fun  ng

              12  to an amount where you can't operate.

              13            SISTER ANN JOSEPHINE:  But he can plan.

              14            MR. ASHBY04  Right.  But it is like saying we are going

              15  to  extend you for one year, Dr. Glover, although we  are  going

              16  to place these restrictions, and here is what you are go  ng  to

              17  come ip with. We know you are not going to do  it  because  you

              18  don't have the facilities and

              19            SISTER ANN JOSEPHINE: I think it is  just  very,  very

              20  important you reflect the thinking of this group.  And  I  don't

              21  hear you reflecting it now.

              22            DR. MAYER: I am reminded of the  comment  tiat  Bo
              23  Marston once made when th ere was a leveling off at $1,,2 billion

              24  in the NIH budget. And everybody was having  at  him.  And  he

  ,e-Federal Ri6pofters, Inc.
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               I           And I would have to say that you@ought to be able

               2  to do a fair amount of planning with $600,000.

               3           Mac.

               4           DR, SCHERLIS:  I was going to say that is particularly

               5  true when you have $250,000 floating around that can be used

               6  for feasibility studies.  Most feasibility studies I have

               7  seen usually have been $3,000, $4,000, $5,000 in the

               8  developmental component stage, And these are in the range  of

               9  $26,000 and $30,000 which to me is a major project and not

              10  just  core function.

              11           I think there is enough fat there to move.,

              12           DR. SCHMIDT: Concerning what Bill said, I  think  it

              13  is important to state the action of this committee as intended

              14  by me is not to be vindictive, punitive, or anything else.

              15  But it is meant to be a directive and be just a little bit

              16  crisper than some of the actions and some of the things that

              17  have been going on, particularly in that area.

              18           It is clear there has to be certain things happening.

              19  And I think that there would be enough money with $600,000 to

              20  reach the end point that is, I feel, necessary to set for

              21  this region.

              22           And the action of the committee is trying to be

              23  helpful,by setting an end point and giving some clear chcices.

                           one of them is to make the case for the region,
              24

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              25          DR. MAYER:  Yes, Phil.


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               1           DR. WHITE:  It seems to me you are going to have

               2  difficulty doing what sister thinks should be done if we are

               3  going to send this clear message you have a year to go or else.

               4 How in the world are you going to recruit that kind of guy  to

               5 come in and help Dr. Glover under those circumstances?

               6           Aren't you going to kind of have to suggest that

               7 Dr. Robbins or whoever is the head of the Cleveland Clinic

               8 or somebody lend some expertise, give them somebody on leave

               9 of absence from one of their institutions to get this thing

              10 moving? At least, he is going to have a job to go back  to  in

              11 case it flops.

              12           DR. MARGULIES:  We have some thoughts about how we

              13 might be able to do that on a 3- to 6-months basis with someone

              14 who can really be of direct assistance.  But that is the

              15 dilemma.

              l@6          We have been carrying them on all this period of

              17 time saying, "Well, you know, if we just give them the chance,

              18 they will get the people and they will get things going."

              19 And it hatn't worked. So it is a situation in  which  whatever

              20 decision you make, you are going to feel a little uncomfortable

              21 with.

              22           DR. WHITE:  I think the point earlier was if Dr.

              23 Robbins -- I am not picking on him particularly -- but if  the

              24 people in that region want to see this thing go, there is

  ce-Federal Reporters, Inc.
              25 probably enough talent already in that area that they ought to


                                                                            201

                1 commit some of those hours of those people to make the  thing

                2 go.

                3           DR. MARGULIES:  And if they can't find something

                4 that needs to be done in Cleveland, they are having great

                5 difficulties in their perceptions.

                6           DR. MAYER:  Johnv you had a comment?

                7           DR. KRALEWSKI:  Back to this budget, I don't want

                8 to beat it to death, but I am sorry I still don't  understand

                9 it.  If we are recommending $600,000, what do we-recommend as

              10  a start -  this year?

              11            DR. MAYER:  September 1, 1972, to August 31, midnight,

              12  1973.

              13            DR. KRALEWSKI:  And that will be consistent with

              14  the letter from Council?  Are we asking them to revise?

              15            DR. MAYER:  Yes.  It can be made to be consistent

              16  with the letter from Council.

              17            DR. KRALEWSKI:  And the group here feels, I gather,

              18  there is enough information in this document right here  that

              19  we can make that $600,000 decision at the moment rather  than

              20  having maybe a.small group.with staff iron out a figure  here

              21  later'in the day?

              22            I don't feel I can, but if the rest of the group

              23  feels they are comfortable with it, I will go with it.

              24            DR. SCHERLIS:  I would submit if you go through
  .e- Federal Reporters,  Inc. the ent
              25        ire application, you will come away with the same feelin


                                                                           202

               I  of restlessness

               2           DR. MAYER:  Yes, Mac.

               3           DR. SCHMIDT:  Two comments.

               4           one, if staff or anybody has a better figure to come

               5 up with and want to justify it, I think it would be fine to

               6 reintroduce that later this afternoon,or tomorrow.  And I

               7 think it would be considered.

               8           The second one is in my conversations with people

               9 at Case, Cleveland Clinic,, Medical Society, and so on, they

              10 haven't got the foggiest idea of whether they want a Regional

              11 Medical Program or what one is.  And I think at some point

              12 everybody from delightful what's his name in the Cleveland Clinic

              13 on down have to get off this business of the Feds are going

              14 to keep putting money in here and we get plenty coming in

              15 anyway,, and we don't need it.  Tiey have got to quit ijnoring.

              16           And the big problem of getting a Regional Medical

              17 Program going in that area from what I have been able-to see

                 is that people by and large have just ignored it.  And if this
              18

              19 is a way to-get them to pay some attention, whether it is

              20 borrowing people from the university or whatever, then, fine.

              21 But people have to,look at it and say, "All right, here is a

                 decision."  They have never really done that.
              22

                           DR. MAYER:  Does everyone understand the motion?
              23

              24           MR. PARKS:  One question.
  ce -Federal Reporters,  Inc. DR. MAYER: Yes, Mr. Parks.
              25


                                                                            203

                1           MR. PARKS:  On the recommendations from the staff

                2 anniversary review panel, there is a rating of 245.  May I

                3 ask what that means-and on what scale?

                4           DR. MAYER:  That is on the one to five scale, I

                5 assume.  That puts it in group C which is the lowest grouping

                6 which at-least says something, but it is at least barely in

                7 there.

                8           MR. CHAMBLISS:  If I may make a comment there

                9           DR. MAYER:  No, I am sorry, it must be..llll.

              10            DR. BESSON:  It-runs from zero to five hundred.

              11            DR.'MAYER:  Yes, right.

              12            Yes, Mr. Chambliss.

              13            MR. CHAMBLISS:  I was simply going to let the committee

              14  know that the desk chief, Mr. Van Winkle, would be available
              15  to answer any questions on that if you have  further.questions.

              16            DR. MAYER:  O.K.
              17            Comments?  Everyone understand the motion?
              18            DR.ISCHERLIS: Is there any feeling of staff  that  we
              19  are misreading the signals?  I am curious.
              20            DR. MAYER:  All I have heard is a feeling that

                  the therapy may not be appropriate.  But I think the  diagnosis
              21
              22  sounds pretty good with everyone. At least, that is what  I  am

                  hearing,
              23

                            MR. CHAMBLISS; The comment from staff would  be  that
              24
  :e -Federal Reporters, Inc. I feel the diagnosis is quite proper. We have some concerns,
              25


                                                                               204

                I  great concerns, about this region.

                2           DR*' MAYER:  Sister Ann.

                3           SISTER ANN JOSEPHINE:  May I just make a comment

                4 to you sitting at the end of the table.after you were  so  nice

                5 to brief us in.  These are the kinds of pressures I get from

                6 my board.  And several years ago, I was saying this is too

                7 harsh a way of doing it. You know what? I  am  learning  it  is

                8 a good management tool.  You will be surprised how many good

                9 things can come out of it. But I do know that  it  is  terribly

              10  important that you share our feeling about it.

              11            This is really a measure to make it possible for them

              12  to get moving.  And so you will have to be very  supportive  of

              13  it because they will read it very quickly.

              14            MR. ASHBY:  I want to apologize.  I was talking out

              15  of  school.

              16            DR. MAYER:  Further comments?

              17            Yes, Lee.

              18            MR. VAN WINKLE:  I think one of the major reasons for

              19  their problem out there is the fact their  executive  committee

              20  and board of directors are one and the same.  And that largely

              21  reflects Dr. Charles Hudson's thinking. And I am hop  ng  t  at

              22  when we get this new piece of paper that tells us what the

              23  RAG relationships and coordinator relationships and these

              24  sorts of things are, we can put sufficient pressure on them to

  ce-Fedefal Riporters, Inc.
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                                                                               205

                1            But that is what is a real grievance  out  there.  And

                2 they are dictating, there is no question, the executive

                3 committee and board of directors are the same, and they are

                4 dictating to the coordinator or non-coordinator.

                5            DR. MAYER:  Other coments?

                6            (No response.)

                7            All those in favor of the motion say, "Aye."

                8            (Chorus of ayes.)

                9            Opposed?

              10             (No response.)

              11             We effectively have gone past coffee, but let's

              12  take about a 10-minute break to mark the sheets and stretch.

              13             DR. SCHERLIS: Just one sentence that  I  think  under-

              14  lines what you said.  The organizational structure is apparently

              15  not well understood, and it is amplified as it goes  on  in-the

              16  next few pages.

              17             (whereupon, a recess was taken.)

              18             DR. MAYER:  Could we start, please? Are we ready,

              19  John?

              20             DR. KRALEWSKI:  Right on.

              21             DR. MAYER: This is new. It  isn't  anniversary,  but

              22  was site visited.

              23             1 might comment before John begins that  what  we  have
              24  just done  in terms of Northeast Ohiop there was a  SARP  rating

  ce-Federal Repofters, Inc.
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                                                                             206

                1  meant.  And then we proceeded to go on to rate it.

                2           I think what we might do in those that have  already

                3 been rated by SARP, we need to make a first decision which  is

                4 do we agree with the rating.  And if we say, yea, then we

                5 stop there and go no further in terms of subratings.  If we

                6 say that we do-not agree, then I think we are saying that we

                7 want to also rate it, and we all rate it.

                8           John. we knew you were coming up because I.assume

                9 that is your material on the blackboard.

