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                                                               VUL. 11












































































                                                                                                                  00








                                          Transcript of Proceedings


                        DEPARTMENT OF ]-IEALTH, EDUCATIONG AND WELFARE

























                                               ACE   FEDERAL REPORTERS, INC.
                                                        Official Reporters
                                                      415 Second Street, N.E.
                                                      Was"-,ington, D. C. 20002                 Telephone:
                                                                                         (Code 202) 547-C222


                                                    NATIO@l-%'!IDE COVERAGE





                            DEPARTMENT OF HEALTli, EDUCATION AND IVELFARE

                i2
                3              REGIONAL MEDICAL PROGRAM SERVICE
                4                      REVIEW  COMMITTEE

                5


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                10
                                                       Conference Room E,
                                                       parklawn Building,
                12                                                 aryland
                                                       Rockville, M
                                                       Thursday, January 13, 197.'

                             The meeting wts reconvened at 9:50 a. m.,
                14
                   Dr. William Mayer presiding
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  ,ce -eral  Repoitefs,  Inc.
                25





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                                        C 0 N T E N T S


              2
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              3    Consideration of applications:
              4         Western New York                                   3
              5         Florida                                           44
              6         Metropolitan D. C.                                68
              7         Susquehanna Valley                              128
              8         Intermountain                                   144

              9         Alabama                                         169
              10        New Jersey                                      174
                        Northiands                                      186

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              161

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  :e - Fede ra I   Repofters, Inc.
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  PF  WESTERN XEW YORK                                                                                      m
































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                                                                                   P R 0 C E E D I N G S
                                                                                   - - - - - - - - - - -
                               2                                DR. MAYER:              I think we better begin.  We do have
                               3          a major task ahead of                         us before we finish the day.
                               4                                And to prove that old RMP review members never die,

                               5          they just             keeping coming                back       from Omaha                   Henry.
                               6                                DR. LEMON:  That's the only advantage I know living
                               7          in Omaha,             you are a thousand miles closer to anywhere you

                               8          want to be.

                               9                                1 am st-bstituting here for Dr. Spellman, very
                               10         inadequately.  He was the chairman of our site visit team
                               11         which wa- composed of ivirs. Mars Of COUDCil; Myself;
                               121        Dr. Rebert Toomey, Director of the Greenville Hospital System
                                          who added a great deal to our capability, very perceptive;

                               14         ahl  Dr.  Silverbia-tt,  coorL.',-nator  of  the  Arkansas  program,

                               15         who  also  was  very  helpful  indeed.    -And  I  think  in  the  course
                               16         of  the  day  and  a  half  that  we  were  at  the  headquarters  of

                               17         Western  New York--
                               13                               DR.  MAYER:    Henry,  before  we                            go  on  I  just  ought  to

                               19                                                                                              Perry  has  left  the
                                          rbally  indicate  for  the  record  that  Dr.

                               20         room.    Excuse  me.
                               21                               DR.  LEMON:     In  the  course  of                          the  day  and  a  half
                               22         we  interviewed  a  total  of  45  individuals                                                more  than  this

                               23         really,  but  there  are  45  listed  on  the  summary.

                               24
                                                                Now  the  general  b@kground,   I  would  like  to
    ce          I Reporters,  Inc.
                               25         say  something  --  one  of  the.difficulties  we  had  at  this  site





                                                                             4


                   visit, the site visit was.structured probably improperly.
               2 They misgauged our needs, and we  had  great  difficulties  the
               3  first day in really finding out'what the health needs of
               4  Buffalo and the seven counties of New York,,IVestern New York
               5  and Pennsylvania that comprise this area.  And then the
               6   second day when we began talkidg with the county health
               7   commissioners we got a very clear picture from them,  and  it
               8   is a very complex situation, and I think this is reflected in
               9   the history of grant applications from this area.
               10                                                      ophisticatio@i
                           .They have been characterized by extreme s
               11  and conce.-L@ration on things like renal disease and cancer
               12  of the -,kin, rather small facets of a very large health care

                   problem that they have,
               14           Tjie Stati-, Univer@ - ty of New York at Buffalo is one
               15  of the strengths there,  But I note that in the American

               16  Federation for Clinical Research help wanted summary
               17  'there are more vacant divisional positions at the State
               '8  University of New York ac Buffalo, every department is looking

               19  fol divisional heads.
               20            There is a very strong department there in community
               21  medicine headed by -- social and preventative medicine --
               22  headed by Dr. Edward Merror.  It is very well financed, and
               23  it has been a department of great strength; and Dr. Saitz,
               24  who has been chairman of the 'program committee for the  RNIP

  ce   I Reporters,  Inc.
               25  in Western New York for'the last two years
                                                                has been  a  key





               I   figure in the operations of this program, and I think this is
               2   one of the great strengths in this area.  It is probably
               3   one of the strongest departments in that medical school.
   t
               4            of course, there is-the Roswell Park Memorial
                   Institute which is an outstanding cancer center  and they
               5
               6   have been extremely hard pressed financially during the last
               7   few years, and I think this is ref lected in some of the
               8   special types of project applications which have surfaced in

               9   this area.
              10            Now there are betwee'n 90 and 100 thousand under-
              11   served core minority groups, chiefly black.  The population
              12   of Buffalo is 22 percent black at the present time.  And
              13   one of the interesting manifestations is that most of the
              14   large hospital ;services are very close to or on the edge of
              15   this core area.  And a number of these hospitals -- most of
              16   these hospitals have really no relationship to the care
              17   of the urban core community, and there is a great deal
              18   of antagonism, has been in the past, between the central
              19   community and several segments of the hospital community.
              20            This was not helped by the fact that in,1969 the

              21   Western New York Regional Medical Program did deve op an
              22   application which got up here to Washington in trial form for

                                  lth center to begin to make some progress in
              23   a community hea
              24   health services for this minority group, and they did enlist

  ,ce -eat Reporters,  Inc.
              25   the cooperation -- there are about 17 or 18 physicians, mostly




                                                                             6


                   black, who work in this community, and they had a number of

                   meetings under Dr. Ing4li's direction, and this got up here
              2
              3    and it received some kind of pocket veto.  We  don't  know
              4    what went on. It never did surface as  a  formai  application,
              5    but the Western New York Regional Medical Program lost

              6    credibility with the black community.
              7              And I think this explains one of the  problems  that
              8    we saw, and it has been commented on by previous site
              9    visitors, the lack of minority representation on the Regional
              10   Advisory Group, on the core staff; and this ws brought out
              11   rather frankly in our visits, that they have had  problems  in
              12   getting cooperation from a number of well  identified  leaders
              13   in the underserved group in their  administrative  activities.
              14             Another thing which Mrs. Mars  was  particularly
              15   concerned about, and some of us, was. that the Regional Medical
              16   Program really doesn't get all the credit that  is due  it
              .17  for the many., many activities that do not even appear  in
              18   the application here which have gone on under Dr. Ingaills ver3.

              19   able direction because it's identified as the Health
              20   organization of Western New York.  And HOWNY has been the

              21   umbrella under which they have operated and to  which  the

              22   physicians and the county medical societies have gotten

              23   used to using, so that HOIVNY gets credit where credit is due,

              24   and Regional Medical Programs do not.

  De -fat Reporters, Inc.
              25             Now this was essential in the  initial  planning




                                                                           7


                  phases, but we had considerable question that this had
              2   anything except historical significance at the present time.
              3             In addition to the hospit al care activities being
              4   fragmented in the past and not serving many of the

                                                            Group has  een very
              5   critical core areas the Regional Advisory
              6   heavily provider oriented, chiefly by physicians; and while th s
              7   is a very dedicated Regional Advisory Group, has some very
              8   able, hard.working physicians, and they participate in every
              9   phase of planning, eviuation, and supervision of projects
              10  together, even some of the members go,on site visits, it is
              11  pretty limited in its outlook still, and this is one of the

              12  things we think has to be improved.
              13            There are some Very grave elements of instability.
              14  in the first place, Dr. Saltz has had the key position
              15  on the program committee, chairman of the program committee,
              16  which is a very powerful filter for all projects.  All decisions
              17  'are made by the program committee, and they have been very
              18  able decisions.  He feels that it's a position that he has

              19  had this power too long, feels it should be turned over, so
              20  he is resigning.  And then Dr. Ingall laid his resignation
              21  on the table of R@IP as of October Ist.  It has not been
              22  accepted yet, and he has indicated he felt that    we got
              23  the impression that he will stay on until somebody can take
              24  over the reins.  He will have been with the program for five

  :e   I Reportets,  Inc.
              25  years this spring.  But he is a surgeon.  There  is a lid on





                                                                               8


                I   all ceilings, they are ke,pt at the level of the other state
                2   institutions, the RMP, and with his children coming of
                3   college age he said he just can't afford any longer to take
                4   this on.  He would like to stay with it, bVt it's an

                5   economic disaster as far as he is concerned.
                6             I bring these out so that when we go to     I will
                7   try to just excerpt portions of this site visit -- you will
                8   have a little better appreciation of some of  the  problems.

                9            Now the., have had a difficult time, as you can
                10  imagine, in turning arounG from categorical, and really
                11  highly si,--cialized categorical interests, to the new guideline;
                12  And thf,-y -ha,! a conference in September, and they have done,
                    I think, on paper a reasonably good job of reorienting their
                14  ideas.  And as I have indicated already, they have not been

                15  unaware of the medical needs.

                16            Dr. Ingalls actually after hours carries on a
              117   small surgical practice in the black community.  He is on a
                '8  first name basis with the physicians there.  He is very

                19  conversant with the problems.
                20            But they have had problems in getting the medical
                21  community reoriented. So they have  identified  --  turn  to
                22  part 6 here of the site visit report -- they have identified
                23  goals, one, the promotion of preventive medical    services,
                24  the development of improved 'primary care services,  and  to
  ,ce- ederal Reportets,  Inc.
                25  integrate rehabilitation services into the continuem of




                                                                            9



                                                           ts of objectives
                    medical services.  Then they have two se
              2     and these relate quite definitely, and they are very articulate
              3     about these on page 7.  I won't read.over all of these.' These

              4     are the fixed objectives.
              5             'But one of the things that concerned us when we
              6     came to the hard problem of which programs you are going  o
              7     fund and which you are going to have to delay when there
              8     isn't enough money, they have floating objectives, and we

              .9    spent some time with the
                                           se floating objectives.  They were
              .10   frank about them; but these relate to political considerations,
              11    feasibility, and a variety of things which are not down on
              12    paper, and we felt this was a matter of some concern to

              13    US.
              14             possibly more concern -- and this is stated on page
              15    9 here   these objectives that they formulated in this
              16    September, 171 workshop as combined with these floating
              17    I should have said priorities.  Now this takes into account
              18    the availability of leadership, the reliability of the
              19    applicant, the local political climate, the impact of the
              20    project on local vested interests.  And we must realize here
              21    that in New York you have a special problem.  There are such
              22    layers of institutionalization on the whole medical care
              23    picture because the state has been interested in public and
              24    has had very real concerns iD public health for years
  ,Ce ,al Reporters,  Inc.
              25    preceding R@-IP.  The medical community is pretty well





                                                                            io


               I   entrenched.  It has been going a long time.
               2            And so there are a lot of these subjective and
               3   intuitive factors, and we felt that these were probably
               4   used a lot by the Regional Advisory Group,in their decisions,
               5   and probably in some cases were necessary ingredients.  But
               6   they did provide some disturbance to us in terms of  their
               7   proposal for use of a developmental component which was

               8   really quite unstructured administratively.
               9             And then 'you will notice in their grant application
               10  on the sixth and seventh years, I believe, they are asking
               11  for something like $250,000,$60,000 of what amounts to

               12  additional development component.
               13            And this relates $to another interesting feature.
               14  This region does not have a large backlog of approved  but
               15  unfunded grants.  They have probably 15 to 20 projects
               16  that axe being formulated. But because of the  very  tight
               17  way in which the Regional Advisorv Group and its program commit
               18  run this, really they sort of take along each project
               19  t-hey think is capable of being carried out and they get that
               20  funded.  But they don't have a list of appXoved unfunded
               21  projects, so you can't really evaluate in terms of at least
               22  the paper what the future direction might be in terms of

               23  approvable programs or projects.
               24            Now I think they have made very real accomplishment,

  :e-Fedetal Reporters,  Inc.
               25  and I'don't in any way wish to deny that this is a very





              I  Valuable resource.  And I think one of the things we would like
              2  to bring out, that IVestern New York could provide leadership
              3  for central New York and other areas in Pennsylvania, other
              4  areas with rural problems, because they have managed really
              5  initially to approach the rural health problem somewhat more
              6  capably perhaps than some of the other areas, and they have
              7  developed a very good model in their community health
              8  information profile system which they are applying county to
              9  county, and this has again worked.  It's done under the
              10  direction of the Department of Social and Community Medicine

              11  by Dr. Ed Merror.
              12           The outstanding new thing which has developed and

              13'  which will be a very significant factor is the Lal,,e area
              14  health-education center in Erie, Pennsylvania, where they
              15  have pulled together five community colleges, a number of
              16  hospitals totalling 2406 beds, a variety of allied health
              17  training programs, and the V.A. hospital there is financing
              18  thisto the tune of $40,000 for the first year for administrative
              19  help, and this is a real going planning concern that is going
              20  to be an area health education center, probably one of the

              21  first in the country.  And I think we have to recognize
              22  that Dr. Roth from Erie, Pa. has Probably been a pretty big
              23  catalytic agent in this.  And this has required very little
              24  RMP money, but the outreach  thro.ugh the State University at
  ce*fat Reporters,  Inc.
              25  Buffalo and the fact that there was a good core operation,




                                                                          12


               I  although understaffed but that had input into all the
               2  medical care activities of the region, this has certaini
                                                                         y

               3  gotten off the ground a lot faster.
               4           Another interesting thing is there is more and more
                  voluntary participation by various physicians, allied
               5
               6  health professionals in the core activities.  They'estimate
               7  that as of last year 40 percent of total R@fP activities were
               8  funded by voluntary contributions from the outside.  I think
               9  this is a good example of their very real success of being

               10 able to act as a catalytic agent.
               11          How they have this telephone lecture network which
               12 has reached now over 30,000 allied health professionals
               13 and physicians.  We saw that.  It has been very useful as a

                                                             'It,-is used
               14 tie in to some 50, 60 community hospitals..;, .
               15 probably more valuably, I think, by the smaller community
               16 hospitals, particularly for allied health continuing
               17 education than by physicians.  But this is a very valuable
               18 resource, and it is going to be one of the things that will

               19 be continued.
               20           Their evaluation has not been as strong as it should
               21 be.  It is headed by a very capable girl.  We feel definitely
               22 she needs more help.  And I think their evaluation system
              ,23 is improvin- rapidly, and it feeds directly back to RAG
               24 and is participating in their evaluation activities.  As a

  Ce- Federal Reporters,  Inc.
               25 matter of fact, they cut off one of their projects a year in






               I  advance because they felt it was not being productive.