              10            DR. XRALEWSKI:  Right on, yes, indeed.

              11            DR. SCHMIDT:  Were you asking a question or making a

              12  comment?

              13            DR. MAYER: I am making a statement unless  you  want

              14  to approach it otherwise.

              15            DR. SCHMIDT:  I think we should rate the region.

              16  Is that what you were stating?

              17            DR. MAYER:  Yes.

              18            Wello maybe we need to take a minute.

              19            DR. SCHMIDT: I think staff rated. I  think  that  is

              20  beautiful.  I think we ought to rate  it, too, as a committee,

              21            My gut feeling is that staff's numerical score is  a

              22  little bit high, although I agree with the comments and

              23  suggestions.

              24            Am I out of order?  Am I talking about something

  ce-Federal Repoiters, Inc.
              25 else?


                                                                              207

                            DR. MAYER:  No, it is a question of     Well,  let

               2 me go back.  When we originally talkedt and I don't know

               3 whether I am two meetings back,, one meeting back, or three

               4 meetings back# when we were talking rating scales, we said

               5 that those which are anniversary reviews within  the  triennium

               6 would be handled by the staff anniversary review  panel,  SARP,

               7 that we would also comment on those and  discuss  those.  And

               8 then the question came in terms of how much time would we spend

               9 on them and would we rank them, etc.

              10            And I think where we were was to say,, "All right,, we

              11 will look  and see what the staff anniversary review panel

              12 which was  set up to do that job does, and if we agree with the

              13 figure that they are at, fine.  And if we don't,, then we@owe

              14 it to ourselves to go ahead and rate them."

              15            DR. SCIU4IDT: Are you talking about the 245  score

              16 that was brought up before?

              17            DR. MAYER:  Yes, for Northeast Ohio.

              18            'DR. SCHMIDT:  I would be uncomfortable with matching

              19 my motion  against that point score.

              20            DR. MAYER: And we therefore rated it.  So  I  have

              21 no problems with that, All I am saying is we  need  to  address

              22 ourselves with each of the applications which oft this  sheet

              23 have numbers.  We have to address ourselves do we want to

              24 accept that level or do we want to rate  them  ourselves?  That

  ce- Federal Reporters,  Inc.
              25 is all I am suggesting.


                                                                               208

                            Maybe what you are saying is you want to rate them

                2  all.

                3           Yes, Leonard.

                4           DR. SCHERLIS:  I think having this sheet in front of

                5 us makes us focus on individual items as they are presented.

                6 And as such, it it a very good way of focusing the attention

                7 of the group.  in so doing, a rating is arrived at.  And I

                8 would think -we should do this with each  presentation  that  is

                9 made  here,

              10            I find it difficult to accept another rating without

              11  going through the mechanics myself to see if I agree'.  But

              12  once I have done the rating, then it is there and it is written

              13 and something might as well be done with it even if the

              14 committee that goes over this chooses to disregard it.     But at

              15 least I would like to go through the mechanics of doing    it.

              16            DR. MAYER:  O.K.,, does staff have any troubles   with

              17 that?

              18            DR. SCHMIDT:  If there are great discrepancies in

              19  this rating and staff's rating? I think that is  a  nice  danger

              20 3i4nal that would signify we have got a-problem that ought to be

              21  looked  at.

              22            DR. BESSON:  I  have viewed this as just your calling

              23  the presence of this rating to our attention, no more.

              24            DR. MAYER:  All right.

  ce -Federal Reporters, Inc.
              25            DR. SCHMIDT:  You got that?


                                                                             209

                1           DR. MAYER:  Yes, I got that, Mac.

                2           DR. SCIIERLIS:  Does the chair understand the message?

                3           (Laughter.)

                4           DR. MAYER:  Fine.  I-am happy with it.  I very

                5  comfortably ranked it.

                6           Herb,, do you have any problems with that?

                7           DR. PAHL:  No.  The committee is at liberty to

                8 rate any application at all. The whole purpose of  SARP,,  of

                9 course, was to relieve this committee to the extent  possible

              10  from having to look at those applications which in general it

              11  didn't have concern with. But you are at liberty to  take  on

              12  the full job of rating each and every application if  you  so

              13  desire.

              14            The rating by SARP is to give you assistance to the

              15  extent that you find it to be helpful.

              1.6           SISTER AliN JOSEPHINE: Are these figures  converted

              17  into figures like this? Isn't that where  these  figures  are

              18  derived from?

              19            MRS. KYTTLE:  Yes@, Sister.

              20            DR. MAYER: O.K. I gather  when  we  have  discussed

              21  them, we want to rate them.  Is that it?

              22            O.K.  Sorry I raised the issue.

              23            John, are you ready?

              24            DR. KRALEWSKI: O.K. The  NaSsau-Suffolk  RMP,  most

  ,e -
    Federal  Reporters,  Inc.
              25  of you, I guess, know that covers the two counties of  Nassau


                                                                              210

                1 and Suffolk in Long Island, a long narrow, expensive piece  of

                2 real estate a little east and north of there.

                3           The program was site visited a year ago,  And at that

                4 time they approved a three-year

                5           DR. MAYER: John, could you get a little  closer  to
                6 the mike'or get the mike a little closer to you?

                7          'DR. KRALEWSKI: The program was site visited  a  year

                8 ago and at that time decided to approve a 3-year  application

                9 for them, but to site visit them again this year-to  determine

              10  the  progress they were making and determine at this point

              11  in time how much money we should recommend for the next  two

              12  years, of that three-year grant.

              13            By way of history, the program is relatively  new,

              14  It developed initially as part of metro New York program.

              15  Then it was split off some three years ago.  They got a

              16  planning grant to form a new region, Nassau-Suffolk  Region.

              17  They operated under that'planning grant for two years,  made

              18  a fair amount of progress. They had a lot of support  from  a

              19  lot of the different health care agencies in the  region.  And

              20  then at the end of that time, they applied for an  operational

              21  grant.  That  is when we got into the scene in terms of a site

              22  visit which I chaired at that time and was.a three-year operat cn@

              23  grant that they were asking for.

              24           Now, at that time on that site visit we uncovered some

  re - Federa I Repoi te rs, Inc.
              25  seaknesses that we were concerned over, and they are as follows:


                                                                             211

                            Number one, their organization was difficult to

               2 understand if not to say the least in fact it  was  difficult

               3  to explain. They had one organization that was both  part  of

               4  RMP and CHP. They had difficulty explaining  the  difference

               5  between their Regional Advisory Group and their grantee

               6  organization. They had numerous amounts of committees  and  it

               7  was difficult to determine exactly what those committees  were

               8  doing.  So organizationally, a problem.

               9            Secondly, within the organization, it seems  as

              10  though they had some weaknesses in their staff.  They were

              11  hiring people.kind of at random the way it looked to us,  and

              12  they weren't fitting them together into a cohesive  unit.

              13  They lacked the data bate and, therefore, many of the activities
              14  that they were engaged in again appeared to be kind of on  a'

              15  random basis rather than based on a rational plan.  There  was

              16  some data to support that plan.

              17            The Regional Advisory Group was large, and t  e

              18  participation was relatively minimal. They had  fairly  good

              19  mechanisms to involve consumer groups and underserved  groups

              20  in the decision-making process, but again it looked as  though

              21  they were probably not taking advantage of those opportunities.

              22  And the attendance at the RAG meetings was low,  particularly

              23  among the minority groups.

              24            The goals and objectives were another  area  of
  ce-Federal Riporters,  Inc.
             @25  concern, They were broad and difficult to operationalize.


                                                                             212

                            Well, we found at that timer however, that t ere was

                2 a great deal of leadership being expressed by  Dr.  Pellegrino

                3 at Stonybrook, and there was a great deal of leadership,, we

                4 thought, at least, in terms of the coordinator of the program,
                5 Dr. Hastings.  So we believed that  they had the potential

                6 and that:they were on the right track. The  kinds  of  projects

                7 they were becoming involved in seemed to make sense.  They

                8 seemed to express a great concern over -the health needs of

                9 the underserved populations of the area. And  it.looked  to  us
              10  as though they could in the long run be capable of-running this

              11  organization and doing a pretty good job of it.'    I

              12            on that basis, we approved that three-year grant.

              13  And then this committee last year again with  the  stipulation

              14  that we site visit them this year to see how they  were  doing

              15  and determine how much money we could give them or if we

              16  should cut them back in terms of amounts of dollars.

              17            Well, this year's site team then, it is noted in the

              18  book here, I chaired it, Dr. Komaroff was there from the
              19  National Advisory Council) Dr. Sattler, general practitioner at
              20  the Yankton Clinic in South Dakota;  Charles  Moore,  Assistant
              21  to the Dean for Financial Affairs at Eastern  Virginia  Medical
              22  School who helped us a great deal in terms of ironing  out  the
              23  financial problems of this organization; and then  the  usua  y
              24  excellent staff.hete from ILMP that accompanied.us on the  site

  ce- Federal Repofters, Inc.
              @25 visit.

                I


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               I           This application, then, that they were presenting  to

               2 us at that point, and they are one year now into their

               3 triennium, is asking for a continuation of their core  staff.

               4 It  is asking for developmental components.  It is asking for

               5 four new projects. And it is asking for funds for  one  project

               6 that had .been previously approved, but not funded.

               7           We spent two days with the group and generally  tried

               8 to look at again their organizational structure, goals and

               9 objectives and how they were formulating projects and  programs

              10 to meet those objectives.

              11           We found that they had made a substantial amount of

              12 progress.  First of all, they have reorganized their top

              13 echelons of the organization.  They split off a group of

              14 individuals from their RAG, and they formed a separate  corpo ra-

              15 tion.   And they now have therefore a grantee organization

              16 it is a separate non-profit corporation -- and a Regional

              17 Advisory Group.

              18           Now, the membership, there is a great deal of  cross-

              19 membership on these two groups.  And that, I gather, is the

              20 concern of some. And you may note in here some  letters  that

              21 have gone back and forth between RMPS and the program.

              22           But the site team felt that they are making an

              23 honest attempt to live u  to the requirements of MIPS and still
                                         p

              24 have a functioning policy-making group here that will keep  the

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              25 program on the right road.  And we felt that although still


                                                                              214

                I cumbersome and still a bit artificial and still a little  bit

                2  difficult to explain unless you are an organizational theorist,

                3  the doggone thing appears to be working4  And that in the

                4 final analysis is a real plus, we thought. And it  seemed  to

                5 be doing the job for them.

                6         . So they have reorganized the top echelons and

                7 they keep them together, then, through a number of interrelated

                8 again committees.

                9           They have also reorganized thei r staff.  They  have

              10  had a turnover of some of their internal staff, and this  has

              11  given Dr. Hastings an opportunity to bring on some new  talent.

              12  And he has'done so in terms of one deputy manager who we felt

              13  was a real strong individual.  And he is in charge of program

              14  development.  And they have also brought on a gal who is

              16  a CPA..

              16           Now, in terms of the functioning of'this  group,  they
              17  have allowed the CPA to really take over most of the  financial

              18  management of the program and have split their organi tation

              19  away from the Stonybrook Foundation.   This foundation was

                  previously providing them with administrative support, mostly
              20

                  financial management  So they  are providing their own  support
              21
              22  now with this gal who is a CPA. And as a result of  that,  they

                  are saving a fair amount of overhead expenses in their program.
              23

                           We felt she was,really a strong gal.  And we felt
              24

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              25  that the reorganization of this staff has been a real plus.


                                                                                215

                I People now know who they are  reporting  to.  They  know  what
                                                                                they

                2 are supposed to do. They have still got  a  few  people  in  the

                3 wrong boxes, but he knows that.  And we felt that in the long

                4 run, he is going to iron this out  probably  within  the  next

                5 12 months in terms of shifting  some  people  and  adding  some

                6 people.

                7            He wants to add someone wit h a little more quantitative

                8 methods background,, and we supported,that@. And  he  wants  to

                9 add someone with a  continuing  education  background.  We  felt

              10  that that was perhaps a move in the right direction.

              11             They have developed a fairly  tight  review  system.

              12  And that was  reviewed separately by RMPS staff.  And the

              13  report that they gave us was that it was a good system both in

              14  terms of the review process and  monitoring  of  the  projects

              15  after they are oh board.

              16             In terms of questions regarding  the  central  thrust

              17  of the program, we were fairly satisfied  that  they  were  now

              18  able to take their projects that they  have  ongoing  and  the

              19  new projects and the core activities of which they have many,

              20  and put those together into thrusts that are meeting needs in

              21  the area.

              22             Now, the data base that they are  attempting  to  use

              23  for this is still very weak, although  they  are  making  some

              24  progress in it, and they are making  some  progress  in  getting

  ce-Federal Repoftefs,  Inc.
              25  Stonybrook to pick up a part of it. So  there  may  be  a  data


                                                                               216

                I  base form at Stonybrook in the next couple of years.  Still?

                2  at the present time, the data base I would say is relatively

                3 weak.

                4           But we were impressed with  their  informal  communica-

                5  tion system with the community   They are working  very  closely

                6 with the planning agencies.  They  have  subregional  groups

                7 organized under their planning activities  to  bring  minority

                8 groups and other consumer groups  into  the  decision-making.

                9 So they stay pretty close to what is going on.

              10            As a matter of fact, when we question  them  about  the

              11  activities in the area, they really show a  high  degree  of

              12  knowledge of the activities and where the needs  are  and  how

              13  they might put together some programs to  meet  those  needs.

              14  And we were impressed with that even though they weren't   able

              15  to demonstrate it again with hard data.

              1.6           Cooperation with the medical  profession  and  the

              17  hospitals and health departments again  was  good.  I  talked

              18  with a number of docs from the medical societies and while they

              19  disagree 'With some of the things that lu4p is doing in  that

              20  area, they nonetheless to the man said that Hastings  is  a  good

              21  guy, he is honest with them, he is doing a  few  things  that

              22  may:-be a little too much for them to handle  at  the  present

              23  time, but they have no big fight with  his  overall  mission.

              24            And he is doing some things in terms  of  trying  to

  .e-Federal Repofters,  Inc.
              25 change the pharmacist rolep for example, where the pharmacist


                                                                            217

                  will be acting as-a consultant to the physician.  And I asked
               2  the docs whether anyone is going to accept this.  And they

               3
                  said they thought it was the greatest thing that ever happened.
               4  They want to get that pharmacist out of his pouring from  one
               5  bottle to another. And they sure agree that this  was  going

               6  to be a real asset.

               7            I don't know if they will ever pull it off or  not,

               8  but nonetheless, to hear a fair amount bf d6cs say that  they
               9  supported it and understand what he was trying to do,  ituas
              10  impressive to me. He had got onto these guys  and  convinced

              11  them it was a reasonable approach.                  1

              12            He has also provided assistance to a couple of groups

              13  to develop HMO planning grants. one of them is funded,,  two
              14  more are in review cycles.  Th ey may not be funded now because

              15  those funds were cut back.  But nonetheless they provided
              16  assistance to providers in that capacity.  And he has provided

              17. assistance to some of the larger corporations in the area  so
              18  that what they are doing is attempting to develop some  kind
              19  of a rational plan of health care for their  employees.  And,
              20  of course, these groups are looking toward HMO kinds of

              21  or anizations to provide that care.
                    9
              22            And then, the medical society in turn is saying,
              23  Maybe we better get into this act if industry is going to
              24  start buying care from organized groups so that we can be

  -e -Federal Reporters,  Inc.
              25  one of the providers of that care.


                                                                              218

                1            Again, he has been abl
                                                   e to do this without  '.blasting

                2 it out  of the water.  we were fairly impressed with it.

                '3           Well, a number of other activities underway that

                4 we felt were useful.  Two projects that he has here for approval.

                5 one of them deals with manpower problems in  terms  of  providing

                6 pediatric nurse practitioner training, and one of them

                7 deals with both manpower and distribution of  care  by  forming

                8 a department of community medicine in one of the community

                9 general hospitals, again a task that took some doing with the

              10  medical staff of that hospital.

              11             We felt that these were on the right direction.

              12  They  were making a contribution.

              13             Maybe I will stop there for some comments  from  the

              14  secondary  reviewer before I go on to some  recommendations  and.

              15  the funding requirements.

              16             DR. MAYER:  O.K., Gladys.

              17             DR. ANCRUM: By and large, I agree  with  the  report

              18  that Dr. Kralewski just gave.  I think they have acted and made

              19  satisfactory progress:  on most of the recommendations  of  the

              20  year before.

              21             A few of the things that he talked about, I  did  have

                  some questions on.  I think he has cleared,up a little bit.
              22

              23  I was concerned about  howmuch input they were getting from

              24  the target groups, especially the poor and the  near  poor  And

  ce- Federal R,@porters,  Inc.
              25  the elderly and disabled that they talked about increasing


                                                                            219

               I  accessibility of primary health care.

               2           They had had one conference- but it  didn't say exactll

               3 what the representation or composition of the  group who was

               4 there or any plans of following through with having any

               5 more community input or getting what the felt needs or

               6 expressed needs were for the groups they were trying  to  plan

               7 programs.

               8           The other thing that was in the report and  I  think

               9 you just mentioned it was the representation of the RAG of

              10 minority groups.  They do have nine minority members out of

              11 a group of 84.  And of these nine, only appr oximately half are
              12 any of the committees.  And I would presume they could probably

              13 get more involvement by assigning.

              14           They have currently four out of nine people on

              15 committees.  And there are five that are not serving on any

              16 of the committees,

              17           The other questions I had or comments were two about

              18 the new program.  And one was cleared up just now when he

              19 talked about that new pharmacist assistant. I didn't  see  how

              20 this would fit in, but the doctors think that they can  get  a

              21 lot of help from this. Then I guess that isn't as  much  of  a

              22 question as I thought.

              23           The other was in line with the nurse pediatric

              24 practituiner training.  Here again in the original proposa

  ce - Federal Riporters,  Inc.
              25 they mentioned having a program which would train  both  LPNS,


                                                                                   220

                 I  licensed practical nurses, and RNs simultaneously in the same

                 2  programt I should say.  And both the American Nurses Associatioi

                 3 and the Academy  of  Pediatricians  had  recommended  the  program

                 4 be for registered nurses who have been prepared on a

                 5 baccalaureate level.

                 6            And I was wondering  what  rationale  they  were  using

                 7 in order to institute-'a  program  that  two  professional  groups

                 8 make a different recommendation.  And apparently this has

                 9 been changed.  They are going to use the registered nurse

               10  now.  Is that correct?

               11             MISS FAATZ:  From what I understand, their proposal

               12  is for training baccaluareate degree nurses.  The CHP comments

               13 -and particularly the CHP group, is we think you ought to

               14  train half.  Half the group trained should be LPNS.  There is

               15  no indication they acted on that suggestion.

               16             1 don't know where it stands, but the project

               17  proposal-  as submitted in here is for baccalaureate degree.

               18             DR. ANCRUM:  I know on the original grant, it

               19  said both-, and I felt it should be. I agreed with the ANA

               20  and the Academy  of  Pediatricians  that  it.probably  would  need
               21  to be someone prepared on a baccalaureate level in order to go
               22  out and then further function as an independent practitioner.

                              DR. MAYER:  Any other comments, John?
               23

                              DR. KRALEWSKI:  We were concerned over the involvement
               24

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               25  of  minority groups and the RAG decisions also and brought

                 I


                                                                              221

                I that to their attention again.  And it is a bit of a dilemma

                2 for two reasons.

                3            Number one, they are aware that their  participation

                4 of the RAG members is not good.  And they have been holding

                5 RAG meetings at different times of the day,  evenings,  instead

                6 of during the day, and different locations, and it still hasn't

                7 improved.  And we suggested probably they are going to have to

                8 develop more working committees to get RAG involved.

                9            The second thing is that with the minority groups

              10  they rely  pretty heavily oh one of their CHP men -- I have

              11  forgotten  his name -- Jim Mural to make those contacts through

              12  his subregional areas that he has set up.  And he is a good

              13  guy.  I thought he was a good guy.

              14             And I checked him out with a couple of other  people

              15  who I thought would rule on his qualifications fairly in terms

              16  of  his ability to rap with the groups.  And they said,4,,.ye.5p,,--,..

              17  he is a good guy.  And they thought he was doing an honest job.

              18             I think that their input is probably more than looks

              19  like on paper is what the feeling I think that our.site team,,,,-

              20  got out of the business.  But still they needed attention to it,:.