               2
                           They have given a lot.of help to the CHP agencies,
               3  eleven, and the CHP and the OEO -- there  is a $700,000
               4  OEO grant to help in the care'of the urban poor which was

               5  helped very materially by Dr. Ingalls and his group.
               6           We come to page 12 here, this documents this -a
               7  little more in terms of what I said, this i969 project
               8  that they developed which didn't catch fire here in Washington
               9  for some reason. And I just cite this to emphasize that

               10 they have been aware of their responsibilities.
               11          They have also carried out career  ladder training
               12 for innercity girls.  This has been assisted by their core
               13 staff.  And they have been instrumental in getting the
   0
               14 innercity hospitals to begin to look at the community adjacent

               15 to them  as we will bring out.

               16           It's emphasized, however, they do have Mrs. Mary
               17 Northingto'n,  at the bottom of pa-e 12 here, a new member
               18 of the RAG.  She'had worked as a research technologist, I
               1'9 believe, for years.  This is part of the incredible medical
               20 background here,  that they can  get people to serve on their
              ..21 RAG who are very familiar with sophisticated medicine and.
               22 who worked in research programs at Roswell Park.   But they
               23 haven't fully utilized these people, as was apparent from
               2 4Mrs. Northington's testimony.   They need certainly to expand
      @,al Repotters,  Inc.
               2 5their RAG.




                                                                              14



                             Now we felt that Dr. Ingalls had done  a  very  good

               2   job.  We don't feel that Dr. Ingalls is the worid's best

               3   administrator.  And I would just like to cite from this

               4   page in your summary.  This gives a very good picture

               5   of the way their core staff operates.  You  notice  there  are
               6   no clearcut lines of relationship.  Everybody is doing his job

               7   and Ingalls has got his finger in every pie, and it is

               8   incredible that they submitted this, because this  is  a  very

               9   frank statement in their organizational  chart.  Vie  couldn't

               10  see that it was nearly as well organized as it might be.
               11            Ingalls has to have a deputy coordinator  if  he  is

               12  going to do more. This is  getting  so  complex.  They  need
               13  to have additional staff and evaluation to help Miss Helberg,

               14  they need to have more liaison people  for  their  innercity
               15  programs, and they need to have -- they just have   one  man
               16  now trying to serve eight rural counties, and  it  just  can't

               17  be done in that area. So that these are  some  of  their  real

               18  needs.

               19            The Regional Advisory Group, to come back to
               20  them, the preponderance of physicians, 20 out  of  3i  members

               21  there are no representatives of labor unions, teachers

               22  associations,, no hospital representatives, although they

               23  have an excellent hospital network  there,  much  better  than

               24  many other places.  And as a matter of fact, we got a strong
  6ce- Federal Reporters,  Inc.
               25  sense of noncooperation from the testimony of the local head





               I   of their hospital association.  I don't think this reflects

               2   the attitude of individual hospitals.
               3            The Regional Advisory Group does not have a
               4   functioning executive committee.  It's extraordinary.  They
               5   operate as an executive group, meeting monthly.  They  make
               6   their decisions.  The program committee meets twice a -year to (e
               7   cide which programs will be funded, which will be cut  off,
               8   which obviously is not often enough for an active committee.
               9            Proposals are disseminated among over  300  people

               10  because each county has its own county advisory.group, so
               11  that any proposal goes to this 300 group, and  it's  obvious
               12  thet the rural counties don't feel they are part of the
               13  show, that the urban RAG is running things, and it really is.
               14           Furthermore the RAG -- there's no provision for
               15  turnover.  Some of these people have been around six, seven

               16  years, and we were very critical of this.
               17           We were also critical of the grantee organization,
               18  and I don't know what RMP can do about it, but there's a
               19  58'percent indirect cost charge for on campus activities and
               20  48.6 for off campus activities.  So really the R@IP dollars,

               21  for every dollar that you are putting into an  RMP  program
               22  there another 50 to 60 cents is going, siphoned off to
               23  Hoalth Research, Inc., which is the grbLnts obtainin- arm

               24  for all thestate agencies in New York like Roswell Park and
  Cele'll Repoiters,  Inc.
               25  the various public health research institutes, and so forth.





                                                                                16



                I             And I think this together with  the  fact  that.they

                2  are tied in with an  antequated,  absolutely  antequated  salary

                3  basis, which has provented.recruiting  people  into  this,  this

                4  is going to be more and more  of a handicap;

                5             Participation -- I have noted the  lack  of  hospital

                6  and institutional  involvement.  Butthis  is  improving  because

                7  the Meyer Hospital and two of the  sections  of  this  current

                8  application deal with assiStiDg  the  Department  of  Medicine

                9  at the State University, at the  Meyer  Hospital,  to  develop

              10   a continuing care program with some continuity which

              11   would apply to the innercit,y underserved group.

              12              ti,,d then the other outreach is a family  practice

                   program, which was ine of the e arly ones to get  going  at  the

              14   Deaconness Hospitul, one of the first  in  the  country,  which

              15   is quite successful, and it is now serving  --  this  is  also

              16   within the black community now, it is providing major service

              17   to the black community, and it is growing very fast.

                              We felt, howe ver, the amount of  money  they  wanted

              19   to aid in this was possibly a bit excessive since this is

              20   70 percent paying practice of medicine.

              21              Local planning -- the county rural  health  for  the
   0          22   ambulatory care proposal which is sort of a mobile health

              23   education unit, it's a very valid concept, it's backed by all

              24
   0               of the physicians in this one county, and has active'
  -e Federal Reporters,  Inc.
              25
                   participation from allied health.  It's  a  very  viable  idea,






                I  and we think that it will be an answer, at least one answer
                2  towards getting closer to the interface of the health

                3  care at the rural end of the scheme.

                4          'It wasn't our charge, of course, to look into
                5  projects, but I must say in terms of the million and a half
                6  dollars that were appropriated for respiratory care the
                7  testimony of Dr. Vance was kind of disastrous.  He didn't
                8  even have letters of approval on exters ion of this program

                9  into the various rural hospitals for the next hundred
                10 thousand next two or three -years.  And we felt that obviously
                11 not all of the appropriated money had been spent, and we
                12 were very leary about any further allocation of funds.  As
                13 you will note in our recommendations, we wanted to turn off
                14 the respiratory care program within 18 months.
                15           The management, on pa-e 16 -- as I have indicated,
                16 we feel that the project surveillance has been good, but
                17 they need to have a better management structure, and,this,
                18 would be aided by a deputy coordinator, and assistant
                19 eV&Iuator, and also having field people to cover not -- a
                20 least two counties, two or three counties, and these will be

                21 in our recommendations.

                22
                             I think that gives the general picture here.  The

                23
                   details are pretty well spelled out in this very good

                24
                   summary'that Mr. Kline developed.  And we think there is
  @ce lea I Repofters,  Inc.
                25
                   considerable short term pay-off with continued activity in thin








                I  area,
                2            In the first.place, the Alleghany County mobile.
                3  health unit is a pattern that can be applied  to other counties,

                4  and it has the cooperation of the rural physicians.
                5            Another  intoIresting feature is that in another
                6  -year they will have physicians that are trained in the.family
                7  practice program in the Deaconness Hospital who have signed up
                8  to go out to the rural communities to continue family
                9  practice.  So they are beginning to make a little headway into

                10 tho-deficit of physicians in their rural area.
                .11          The Lake area educational project should certainly
                12 get off the ground in the near fugure, and this  will  bring
                13 in a variety of colloges,which are resources that  have  not
                14 gotten involved, but which are very interested in getting

                15 more involved in allied health Itraining.
                1 6          one of the interesting facets here is that Dr. Perry
                17 has never been a member of their RAG group there'and has
                18 always been in a peripheral position, although he  has  been
                19 extremely influential in developing the concepts  of  allied
                20 health training and in the Lake area educational concept
                21 in Erie County.  He is certainly one that we were very, very
                22 strong in our recommendations that they are neglecting a very
                23 valuable resource by not having more allied health people

                24 on thei r RAG.
   -*,,I Reportefs,  Inc.
                25            Now the recommendations.  They are asking for the





                                                                            i9


               1  05 level, coming to page 22, a total of $1,419,000 for the
                       -year.  And we made specific deletions on this.  We
               2  fifth
               3 cut back the respiratory disease project by $50,000  for  the

               4  first -year.
               5           We-felt that the comprehensive family health project
               6  that is the training program for family practitioners  which
               7  is being run largely as a successful private practice
               8  residency program at the Deaconness Hospital    in the first
               9  year would not need all of the funding that they had
               10 requested, and we felt this should be site visited because
               11 it is an important program, but we want to know, I think, how
               12 the money which we are putting in, how this is going to be

               1-3 utilized.

               14           We also felt that this region probably  shouid.not

               15 have a developmental component until.their Regional Advisory

               16 Group has been reorganized and until there is a better

               17 characterization of priorities and how they are going to

               18 utilize their developmental component. At the  present  time

               19 their broad strategy is to divide this developmental
               20 component half and half between the urban and rural communities
               21 and to put it out in $5,000 contracts here and there.  lVeil,
               22 this may be a very good mechanism, and I am sure would  have
               23 some impact, but we felt that they were still pretty much
               24 project oriented, until  we could see more evidence of
  ce-Federal Reportets,  Inc.
               25 program development we should wait.





                                                                             zu


                             We felt that the mobile health unit which is
                 2  going to cost $47,000, that R@IP should not be in the position-
                 3  of putting the whole money down for a piece of equpment,
                 4  that there should be matching funds.  So we are OD Y
                 5  recommending 50 percent funding Of this.  So we deleted
                 6  a total of $284,000 there from the grant, which would bring
                 7  down the recommended level to close to what  it is now,

                 8  $19 1360000.
                 9           But in the light that we feel  their  core  staff
                 10 needs enlargement by at least six members    and  this  is
                 11 recommendation 4 -- dep-'.-y coordinator, an assistant  or
                 121the preqent evaluator, two additional members to work 'with the
                    county committees as liaison, and two specialists in health
                 14 aat+ers in innercity and r,,al health -- this might put back
                 15 somewhere around 80 or 90 thousand dollars.  And  this  is
                 16 how we got at this figure, $1,219,000 for the first year,
                 17 and then I think something on the. order of ten percent

                 -8 increments for the subsequent two years.
                 19           We felt that the respiratory disease project should

                 20 be cut back sharply.
                 21           And recommendation number 6, we felt there is a
                 22 real  need for the salaries of the staff members to be increase
                 23 to  levels consistent with people doing comparable jobs in
                 24 other RMP's., Now here we are up against a problem with the

  Ac   ral  Reportets,  Inc.
                 25 Wage and Price Board.







                I            Those were our principal recommendations.

                2            The expansion of the minority groups representation,

                3  consumer representation, hospital representation on the RAG.

                4  And we felt that the coordinator should  be  congratulated  on

                5  doing an excellent job  working 12l 18 hours a day many days.
                6  He has tried to carry :oo much of this on his own shoulders.

                7            We felt that the leadership role in the creation

                8  of the Lal,,e area health education concept in Erie is a tremond(L

                9  forward step, and the fact that they are profiling the

              10   health needs of all of the county  systematically  with  t  ir

              11   Chip pror-am, very gOOL.

              12             We think that their  telephone  network  information

              1.   dissemination     their regionaiization needs to  be  improved

              14   further, but with their t6 Pphone net they  have,got  all  the

              15   tools here.

              16             So we fcel strongly that they are ready for

              17   triennial support.  But I think we have to recognize that

              18   these two major elements of instability -- we don't know

              19   wh  is going to be the new director of the program committee

              20   or chairman of the program committee -- this is a position

              21   appointed by RAG -- and the 20sitiOn of Dr. Ingalls here

              22   is tenuous.  But I do want to emphasize he gave us the      at

              23   least he gave me the feeling that he would stay until a

              24   replacement could be 'found.
  kce*,al Reportefs,  Inc.
              25              DR. MAYER:  Thank.you very much, Henry.







                              Comments of staff before we go on?  Any additional

               2    comments?-

               3              All right, questions?  Jerry.

               4              DR. BESSON:  I am not sure, Henry, what your

               5    recommendation was for the diminution in support for the

               6    chronic respiratory disease prograxa.  It is requesting

               7    93,000 and 17,000.

               8              DR. LEMON:  Weil, this has been a large project

               9    which has concerned itself largely with training of

              10    respiratory care personnel in some of the innercity hospitals,

              11    and their projection w       they felt it was really a

              12    different project, but we didn't -- to move this out into

              I'l   the community hospitals.  But they nad Dot taken any steps to

                                            d @or this in the community hospitals
              14    really det-3rmine -,,he nee

              15    or the cooperation.  And we recommended here on number 3, this

              16    is page 22, the finding periodfor March ist, 172 to

              17  February 28, 173 not exceed $60,000, and that this really be

              18    in the phase of tapering down their present trainii,g activities

              19    ar' evaluating what they have doni.  We felt it was very

              20    important to get maximum evaluation out of this for the

              21    benefit of other R@IP's to sce what they have really

                           ished.  And not more than $32,000 for the
              22    accompi                                           subsequent

              23    -ye ar .

              24              So instead of putting in some 600 or 700 thousand
  .eO,,i Reportets,  Inc.
              25    dollars they wanted over the next triennium we recommended






               I   only approximately $94,000 over the next two years.

               2             -We didn't really want to penalize them too much

               3   because we felt -- we didn't have time to go into all facets

               4   of this., but it was apparent that Dr. Vance was not well

               5   prepared to document his achievements or to indicate the

               6   directions in which they were going to go in the next triennium

               7             DR, BESSON:  The other question I have has to do witi

               8,  the function of the research foundation and their  charges.

               9  What are included in those overhead costs that they pays

              10             DR. LEMON:  Bert, I may need your help in this.

              II   But they process the cl 4.rges.  The Western New Yor4 RITP

              12   pays its own rent, does it not?

                             MR. KLINE: As I understood what  they  described,

              14   they provide recrLitiDg se-vices, attempt to iocate personnel,

              .15  they maintain ail records of expenditures, provide these

              16   on a periodic basis. By and large I think they serve  as  a

              17   resource to Western New York, and they didn't get into a great

              18   deal of detail. rut as I recall the conversation, the  R@IP

              19   st-ff felt they were getting a considerable number of

              20   services.

              21             DR. LEMON:  They get consultant services, too.

              22   They get a wide variety of health consulting services for

              23   free from the other state agencies andbureaus through this.

              24   And they came back several times -- the associate dean, I
   *I Reporters,  Inc.
              25   believe', testified -- or was in Ingalls -- testified that they






                    felt they were probably getting more for their money than

               2    RMP was putting in.  But we were in no position -- you know,

               3    we weren't accountants     we couldn't really get the dollar


               4    value of this.

               5              DR. BESSON: What is  the  customary  charge  that  a

               6    grantee organization makes for  this  kind  of  service?  This

               7    is not really overhead.  It isn't covered in the usual

               8    contract sense.

               9              DR. LEMON: It is overhead because some of the grants

              10    or contracts thut the state of New York accepts through the

              11    Health Rt-search, Inc. "ive no overhead provision, or 8 or 10

              12    or 20 percent; and the reason that they  have  to  charge  RMP

                    this figure is to make up for these other low overheads

              1 4   so they co-ne out -with an -,rerage somewhere on the order  of

              15    25 percent overhead for all of their research grants,

              1 6   contracts and outside funds.

              17              DR. BESSON:  Of dourse) the aspect of your site

              18    visit comment tha-'%-, somewhat astounded me when I read it,

              19    tt.,t RMP is really bearing the br,.int of the ceilings on

              20    overhead that thestate of New York charges for entirely

              21    different programs, and thir kind of penalty makes me wonder

              22    why you are chary about recommending a new grantee

              23    organization.

              24
                              DR. LEMON:  I  think  this  involves  administrative
  ,elat Reporters, Inc.
              25    decisions involving several,other RHIP grants.  All we could






                   do was to point out two things, that this seemed like a very

              2    high overhead figure, which, of course, is magnified

              3    in central New York and other areas in Now York; and secondly,

              4    that operating as a part of Ilealth Research, Inc. they are

              5    locked into the salary levels, but do have  more  flexibility

              6    than if they were funded via the state.  This was one of

              7    the other reasons why Ileaith Research was developed,

              8    because it provided more flexible utilization of funds

              9    than the very rigid restrictions which the state--

              10             DR. MAYER:  Henry,  let me comment.  I find it hard

              11   to believe, knowing how the audit of overhead costs goes,

              12   that they would accept RMP or anyone else carrying  the  load

                   of someone else any more than Medi--are would accept a

              14   hospitals indigeit care component as part of cost.  You

              15   know, costs are costs, and I assume, they are being  prorated

              16   on the cost relative to RNIP or any other group being

              17   involved with that group as a group.

              1 8            And I find that, you know,  that last statement just

              19   a.Praost impossible to believe. If it is going on that way,

              20   that is they are absorbing some of the other costs  of  other

              21   programs, then there is no question that it needs to be

              22   reviewed in detail.   I just find that hard to believe..

              23             DR. LEMON: I believe this came from the Vice

              24   President of the State University of New York.
  'elel Repofters, Inc.
              25             MR. KLIL\'E:Yes, in direct questioning this was





                    @rought out.

               2              DR. MAYER:  Well, then my suggestion would be that

               3    that situation needs very strongly to be reviewed.,

               4              yes, Mrs. Silsb ee.

               5              MRS. SILSBEE:  Dr.   Ingall is coming down to

               6    talk about the possibility of moving  his  Regional  Medical

               7    Program to another grantee situation.  He  is  6xpioring  it

               8    and trying to move ahead.

               9              DR6 BESSON:  Would it make it any easier

              10    administratively if we with fair play of turnabout put a

              11    ceiling on the overher-i that the grantee--

              12              DR. MAYER:  No, you don't have that right.

                              MR. CIIAMBLISS:  May I co.anent?

              14              DR. MA"R:  Yes     Go ahead.

              15              MR. CIIAIIBLISS:  Let me just say, please for  the

              16    committee that the overhead rate, as you  might  know,  is

              17    not negotiated by the individual programs of  HSHMA  or  the
              18    individual  prograns'of HEW. The  overhead  rates  between

              19    t@9 universities and their foundations, or  what  have  you,

              20    is negotiated by HEW.  So once the rate is established and-

              21    negotiated wherever our fUDds are placed in  a  given  RMP

              22    that grantee overhead negotiated rate  will  prevail,  and

              23    that is the case in this RMP.

              24
  ceel Reporters,  Inc.       No w to speak with,regard to the salary policies,
              25    it has always been our policy in RIIPS that the salary





                    policies of the grantee institution prevail.  So whatever
               2    salary polities are in the university system would

               3    automatically apply to the RMP,
               4               That may be the basis uponvhich  Mrs. Silsbee makes
               5    the point that this R@IP is contemplating moving out and
               6    moving into a nonprofit corporation.  This would give an
               7    opportunity then for that nonprofit corporation to negotiate
               8    its own rate and for a  rest.ructuring of the salary  levels.

               9               DR. MAYER:  Additional conl-nents?

              10               Yes.. Lan.

              11               DR. SCHERL.TS: Will you project as to whether  or

              12    not you think the present coordinator will remain, or  were
              13    -you in effect granting funds really not knowing where the
              14    leadership will be derived as far as this area is concerned?
              15               DR. LEMON:  I can't say anything more than I think

              16    that Dr. Ingalls is emotionally very involved in the
              17    program.  He has been the heart and soul of it for the last
              18    five years.   I think he plans to stay in the  Buffalo  area,
              19    abd I think that who ther or not he is in the saddle that
              20    perceptive people would continue to build on what he has

              21    developed.

              22               The other two stabilizing factors are that the

              23    ROgional Advisory Group has some very dedicated people like
              24    Dr. Felsen, who is a very capable practitioner from one
  ceol Repoitets, Inc.
              25    of the counties, very knowledgeable.    And you have to  bear






               I  in mind this RAG has been functioning pretty much as a team

               2  for several years and workings, very closely with Ingalls.

               3            The other thing is Ed Morror's Department of

               4  Social and Community Mediciiie,.which has given  extraordinarily

               5  good leadership, is a stable factor.

               6            DR. SCI-EERLIS: I recall making a site visit there, it

               7  was a technical review, and one thing that impressed us was

               8  their number of project.requests relating to what really

               9  amounted to central laboratory support at the university.

              10  And I note on page 7 of the yellow sheets that they now have

              11  an immunofluorescence service and training, and a regional

              12  coagulation laboratory that is to be  supported  through  carry-

              13  over and rebudgeting funds.

              14            I was wondering if there still is that emphasis

              15  on using the central laboratory   supporting its functions for

              16  the community.  I think our technical review, as I recall

              17  it, was not too favorable, if-I am not mistaken.

              18            DR. LEMON:  Right.  I think I tried to indicate

              19  'the@ were trying to phase this out, and this is  definitely  on

              20  the way out.  They realize the new direction, and the-y are

              21  quite conscious of it.

              22            DR. MAYER:  John.

              23            DR. KRAWLEWSKI:   Ivas wondering if you  would  expand

              24 a little bit on the salary problem, because we are giving
  ce   I Reportefs, Inc.
              25 them a fair amount of increase for core budget here to hire some




                                                                           29



                  ten new people, or something like that, isn't it, and are

                2  they going to be able to find these people, are they going

                3  to be able to hire them under this schedule, or is there

                4  a change imminent?

                5           DR. LE-MON: I think i t was they had an'assistant

                6 evaluator, didn't they, Burt, that they finally dropped

                7 from their table of organization because they couldn't find one

                8 under their present salary levels.

                9           This is a very high cost area in terms of taxes and

              10  living expenses.  The ceiling present on salaries is, I am

              11  sure, one of the reasons why the university medical school at

              12  Buffalo is in want of so many division directors,  And I

              1.3 think Dr. Ingalls indicated he had great difficulty -- he

              14  was looking for a replacement, had been looking for several

              15  months, and there is no one in sight,

              16            DR. KRAWLEI@BKI:  How much is he getting paid?

              17
                            DR. LEMON:  Thirty thousand.
              18            DR. KRAWLEWSKI:  lYe are recommending about $250,000
              19  inc@ease for core., is that correct?
              20            DR. LEMON:  No, about $80,000.  Some of it could
              21  probably be rebudgeted, but the two most expensive things
              22  that -- Burt, you correct me, but the deputy coordinator and th:!
              23  assistant to the-present evaluato:e"and then two additional
              24@
                  members to work in liaison.  But'the increased core would be
  LI   Repofters,    Inc.
              251 somewhere on the order of 80, 85 thousand which we woLild








              I  recommend.


              2           But, of course, under.a triennial, as Iunderstand

              .3  it, this would be their option that they could make these

              4  salary adjustments if it could be done within the framework

              5  of the sponsoring institution.

              6           DR. KRAWLEIVSKI: I guess I don't understand that

              7  budget.

              8           DR. MAYER:  You need to go to the yellow sheet,

              9  page 5, which is where John is and where I am., I have got

             10  the same problem.

             11           DR. LEMON:  On the yellow sheet, page 5, okay.

             12           DR. MAYER:  Which, depending on your visual

             13 acuity,  it says in effect that their current budget for core

             14  in the current fiscal -year -;Ls $343,903, and what is being

             15  requested in the 05 -year is 587.  That's the point I think

             1 6 John is making.

             17           DR. LEMON: I think we are looking at least the

             18  figure we were working on was this is awarded three one

             19  sev@nty-two twenty-eight seventy-one.  That says 447 for core.

             20  But what we were working on was the awarded for the 05 year.

             21           DR. MAYER: I see.

             22           DR. LEMON-.  That's the 05 year, where they are

             23  requesting 587 thousand for core.  So, see, they have

             24
                 already made an increase in their request for core to provide
 ,e   I Reportefs, Inc.
             25  some of the things that they need in terms of better Liaison








                   with the rural counties.


               2             The community continuing   education network  of

               3   hospital  -- that's their telephone  network -- we  didn't

               4   touch that, $82,000.  The items 3:and 3A for chronic respiratory

               5   disease, we cut from 110 to 60 thousand for that year.  They

               6   have already phased out the fluorescence.    The tumor

               7   registry, there was some question about this.  This supports

               8   four secretaries at Roswell Park, and it.'s just a  locali

               9   based tumor registry, you,know. And in this  day  and  age  of

              10   nationwide programs like the pass map, and so  forth,  I  just

              11   wondered, but we felt we would leave that  in  because  this

              12   is one of the things that ties  these  divergent  elements

              13   together, and it does cover the  entire  local  region.  And it's

              14   obviously well directed, I think. It  is  going  to  provide

              15   information.  It is the only activity in cancer.

              16             The model pro-ram for comprehensive family health,

              17   that is the family practice program, 171  thousand,  we  cut

              18   that back to 50,000 a -year for two years until it can be

              19   site visited technically and until we see what the

              20   potentialities are,.,

              21             DR. MAYI@CR: I think, Henry, the only question  that

              22   John is raising really relates to it would appear -- and I

              23   still don't understand -- what we are recommending is

              24   a $240,000 increase over their existing year as  far  as  core
  cel*al Reporteis,  Inc.
              25   is concerned. And he is raising, I  gather,  the  question  in







                I  light of the  other comments -you made concerning recruitment,

                2  salary levels, et cetera, whether that was feasible.

                3             DR. LEMON:  I think this is a big question.  We


                4  felt that their core staff was really much too small for

                5  an area with as complex medical interests as this.  Dr.

                6  Ingalls, you see, has been trying to do all things, and it has

                7  just become apparent he can't knit the hospitals together

                8  into a better integrated program.


                9             There is now one Lackawanna health clinic functionin


              10   that was developed by a medical student, who is now its-direetor

              11   in  an  area of 7,000 underserved people imprisoned in this

              12   industrial cage of railroads and factories where they only

              13   had two physicians, one of whom was 80 years of age two

              14   years   ago.

              15              There are two other OEO health centers in the


              16   process of formulation which will serve another 30,000 people.

              17                                    'nded th ough OEO, and it  is
                   .There is a lot going on there-fu       r

              18   supported by the State University, that he is  going  to  have

              19   to try to keep tabs on.

              20              So that whether he can find these people  we  don't

              21   know.  Obviously there are good people there who-are doing

                2
              2    a job which aren't represented on the RAG or on  the  core  or

              23   anywhere else.

              24              DR. MAYER:  Sister Ann'.
  ,ceoal Reporters,  Inc.
              25              SISTER ANN JOSEPHlh'E,:  Dr. Lemon, do you think.that








                                                                    ail this
               I   when for a while Dr. Ingall has been coordinating

               2   effort himself and not letting anyone do it that under his

               3   direction it would be possible for someone else to function

               4   effectively and have satisfaction from his job?  This is
               5   always a problem.  You knowt even if he brought in extra
               6   people, because of his tendency to do it all himself they

               7   might not stay.
               8            DR, LEMON:  I think he is interested in getting back

               9   to surgery.  lie is a board certified surgeon, and he

              10   indicated he has been trying to keep his hand in doing some

              11   after hoi,--s work in thL community hospitals, but he would

              12   like to got back to his professional life.  So I think

                   he would gradually phase back into being a practicing surgeon.
              14   I don't ha@,e any real -- E rt, what would you say -- I think

              15   he was anxious to let go of this thing.

              16            tiR. KLITIE: I don't know.  I didn't come away with
              17   'any.real strong feelings.  I came away vague, as may be

              18   reflected in the report.  But I got the feeling th&t he would

                     0
              19   not leave)certainiy until there was an adequate replacement.
              20   And he seemed a little bit'vague as to whether or not

              21   his resignation he has officially submitted was still in

              22
                   effect.  He made some indication that it was his hope

              23   that through this he might get some assistance from the

              24
  cet,al Reporters, Inc. grantee organization.
              25            And I also possibly  might just indicate a little






                   bit about what has happened in the interim period here.   I

               2   know that they are giving consideration to change of grantee, )r
               3   trying to give consideration to this, because this would, I
               4   think, ease Dr. Ingaills problems which are primarily salary
               5   based, and also relieve his recruiting problems where he

               6   recommended here six new people; if he were to get some
               7   salary levels I think he would feel he would be able to attrac;

               8   the kind of people he would like to have.
               9             Then also they are working to expand the current
               10  RAG membership from 33 to 55, which is consistent with the

              .11  kind of  re            that is suggested here.

               12            These are just some additional  thoughts.  But  I

               13  really don't know the answer to the question posed, Dr. Lemon.

               14
                   I came away very vague on this.
               15            DR. MAYER:  I think Sister Ann is suggesting that
               16  even if you are able to change the grantee organization,
               17  even 1'f -you are able to produce salary levels that are
               18  recruitable, the question that is being raised is, you know,
               19  maybe because of his concerns and lack of ability, or whatever
               20  you want to call it, in administrative  activity,  that  he

               21
                   may not even be able to do that job with  those  restraints

               22  removed.

               23
                             Welcome, Robert.

               24
                             DR. LEMON:   I would like to say one other thinm.
  -cee'l Reporters,  inc.
               25
                   Dr. Saitz, who is a dentist, but who has really been





               I   functioning as the deputy director for the last two years,
               2   is chairman of the program committee with the power to appoint
               3   his own ad hoc evaluation group, his own membership to

               4   his committee, get any kind of technical advice he needs --
               5   very able health planner, very good know-how, very good
               6   community relationships.  And I think Dr. Saitz could step in

               7   and keep much of the program going if any crisis arose.

               8             DR. MAYER:  Phil'.

               9             DR. WHITE:  Henry, on the one hand -you tell me
              10   thalyou feel that this region is capable of managing its own

              11   affairs presumabi y, because you are recommending a

              12   triennial award, which to me suggests 'your consider ation

              13   of their corporation is favorable.  on the other than, you

              14   make recommendations for specific dollar reductions of
              15   specific projects. And subsequent to that we have these
              16   conversations now on these various points. These two sets

                                              s
              17   of discussions seem inconsitent,.paradoxical.  I am

              18   reluctant to accept your recommendation for a triennial

              19   award in view of what subsequently 'you have said.