              21  and I think that they are going to have to do that in the next

                  year or  so.
              22

              23             DR. MAYER: Leonard.
              24             DR. SCHERLIS:  I note in the site visit of June 1971

  ce- Federal Repofters,  Inc.
              25  a comment was made that although none of the projects are


                                                                               222

                I  specifically disapproved, disenchantment  was  expressed  with

                2 the project which was computer assisted EKG diagnosis.

                3 I noted that it was funded for about $98,000  a  year  and  they

                4 requested another $58,000 the coming year.  And I was wondering

                5 if either you or Dr. Hinman had further details as far as

                6 what is the exact contributory nature of  that  program  to  the

                7 overall RMP assessment of needs in  computer  assisted  EKG  in

                8 the area.

                9            DR, HINMAN: I am not  familiar  with  that  specific

              10  program.   From a policy standpoint, the position that was

              11  taken was  that on currently funded activities would not

              12  be affected by that decision.

              13             DR. KRALEWSKI: Questioning that  project  with  the.

              14  group, they justified it on the basis that  it  is  creating  a'

              15  system of hospitals, and I don't know.  I suspect that in the

              16  long run it probably isn't to the degree they think.  In other

              17  words, they think it is persuading some hospitals to start

              18  sharing some ideas and start sharing some data.  And    therefore

              19  theyare going to start falling into more  of  the  system  than

              20  they have in the past.

              21             Now, many of the hospitals in this area, by the way,
              22  are proprietary hospitals.  And this makes some of these things

              23  very difficult.

              24             I can't defend that project.  I really can't.

  ce-Federal Riportefs,  Inc.
              25             DR. SCHERLIS:  I bring it up only because there has


                                                                              223

                  been RMP statement on this, and I was interested in exactly
                2 what the yield of this was.

                3
                             I would suggest that this like all of  the  programs
                4 be collated and looked at to see what yield there has been,

                5 Because I think there would be some valuable information on

                6 planned programs.

                7            MR. STOLOV: Dr, Komaroff  was  extremely  interested

                8 in this, and he pursued this in the discussion with the project
                9 directors, in fact to the point of mentioning that there is

              10  something up in Boston that is  self-supporting.  And  you  are
              11  probably more familiar with it.

              12             And I believe in their rationale for budget which we

              13  will go into later, we took this into consideration.  The regior

              14  does plan to look at this closely and look  at  the  ne xt projected

              15  funds and hope to cut them sharply or eventually make it self-

              16  supporting.

              17             So I believe this was focused on in the executive

              18  session and in the discussion we had of the
                                                                _project.

              19             DR. SCHERLIS: The financing  of  this  could be, as was

              20  pointed out in the site visit  report,  rather  sticky.

              21             DR. KRALEWSKI:  Again, they hope those hospitals,

              22  apparently, will come up with that kind of funding and this

              23  will build the bridges between,them.  It is kind of-shaky.

              24             DR. MAYER:  Sister Ann.

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              25             SISTER ANN JOSEPHINE: I noticed here on  page  5  of


                                                                              224

               I  the yellow sheets that it said one of the other issues requiring

               2  attention of the reviewers is the mechanics of the project

               3  evaluation strategy.  And if this is not too cleart then the

               4  accomplishment of this obective we are just talking about
                                           3

               5  isn't too likely to happen effectively.

               6            DR. MAYER:  John.

               7            DR. KRALEWSKI:  I think our site team felt that

               8  they had tightened up th eir review process considerably  since

               9  last year and that, as a matter of fact, we are in a  position

              10  now where they could and probably are going to phase  projects

              11  out before the project comes to its normal termination.

              12            If anything, the process they have developed is so

              13  elaborate it is going to take up a lot of their time to do  it.

              14  But they have got it well ironed out. And it is, I  think,  one

              15  that will  work.

              16            SISTER ANN JOSEPHINE: Is it accomplished  by  setting

              17  criteria at the same time for evaluation?

              18            DR. KRALEWSKI: Yes. What they do is  on  a  project,

              19  they outline the things the guy says he is going to  do.  They

              20  get six-months reports on whether he has accomplished what  he

              21  said he was going to do.  If he doesn't, they go out and

                  visit hin, see if they can help him.  If he hasn't made
              22
              23  corrections in x amount of time they give him after that,  they
              24  say they are going to phase it out.  They.haven't yet, but they

  ce-Federal Roportefs,  Inc.
                  are getting those reports.  We did see the reports they are
              25


                                                                           225

               1  getting.

               2            DR. MAYER:  Additional comments?

               3            (No response.)

               4            Johnf do you want to lay out

               5            DR. KRALEWSKI:  The budget I put over here so we

               6 see it perhaps a little better.

               7            What  they are requesting, then, is staff, core
               8 staff, here $446,000 which is the same as last year.  But in

               9 addition, then, a developmental component, new projects at

              10 $235,000 and then their ongoing projects that have been
              11 approved before, $475,000, which would come up to $1.3 million,
              12            And in reviewing thatwhole thing, we came up with
              13 these figures over here.  They have some unexpended funds from
              14 their core staff.  And it looked to us as though they are
              15 probably going  to continue to have that and that they are
              16 not going  to fill all the spots they have vacant, but will
                 probably fill a couple, but not all of them.  Therefore, we
              17

                 could probably deal with a sum along about $381,000.
              18
                            We thought we should give them the developmental
              19
              20 component, so we did vote that.
                            And then looking at these new projects, a couple of
              21
              22 them, again, the kidney projects, one of them has been visited
              23 by a separate committee and disapproved, and the other one,
                 the regional organ procurement program, which ;as recommended
              24

  ce -Federal Reporters,  Inc.
              25 for approval, so that is in this.  And that total was $235iOOO.


                                                                             226

                1  And going through those projectst we thought they could
                2  probably do as well at about the $200,000 level,  It may mean
                3  that they are going to cut back a little bit on them.
                4            Then, with their ongoing projects again takin g into
                5  consideration the things that were just mentioned here and some
                6  of this project that is a little bit shaky and what it is getting
                7  accomplished and the fact we feel somebody else should probably
                8  be picking this up, we thought we could reduce that from  t  e
                9  $475 level to the $360,,000.  And so therefore, our recommenda-
              10   tion would be to give them $1,099,000 which would  be  about
              11   a $230,000 increase over what the Council has  now  approved
              12   them for which is $868,000 for this  coming  year.  We  would
              13   give them then roughly $230,000 increase for the program at
              14   the present time and recommend that both for the 02  and  03

              15   years.
              1.6            We felt that their quality of their leadership  at
              17   this time and the progress of the program would  warrant  that
              18   kind of increase.  And yet, as you can see, it is less of  an
              19   increase than what they had asked for and one that  I  think

              20   they can realistically handle to do the.job.
              21             DR. MAYER:  Comment on the kidney proposal.
              22             DR.HIN14AN: This was the one I had started  on  this

              23   morning when the sequence was rearranged.
              24             The one that was recommended for approval was the

  ce-Federal Reporters, Inc.
              25   renal organ donor program which is a prototype or prelude, if


                                                                              22 @7

                I  you will, to a New York metropolitan area, the New York Metto-
                2 New Jersey,, and Nassau-Suffolk 910 application for a coordinated

                3 organ procurement for that region.  It was our feeling that

                4 the part that was being  submitted by Nassau-Suffolk was

                5 appropriate, and we recommended funding at $27,060 which I

                6 understand is in your figures here.  Is that correct?

                7           DR. KRALEWSKI:  That's correct.

                8           DR. HINMAN:  The second vTas the home dialysis training

                9program,, and that is the one over -a year ago staff had

                                          ek@a
              10 recommended that  they,  e   dvice from a mature program that

              11 was doing home dialysis trainihg.and had developed appropriate

              1 2curriculum.
              13            They ignored that advice and came in with a rediscovery
              14 of the wheel type of application for $31,200.  And we recommended

              15 disapproval of  that  one,

              16            DR. MAYER:  Additional comments?
              17            DR. BESSON:  Will our letter of advice indicate the
              18 Council opinion about that home dialysis projdct?

              19            DR. HINMAN:  Yes, sir.
              20            DR. SCHERLIS:  Is there a developmental component?

                            DR. KRALEWSKI:  Yes.
              2 1

                            DR. SCHERLIS:  That is included?
              22

                            DR.  KRALEWSKI: That's right.
              23
                            DR. BESSON:  Are there any aspects of the developmental
              24

  ce-Fedefal Re'pofters,  Inc.
              25 components, John, you felt were not meritorious?


                                                                             228

               I            DR. KRALEWSKI:  Well, they list a relatively large
               2 amount of activity that they thought they could get.'into  with

               3  the developmental component.  And our question was wh ether  or

               4  not the value. of them because it seemed as though they made

               5 sense, or most of it. But our question was how  they  were  going

               6 to decide which ones and how they were going to carry  them  out.

               7 Because they have a certain amount of capability on  their  own

               8 staff, and obviously they are going to have to buy  some  other

               9  talent On this,

              10            And I think they convinced us again the review

              11  technique they are going to use would sort that out and that

              12  it would be a negotiation process where a number of interest

              13  groups would have a chance to shoot at it.  And so we.were

              14  fairly satisfied with that'.

              15            Then, their ability to carry it out, they have a

              16  fair amount of contacts now withp of course, Stonybrook and

              17  can draw on a lot of the talent out of those programs.

              18            There  is, for example, a health administration program

              19  forming at Stonybrook. And they have graduate students  on  hand

              20  now.  And they have plans to use some of those graduate students

              21  with relatively small funds to collect specific pieces of data

              22  for them in different areas. It seemed as though it  made  sense

              23  to do it.

              24            maybe some of the staff would like to comment.
  ce-Federal Ripofters, Inc.
              25            DR, ANCRUM:  May I just ask a question in that area?


                                                                               229

                            I am not terribly familiar with the  Harvard  study,

                2 but I know some' of their proposed programs.  And they are

                3 also tied in with the Harvard information  system.  Would  there

                4 be some duplication in what they have been getting from the

                5 Harvard study and what they would redo themselves?

                6           DR. KRALEWSKI: That Harvard study  was,  in  my

                7 estimation, a very unfortunate investment. I don't  th  nk  they

                8 got any information out of  it. I think they put  some  bucks'in

                9 somebody's pocket. And I think that they made  a  real  mistake.

              10            DR. BESSON:  What Harvard study?

              11            DR. KRALEWSKI: They had a group  from  Harvard  come

              12  in and do a study last year

              13            DR. MAYER:  John, we can't hear you.

              14            DR. KRALEWSKI: They had a group  come  in  last year

              15  and do a small study for something like $45,000 worth,  something

              16  of that nature, And what they were supposed  to  study  is  the

              17  degree to which the community had really  understood  what  RMP

              18  is all about, to'get an idea of how well they  are  doing in terms

              19  of their publics.