              20             Can you clarify this for me!

              21             DR. LEMON: Well, I think we felt we had misgivings

              22   about specific phases of this program.   I think we came
              23   away quite aware that their awareness of the direction that
              24   they have to go is very good.   I think our problems revolve
  .ce0rat Reporters,  Inc.
              25   around the fact that these are not spelled out in detail in





                   projects or programs that we can pinpoint.  In other
              2    words, there are many.good resources in this area, but as they
              3    have indicated in their application on the seventh and
              4    eighth years, the next two years, there is a large block
              5    of money that they are asking for for program which is not

              6    specifically allocated.
              7              And as I indicated, we were not overly happy with
              .8   the large sum of money that had been spent in the respiratory
              9    disease pro-ram.  And obviously the site visit was partly
             10    tuned to the report of the various projects.  We had to
             11    change the structure of the site visit.  But we did not
             12    get a feedback as to how much accomplishment had  een

             13    performed.
             14              1 think with the present set-up they have a good,

             15    hard working core group with lots of enthusiasm and
             16    excellent leadership.  And they have some things going on
             17    I think that counterbalance some. of tile  uncertainties, like

             18    the Lake area educational program in Erie.  But it

             19    remains to be seen, -you know, how well they ca n bring in

             20    the community college representations and all the power.
             21    There's enormous power here for manpower training and for
             22    development of better health programs.  But the specifics hav(,-
             23    not been spelled out that we could see.  They are being
             24    developed.  I can't read the crystal ball any more than that.
  -e *I Reportets,  Inc.
             25              DR. MAYER:  Jerry.




                                                                           37


               I           DR. BESSON:  Henry, I would like to return to this

               2  matter, even though I know that there's some constraints

               3  that Mr. Chambliss has indicated about that 60 percent rathole

               4 that we are working with in this region.  If  I  understand

               5  correctly, the funding level that you are talking about,

               6  1.13 million plus an extra 90,000 for core, 1.219, 60 percent

               7  of that, 58 percent of that is never going to reach the

               8  program?

               9           DR. MAYER:  That's a direct cost figure.

             10            DR. LEMON:  This is direct cost.

             11            DR. BESSON:  So that any way we slice it they will

             12  get a 60 percent gain if that hole is plugged.

             13            DR. SCHERLIS:  No.  Mr. Chairman, don't I interpret

             14  our  ground rules as not being concerned with overhead, that's

             15  an  outside negotiated item?

             16            DR. IIAYER:  Right.  And I think we have suggested

             17  that it is certainly one that needs  to be looked at from the

             18  evidence that has come back from the  site visit, at  least

             19  somL evidence that I have just heard, and'I think it ought

             20  to be pursued.  But the figures that Henry is dealing with

             21  are direct cost figures, Jerry.

             22            DR. LEMON:   I am tryingto justify the level.   IkDOW

             23  from previous discussions here this is where we have problems..

             24  And -you look at their present fundin- level, which is

  ,e
   eal Reportefs,  Inc.
             25  $1,100,000 -- is this correct?







                            DR. MAYER:  Yes.
               2            DR. LE-MON:  Somewhere in this bail part.  We wanted tD
               3  try and hit a funding level that provided some level for
               4  growth of their activities.   This is an area extraordinarily
               5  rich in medical resources, and on the basis of ground work
               6   they have done I think there will be  considerable  development
               7   in the next two or three years.  So we didn't feel that we

               8   should really cut them back below their previous funding

               9   level.  And we did feel that we wanted to give every
              10   inducement to have Dr. Ingai.Ls stay on in an active  capacity,

              11   and this consideration, if -- see, they do have -- under

              12   Health Organization of Western New York they do have a
              1-.  potential funding agency right ther,..  This was the original

              14   reason for thu creation of the Health organization  of  Western
              15   New York, to have a funding agency for this program,  and  this
              16   is where the allegiance of the physicians of Western New York,

              17   is the Health organization of Western New York

              18            So that if this could be taken out of the

              19   acc--ie,.nic lid and put into an HMO, or something, where they

              20   could pay some realistic safari es -- you know, -you have to
              21   pay a little extra to live in Buffalo.  This is the other
              22   problem.  They have probably got the world's worst climate.
              23   It isn't Southern California.  These are some of the realities

              24   that people face in recruiting for Buffalo.
  ceeal Reporters,  Inc.
              25             DR. MAYER:  Sister Ann.




                                                                              39



                             SISTER ANN JOSEPIlIbTE: Dr. Lemon, did, they give any

               2   indication of their plans for phasing out this tumor

               .3  registry from their projects?

               4             DR. LEMON:  They have been careful to put down on

               5   paper with the other projects that they plan to phase this

               6   out, and right now I cannot recall any specific statement to

               7   this effect.  Burt, will you correct me?    I didn't hear

               8   of any.

               9             MR. KLINE:  They initiated this for five years

              10   and they have completed three years--

              11             DR. MAYER:  Can't hear you, Burt.

              12             MR. KLINE: I'm sorry.  They initiated this as a

              13   five year venture, they haveIcompleted three years, and their

              14   plan is to fund the fourth and fifth years as originally

              1 5  planned.

              1 6            DR. MAYER:  All right, other conuneDtS?

              17             Would someone like to surface a recommendation?

              18             DR. BRINDLEY: I move the approval of the funding

              19   level as suggested by Dr. Lemon

              20             MISS KERR:   I second the motion.

              21             DR. ?4AYER:  All right, discussion?

              22             The motion was that we approve the recommendation

              23   of the site visit team.

              24             MISS KERR:  lVhich is not to include a developmental
  ,ce   I  Reporters,  Inc.
              25   component, but at the funding level by amounts that he





                                                                              4U



                I  indicated.

                2            DR. MAYER:  Ail right, discussion  of the motion?

                3            Philip.

                4            DR. WHITE:   I can't  accept  that  recommendation.
                5  1 just can't -- if -you tell me you need a crystal ball to be

                6  sure what is going to happen in the future in this

                7  region then this region is not ready to manage its own affairs

                8            Further, as I understand the mechanism,  Henry,  if

                9  you do indeed award them triennial status with whatever

              10   amount of money is involved you can only recommend that

              11   pulmonary diseases, or so on,  be  restricted.  They  indeed

              12   then have the option of managing their own affairs.     They

              13   may be in danger next time around if they have  gone  against

              14   your recommendations, but you can't actually control this.

              15   Is this not correct?

              16             DR. MAYER:  That is correct.  Let me suggest a

              17   possible modification because I have the same kinds of

              18   concerns simply because the coordinator  is up in  the  air,

              19   wh6re the fiscal agent is really going to be is  up  in  the

              20   air.  Maybe what we need to do is throw in an amendment

              21   which says that the allocations of funds for the 02, 03 year

              22   of this triennium would be subject to review  and  site  vis it

              23   at the end of the 01 year, because 'by then my assumption  is

              24   by then Ingalls is going to opt one way or the other, they
  ,Ceoal Repofters, Inc.
              25   are going to opt one way or the other by that time  in  terms





                                                                               -2 JL



                   of where they  are going to put their money, and whether they

                2  can recruit, et cetera, et cetera.

                3             M . KYTTLE:  Dr. Mayer, if you move to accord

                4  them triennial status on the-one hand which accredits them

                5  with some decisionmaking authorities within the triennium,

                6  and then on the other hand say that at the time of t  heir

                7  first anniversary application within the triennium you
                8  want prerogatives over the allocations offunding decisions,

                9  that's, I think, inconsistent.

              10             DR. HESS:  I wonder if maybe -the way to deal with th E
              11   is the  way we dealt with two regions yesterday, two -year
              12   funding with site visit, giving them some money to plan
              13   some basis for competence, but not going all the way as far as

              1 4  triennial status is concerned.

              1 5            DR-. @IAYER:  All right, that's another option.
              16             DR. KRAWLEIVSKI:  A question of procedure.  If we
              17   gave them two year funding now could they come in for a

              18   triennial application next year?

              1 9            DR. NIAYER:  Yes.

              20             MISS KERR:  That sounds like a good alternative.
              21             DR. MAYER:  Would someone care to suggest a
              22   substitute motion?  I know who the seconder was.  Who made

              23   the original motion?
              24             DR. BRINDLEY:  I did, and I will remove it and
  -0  Reporters,   Inc.
              25   Joe make his.







                             DR. HESS:   I move two year funding at the level

                   recommended by the site visit team,  Dot  granting  triennial

                3  status, and with the provision of a site visit in o  ne  year

                4  and their option to submit another triennial application at


                5  that  time.


                6            DR. MAYER:  All right.  I assume there is a second


                7  to that.


                8            DR. WHITE,:  I will second it.

                9            DR. MAYER:  All right, further discussion of that

              10   substitute motion?

              11             yes,, Jerry.

              12             DR. DESSON:  I have a question of operational format.

              13   Once a region reaches triennial status they are then not

              14   subject to review committee action, but only staff

              15   anniversary review recommendation if there is request for an

              16   increase of funds, is that correct?  Does the review committe  e

              17   then have any funding jurisdiction?

              18             MR$. KYTTLE: If the  requested  increase  of  funds

              19   exc'eeds the'level of approval it may well exceed  its  level

              20   of funding, but a region in a triennial statu s has the

              21   latitude of movin- within its approved level.  Staff

              22   anniversary review panells action on an anniversary within a

              23   triennium will come, and indeed we have some  today  to  look

              24   at, for basically information.   But wealso have one today
  :e   I  Repofters,  Inc.
              25   that the SARP opted to send to the committee for action.    But







                  the anniversary within the triennium, unless it requests funds
               2  that exceed the level approved,. or three or four other'

               3  reasons not having to do with the question you asked, would


               4  not necessarily come to this-committee for action.  it


               5  would come as information.


               6            DR. BESSON:  When does SARP take that option of


               7  asking the review committee to go over the funding request


               8  during a triennium?


               9            DR. MAYER:  Well, let me try, because I need to

              10  see if I have got it.  If it exceeds that level that is

              11  approved by Council as @he funding level in that second year
              121 of the triennium they would in all probability ask the
                  review committee to look at it  nuniuer one.


              14            IJumber t-70, if i- their judgment there are some


              15  issues that are there that are different than the basis


              16  upon whicn the original triennium was granted and there are

              17  significant changes, they might ask.  And that's why

              18  Northiands, for example, is coming back today.

              19            DR. BESSON:  But this is at the option of SARP?

              20            DR. MAYER:   Yes, that is correct.  And that's

              21  why I think that Phil is a little chary about triennial

              22  status at this particular instance.

              23            Ali right, further comments?

              24            Henry, any comments?
  e    Repor ters, Inc.
              25            DR. LEMON:  I just night say I think it is obvious






                I  that this region is in a state of transition between project
                2  programs, so I really wouldn't argue too strongly.  As
                3  long as they get a durable commitment that will permit them

                4  to work on the Lake area heal'th education center and

                5
                   support what they have ongoing in the rural and innercity
                6  I would think that a two year commitment would give them

                7  reasonable assurance.
                8            DR. MAYER:  All right.  All those in favor of the.

                9
                   motion say "aye."
                10           (Chorus of "ayes.,,)

                11
                             Opposed?
                12           (No response.)
                14           Henry, we thank -you.
                             lie will now take about whatever is necessary to
                15 register our'votes, to remind you that we are still doing

                16
                   that.

                17
                             We winnow move on to,the Florida project, with
                18 Dr. Perry as the chief reviewer.

                19   &
                             The gentleman at the eni of the table now, as most
                20 of -you know is Dr. Robert Carpenter, coordinator of Western

                21
                   Pennsylvania R(3gional Medic&i Programs, who I didn't see

                22
                   flinch perceptibly when I heard all that talk about Erie, so
                23 I assume there is no conflict.

                24
  ceoal Repoftets,  Inc.     DR. CARPENTER:  Just my poker face.   Nice to be
                25 back with you.'



                                   FLORIDA                                                                                        I



































             0                                                 0                                                   0







                             DR. PERRY:  From my standpoint I am especially

               2   happy to have Bob Carpenter here with us.  I think Bob

               3   will share with me how sorry we are that Ai Schmidt is  not

               4   with us for the primary review, for Al was the  continuity,

               5   having been at Florida RMP previously and returning to  it.

               6             We had quite a group on the review  group.  Three

               7   from the review panel -- as Al said, wasn't sure they didn't

               8   think he could handle it, or so damn many problems we better

               9   have a group down there, but it was Al Schmidt, Ed Lewis and

              10   myself from the review panel, Dr. Bland.Cannon from the

              11   Council, and Dr. Bob Cr,,,oenter, as you have introduced,

              12   head of the Western Pennsylvania R,@IP.

                            DR. MAYER:  With a crew like that I would have

              14   been a little shak myself

              15            DRi PERRY:  Reinforced by a really excellent

              16   group here from R@IPS, Jeanne Parks,  Lymon Nostrand, and

              17   Abe,Ringel.

              18            We went to this region full of  apprehension,  and

              19   Dr,'Lemon, who is here in the room, was certainly part of

              20   that apprehension from the standpoint of his having.

              21   participated in Florida and the reports that some of us

              22   remember on Florida RMP.

              23            The major difficulties, to review very quickly, as

              24   you recall,, the problems as expressed and in all of our previous
  ,40  1 Reporters,  Inc.
              25   relationships with Florida, a ,,reat deal of dissent between






                I  the RAG and the grantee agency, a lack of ao executive

                2  committee', other subcommittee groups to do the 'ob;  full
                                                                   i

                3  of in-house conflicts, to a point where the dean of  one  of
                41 the major medical programs was asking for  .the removal of the
                5  director of R@IP; a move toward secession of the north Florida

                6  group area into its own R@AP; an imbalance of the areas

                7  of Florida between the southern naturally headed  by  the

                8  University of iliaxai group, the central University of Florida.

                9  And thus we went to Florida.


              10             Sometimes I think we can say miracles  mrought  by

              11   people can happen. I think we did find  some  major  changes

              12   going on in Florida.  And we were excited, first of all, by

              13   a very excellent triennial application.

              14             Okay. To some of us going down  let's  find  the

              '15  reality OD what has been written, for we knew some of the

              16   people that had gone to Florida recently and their capacity  for

              17  -writing. And so it was a test of reality to  some  of  us

              18   of how much we could find that was in truth fact in terms

              19   of'what had been written.

              20             The triennial application was  extremely  honest

              21   in discussing the problems, but it was -lowing  with  the

              22   changes that had taken place.   It was not a duplication  of

              23   national policies, but it was a selection of those national

              24   directions and recommendations that they felt  might  work
  ,e I*[ Reporters,  Inc.
              25   in Florida. And I think that  distinction  was  extremely






                  important to us as we looked at this.

               2            iYhat are some of these changes then that have

               3 taken place? The coordinator, Dr.  Larimore,  who  had  been
               41 under all kinds of fire, has certainly taken a major leadership
               5  role of coordination.  I will discussion this  in  various

               6  way, through selection of new staff, through a relationship

               7  throughout the state, CHP relationships and  you  will  see

               8  this come out in many ways in this discussion.

               9            Tho region has been successful in developing,

              10  perhaps forcing in some ways, cooperative  relationships  with

              11  the three medical schools in the  region.  The  University

              12  of Miami, University of Florida have been the  major  programs

              13  in the past. But with the emergency of  the  University  of

              14  South Florida in Tampa, and as many of us know  that  program,

              15  as iVs stren-henin- with sorm really. strong personnel that

              16  is going to it, this one in the middle has  seemed  to  be  a

              17  part of the major force of bringing three to talk together.

              18  So there has been a drawing together  of  the  entire  state

              1 9 of i'lorida into much'mo re of a region than had been seen at

              20  any time before

              21            The close working relationships  with  the  V.A..  the

              22  State Medical  Association,  Hospital  Association,  Nursin-

              23  Association, these were very strong.

              24            The workin- relatioiislii.p with CHP described and  in
  e    I Reporters, Inc.
              25  action by the people appearing before us  --  the  chief  of






                I  Florida CHP serves as a member of the RAG and as chairman

                2  of RIIP planning committee.  The, RIIP director is on the CIIP

                3  council working directly with the Health Services Committee.

                4  Okay. This relationship is in  action  and  is  functioning

                5  very, very well.

                6            The core staff, though small, we found to be extreme-

                7  ly effective.  And to me one of the coups  that  has  taken

                8  place in this region is the attracting of Dr. Herman Hilleboe

                9  to be head of their Planning  Evaluation  Committee.  To  some

              10   of us from the state of New York, we recognize that

              11   Dr. Larimore has brought down one of his former workers

              12   and one of the people that he worked very close  with  in  the

              1 3  state of New York. Dr. Hilieboe was  former  co,,missioner  of

              14   health in the state. He hasn't gone  to  Tampa  to  retire.

              15   He is intimately involved in the planning of   this program

              1 6  and the evaluation of this program. And  again  I  will  speak

              17   to the way in which this committee has moved  out  in  closing

              18   up some projects that have been in operation for quite
              19   so@e time, much needed things I think in many  of  the  RMP'S.

              20             Additional staff in terms of a member out of the

              21   RMPS that many of us here around the  table  and  certainly

              22   around the room have worked with, Spiro  McSossacits(?)  is

              23   joining the staff there in evaluation.   He is looking forward

              24   to working close with the big b6y, Dr. Hilieboe,  that  lie
  ,ce  al  Repottefs,  Inc
              25   knew in New York state also, and he will be a strength







                   to the program.

                              Sidney Froberg, the nurse coordina  tor on the   staff,
               2

               3   I found to be a very strong forcein the total project.

               4              Their monitoring and their financial system has
               5   been completely  re-audited.  The  quarterly  budget  system  that
               6   was explained to us in detail  for  rebudgeting  of  unused  funds

               7   and the forces moving on that for efficiency and effective use

               8   of money we were impressed with.

               9              I think in looking at the goals      I am not going

              1 0  to take time, I know the amount of time -you spent on the

              11   last one -- that I am going to go as quickly as I can in

              12   relation to some of these areas.  But the important thing in

                   looking at the new goals, which for the first time they have
              13

              14   spelled out and are attempting to implement, the key word in

              15   the statement of goals is not just one of these motherhood

              16   kind of things. It starts out  let's  identify  the  gaps  in  our

              17   'health delivery system rather than we are going to do the

                   whole bit of health manpower and all, let's find the gaps

              19   and let's move in this direction.

              20              They have come up wit h good data resources for

              21   planning to the RAG, and I am sure that John remembers some

              22   of the problems in relation to that group.  There has been

              23   a broadening of membership.  They are looking at taking

              24   on other people into the  RAG.  As  I  mentioned  previously,  CHP

  le   I Reporters, Inc.
              25   etc. have been involved here.




                                                                            50



                             The head of the RAG, the chairman of the RAG is  Dr.

               2   Kyle E. Moore, Dean Emeritus of social work at Florida

               3   State.  Haven't found a social worker involved in this role

               4   in any other regions that I have worked with. He is  not  only

               5   a politician, maybe he does a little role playing and all

               6   with some of them, but he is proving that age has very  little

               7   to@ do with new ideas; and in this state in the way in which

               8   they are moving ahead, I think he has been a strong part

               9   of this.


              10             Effective task forces have been set up, not only

              11   the categorical ones, but in addition to the categorical  ones

              12   Council on Continuing Education, Committee on Health  Services

              13   for new directions and to look at some of the broader  issues;

              14   a new steering executive committee, and a very strong executive

              15   committee, has just been put together.

              16             Okay, examples of strength as I am going on on this,

              17   the Planning and Evaluation Committee that Dr. Hille oe

              18   is in charge of, began looking at ongoing projects, and

              19   as a result some of the projects were terminated early and

              20   others have been cut back.


              21             1 would like to speak specifically to this, and I

              22   think certainly Al Schmidt would have done this.  At the

              23   time of the previous site visit the "ruler of the house''

              24   at that time was in many ways the University of Florida at
        Reporters,  Inc.
              25  Gainesville with the strength and the powers that be in that






                    situation. Some of the projects that  were  closed  out  and

               2    that were reduced are those  projects  from  the  University

               3    of Florida as the region has  become  strong  through  their

               4    Planing Evaluation Committee-and through the total regional

               5    approach of a state.

               6              The.grantee agency, fiscal agent, has been changed

               7    from the Florida Medical Foundation to the Florida R@IP


               8    Programs Inc.

               9              These kinds of changes that have taken place through

               10   the direction, u@Ohn, of -- you know, of.a period  of  time,

               11   to Al?e and to those of 'is who were there the first time

               12   were extremely significant, we thought, in terms of what had

                    gone before.

               14             rontinuEtion of qupport.  This has been built into ti,

               15   evaLu ation approval of each new project.  And listen at

               16   this -- seven of the projects currently in  the  final  year

               17   of RLIP support will continue through non-R@iP support  next

               18   year.  Seven projects.  I was most impressed with that.

               19             There is effective planning at  the  local  level.

               20   Eight district offices have been set up.  I will talk-@ong

               21   the weaknesses of something that I think can be added there.

               22             The process  of  application,  the  decisionmaking

               23   process and such, has been greatly strengthened in writing,

               24   in all kinds of effective communication systems throughout
  'ce0al Repoiters,  Inc.
               25   the state.  I can mention son.e of the  kinds  of  materials





                I   Planning guides for applications, application materials,
                2   staff review checklists   you know, in addition to the

                3   panels and such that we spoke of.
                4            To give just a brief feel on the kinds of projects
                5   that they have moved into this regional scope I will mention
                6   just a few, but they do support their goals and priorities.
                7   For the distribution of health care services in the region,
                8   improving delivery; the children's cancer program has
                9   succeeded in developing a regional network of four centers
              10    in the areas of Miami, Tampa, Gainesville' and Jacksonville.
              11    The cervical cytology nroject has also established a
              12    network of six centers for'screening high risk wo,me@n for
              1:    cervical cancer, and these are in 'he target populations

              14    of,Jacl,.sonvi.Lle, Ifiami and Tampa, where they will move

              15    ahead into other areas in the following -year.
              16             The health guides project was one of the exciting
              17    projects we saw down there. This is a new type  of  health
              18    worker that has bpen developed to improve the health  care

              19    services of the model in the neighborhood area  of  Tampa.

              20    This is bringing the indigenous people into the area  into

              21    the process of moving into the home, finding where the
              22    prcblems are, ge tting information of where you can get service

              23    on that very level.  We suggested a replication of this

              24    in several other places.
  Iceis al Repoftets,  Inc.
              25              The extended campus concept project,  involving





                1  large numbers of nurses and allied health workers in 15
                2  county hospitals utilizing resources of a community junior

                3  college is also moving out in various ways.
                4           There is a proposal. among their new projects in
                5  the triennium, the region proposed developmental educational
                6  program designed to educate the black community, physicians,
                7  nurses, allied health personnel, regarding sickle cell
                8  disease.  The leadership will come from the black community

                9  on this.
                10           Not just in writing  we saw that they- are indeed
                11 in the process of planning a health care delivery system for
                12 the poor, and this study is being conducted, will be
                13 for the medically indigent target groups, and they have got
                14 quite a few in Florida, including the aged, the migrant,

                15 the rural poor, and the suburban poor.

                16
                             I would mention finally among the projects project

                17 'number 44, which is an assessment of health manpower

                18
                   that will be done in their eight district offices for the
                19 assessment of physician, nursing, allied health manpower,
                20 which they are using as their assessment toward the
                21 viability of area health education centers in each of those

                22 areas.

                23
                             In terms of the last area here that I want to
                24 really hit here on some of the materials that that region
  @ce*,al Repotters,  Inc.
                25 has developed -- and I feel a lot of this could be used as a






                   model other places    these checklists for new  operathnal
              2    proposals, the staff review checklist, the summary of
              3    cIo=ents and findings form, some of the things they have put
              4    together there for information to prospective people  that
              5    are putting together grants.  I think some of our projects
              6    that are in such need of how to develop and where to go,
              7    they have got some real strengths there going for them.

              8                                             at they are doing
                            For the weaknesses:  granted th

              9    a lot in the area of minorities, and such  we found no
              10   minority groups on the core staff, minimal representation on
              11   RAG.  There is some evidence of minority representation on

              12   task force.

              13
                             More important than anything, however -- this is
              14   hot something they hid behind, they recognized the problem

              15   and discussed it quite openly.
              16             They also discussed the difficulty they have found
              17   in implementing certain programs and projects because
              18   many other state agencies have moved out in this area   in

              19
                   Florida to so implement.  As an example, the Cuban population
              20   in Miami has money coming out of its ears from  all  other
              21   kinds of projects attempting to do something for the Cu an
              22   population.

              23
                             We have recommended, however, possibly the Tampa
              24   health guides project is something they can move in here.
  ce*,al   Reportefs, Inc.
              25
                             They are looking for some leadership  people  in the
                I  @






                I   minority groups to move with, for they have'involved  in  the

                2   health guides program membersfrom particularly the black

                3   community working in some of their  training  programs.  They

                4   have got one key person that has just arrived there,  as  the

                5   dean of Allied Health,, Florida International, Dr. Van  White,

                6   who I had the privilege of bringing up from Louisiana

                7   and training in my own place as my assistant dean,  has  just

                8  -taken the deanship in allied health in Florida International,

                9   where he he setting up programs for South America and for

              10    the blacks in that area.  The y aiready.knew him.  I didn't

              11    have to introduce him. They already knew him,  and  they  are

              12    planning to get him involved in the program.

              13              These then are the major strengths of  the  program

              14    as I saw it.


              15              Before we go into any recommendation or I  give  any

              16    recommendations on the funding I would like to ask Bob to

              17    jump in here.

              18              We do have a renal disease project to  very  briefly
              19    discuss because Ed Lewis was with us, as he mentioned to

              20    you.  This project had not oni y his review while he was

              21    there, it has been brought back with  representatives  already

              22    from the Florida program meeting with the people on kidney heie

              23    in the office.  The recommendation is for a major cut

              24    from over $660,000 in the project to $250,000.  We can get
  :eoal  Repofters,  Inc.
              25    into that later,








                              Bob.

               2              DR. CARPENTER:  Thank you.   I can't imagine what

               3    1 could add to that fine description of the region-p-

               4              DR. MAYER:  Comma, but.

               5              DR. CARPENTER:  Beg your pardon?

               6              DR. MAYER:  Comma, but.

               7              DR. CARPENTER: Yes. No, I  am  just  going  to

               8    highlight some of the points that Warren brought out.

               9              I wanted to clarify that we,did in fact the night

              10    before  the meeting go and purchase guns, one apiece, and

              11    slipped them in our be-k pocket and went in, and I am
              .12   happy to report also that at the end of the site visit I

                    sold my gun at a five dollar prof i

              14              We founi, as Wa-ren said, much support, in

              15    watching the interactions of people and hearing their detailet

              16    descriptions of projects, much support for the very well

              17    written application.

              18              We were impressed, all of us, with the f act that

              19    tr,)y had arrived at a very logical arrangement to  link

              20    CI[P and RHIP.  They sim ly aske d the state CHP chairman to
                                          p

              21    set the objectives for the 'Regional Medical Program through

              22    an objectives committee, and this has been done.

              23.             The objectives are still somewhat broad, and they wil

              24    have opportunities to refine. their thinking about  what
  cel&i Repotters,  Inc.
              25    should be done and what can be done in Florida.   But




                                                                             57



               I   nevertheless they are well started in that direction.

               2             The cast of characters is impressive.  The staff

               3   are active and intelligent and alert and excited  about  their

               4   program.  State health leaders visited us,  The medical

               5   society leadership was actively involved, and the universities

               6   in Florida were becoming involved more evenly and I  think  in

               7   a very effective way in the program.

               8             All of us were impressed with the management, and I

               9   think that such evaluation as has been accomplished  has  been

              10   largely from the management people, because Dr.  Hiileboe  has

              11   only recently joined t -3 program. They have been  very
              121  effective, and it was partly because of this and partly
                   because of the great success in phasing out projects and

              14   achievin- private support that we all came away with a feeiini

              15   that you could trust these people with really a good bit

              16   of money.

              17             I was impressed that the subdivisions of  the

              18  'program, the area advis:)ry group, the subregional groups,

              19   w( 7e led by physicians, and not cid retired physicians, and

              20   not young physicians that couldn't have their  practice

              21   going well, but seasoned, a,tive physicians.  The one from

              22   Miami, for instance, was a past president of the  Miami

              23   County Medical Society.  And each of the eight regions is

              24   led in this way.
  ,e
      al Reporters,  Inc.
              25             Organized medicine is also very much involved






               I   through the offices of Dr. Philip Hampton, and he holds the
               2   grantee organization together-and has been, I think, iargeiy
               3   responsible for puiiing the medical schools, the medical
               41  society, and the other elements of the health care  system
               5   into some working order.  And he is aided just magnificently

               6   by a social worker who is now    social scientist who is ieavin

               7   actually he is not, he is a southern gentleman and a  very

               8   talented individual, and I want him for a,RAG  chairman  n

               9   my region. He's really great. And the  training  in  group

              10   dynamics that he lived with ail those 'years is really,' you

              11   know, just rightfor a RAG chairman.

              12             Dr. Lamar Kravas at Gainesville has led the

              13   medical school involvement in the program, and he did it

              14   a little actively at the beginning; and I think until  the

              15   understanding about an appropriate-role for medical

              16   educators in the regional program came along perhaps there

              17   was some problem about that,. but in the end this tremendous

              18   energy has been harnessed very well and has been working

              19   very hard for the program, and the other schools have

              20   followed that leadership from Gainesville.

              21             1 think Warren mentioned also their  willingness
              22   to follow a good many federal initiates.  As you see,'their

              23   a-re& advisory groups, subregional groups, are to move into

              24   the area of area health education centers and emergency
  ,e*1 Reporters, Inc.
              2 5  medical service in the coming years.