              20            Well, the people that they interviewed, we discovered

              21  after we asked them if we could look at the study,, were  unfor-

              22  tunately the people who were on RMP's board.  That seemed to be

              23  a strange group to look At from my point of view.  But they

              24  pointed out this is a group they really could get ahold of.-

  ce-Fedefal Reporters, Inc.
              25            DR. SCHERLIS:  It is a well-controlled study.


                                                                             230

                1            (Laughter.)

                2            DR. KRALEWSKI: Strangely enough,  they  found  this

                3  group  had heard about RMP and made everyone  extremely  happy,

                4 and made everybody extremely unhappy as soon as we raised the

                5 issue of who they had interviewed.

                6            MR. STOLOV: A footnote to that, in defense  of  the

                7 region, this is a headquarters contract, and the RMP graciously

                8 accepted to participate in a headquarters  contract  that  was

                9 not initiated by RMP.  They are one of the regions cooperating.

              10             DR. KRALEWSKI:  They  aid for it, though, didn't they'
                                                  p

              11             DR. I-LAYER: When you are saying headquarters,  you

              12  are saying RMPS?

              13             MR. STOLOV:  Yes.

              14             DR*  MAYER:  Very interesting.

              15             DR. ANCRUM: I didn't hear all of  the  details,  but

              16  I  heard  alittle bit about the Harvard study when I was at home.

              17             DR. MAYER:  You understand, Gladys, what the Harvard

              18  study was, not a study at Harvardt but a poorly done study by

              19  Harvard,  I gather.

              20             DR. KRALEWSKI:  Maybe I am being  too tough on  them

              21  since we  reviewed the study so rapidly. Maybe  we  didn't  get

              22  the full  impact.

              23             DR. BESSON:  As I look over their development

              24  component, they have had 15 projects  thcy-are  talking  about.

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                                                                              231

               1  $79,,000?

               2            MR. STOLOV: This is RMP policy, 10 percent  of  their

               3  last year's funding if they made requests up to that.  That

               4  is  policy here.

               5            DR. KRALEWSKI: The question we have is how  are  they

               6  going to take those and decide which ones to do?  It is a

               7  real, test of their ingenuity.

               8            DR. SCHERLIS:  of their maturity.,

               9            MR. STOLOV: There is a footnote they are  thinking

              10  of some contract mechanism and are interested in exploring

              11  that of Harvard.

              12            DR. MAYER:  O.K., further comments?

              13            Sister Ann.

              14            SISTER ANN JOSEPHINE: This 13 percent  overlap.in'

              15 their organization between CHP and RAG and with the need  now

              16  by law, I think it is spelled out somewhere here, for CHP

              17  comment and review, I would think you have a little  difficulty

              18  here.

              19            DR. KRALEWSKI:  Well, because their projects are

              20  going to be reviewed by their own staff?

                            SISTER ANN JOSEPHINE:  Possibly.
              21

                            DR. KRALEWSKI:  Their projects are also reviewed
              22

                  by some other planning groups in the area which may give them
              23

              24 some checks and balance. But there is no question  about  the
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                  time.

               2
                            And you know, we in looking at it and looking at
                  things they are doing felt there was a strength,  I don't know.

               4
                  I suppose you could deal it either way.  But it seems as though
               5  they are making a lot of use of that interchange of talent.
               6            Certainly in terms of administrative services, it
               7  saves them a lot of problems.  Because they have got this-one
               8  gal, the CPA, who is really handling all of the financial
               9  affairs for both organizations.  And that is a real plus.

              10  They are doing that At a very low rate.

              11            SISTER ANN JOSEPHINE:  Who is funding it?

              12            DR. KRALEWSKI:  We are funding it.  We raised that
              13  issue, too, by-the way.  And they probably are going to switch

              14  her half over to another one.  But they have other people who'.

              15  are funded the other way,

              16            DR. SPELLMAN:  Is Dr. Pellegrino still as strong?

              17            DR. KRALEWSKI:  Yes, he is still actively involved

              18  and was very much in support.  And he was there at the site

              19  visit.

              20            DR. MAYER:  Yes, Dr. Schmidt.
              21            DR. SCHMIDT:  The coordinator is a very well-trained

              22  person.

              23            (Laughter.)

              24            DR. MAYER:  One of my finest,, is that what you am

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                I           DR. SCHMIDT:  The pharmacist     now, I am blocked

                2 what we call him -- the clinical pharmacist has been functioning

                3 on the wards of our hospital for years. And  one  of  the  most

                4 beautiful things is I asked for them to start rounding.  They

                5 have been dispensing all medications on patients floors for
                6 years, but I asked them to start making rounds with the physicians,
                7 And every time the physician writes a  prescription,  an  order

                8 for drugs, the pharmacist has one of these little battery

                9 computers, and he just within seconds tells  the  resident  how

              10 much that cost. And that one single thing,  as  far  as  I  am

                  concerned, has made the program very worthwhile.

              12            He has come back and checked with  people  in  George

              13  Miller's operation and so on, some of the theory of the review

              14  system. And we reviewed the procedures  there  from  time  to

              15  time.  We have a lot of consultation on them.

              16            If anything,, they are a little  overly  elaborate.

              17  And he needs seasoning and experience.  But we have great

              18  confidence in him that he will be able to knock the coL-.ners off

              19  and get the-complexities out and come up with some very sound

              20  and perhaps some of the soundest procedures in PJ,4P as a whole.

              21            DR. KRALEWSKI: We  were  impressed  with  him.  The

              22  question that came up with our team was whether  he  was  going
              23  to stay there or not because he was developing so well, whether
              24  he would stay or not. And I had a chance to  chat  with  him  a

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              25  littlei about that one evening, and he assured me that  he  has


                                                                              234

               I at least a 2-year commitment to the program. And then  he  may

               2  consider some other  thingso but he will be there for two

               3  years.

               4            DR. SCHMIDT:  He will duck back into academic

               5  medicine someplace in two or three years.

               6            DR.  MAYER:  Any further comments?

               7            DR. KRALEWSKI: Should I put that funding in  the  form

               8 of a motion?

               9            DR. MAYER:  Yes.

              10            MR. GARDELL: Before you go any further, I  wondered

              11  whether you had given any thought to the possibility of  funding

              12  that activity jointly with CHP.

              13            The reason why we are considering it is that there  is

              14  quite a thrust.coming from the administration to jointly fund-

              15  activities that Are closely related and interrelated as far as

              16  expenditures of funds are concerned. This would seem to be  a

              17  natural.  This is probably the closest this program has come

              18  to any such possibility.  And it is being discussed at the

              19  moment.

              20            Now, did this come up at all in your survey time?

              21            DR. KRALEWSKI:  It did not.  We never talked about

                  CHP funding at all.
              22

              23            MR. GARDELL: I don't know whether it is  appropriate

              24  to raise it now or not, but I might just ask what your  thoughts
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              25  would be to the possibility of this'should we be able to come


                                                                                                                                                 235

                              1    up with  one  grantee,  one  award  funding  two different programs.

                              2                     DR.  KRALEWSKI:    Well,  from  an organizational  point

                              3  of view,  I  think  it would be  a good,move.;    From a  theoretical

                              4  point  of view,  I  think  it would be  a  good move.    Because  I

                              5  think  they  could  identify  to you  the  kinds  of  things,each

                              6  organization  is  doing and  lay  out  a budget  for each.    And  there

                              7  is no  question  about  that  they  can  do  that  very well.

                              8                     Whether you  can  get  things  together  at  the                                 next  level

                              9  to do  that  through  the  State'and  region,  etc.,  I-really  couldn't

                           10    answer.

                           11                       MR.  GARDELL:    It would  in  effect mean we would get

                           12    a single  application  from a single.agency  and make  a  joint

                           13    award  coming  from one  of  the  two  programs,  possibly  the  RMP,

                           .14   So  in  effect,  we would be  coordinating our efforts  with CHP

                           15    in  a  review of  the  application,  the  expenditures,  visits,  etc.

                           16    We  could work  together very  closely.

                           l@7                      DR.  BESSONI.    Could we  have  more  of  a  discussion

                           18    about  joint  funding?    That has been  talked  about  for a  long

                           19    time.    This  is  the  first  time,,  Jerry,,  that  I  have  heard  there

                           20    is  a mechanism established  for doing  that.

                           21                      MR.  GARDELL:    There  are  several  mechanisms  for

                           22    jointly  funding  grants  that  are  coming  into being.    There  are

                           23    programs  presently  staffed in  the  office  of  the  Secretary,

                           24    one  for  jointly  funding  grants between  Federal  agencies,  and

    ce-Federal Reporters,  Inc.
                           25    the  other  for  funding  grants  jointly within  the  Department.


                                                                            236

                1           we have a third one now that I am working with  off

                2 and on in the office of the Administrator which has to do with

                3 jointly funding programs within HSMHA. And I think  what  is

                4 going to happen ultimately is if we don't get on board and see

                5 some of these occasions where we can move in this  direction,

                6 we are going to be instructed to do so.  That is already coming

                7 from the Department.  The Department didn't even have an

                8 option.  It was told that was what was going to happen.

                9           So we are trying to look for avenues where we  can

              10  do this where it would be the easiest way possible.

              11            Now, there are a lot of administrative problems that

              12  can arise. with this program, however,, we are probably  the

              13  closest to any,of them where it could be worked out.  We have

              14  had some preliminary discussions with the Regional office

              15  staff.  And, again, here is another problem because that

              1.6 program is decentralized to the Department's regional  Office

              17  whereas we are a headquarters operated program as far as  the

              18  funding is'concerned for review.

              19            DR. MAYER:  Leonard.

              20            DR. SCHLERLIS:  I find myself unable to participate

              21  in this discussion since I have no concept of what the

              22  organizational structure is in that area, what the funding

              23  problems are, what portion of the budget is involved  how

                  this would affect total RMP package and so on   And I  would
              24

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              25 1 take this as an informational item which I. find very interestin


                                                                            237

                  but I would find it impossible as a member of the committee
                2  to support this or to deny it.

                3           I would think if it is thought to be something we

                4 should be involved with,, we should have time enough to be

                5 briefed in it. I would hate to see a preliminary  expression

                6 come from this group.