                I             The renal grant I think was a nice example of how
                              1
                2   well things are working.  We were faced with tatented'people.
                3   They were hard working, knowledgeable, bright, and had been
                4   successful in the past, just the kind of'health professional
                5   that one would like to have serving a region.  The
                6   geographic distribution of the people talking about that
                7 renal grant was exactly what a master planner might have
                8   hoped for, and they really could work together.
                9             But there ware some discussions, you know, where
                10  things were not seen exactly the same right off the bat
                11  by people from Gainesville and people from Tampa and people
                12  from Miami, and in the site visit situation they very
                13  quicl@,ly handled this, and each person's leadership role

                14  became pretty evident.
                15            So I think, as Warren sai.d, they need to realize
                16  that there are other allied-health professions other than
                17  nurses, and they do, and Warren.helped them.considerabi-y to
                18  see the importance of that, and I think that they will

                19  b3&oaden'their representation on planning committees.
                20            They need a little bit better objectives, little morc

                21  active evaluation of the kind-other than the fiscal

                22  evaluation.
                23            But all of those things are'under way, and it
                24  was, as Warren said, all our impressions that this was a regici
  @ce0al Repotters,  Inc.
                25  that has the mechanism, has the leadership, and needs the









                     money.
                 2             DR. MAYER:  Before you go on to the discussion I
                 3   might make a couple of comments.  I did have an opportunity
                 4   to talk to Mac Schmidt in   Chicago on  Monday  and  Tuesday,
                 5   and I would only indicate        his real concern about not
                 6   being able to be here, and I know that that concern was real
                 7   because not only did he apologize to me, but his vice
                 8   chancellor came up to me and said "I'm sorry that we are going
                 9   to keep him from coming because I know how strongly he

                 10  wants to come to be there with you."
                 11             I suspect hc -.ot to me because in one respect, not
                 12  only because I was going to be here, but as some of you who
                 I'  may have better memories than others -- and I am surfacing
                 1 4 this becase there may be some of those of you who remember
                 15  that when the discussion came of the possibility of turning
                 16  the Florida region into two regions or three regions, I was
                 17  one of the individuals that felt that that     might  be  the
                 18  appropriate direction that they might have     to go  in  the
                 1 9 s  ate of Florida, and I was coming off of the base of having
                 20  grown up in that area and with some continuing knowledge
                 21  of what is going on in that area, and feeling that t e
                 22  direction we were going and trying to superimpose on the
                 23  state of Florida might end to the destruct of the Florida
                 24  RMP.   I would have to say that what  has  come  out  of  the
  @co@rat Reportefs,  Inc.
                 25  site visit report and what lias happened in the state






               I    indicates to me that, by god, I am wrong once in a while.

               2    It is certainly clear from the enthusiasm of the-site

               3    visit.

               4              I might just read you the very brief note  that

               5    Mac gave me, which said simply:  "Bill, were I giving  my

               6    report to the review committee I would  enthusiastically
               7    describe the great strides made by that region in solving the

               8    messy problems they were faced with two years  ago."  And

               9    as Warren reminded you, he was on the site visit originally.

              10    "They have realistically and forthrightly come to  grips

              11    with the4r problems at.-' have solved a great many. Both
              121   Bland Cannon and I feel strongly that they should be approved
              11    at the level requested save for negotiation re the  renal

              14    project ard approtal of t'-3 developmental component.  it

              15    is now a B plus region.  Mac.

              16              Discussion.  Yes, Leonard.

              17              DR. SCHERLIS:  Just a question.  Perhaps I missed

              18    it.  The grantee institution has Dr. Hampton listed as

              19    c( 3rdinator and Dr. Larimore as the director, and I notice

              20    that Dr. Hampton is listed as 20 percent effort.  I  was

              21    wondering what is the channel of command and what are

              22    Dr. Hampton's responsibilities in terms of Dr.  Larimore.

              23              DR. CARPENTER:  My observation was that Dr., Hampton

              24    sat in the back of the room-through the whole meeting,

  ,e - al Reporters,  Inc.
              25    when he was asked by Dr. Larimore to comment he did so, and





                                                                               bz


                I   very effectively. And when something needed to be done to

                2   put the polish on Dr..Ilampton was right there to do it..

                3   I think he works as a long time respected member of the

                4   Florida community who can contact people and get things done,

                5   but that he is very ready to take advice from the technical

                6   people on the staff, the advisory committee, and so on.

                .7            DR. SCHERLIS:  What does he do with his other

                8   time?

                9             DR. CARPENIER:  Practices medicine.

                10            DR. BESS:  Dr. Hampton is a well respected

                11  internist and formerly president of Florida State Medical,

                12  has been a director of AmPak.  He is highly regarded in the

                13  American Medical Association.  He is a good man to have on thcr

                I4            DR. SCHERLIS:  Gives them strength in the

                15  community.  Dr. Larimore has the day to day operation, I


                16  assume.

                17            DR. CARPENTER:  Right..  No question about that.

                18            DR. MAYER:  Dr.-Brindicy.

                19            DR. BRINDLEY:  May I ask you a question?

                20            DR. MAY'ER:  Could you use the mike, please?

                21            DR. BRINDIXY:    May I ask you a question on page 7

                22  of the synopsis about one plan,"bsaith care services for

                23  the underservea rural areas of the state whereby plans are

                24  to follow the Mayo, Florida experiment', whereby medical
  ce*al Reporters,  Inc.
                25  students are sent to Mayo for training and providing this






                    type of care."  What are they talking about there?

               2
                              DR. MAYER:- Beautiful. By  happenstance  it  turned

               3
                    out to be Mayo.  Bob, do you want to try it?  I would be

               4    glad to comment on that,one because I have been involved.

               5
                              DR. CARPENTER:  Well, as you can see, the Chairman

               6    and I are both excited about this.  Florida is excited, too.

               7
                    They feel that this is the new Mayo Clinic, the other one

               8
                    being somewhat old fashioned. And it is  really  an  outreach

               9
                    program of one of'the medical schools to a town called

              10
                    M&yo, Florida.  They have introduced into this,very small

                    rural community physicians--

              12
                              DR. 13RINDLEY:  Not Rochester we are talking about?
              13              DR. CARPENTER: No. Everybody  is  very  happy,  and

              14
                    the people in the town are getting medical care they never

              15
                    got before.'

              16
                              DR. BRINDLEY:  That's good.  I just couldn't see
              17    how Rochester--
              18              DR. MAYER-.  I might just comment that those of you
              19    who are interested in issues  that relate to how can a
              20    medical center effectively relate to a community which has

              21
                    no health care and what are the impacts of that relationship,
              22    this is an absolutely magnificent experiment which  is  being

              23
                    well studied, and some of the even economic effects  of  that

              24
                    effort have been just remarkable because Mayo has how
  'Ceeal Repoiters,  Inc.
              25
                    become somewhat of a referral center which has  enhanced  its






                I    trade center, and they have literally doubled the tax base

                2    of the community from, the sales tax receipts and the rest

                3    just in the period of time since they moved in.  It is

                4    a fascinating experiment.

                5              I bring it up only if some of you are interested

                6    in those things there is a good example to look at.

                7              DR. SCHERLIS:   Is there a motion on the floor?

                8              DR. PERRY:  I would like to make it more specific,

                9    if I can, because of the specific amounts to give you a

               10    feel of what it is.  The current funding is for $1,355,718.

               11    The total request is $2,2i3,435 including the renal.  We are

               12    recommending what they have requested from the $1,355 to

               1 3   $1,552,706, which is an increase, including the developmental

               14    of 135, of only $196,988; because they are reshifting

               15    so many of their priorities,, they are phasing out seven

               16    projects,, we are giving them this, and this is only an
               17    increase of'$196,983 plus.  And the renal project which has becr,

               18    recommended at at a 250,000 level, what was requested

               19    was 660,000.  This has all been negotiated with Dr. Lewis

               20    and the other people.

               21              So it is a total increase, if you include the

               22    renal, up to one million 802.

               23              DR. MAYER:   Including approval of the developmental--

               24              DR. PERRY:  Approval of the developmental of 135.
  ceie,ll Repoiters,  Inc.
               25              MISS KERR:  And the triennial status?







                              DR. PERRY:  Yes, full approval.

               2              DR. MAYER:  Is there,.a second to that?

               3              MISS KERR:  I would second it.
               41             DR. MAYER:  All right, discussion.
               5              Yes, Dr. Hinman,

               6              DR. HIN'IIAN: Is there a level established for the

               7    second and third -year, because the kidney level was not

               8    recommended the same for the second and third year.

               9              DR. PERRY:   In relation to this I believe  Ed  had

              10    suggested to the group that this.would.be negotiable

              11    as they went along.  We did not establish that level for the

              12    total in relation to the kidney.

              13              DR. MAYER:  But you are recommending--

              14              DR. PERRY: But we  are  recommending  the  movement

              1 5   ahead in their other triennial as far as  the  total  amount.

              16              DR. HIN@IAN:  Have you talked to Ed since the

              17    discussions Monday that were- held here with the Florida

              18    group, because there was a suggested figure  of  187,000  for

              19    the second year and 150,000 for thethird year for the kidney.

              20              DR. PERRY: That woul d be excellent because, as 'you

              21    see, that is going downhill rather than  uphill  in  relation

              22    to this, and they have many resources they are hoping to

              23    indeed put together in this.  So this is very strong,

              24    and we would certainly as a sit visit group  go  right  along
        f Repottefs,  Inc.
              25    with  them.







                               DR  MAYER:  Leonard.
               2             DR. SCIIERLIS:  I was jut3t going to'say that I>erhaps
               3     we shouldn't be spec ific on the renal  since  that's  really
               4     negotiated outside, and I would certainly second the motion
               5     that was made, leaving the renal item open for whatever

               6     negotiation--
               7               DR. MAYER:  Well, we are  going to need to make a
               8     recommendation to Council relative  to level of  funding  as

               9     far as the renal is concerned.
              10               DR. SCHERLIS: What is the item,  240  or  187,  or

              11     what has been the  negotiated  level?

              12               DR. HINMAN: I;'m  sorry.  Ididn't hear.

              1 3              DR. SCIIERLIS: What has been the  negotiated

              14     level at  this point?
              15               DR. HIMIAN:  The negotiated level  at this point,
              16     my understanding it was not quite the 250;  it  was  223,500
              17     for the first year, i87 for the-second year, and 150 for

              18     the third year, which would be $660,500 over three -years

              19     560.

              20               DR. MAYER:  Bob.
              2 1              DR. CARPENTER:  If I hear this discussion right, I

              22     think I hear that becaise the renal disease grants will  not
              23     be as expensive the second and  third yeartliatthe  regionts
              24     approved level for the second  and third year should be
  'Ceeat Reporters,  Inc.
              25     reduced, and I wouldn't offhand know if you  would  want  to




                                                                              67



                I go exactly that direction because this is a very strong

                2 region, and the reason they phase out activities  is  so  they
                3 can phase in new ones.   I have no doubt they will maintain thei@

                4 level of activity in the first year of the triennium and

                5 subsequent years.

                6            MRS. KYTTLE:  Dr. Carpenter, if you add the
                7 descending renal approval to  the  ascending  programmatic  apart

                8 from that approval you come up with a 1.776 for the first

                9 year of the triennium, 1.824 for the second year of the

              10  triennium, and 1.863.  So the total does. not descend because

              11  the rest 3cends.

              12             DR. MAYER:  All right, further discussion or comments?

                             All those in favor of the motion say "aye."

              14
                             (Chorus of "ayes,

              15             Opposed?

              16             (No response.)

              17             Robert, we thank you.

              18             DR. CARPENTER:  Thank you.

              19             DR. MAYER:  It would be iny thought since I  gather

              20  that there are some lengthy components relative to the

              21  Metropolitan D. C. perhaps, that we  try  to  catch  Metropolitan

              22  D. C. beforeva break for lunch, and  then  after  Metropolitan

              23  D. C. we break for lunch and come back and  pick  up  those  that

              24  are either anniversary before'trienniuni  or  anniversary  within
  .e   I Repotters,  Inc.
  , -*a
              25  triennium after lunch. So I think we would  like  to  move  on

















                                                                               40                                                        so






                I  then, John, if we could, to Metro D. C.

                2             DR. KRALEIYSKI: The Metropolitan  D.  C.  program  was

                3  site visited this past December by myself, Miss Anderson

                4  and Mr. Hilton from this committee, Dr. Ochsner from the

                5  Ochsner Clinic in New Orleans, and soneconsultants, Dr.

                6  Reustis, who is the former coordinator of Michigan, Dr.

                7  Shapiro and Dr. Kountz, looking a a renal dialysis, kidney

                8  disease program that they were proposing, plus staff from RIAPS

                9  including Judy Silsbee and  Jerry  Stolov,  and  some  assistance

               10  from Mr. Russell and Mr. Spear.

               11             A little background about this   program before we get

               12  into it.   The area, for those of you who   are not familiar

               1 3 with it, centered here in the District, with    the counties,

               14  two counties of Maryland that are contiguous    to the District,

               15  two in Virginia, Arlington and Fairfax Counties, and the

               16  city of Alexandria, Virginia.

               1 7            The program was established in 1967 with a planning

               18  grant, and it went operational in 1968.

               19             At the last review committee meeting       well,  last

               20  year at this  time when it was  reviewed  the  programvas  funded

               21  for a triennium with the recommended level for this opera    tional

               22  year  that they are in right now of a million six.  That

               23  level was funded at somewhat over 900,000 by the R@IPS staff
                                                                   I

               24  here, Dr. Margulies and his,.staff, and then was cut back as a
       ral Reporters, Inc.
               25  result of the cuts across the board to 887.  So that is the





                                                                               bu



                   kind of Mnding they have at the present time.

               2              But they do have a three year program approved by

               3   this   committee and by Council, and they have levels of approve(

               4   funding  of  one six for this year, one  three  for  the  coming

               5   year, and one  one for the -year after that.

               6              This was an anniversary application then within    the

               7   triennium and was referred to us for a site visit.  Ana

               8   they are requesting in this anniversary a developmental

               9   component, a continuation of four projects, a renewal and

              10   slight expansion of core, and   the activation of four previously

              11   approved nonfunded pro".--ts.  It also included a review,

              12 1 as I mentioned, of tte,@kidney project that@,had@@been

                   developed, staiA@        @velop two !years ago, and this past

              14   year was SLbmitted in a te tative form, sent back for revision

              15   and now is included in this review process.

              16              The program was organized with the  D.  C.  Medical

              17   Society as the grantee organization, and the Medical Society

              18   when they organized the program developed a board of
              19   di,.3ctors as a steering committee out of the board of director.,

              20   of the Medical Society, and they pretty much started out to

              21   run the program from a polic.,r and fiscal and every other

              22   point of  view.

              23              Now the reason that we were asked  to  review  this

              24   and to site visit was because of the fact  that  the  program
  @ee'l Repofters, Inc.
              25   has had a very stormy history. They had  a  lot  of  problems






                I   getting off the ground, and this application again asks  for

                2   more money, including the kidney project, and therefore  it

                3   was believed that it  should be looked at again.  I  say  again
                41  because they have been site visited every year for  the  past
                5   four years, and they are really getting to be good  at  site

                6   visits, if nothing else.

                7             Now I just want to briefly review the  history  of

                8   some of those problems to put this in perspective so  we  can

                9   then go to our findings.

              10              The problems were really in three  general  areas.

              11    First of all,         p              a viable pr  r    o   the
                                          ability    get

              12    gr,              f putting                 toge.ther,-.&@hd

              13    de V  p  g-@@ ove   I organizational thrust.   In their  first

              14    year of operation, for example, it was noted that many o

              15    their projects had a hard time getting started, and  in  the

              16    review that took place at that time byreview  committee  they

              17    discovered that the program management for some reason or

              18    other was not able to get the information out to  the  project

              19    directors that their projects had been funded and  they  were

              20    able to start them off.  So there was some undue delay in

              21    getting their projects going. once the  projects  were  going

              22    the program had a tendency to turn over all the funds  to  the

              23    project directors and then not monitor them sufficiently

              24    to be assured that they were getting anything back  for  it,
  @ceie,al Repoitets, Inc.
              25    so there was a problem of control.







                               The staff that Dr. Vlontz, who is the director

               2    of the program, has was pretty much inherited from the
               3    previous director, and in many    cases viere not located in his
               4    organization.  They were located in the medical societies,
               5    they were located in the hospital council, they were located
               6    in the health department.  And these organizations in most ca,-Q@s
               7    appointed those staff members, so he really didn't select
               8    them.  They were appointed by these other agencies, they
               9    are on his payroll, they  were  part  of  his  organization,  but
               10   they were operating in these decentralized units.  So that
               11   again was  a problem in terms of trying to get a viable
               12   program off the ground because they were each going their

               13   own separate direc@,,pn.
               14                    tm,    sion change of RIAP again  t here was  ad

               15   u44ue delay in  their grzlsp of this new mission   and getting

               16   t   mission  stateme@ t out to,the Regional Advisory Group.

               17   As a   matte    fact,, they floundered  around,with  that

               I 8             b   are@a@@@ r some, nine or@ ten. months, and  inally

               19   Dr. Margulies met with them and went over the whole bit --

               20   this past summer I gather is when this took place -- and

               21   as a result of that the RAG group now has a little better
   C)          22   understanding of what is going  on,  but  a  real  difficulty  in

               23   changing over to the new mission.

               24              They had developed a number of continuing education

  :e -tat Reportets,  Inc.
               25   programs,  but they were not tied in with universities, and





                   they were operating pretty'much through,& hospital councilt,
              2    and they Were attempting to build the staff. for these
                   continuing education programs in their  own  organization
              3
              4    rather than using the t@ients that were available from the thraf

              5    medical schools in the-region.
              6              They had a very difficult time  developing  any
              7    viable programs to meet the needs of the  underserved  in the
              8    area. And as you well know, there are  many  unmet  needs in
              9    this region.  Most of their programs, however, were still
              10   categorical in nature, and most of them really weren't
              11   serving the needs of the poor.  And this again was a concern to

              12   R@ here.
              13             Well, that was the general problem in  terms  of
              14   trying to formulate a program that would meet the needs of

              15   the region.
              16             They have not been able to develop a data base.
              17   Comprehensive Health Planning has not been terribly active
              18   in the region, and therfore they just  haven't  progressed

              19   very wall in the whole program area.
              20             The second area of concern was with administration.

              21   As I mentioned, the medical society was the grantee
              22   organization, and initially they took a very strong leader-
              23   ship role in running the program.  Vhen this was challenged
              24   during this past year they backed off completely and now are
  ce*al Reporters,  Inc.
              25   referring many decisions that they should be making in terms






               I  of fiscal policy to the Regional Advisory Group.  So it has

               2  been that kind of a fluctuating.situation.

               3            The medical society is a small organization   and RMP

               4 dominates it. RMP has the larger  staff,  more  money,  more of

               5  everything than the medical society has, and it hasn't been a

               6  very profitable relationship.

               7            The services that were supposed to be provided by the

               8  medical society have not been very useful, and even the

               9  limited fiscal services that were supposed to  be  provided

              10 have not come forth, and as  a-Tesuit  the.Regional  Medical

              11  Program developed their own staff capabilities  in  handling

              12  fiscal management.

              13            The leadership in the program has not  been  strong.

              14  Dr. Wentz is a nice guy, is well meaning, I think he has

              15  developed a lot of contacts in the region, he has developed a

              16  lot of rapport with the producers of services; but he is

              17  just not a strong administrative leader, and he has  not  over
              18  the past years appointed anyone on his staff to fill  in  that

              19  gap:  So the organization lacks  the strong leadership  from

              20  the top.

              21            The staff members, as I mentioned, were appointed

              22  by other agencies, at least in somecases, and they are busy

                  doing eheir own thing, have been for the past two  or  three

                    ars, and he has just not been  able to bring them into  an
  cost Reporters,
              25!  rganized group.  At least that  again was a problem that  was





               I   being presented to  RIJPS here. The  staff  members  have  pretty
               2   much their own personal interest in mind.  They have personal
               3   projects that they would IiJke to develop, and they have not

               4   been able to relate those   to an overall organizational thrust.

               5             They have right   now 31 gore staff members on board,

               6   and they want to expand that by   about five members.

               7.            The staff unfortunately, in addition to having

               8   individuals appointed by other agencies and individuals who
               9   have very personal kinds of things they want to accomplish,
              10   have another component made up of individuals who have retired

              11   from other jobs.  And t',i whole administration of the program
              1 2  and who]*                       hose taJe ts togethe@r has  @been



              1 4             Wsiit thL third e-ea was with RAG.  The bylaws state
              15  that the RAG membership can consist of as high as 70 members.

              16   They now have 58 members with 53 alternate members that can
                                          1
              17   attend meetings if these  original  members  are  not  available.

              18   Most of these members of RAG are appointed again by
              19   int*,)rest group agencies.  That's the way their bylaws read.  The

              20   have some 70 members, as I  mentioned,  that  can  be  appointed.

              21   Sixty-five of these are appointees of various pro ucer
              22   agencies.  So t           very little flexibility in terms of

              23   how- they can@@ b  ge@ their RAG structure.
              24              The RAG group appeared to be relatively inactive also.
  te 101 Repofters,  Inc.
              25   We noted in the past that while they may get a large turnout





               I  f@r a morning'meeting, by midafternoon there.'s very few,

               2  less than-perhaps a third in some cases that are still'there

               3  to deal with their problems.

               4            They have not been able to really  integrate  minority

               5  groups into the RAG structure, and it is pretty much

               6    Mina ed, as I mentioned, by providers of services.

               7            Well,, okay, these were the major concerns, and

               8  these were the instructions that we had received from

               9  Dr. Margulies,to site visit the program and to explore the se

              10  problem areas and see how the  program was shaping up at the

              11  present time.  And I will try to consolidate our findings

              12  under those throe rubrics then, going on to some of the
   0          1 3 projects that they now have in mind and the program  that  seems
   0          14  to be developing.

              15            First of all, under administration  Dr. lYentz

              16  has been able to bring the staff into his  parent  organization.

              17  He brought them out of the me.dical society, the health

              18  department, what have you, and he has  brought them now into

              19  his own organization.  At least he has  brought them into his

              20  own organization structurally. Philosophically  they  are  still

              2 1 operating as individuals, and they are still operating in

              22  terms of what their own personal interests and desires are in

              23  terms of projects. So therefore what he has is  a  very  diverse

              24  group of people with varied talents now brought into an
  Ile* a[ Repotters, Inc.
              25  organization     and by the way, this caused him some space







                                      t

                   problems that he didn't anticipate -- but brought into this

               2   organization, and what he is trying to do now is to
               3   solidify those talents to try to carr   y out some kind of a

               4   program role.  And this has been very difficult.

               5              He has appointed one of the members as his

               6   administrative assistant, or  what  I  think  he  will  probably

               7   call deputy director a little later, and I think this

               8   individual may offer him some help in bringing these talents

               9   together.

              10              But his organizational chart is ill defined, people

              11   are not following the organizational structure, whatever.  if

              1 2  they have a  Oioblem they bypass their supervisor and they
              13   go and see-Wentz.  He has not been able to get them to really

              14   appreciate how they  fit  into  an  organization  structure  and

              15   report up the ladder to supervisory.personnei.

              .16             Again as I mentioned, v;e found at least part of

              17   the staff members, par@,lof his@s@taff were retired from other

              18                     JL@y-,doesn't have a,gooo plan in mind  as  to
                          and he

              19   hoi@to,@phase@lthe;m out of his operation.  He hopes that they

              20   will retire.  He is hoping this wiiJ. occur this coming year

              21   for a couple of individuals.  But,yet he wont take the

              22   initiative to talk to them about their future role with him

              23   and to weed them out of his organization.  He is taking the

              24   easy route again,, and  the  human-relations  kind  of  approach
  :e lei Reporteis,  Inc.
              25   that you would expect, if you  would  meet  him  and  talk  with






                 I  him five minutes you could appreciate totally, of how he

                 2  is.;-going to deal with these very, very difficult problems

                 3  of putting that staff into some kind of order.

                 4             They have some  good people on board, and I think

                 5  they have  a lot of talent there if they can  put  it  into  some

                 6  kind of order.  The good people, as you would expect, of

                 7  course, are getting very  upset  with  the  organization  because

                 8  of the way it is kind of floating along and with their inabiiil3

                    @o even get their employees or  their  people  that  he  wants  o
                 9

               10   report to them to be able to follow that channel and stop

                    bypassing them.

               12              Okay.  WEJLJL, the next thing is the question  of  the

               I'   medical society, and this has  been  at  least  partly  resolved.

               14   There :0 n(Nw a co@ittee b-en formed between the Rllp staff and

               15   the medical society.  They meet weekly to try to iron out

               16   some of their differences.  They are trying to iron out now

               17   exactly what the role shouJLlbe in terms of a grantee

               18   organization in fiscal management, and  I  am  fairly  --onfident

               19   tht that is going to improve, that relationship will improve

               20   over this coming -year.

               21              The newly elected President  of  the  medical  society

               22   assured us that lie is going to tive them his fullest

               23   cooperation to expand Rl,,IP, and that in his estimation  it  was

               24   perfectly agreeable to lot RAG be the policymaking body and

         Reporters,  Inc.
               25   for the medical society to act in a different capacity.






                              They have a tentative agreement at least that the
               2   program will probably move out of the building that the

               3   medical society is operating in  and  get  into  a  different

               4   building which will give them more space, and probably also a

               5   little more freedom from organizational constraints.

               6              The   gional Advisory,@Group  has  been  totally

               7   roio an@ized,,4v@and they have organized it now into a number  of

               8   working committees, and Dr. rientz believes that            rki g

               9   c@ittess@will involve RAG more actively in the deci       ion

              I 0  making :an  t  rl3fore will be  helpful in getting  them  to   me

                      moo- ings.and'take  ar  active role in the program

              12              They have been only minimally effective    in involving

                   minority  groups  into  this  decisionm@ing  structure,  although

              14   they have added on) black -oman -- her name is Mrs. Bullock

              15   to tha groupi and she was very impressive to us.  Unfortunatel3,

              1 6  they didn,t invite her to the site visit meeting, buo     we did;

              17   and we brought her in and sat down and chatted with her

              18   in the afternoon, and the plain fact is that she had been

              19   inVtted to Join RAG some  six  months  ago.  They  have  not,

              20   unfortunately, done  a  good  job of bringing her up to  date  on

              21   what RAG is all about  or  abolit the program.  They have not

              22   involved her in the decisioniaalring process as of yet.  But

              23   she has attended the  meetings, she has made herself heard,

              24   and we think in the long run she is  going  to  be  an  extremely
       I Reporters,  Inc.
              25   beneficial influence to the program.






                            The chairman of the RAG group,that is now chairman

                    f the group, and,  wasn't last year, as I understand it,
               3   assured us that he fully intends to integrate all interest

               4   groups into the decisionmaking of the Regional Advisory
               5   Group.  And through their reorganization and their formation
               6   of working committees he believes that he can do that.@",.Ye
               7   ay  y,one of his working committees are headed by physician
               8   aud      &X4e@ @prOtt-y much representing interest group @encies,
               9   and I think it's yet to be tested as to whether people like
               10  Mrs. Bullock, who I think Will be very influential on the

                        am, will be able to alter those committees or be
                   progr

               12  alter the decisions that come out of those committees.  We

               13  think that she might, but yet it's untested.

               14            The RAG group during the past year have only met

               15  three tinws.. They have an executive committee that issupposed

               16  to handle decisions between meetings, and the executive

               17  committee only met once.  Again this RAG chairman assured us

               18  that this was not going to be the case in the future.  And

               19  he did come across as %n aggressive kind of guy who will

               20  make changes.  Again it is of yet untested.

               21            Twenty-three out of the 110 RAG members and

               22  alternates are minority members.  But with the exception of

               23  aboutthroe of them they are a relatively passive group, and
               24  it would appear to us that they were handpicked    maybe that'r
  @Ce*,al   Reporters, Inc.
               25  being a little too unkind, but they were brought in there with





                 I  the idea that they weren't going to cause any waves.  Mrs.

                 2  Bullock, on the other hand, will cause waves, and again we

                 3  pin a lot of hopes on this gal,.

                 4             ALI right, the program in itself, they have broadly

                 5  stated g     .,,,,Ond objecti s that kind of go along  with
                 6  what everyone else thi4s should be done 'and ref lect the

                 7  national interest.  Their projects that they have developed,

                          r, don't really fall into these general areas,
                 8  howeve

                 9  although the areas are so broad that-you could fit everything

                 I 0into them, I suppose.  They have few new projects.  As a

                 11 matter of  fact, the ap-tication we have in'front of us here,

                 1 2all of the  projects  have  been  previously  approved,  So

                 I  there's no now projects in it whati,3ever.

                 14            Thcy ha,-e asked for money for a number of contracts.

                 15 In fact they have asked for $700,000 in,this application

                 16 for contracts.  And they hope through those contracts for

                 17 small studies to give advice  to  different  groups  to  be

                 18 able to implement some new strategies dealing with HMO'S,

                 19 dr*-tling with manpower development -- for example, the

                 20 geriatric nurse program, this kind of a thrust.

                 21            Their priorities again have not been well developed.

                 22 Ana as a matter of fact, in loooking at the projects that
                 23 they  are'requosting funds for here, with the R'AG group that

                 24 was in front of us that day :we were asking them what they
         Repofters,  Inc.
                 25 thought of these projects  and  the  priorities,  and  they






                   essentially reversed many of the 'priorities as opposed  to

              2    what we have seen in our application.

              3              Now we were both dismayed, and on the other hand

              4    somewhat appreciative that this might be effective  in  the
              5    long run.  Number one, we were dismayed because of the fact
              6    that it appeared that the priorities as they  were  spelled

              7    out here in terms of projects probably hadn't been effective;

              8    but number two, RAG had been reorganized,  the  reorganized

              9    RAG had not had an opportunity to look at these projects, and

              10   it appeared to us as we were dealing with RAG in that
              11   meeting the day we site visited them that probably they were
              1 2  going to be effective in reallocating those  priorities  in
              13   a more meaningful manner. So we did got a  glimpse  of  the

              14   fact that RAG may be shaping up and may be willing to really

              15   take this program and turn it around,
              16@            Of course , in terms of a program they have had
              17   a difficult time getting a thrust from the  core staff because.

              18   of the fact that they are all operating in  their  separate

              19   ways. This isn't exactly true, but still  we  see  programs

              20   such as the continuing education program for nurses

              21   being developed by itself, continuing education program

              22
                   for physicians being again a separate entity.  And when we

              2 3  raised the issue of trying to put these together into some

              24   kind of a continuing education thrust it was really a new
       I Repoiters,  Inc.
              25   thought, and they really had not done that at all in the past.






                              They have totally reorganized their review procedure,

                2   and they have an office that they call an office  of  Ptogr=

                3   Appraisal which will be evaluating the projects once they are

                4   funded and will be reviewing the projects, and again on

                5   paper it looks as though it might be pretty functional;

                6   again, however, it is untested.

                7             In terms of projects they have some few that we

                8   feel had some real merit. For example, one of  the  projects

                9   they are asking for is a nurse midwife project that would

              10    train nurses to work in the poverty areas.

              11              Through their contracts they are asking for  money

                    to involve medical students and nursing students and other

                    health students into a program in the poverty areas for

                    two purposes, one, to got them to appreciate the problems;

              15    and number two, to got them to start working together as a

              16    team.  And it seems as though this has somemerit.