                7           1 find it fascinating, but I have no idea how to

                8 react to it.

                9           DR. BESSON: I find it fascinating, too, Ed. but  I

              10  have an idea as to how to react to it-.  And that is for us to

              11  use it as a model. As I have been looking over in line  with

              12  sister's comments about whether the relationship between

              13  -Comp Planning and RMP here was cooperative or incestuous, I am

              14  very much impressed with how well they do those things,

              15            DR. SCHERLIS:  Sister did not use those terms.

              16            (Laughter.)

              17            DR. BESSON:  No, I am sorry.

              18            DR. KRALEWSKI:  Let the record reflect.

              19            DR. BESSON:  We can expunge that.

              20            This was an opportunity for us to do something like

              21  that.  There seems to be a great deal of joint staff, joint

                  interest and programme programs which I see in their development
              22

              23  component could very easily be funded through Comp Planning

              24  rather than Regional Medical Program.  And if there is a

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              25  mechanism now through even the office of the Development and


                                                                            238

                  out of the administrative office in HSMHA, Secretary's

               2  office, for us to try itt maybe we will like it.

               3            DR. SCHERLIS:  You end up eating the whole thing.

               4            (L aughter.)

               5            DR. MAYER:  Mac.

               6            DR. SCHMIDT:  My pr oblems with this would be sort

               7 of the confidence limits of getting through such a mechanism,

               8 If somebody would tell me it is a point 9 type of thing,

               9  1 would be comfortable.  I suspect it right now about a point 1

              10 or 2.  And I would hate to have this committee action in some

              11  way tie things up which is what I would be afraid would happen.

              12            It takes longer to do things, to work things out,

              13 to get things clear, to get HSMHA to agree, to get the OMB to

              14 agree, to get so and so on.  And whatever you are trying to do

              15 is what we have been hearing earlier this morning.

              16            So if there is money that can come, fine.  It is a

              17  beautiful thing to do.  tut if it puts something at risk , then

              18  I would say no.

              19            DR. BESSON:  Could we try it, let's sayr for one

              20  project just to let the Council know we are thinking about

              21  it and to enable the Council to run with the ball if they like.

              22            MR. STOLOV:  May I comment on that?  Dr* Komaroff

              23  is on Council, and I think he shares your concern. -He may

              24  bring it up then.

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                                                                              239

                I  as expressed here,

                2           DR. BESSON:  i don't think we have to do anything

                3 else except approve of John's recommendation with the added

                4 paragraph that the fact that the review committee is aware  of

                5 joint funding possibilities and would encourage the Council

                6 to choose one or another program.

                7           MR. GARDELL:  That is all we need.  That would be fine.

                8           DR, MAYER: With the caution that we would  not  like

                9 to see such efforts through the administrative entanglements

              10  inhibit the development of the RMPs we are voting to  support.

              11            DR. BESSON:  That is your proviso, but it wouldn't be

              12 mine.  I would like to  think that somewhere along the line-

              13  RMP is going to shed its parochialism and think of the problem

              14  in a systems fashion rather than what RMP's territory is  and'

              15  be sure our territory is protected at all costs.  Because'we

              1.6 will  never approach the problem inherent in health systems

              17  if we  only think in terms of our dollars and protecting what our

              18  dollars buy.

              19            DR. MAYER:  That is not what was implied in what I

              20  was saying here. All I was saying was I  was  hearing  concern

              21  being expressed by Leonard that it is difficult with the  data

              22  base that we now have about this particular region to know what

              23  the implications of that are. That is the concern  I  have  got

              24  which is a very simple.one.

  ,ce-Federal Reportefs,  Inc.
              25            DR. SCHERLIS:  I support completely Jerry's


                                                                          240

                I  philosophy, but I would not suggest any action relevant on the

                2  basis of the information we have.

                3           1 agree with the systems approach.  I agree these

                4 two programs have to be brought closer together.  I don't think

                5 I know enough to make any judgment relative to the specificities

                6 of what you come out with.

                7           DR. MAYER:  Further comments.

                8           John.

                9           DR. KRALEWSKI: Should I put this in a motion.  the n?

              10            DR. MAYER:  Yes please do.

              11            DR. KRALEWSKI: I move that we approve the  funding

              12  level of $1,099,000 for the 02 year with-then an equal increase

              13  for the 03 of $230,000 and along with that we indicate our

              14 support for joint funding of programs such as this if it can bis.

              15 worked out at some future date or something such as that.

              16            DR.  MAYER:  O.K.

              17            DR. SPELLMAN:  Second.

              18            DR.MAYER: And.I assume that figure if in fact  the

              19  kidney dollars come out separately that that figure would be

              20  reduced by the $27,060 if that is how it happens.

              21            DR. KRALEWSKI:  Right.

              22            DR. SPELLMAN: I was going to ask a  question.  You

              23  said the CPA, a woman, that actually provides the financial

              24  management system, yet the grantee is a separate corporate

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                I


                                                                              241

               I  not providing management.  What is it doing?

               2            DR. KRALEWSKI: What they do is provide  --  they  are

               3  fiscally responsible.  In other words, when they spend dollars,

               4  they review large expenditures, and they audit the firm and

               5  things such as that.  But they are providing their own internal

               6  support.

               7            DR. SPELLMAN:  So they are buying a very small

               8  grantee service package.

               9            DR. KRAIXWSKI:  As a matter of  fact, as a result  of

              10  that, and it doesn't alter our figures, they take away all

              11  of their overhead so they probably save T don't know  how  many

              12  hundreds of thousands of dollars.

              13            MR. CHAMBLISS:  Very low indirect costs there, Doctor.

              14            DR. SPELLMAN:  I was interested how they do it.

              15            DR. MAYER:  It reduces their indirect costs.

              16.           DR. SPELLMAN:  I don't know that we want to encourage

              17  that.

              18            (Laughter.)

              19            DR. MAYER:  If my leg were.,long enough, Iwould have

              20  kicked you under the table, Mitch, but I couldn't do it.

              21            DR. SPELLMAN:  There is such a thing as taking merit

                  too far,
              22

              23            DR. MAYER: John, I assume you are  including  in  the

              24  recommendation the 03 suggested level Of $1,000,138 because

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                                                                 242

             I  take action by this group.

             2          DR. KRALEWSKI:  Right.

             3          DR. MAYER:  O.K., further comments?

             4          (No response.)

             5          All those in favor say, "Aye.11

             6          (Chorus of ayes.)

             7          opposed?

             8          (No response.)

             9          All right, shall we try one more prior to departing?

            10 Nebraska?

            11          Joe, are you ready? Have you got an estimate

            12 before we tutn'you loose of the time sequence we are talking

            13 about here?

            14          DR. HESS: Well, more depends on the committee than

            15 on me.  Ican do my part in about 15 minutes.

            16          DR. MAYER: That's all I can ask.

            17          DR. HESS: A little over a year ago, Sister Pmn and

            18 I were out there as a member of the site visit team to visit

            19 Nebraska.' And we had to bring back a rather gloomy report
            20 and some recommendations for rather difficult.actions which were

            21 conveyed rather clearly and explicitly in the advice letter
            22 that went from the main Council under the signature of Dr.
            23 Margulies. And the purpose of this site visit then was to

               determine among other things what actions had been taken in
            24

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                                                                             243

                            And those eight recommendations are outlined on
               2  the secondpage of the site visit report that you have.

               3            The region at the time of our earlier visit had just
               4  come through the process of separating from  the  South  Dakota
               5  component, just reformed as a  separate  Nebraska  region.  And

               6  there are some problems relating to that.

               7            We found that there were some very fundamental
               8 problems in terms of program management and direction.  And
               9  these eight points which you see outlined on the site'visit

               10 report addressed those issues,
               11           I could say that.in summary all of these issues,
               12 that this advice letter had been taken very seriously, that
               13 shortly after the receipt of the letter, the program coordinator

               14 resigned and very shortly thereafter a  new  coord  nator  was'
               15 appointed.  He had been with the RMP previously.  And by
               16 September of last year, the RAG had sort of  reformed  itself,,
               17 and they were down to brass tacks and  working.
               18           And most of this past year has.been devoted to
               19 reorganization, reforming the region and trying to address
               20 those questions and suggestions which were raised in this advice

               21 letter.
               22           The newly appointed coordinator is proving  to  be  a
                  good coordinator.  He has:shown the ability to provide
               23
               24 directions to RAG. Many of the actions of  the  RAG  have  been
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                                                                              244

                I
                   reaat to his leadership,

                2            He has made a number of  rather  difficult  decisions,

                3
                   one of them being that some negotiation with the medical

                4  school and the core funds now were under his direction instead

                5  of under the medical schoolls control. And  I  think  that  kind

                6  of action is indicative of the strength of  leadership  that  he

                7  is  providing.

                8            The RAG is playing a much more active  role  now  than

                9  they used to.

               10            DR. MAYER:  Joet can you use the microphone

               11            DR. BESS:  The RAG is playing a much more active

               12                                             grwn policies.  They
                   role than they formerly had in setting pro

               13  have reorganized themselves into five working committees,

               14  an executive committee, nominating, the budget and finance

               15  and the resource and development an d operations review

               16  committee.  And each of these appear to be performing their

               17  functions.

               18            The pro ram has developed documents  which  spell  out
                                    9

               19  the procedures whe reby projects are to be reviewed,.  And   the

               20  relationship between the gtantee and the RAG and  all  of  these

               21  kinds of things, all of those issues were appropriately

               22  addressed.

               23            They have had.a management consultant from the

               24  University working with them, and they,developed a new

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               25  organi;zational structure and developed job descriptions of each


                                                                             245

               I of the positions. And in terms  of  program  management,  there

               2  has also been much strengthening.

               3             I would also indicate that the morale of the  staff

               4  which is one indicator is much different than it was a year

               5  ago. A year ago, we had indications in  talking  with  members

               6  of the staff informally there just was no communications,  that

               7  they were not working together, that the,coordinator wasn't

               8  listening to them and so on.  But you get an entirely

               9  different feel this time. They  were  working  together.  They

              10  felt they were part of the team and that everyone seemed to be

              11  unanimous in the feeling they had made a rather  major  change

              12  in direction and  function.

              13             As far as identification of regional needs is

              14                                     ich we learned about a
                  concerned, there was one survey wh                         yeAr

              15 ago which still is the major systematic survey  that  they  are
              16  using.  This is supplemented, however, by the information which

              17  was picked up by the RMP staff in the visit throughout the

              18 Nebraska region. And you can perhaps see  from  the  little  map
              19  they have in the yellow pages, they have project activities

              20 that pretty well blanket Nebraska. -So they do get  out  and  do

              21  spend a lot of time out in the community.  And that supplements

              22  and is one of their sources of gathering information.

              23             But another important thing which at least has  the

              24  potential  of having made their impacts in terms of needed

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                                                                            246

               1 the CHP agency which will be in its completed form  in  June.

               2  And in talking with the AAUC director who is a very intelligent.

               3  dynamic woman, already there are things coming to the  surface

               4  in that study that are going to have an impact on what  RMP

               5  does. And they seem to be open, their communication  is  good,

               6  their relationships,appear to be-,quite good between those two.

               7  So I feel quite confident that that study will result in  some

               8  change in their objectives and priorities in the months ahead.

               9            The question of phasing out of the programs,  this

              10  has begun. And they are aware of it, and they intend  to  do

              11  more. There has been some joint funding now  through  other

              12  RMPs around them4  The university is beginning to pick up
   0
              13 'certain projects which can be justified and so on.  So  that

              14  they areraking movement in this direction.

              15            The final issue in that letter has to do with  the
              16  mobile cancer project.  The core staff has been actively

              17  involved, and the RAG also, indirecting the course of the

              18  cancer project.  And it seemed to us that they seem to  have

              19  these fairly well in hand.

              20            Going on with the report, they have redefined  their

              21  goals  and priorities.  They look quite different than they did

              22  a year ago.  And they are consistent with national goals.

              23            Most of the projects which have come through  the

              24  review process now tend to be ones which conform more with the

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              25  older mission of RMP than the newer. And as near as  we  can


                                                                               247

               1  determine one of the reasons for this is that much of the
               2   core staff activities and so on, the RAGS, have been  in  this

               3   reorientation process. They haven't had time to  get  out  and

               4   stimulate development of new projects. But they  seem  to  be

               5   aware of the need to do that.  I think the chances are

               6   reasonably good they will do so.

               7             We mentioned continuing support.
               8             Minority interests, these ard not very  well reflected,
               9   but they have told us they have tried to  get  more  minority
              10   representation and will continue to try. @As we  talked  with

                   the lady who is the CHP director, it seemed she  had,some
              12   ideas and techniques.for doing this that perhaps they
              13   could learn from. And we suggested they might  talk  with  her
              14   and get some  as.sistance from her in doing so,  But  at  least
                   there was a willingness, and we indicated that we  hope  there
              15
              16   would be improved performance as well.
              17             1 mentioned already the coordinator in  relation  to
                   the RAG,  The core staff seems to be quite strong,  In working
              T8
              19   with the management consultant, they have identified the need
              20   for some additional staff positions -- one in the area of
              21   bolstering their program evaluation segment and others in
                   area consultants.  And after he aring the rationale and so on,
              22
                   we concurred with that,assessment and agreed they should further
              23
              24   strengthen the core staff.
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                 I provider dominated, but there has been  some  change  in  the

                 2 balance since we were there a  year  ago.  They  seem  to  be

                 3 aware and were receptive to our  suggestion  that  they  need to

                 4 give further attention to a  broader  representation  on  the RAG.

                 5           The grantee organization is  the  State  Medical  Society.

                 6 I think there has been -.-.significant movement in the  relationship

                 7 between grantee and RAG, the RMPS, since we were there a

                 8 year ago.  I think there is qtill some further delineation

                 9 refinement that needs to be carried on there, but certainly

               10  they are moving in the right direction.

               11            we pointed out some of the areas which we thou  t

               12  they needed to give further attention to.  And I would hope

               13  that these further additional details will be attended to.

               14            Their-participation, we mentioned, in terms of RAG

               15  participation and so on.  The  State  Medical  Society,  physicians,
               16  seem to be the majority, but there is good participation in the
               17  State Health Department, appears to be good working relation-

               18  ships there.
               19            The CHP seemed to be reaching out in the communities
               20  to a considerable extent, and their record is reasonably good

               21  in that area.
               22            Hopeful planning, they are working  with  CHP  B  agencies
               23  that exist, but that program was just beginning to get geared
               24  up.  They have some of their own local mechanisms for doing it,

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                             We have talked, I think,  enough  about  management.

                             The evaluation has improved  substantially  since  we

                3  were there a year ago. We agreed there is  a  need  for  more

                4  staff in this area. And this function in  this  area  has  been

                5  hampered somewhat by the ill health of their evaluation

                6  person. But I was filled in this  morning  they  have  alre  y

                7  taken steps to bolster this area, and  they-recognize  the  need

                8  for further improvement.

                9            The action plan, again, is more  in  the  formative

               10  stages because of this reorganization they  have  gone  through.

               11  They have their goals and their priorities developed  now,,  and

               12  I would anticipate in the next few months, we  would  see  an

               13  action plan based on those goals and priorities begin to appear

               14  in terms of projects more related to that.

               15            They have been successful in the  area of dissemination
               16  of knowledge.  they have had coronary cake  training   programs
               17  and other educational type projects which have apparently been
               18  well received and have served a real need and  have  been  the
               19  means of bringing inactive nurses and other  people  back  into
               20  the health care system. And there have been  a  lot  of  spinoff
               21  benefits from the projects that were  built  as  dissemination

                   of knowle dge.
               22
               23            Manpower and facilities, there have been   some, as  I

                   mentioned, spinoff benefits from the coronary dare   and  other
               24

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               I  But we really were unable to get a very good handle on just

               .2 how much impact the RMP is having on use of  those  facilities.

               3 They have stimulated cooperative  arrangements  among  hospitals.

               4  There is sharing going on as a result of these  RMP  projects.

               5  So we got the feeling that they have had some impact.

               6            The improvement of care, I think what I  have  already

               7  said more or less summarizes what I want to say  in  this  area,

               8            Short-term payoff, I think there has been  some  with

               9  the coronary care learning resource center.  They  have  plans

                  for more.regionalization in the sense they are  developing  area

                  coordinators who are going to work in specific areas within

               12 the.re,gion to stimulate more cooperative arrangements and  more

               13 joint.activities in that area.

               14           In summary, then, we  felt that the region had
               15 seriously addressed all of the  issues which have been  raised

               16 as a result of the site visit of last year and has  made  very
               17 substantial progress in making the necessary changes in
               18 reorganization and changing the direction of the RMP.
               19           As a result of this, we came up with a funding

               20 recommendation of $725,000.
               21           Now, that is based in part on the  recommendation  of
               22 thd.Kidney Review Panel that neither of the kidney projects
                  ought to be funded. And one of the important  reasons  is  they
               23
               24 had not developed a well-thought-out regional plan  for  kidney

  @ce-Federal Repoftefs,  Inc.
                  disease.  So that accounts for one of the major reductions
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                                                                                  251

                I  below their request.

                              And we felt that there  were  some  savings  that  they

                3   could make in terms of the mobile cancer  unit  and  one  or  two

                4   of the other  projects without hurting them and also that

                5   some cutbacks should be made in the funding of current

                6   projects to give them some seed money for feasibility studies

                7   and so on to start off and do,some planning at,least in the

                8   new directions which they want to go.
                9             So that this  was  the  rather  simplistic  rationale

               10   for arriving at the recommendation for $725,000.  We recommend
               11   that they find within that budget about $25,000 for initiating
               12   some small planning  feasibility  studies,  mentioned  the  two
               13   kidney disease activities, and  we'felt  that  they  should  be
               14   given the option to submit a triennial application next year,

                    feeling that with another year to  work  and  develop  that  they
               15
               16   may be in a position to merit that.
               17             DR. IAAYER:  Dorothy, comments?
               18             MISS ANDERSON:  I was amazed, just reading the material
               19   I wasn't on-the site visit -- at  the  progress  they  have  ma
                    in just six months with  this  new  coordinator.  And  I  think
               20
               21   this is a real good example where rather than getting the
               22   person to change their  thinking  in  coordinators  and  changing
                    their action that maybe we do need to look seriously and
               23
                    encourage some areaso regions, to get new coordinators.
               24
  kce- Federal Reporters, Inc. Now, I was impressed by the  involvement  of  the  RAG
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                                                                             252

               1  group.  They really got involved in committee meetings.  They

              .2  were involved in site reviews and made recommendations for

               3  changes of budget and relocation and reallocation of  money,

               4  as I understand,

               5            They have also changed their by-laws and realigned

               6  budgets and did other things that really showed  involvement

               7  of the group.

               8            I was interested that the staff kept relating to

               9  a 1968 survey that was done.  And I had a feeling that maybe if

              10  the staff had been out in the community more, they  wouldn't

              11  have to wait for this new survey for some direction.

              12            DR. HESS:  I think maybe that is an unfair reflection

              13  of the report because the staff is out in the community.  They

              14  get very high marks for being out and visiting around.  They

              15  really tide the circuit.'

              16            MISS ANDERSON:  It seems like they have quite a few

              17  things they are holding off until they get this new  survey.

              18            DR. HESS:  That may be more a reflection of our

              19  report than it is in reality. I am not sure that  is  really

              20  fair.

              21            MISS ANDERSON:  Thank you.

              22            Another area I thought was interesting was the
              23 development of the new goals in regard to the  new  direction

                  that Rr4P is going in regard to health manpower, health  care
              24

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              25  delivery and management and administration.


                                                                              253

                I            I think everything else we have touched  as  far  as

                2  I can  see.

                3            DR. HESS:  Just to elaborate on one point that you

                4  picked up and I forgot to mention is that the  RAG  is  involved

                5  in the site visits:-to projects,  I think this is a very

                6  tremendous thing. At least@-some member of the  RAG  has  some

                7  detailed knowledge of nearly every project.  And  that  is,  I
                8  think, rather unique. I don't know.  @here  may  be  some  other

                9  regions, but offhand I dan't recall others that have that

               10  degree of involvement of the RAG.

               11            14ISS AI\TDERSON: And I think another point,I  would

               12  like to support you in is ih@regard to representation on the

               13  RAG.  They do need more minority people.  There are many

               14  Indians as an example in this area.  And blacks also.

               15            And, also, they need more  allied  health.people  on

               16  their RAG from what they have had in the past to make it,

               17  if you are thinking of comprehensive health care.

               18            DR. MAYER:  Dr. Hinman  comments?

               19            DR. HINMAN:  Yes.  This region had two applications.

               20 in for support of kidney  activities.  They  both  had  technical

               21  review in the region by people from within the region who

               22  made strong recommendations against the appropriateness of the
               23  proposals. And on that basis, it  is  the  staff  recommendation

               24  it not be approved even though the RAG sent them in.

  @ce-Federat  Reportvs,  Inc.
               25            one of them was to produce six films of teaching


                                                                               254

                I tapes of undetermined type  for  an  undetermined  audience.  And
                2 the other was to train some people for  we  didn't  know  exactly

                3  what in the application.  So it was our recommendation that
                4  the region be given advice that there  were  existing  guidelines

                5  that could have assisted them, staff could  have  assisted  them,

                6  there were new guidelines coming out, and we recommended,

                7  disapproval.

                8            It was $48,838 requested.

                9            DR. MAYER:  Further comments?

               10            DR. KRALEWSKI:  I have a question about the core

               11 staff. How many people do they have  and  how  was  this  affected

               12  when they split apart and all that? Are  they  saving  any  mone
                                                                                   ,y

               13  or what is happening to,the core?

               14            DR. BESS: Well, you  mean  when  South  Dakota-NebraSka

               15            DR. KRALEWSKI:  Yes.

               16            DR. HESS:  They decided there was a division of funds

               17  and so on that was negotiated with RMPS.

               18            DR. SCHMIDT: I think the answer is  in  light  of  the
               19  activity, the core type of activity, was  really  Nebraska  and
               20  South Dakotals problem is really to build up.  The flow was
               21  into -- at least, I was representing South Dakota  at  that  time
               22  the flow was kind of into Nebraska. We  had  a  core  staff.  I
               23  don It think they are cutting back any.  The loss of South Dakota,

               24  there wasn't much in South Dakota there.

  kc,e-Federal fteporters,  Inc.
               25            DR. KRALEWSKI: This budget  expands  that  core  now,


               I does it?

               2          DR. HESS:  Iwould have@to go back and look at the

               3 figures ayear ago versus now,

               4          DR. MAYER:  Yes, by about $140,000.

               5          DR. HINMAN:  $232,000 to $376,000.

               6          MR. POSTA:  I might make the statement here I

               7  think the core budget as outlined here for this upcoming year

               8 really indicates the inclusion of four new members to the

               9 staff.  But in view of the fact that the drug information

             10  center and resource learning center that was appointed a

             11  project last year would be included under the core, I think

             12  would be increased for the next year total within core is about

             13  $115,000 rounded off.  And that would take care of assuming
             14  those two new programs or the two old programs and a couple,of

             15  new additions to the core staff.
             16           DR. KRALEWSKI:  How many vacancies do they have?

                          MR. POSTA:  Frank.
             17

                          MR. ZZZLAVSKY:  They are requesting four full-time
             18
             19' positions, -- deputy coordinator, associate coordinator for
             20  evaluation, and two additional area,consultants.  And this

                 totals about $70,000.  $20,000 increases for fringe benefits.
             21

                 Previously under the previous coordinator, fringe benefits were
             22
             23  non-existent.  This is something they have been fighting for

                 three years.  They have finally established it.
             24

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             25           That speaks to about $lOOtOOO.  They have a couple of


                                                                               256

               1  pharmacy students on part time answering the phones 24 hours

               2   a day which speaks to about $10,000. That  accounts  for  about

               3   $110,000.

               4             We have got a little bit more money in travel, a

               5   little additional money in equipment.

               6             DR. HESS: I think you are asking  how  many  existing

               7   vacancies.

               8             DR. KRALEWSKI:  Right.

               9             DR. HESS: And I don't believe  there  are  any.  They

               10  are all new ones that they are asking money for.

               11           .DR.  MAYER:  rour new professional positions, is

               12  that what you are saying?

               13            MR. ZIZIAVSKY:  Right.

               14            DR. MAYER:  Further comments?

               15            DR. HESS:  I would move formally, then, they be

               16  approved at $725,000, and we also felt we ought to make a

               17  tentative recommendation'for $700,000 for the second year so
               18  they have something to plan on, but with the  understanding  --
               19            DR. MAYER:  They will probably be coming  in with a

               20  triennium.
               21            DR. HESS;  That's right.

                             DR. MAYER:  But in case they don't, we are recommending
               22

                   $700,000.
               23

                             DR. HESS:  Yes, some sort of assurance for them.
               24
  @ce-Fedeial Reportefs, Inc. DR. MAYER: O.K., is there a second to that?
               25


                                                                           257

                            MISS ANDERSON:  I second it.

                2           DR. MAYER:  Further comments?

                3           Yes, John.

                4           DR. KRALEWSKI:  A point of clarification.  That

                5 $25,000 is included?

                6           DR. HESS:  In the $725,000.

                7           DR. SCHMIDT:  I am curious about this renal business,

                8 Dr. Hinman.  You said that the RAG approved it, but that people

                9 within Nebraska recommended disapproval?

              10            DR.  HINMAN:  There was a technical review by three

              11  physicians from within the State who had adverse comments the

              12  program was not adequately documented, adequately structured,

              13  and they still sent it.

              14            DR. SCHMIDT:  From the university or Creighton  or

              15            DR. HESS:  One was Dr. Holmes from Colorado.  They

              16  were experts, kidney experts, that were called in.  But they

              17  were not all from without Nebraska.

              18            DR. HINMAN: Two of them were,  weren't  they?  You

              19  are right about Dr. Holmes, but I thought the majority  were

              20  from within Nebraska.  But either way.

              21            DR. SCHMIDT:  It was on technical grounds that it was

                2 turned down, then?
              2

                            DR. HINMAN:' Yes.
              23
              24            DR. MAYER: Technical plus regional3zation,  I  was
  @ce-Federal Riporters, Inc. hearing, Mac.
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                                                                                                                                                258

                                                     DR.  SCHMIDT:    I  know,  but you  see  the  RAG  approved

                              2   it.

                              3                      DR.  HINMAN:    That  is  correct.

                              4                      DR.  MAYER:    In  spite  of  the  negative  comments.

                              5                      DR.  HINMAN:    Yes,  sir.

                              6                      DR.  MAYER:    Which makes  the  point we.-were  trying

                              7    to make  earlier.

                              8                      O.K.,  further  comments.

                              9                      (No  response.)

                           10                        All  those  in  favor  of  the motion?

                                                     (Chorus  of  ayes.)

                           12                        Opposed?

                           13                        (No response.)

                           14                        Before we break,  I  have  got  a  couple  of  issues  I

                           15   want  to comment  about.    The  first  relates  to  this  evening's

                           16   activities    to make  sure we  all  understand where  we  ate  going

                           17   and how we  are  going  to get  there.

                           18                        (Announcements  were made.)

                           19                        DR.    MAYER:    One  of  the  individuals  who  has  been

                           20    participating  in  RMP  applications  as  long  as  anyone,  including

                           21    maybe  myself,  Lorraine  Kyttle,  who  is  on  my  right,  who has  been

                                 serving  us  very  effectively  for  the  last  three  years,  four
                           22

                                 sessions  of  this  committee,  this  is  also her  last  review
                           23

                                 committee  session.    She  is  going  to  be  assuming  responsibility
                           24
    ce-Fedeial Repoiters,  Inc.  for  South  Central  Operations  Areas  which  will  include Memphis,
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                                                                             259

                I  Illinois and South Carolina as her activities, but will not

                2 be serving in the capacity she has.  So I just wanted to

                3 indicate to you this evening while we are there that it is

                4 also her last go with the committee.

                5           On the agenda for times I will not be with you

                6 tomorrow, My chancellor has called a budget session  which  I

                7 have to be at if.I hope to survive for tomorrow. And  I  will

                8 have to go back tomorrow    But there were two items or  three

                9 items that were on the suggested items for the agenda that  I

              10  wanted to remind you all about so that you didn't forget them.

              11            One was the,, if-I may call it that, emasculation

              12  issue which Jerry had raised and others had raised that we

              13  needed to talk about a little further.

              14            The second was Mr. Parks raised the question

              15  appropriately about several of the questions that we sent

              16  up to the Council at the last meeting, and we need to  discuss

              17  a feedback of those. And I Assume, Mr. Parks, you  will  raise

              18  those tomorrow.

              19           And then thirdly, there was some discussion of at

              20  least some of the people at lunchtime about new members of the

                  committee and new chairmen, vice chairmen, etc. And  I  think
              21

              22  that issue needs to be raised.

              23           And with that, I would like to say it has been my

              24  very real pleasure having an opportunity of  participating  in
  ce-Federal Rqporters,  Inc. this committee over the many years and chairing it the last
              25


                                                                             260

               I  two years almost in toto.  I appreciate all the efforts that

               2  have gone on in terms of helping us get through and  the  job

               3  done.  It has been done very well.

               4            DR. SCHERLIS:  I think somebody should   recognize

               5  the fact that you are not being here tomorrow, this  is  our

               6  last opportunity to,formally thank you for, I think,  what  has

               7  been not just superb direction, but maintaining our good

               8  humor and I think giving us a sense of at least  thinking  we

               9  know where we are going. And I want to  On  behalf  certainly

              10  of  the committee extend to you  our thanks for having  been

              11  such an excellent chairman over  the years.

              12            DR. MAYER:  Thank you  very much.

              13            DR. KRALEWSKI: I.'would like to formally move  that

              14  into the minutes.'

              15            DR.  BRINDLEY:   Second.
              1.6           DR. BESSON:  I  move  it up to the Council.

                            (Laughter.)
              17

                            DR. MAYER:  That is really a policy issue.
              18

                           .Well, I hope to see most of you this evening at
              19

              20  6:30.

                            I would also like to remind you do not  forget  those
              21

                  of you because I didn't remind you in Nassat-Suffolk as well
              22
              23  as Nebraska in terms of your rating sheets.  And I would

                  assume that if you held onto those, fold it up neatly  at  your
              24

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              25 place so people aren't seeing them. I  think  you  are  probably


                                                                                                                                                    261

                               I    in  good  shape.   We  can  leave  the  materials  here.

                               2                       What    time,  8:30  in  the  morning?    I  think  we  can

                               3   probably  appropriately  move  it  along.

                               4                       (Whereupon,  at  5:10  o'clock  p.m.,  the meeting

                               5   recessed,           to  reconvene  at  8:30  p.m.  on  Friday,  May  5i  1972.)

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