              17,             The training of nurses-to work with the aged seemed

              18    to have some real merit to us.

                9             The HMO projects that they have in mind in terms

                0   of giving groups of physicians some help, providing them

                    information with the Hllo concept, to'help them get the

              22    organizations off the ground, seemed to have merit.

              23              Again, however, we felt that their program was
              24    still at the embry@nic stage of develop-Lnent. Their organi-
  kc Olal Repotters, Inc.
              25    zation was certainly minimal in terms of its capabilities at






                I   the momenta  It looked as though RAG had some  promise  in

                2   terms of docisionmaving. But yet this all  might  be  for  the

                3   future, and when you are dealing with $700,000  in  contracts

                4   you have got to have, of course, a much  stronger  organization

                5   than that to be able to handle that kind of money.

                6             Now with all of.those -- oh, one other project,

                7   of course, that I should mention in that context  was  the

                8   kidney disease project.  This was reviewed separately
                9   by Dr. Shapiro and Dr. Kountz in a separate meeting,  and  they

              10    found that project to be very worth while. And  as  a  matter

              11    of fact. maybe at thiE time I can get you to comment on it

              12    since you sat in on the meeting with them,l@l,,Itr@. @,S

                              MR. SPEAR:  My naturally poor enunciation is further

              14    burdened ty some oral sur,-iry yesterday, so if you  don't

                    understand me, holler and I will go back.

              16              The renal project has a history that in  many  ways

              17    parallels the history Dr. Kralewski described for  the  region,

              1 8   The history is one burd3ned with poor  organization,  poor

              19    p, -inning, selfish interests expressed. And at the last

              20    Council meeting, one of the last projects in hand, Council

              21    said Let's take'one more JLo,ik, one more attempt to get

              22    these boys to sit down and work  together, and that's what  the

              23    kidney deal is all about.

              24
  Nceo,al Reporteis, Inc.     It was not the first time this had been attempted,
              25    and I think that had some flavor in what happened.







                              There was another element I think that was important
               2    to the flavor of what happened', and that was that a young

               3    doctor by the name of Argie on the  Georgetown  nophroiogy

               4    staff who had been talking with us for some years and

               5    recognized what we were trying to say and  recognized,  or

               6    at least agreed with the kinds of activities and directions

               7    we were suggesting, had in the past had to admit to us that

               8    he was not in a position to come forward with any strength

               9    with his recommendation to this regional group.  As of the

              10
                    meeting in December he was the spokesman and was the central

              11
                    force, I think, that brought the group  finally  together.

              12              It was a very quiet meeting, one that pretty cieari3

              13
                    through Dr. Argie's efforts as well as the R14P, had  done

              14                                                     well.  There
                    its work and gotten its marbles lined up pretty

              15    was a good sense of cooperation. There  was  an  admission

              16    of the need in the area, and the fact that they had resources

              17
                    to build on, and promised to come forward  with  something

              18    more realistic to meet the needs in the renal disease area

              19
                    for the MYTRP.


              20
                              Shall I go ahead and say what came up later,
              21    Dr. Kralewski?

              22
                              DR. KRALEWSKI:  Yes.

              23
                              MR. SPEAR: The plan that came  forward  was  for

              24
        Repoiters, Inc. a total request of $524,000, a little more, about 525,
              25                        f
                    including the indirect.  This is a reductionfrom the





                                                                               on



                I  application we were seeing last fall of about $384,000.  It

                2  incorporates a strong or certainly a stronger transplatation

                3  program which was an element about which  we  had  been  hung

                4  up previously. They had not pursued  this  as  deeply  as  we

                5  thought they should.

                6             It reiterated three elements that were in the

                7  original application; one,  a  neighborhood  dialysis  center

                8  at the -- I have got this listed backward, I think @- yes,

                9  at an Upshur Street clinic to be installed by Howard

              10   University, and a community home dialysis unit at the D. C.

              11   General  Few spital, and L,- outer center home dialysis center

              12   to be placed in Northern Virginia.

                              Let's talk about these separately.

              14              The transplantation component was  a  request  for

              15   $183,000,  and is focused on Georgetown University, and

              16   includes an appropriate number of staff and some very minimal

              17   othor cost elements that need to.go into this.  And rather

              18   than detail it for you, let me give you the reviewers comment,;

              19   Th.36 are comments from Dr. Kountz and Dr. Shapiro.

              20              "The transplantation  program now appears to be

              21   well structured with two exceptions.  The nephrologist, which

              22   was one of the positions listed, is already on duty at

              23   Georgetown, and should not be charged against RIIP.  The

              24   concept of the administrative. coordinator is an error.  The
  ce*al Repotters,  Inc.
              .25  proposal places this individual in the Rf,!P offices to keep





                                                                              OD



                    records on available organs and recipients, to assist

                2   patient referral, and to compile and act on third party

                3   sources of payments.  This position should be located at

                4   Georgetown  with the surgeon, and to work,closely with him.

                5   There will not be a large recordkeeping activity, but there

                6   will be or should be an intensive activity in developing

                7   organ sources which will involve a large public relations

                8   burden on both the surgeon and his assistant.  It is

                9   recommended that these and the other responsibilities

              10    indicated be under the close control of the surgeon."

              11             So the upshot in terms of money was out of 133,000

              12    requested for this component the reviewers are recommending

              13    106,000, a reduction of the salary of the nephrologist.

              14             The transplant program is in the plan and was

              15    accepted by the reviewers as a phased development of three

              16    transplant sites.  The initial one I have just spoken to is

              17  'Georgetown.

              18             There are two wzLys to go in the second year, and

              19    obviously the last one to go in the third year.  The second

              20    year could be either Howard University, who will have a

              21    trained surgeon coming on duty this coming July, a young
   0          22    doctor who I am told is quite capable and has been receiving

              23    a year's tra ining in Minnesota.. @orge.Washington wants to

              24    get a transplant and got going.
  ,e   I Reporteis, Inc.
              25             So that in looking to the future what the reviewers





                                                                            of



               I  are suggesting, they found no difficulty with this, given

               2  the kinds of problems that exist in the metropolitan region

               3  and given the nature of the three institutions involved.  They

               4  accept that premise.  And so they have recommended that

               5  106 of that be given to Georgetown for its kick-off activity,

               6  and during this first year the other institutions will.refer

               7  their patients, and have agreed to do so, to Georgetown;

               8  that in the second year whoever picks up the baJLI and goes, we

               9  give $100.,000, and in the third year we provide on the order

              10  of 30,000, which is very close to the final year requested

              11  bv the region.

              12            The neighborhood dialysis center at the Upshur

              13  clinic was essentially a reiteration of the plan we saw in the

              1'4 request that we were looking at last fall.

              15            It-is worth while to insert here perhaps that in this

              16  review by the ad hoc committee and the comments which this

              17  review group made to the Council it was stated that if the

              1 8 region had only shown a definite focus on transplantation

              19  and'had demonstrated the desire to get transplantation going

              20  then some of the dialysis request could have been approved.

              21           So in the review two reviewers, Dr. Kountz and

              22  Dr. Shapiro, with the transplantation that has been described

              23  are now quite willing to pick up these other three dialysis

              24  activities and think they are quite appropriate for the needs
  eAD  Reportefsi   Inc.
              25  of the community.







                             The region suggests that there are' on the order of

                2  150 patients -- this was the 1970 figure -- on dialysis in th e

                3  region being treated through seven centers.  The gap lies

                4  in the innercity where there is little, if any, resource

                5  for the innotcity residents.  These dial.ysis centers,

                6  essentially the Upshur clinic and the one at D. C. General,

                7  would start moving on that need.

                8            The ljpshur clinic would establish a satellite

                9  center to which could be referred home patients whose  home

              10   environment does not permit self dialysis.  This would be

              11   what we call a satellite center  that v@ould have beds or

              12   reclining chairs with several dialysis machines.  It  would

              13   be staffed essentially by perhaps a nurse and a technician.

              14   There are certain requirements that are unique to the

              15   District that require a physician in attendance for two

              16   reasons: one, Upshur clinic is made available  through  the

              17   Department of Human Resources-, and they don't want it used

              18   this way without a physician in attendance; and secondly,

              19   Med'icaid requires it for reimbursement. So they intend  to

              20   employ probably resident physicians to be there during  the

              21   evening and be in attendance for this dialysis.  But  those

              22   people being dialyzed or using the machines would have been

              23   trained to use them themselves, but would be people whose

              24                                   't them to perform this at
                   home environment would not parmi
  :e -01 Reporters,    Inc.
              25   home.







                             Secondly, they want to train community physicians

                2  to maintain primary responsibility for the patients.  They

                3  want to train people in the Northwest, central D. C. area

                4  to fill the technician jobs that would be open in the  center.

                5  They wantto provide general renal training to other

                6  physicians.  They want to augmnt the city's dialysis

                7  capabilities, and they want to integrate this with the other

                8  activities that are or will be coming forth within the

                9  region.

              10
                             It is worth while noting that-a here training unit

              11   in Iloward University will be in operation next month.  And

              12   they would hope with the RMP support to have the Upshur clinic

              13
                   in operation by about July, and through their own center
              14   operation have the patients trained to start putting this unit
              15   into operation immediately.

              16             The reviewers' comments were:  "The reviewers felt

              17
                  'it would be unrealistic to train community physicians and

              18   to follow up on home trained patients.  University  physicians

              19
                   or center physicians should retain this responsibility.  If
              20   having a physician in attendance will meet Medicaid
              21   requirements then it should be possible to obtain reimbursement
              22   for evening physicians and the technician services.  Since

              23
                   the Upshur patients will be trained in self dialysis  supplies

              24
  .1,0"1 Repoiters,  Inc. should not be reflected in the budget. The reviewers  believe
              25   the remodeling cost to be wholly out of line."  They were





                   $30,000, and they had not recededfrom the earlier application.
              2    And they believe essentially all that is needed if -you
              3    have a room is a source of tap N7ater and you put the machines

              4    in and go to work.
              5              The reviewers recommended that only minimal support
              6    should be necessary to get the Upshur Street satellite.

              7    center into operation.
              8              The requested amount, direct requested was 78,000
              9    plus a bit.  The proposed amount for approval from the
              10   reviewers is 30,000, a reduction of a little over 48,000.
              11             This level of support, given the budget that was
              12   presented, would provide half of the personnel costs that
              13  were requested, all of the proposed equipment, a minimal.
              14   $1,000 to initiate supplies in the unit,  and just under $2,000

              15   for basic alteration cost.
              16             The center proposed on the grounds and in  the

              17   buildings of the D. C. General Hospital--
              18             DR. ttkYER:  Mr. Spear, I think we are going to need

              19   to ..abbreviate the last two components of this.
              20             MR. SPEAR:  All right, very good.  Let me go right

              21   to the comments.  I think they are almost self-explanatory.

              22             The reviewers found the D. C. General proposal

              23   to be unnecessarily lavish for the patient output that was
              24   being proposed, and they raised question that the output

  @e
   -Oal Repotteis,  Inc.
              25   levels given by the applicant was wholly underutilizing the






                    center, and they say even though at thzt level there is  a

              2     question-whether enough patients could be found who  would

              .3    have the financial support back of them to fill this unit.

              4     They think some rather extraordinarily rich ... aides  are

              5     completely unnecessary, they see no reason for the computer

              6     data bank that was proposed, no reason for some  intensive

              7     kinds of almost research activities that are proposed.

              8              So from $175,000 requested they proposed that

              9     only $41,000 be recommended for approval.  This would provide

              10    for a nurse, half a social worker, half a secretary,  two

              11    machines and related build-in, and a basic 1600 for

              .12   alterations.

              13              The Georgetown unit which is proposed to be placed

              14    in North Virginia serves essentially two purposes.

              15    George town presently cannot expand on its present site.

              16    It is estimated that the earliest expansion of its  renal

              17    unit could not occur before-five -years. In this  context

              18    they are being burdened by West Virginia patients who  are

              19    being literally put on the bus and shipped in and dropped at

              20    their doorstep.  And they urge d two things.  Let's help

              21    solve the Georgetown patient problem-.  They can't expand to

              22    take on any more patients at this time. And let's  put  a

              23    center in North Virginia where there are no facilities,

              24
                    but where there will be onough'supported, financially
  ce Of Reportets,  Inc.
              25    supported patients to help cover the West Virginia  load,





               I  vihich is estimated to be  about  25 percent of  the  predicted  loa(
               2            The request is for two part time doctors, ana the

               3  reviewers said we are surprised that you asked for that, you

               4  have doctors coming out of your ears, perhaps you need a
               5  nurse.  But they didn't go ahead and specify.  All they said,
               6  all right, you ask 35,000, almost 36,000 for this, we will
               7  recommend approval for 25,000, which would give the three

               8  dialyzer machines requested, and one or more personnel
               9  depending on how it was laib out.

               10           The total request as recommended by the reviewers:

               11 year 1. 202,265; year 2, i44,000; year 3, 30,000.
               1 2          DR. ITAYER:  Thank you.  And just point out that
               13 the 202,000 in the first year was comparable to a request

               14 of theirs which was 423, which was a deletion from about

               15 700,000 from previous request, which-in turn had been a

               16 deletion from a million five or some such thing as that

               17 sequential.

               18           DR. KRALEV,SKI:  Okay, want me to continue on here

               19 th4n Just briefly with some of the accomplishments,

               20 and one of the major accomplishments-

               21           DR. SCHE-RLIS:  Can we ask. questions about the renal

               22 study while it is still fresh in our minds?
               23           DR. KRALEWSKI:  All right, if' you wish.  That's fine..

               24           DR. MAYER:  Go ahead, Imonvxd.
  ,Oeral Repotters,  Inc.
               25           DR. SCIEERLIS:  I was just scanning the available






                   application, and no mention was made in  the  discussion  of

                   the facilities at the V.A. hospital or at Bethesda Navai

              3    Medical Center, and I gather there are already going on

              4   active transplant units there.               k   -in@ e(

              5    eventually of six transplant centers,,?

              6               MR. SPEAR:  Yes and no.  We are thinking of getting

                   the  three nonmilitary hospitals started.  The military

              8    hospitals  are going right now at developing transplant.

              9    And  there was considerable discussion about sharing facilities,

              10   and this is hopefully down the line.  But  there  are  legal

              11   problems involved for the military.  So rather than deal with

              1 2  that it was pushed aside.

              13              DR. SCHJ,,RLIS:  Lots of problems with the military?

              14              IM. SPEAR:  Yes.  It simply was not addressed,.

              15   It was discussed,, the desire to got together, the desire

              16   to work together and to utilize facilities where necessary.

              17   And I didn't mention that the site for the tissue.typing --

              18   the group did agree to have a single tissue typing site.  it

              19   mtwy be a military hospital or it may be  George  Washington

              20   or it may be Georgetown.   It has not yet been decided.  They

              21   simply agreed they will  determine on one site.  And the

              22   V.A. could do it, Walter Reed is willing if they can overcome

              23   their problems, or these other hospitals.    If RMP  support

              24   is given there will be one transplant site.
        Repoiters,  Inc.
              25              DR. SCHF.RLIS:  one transplant site?






                              MR. SPEIR:  I'm sorry, one tissue typing site.

               2              DR. SCHERLIS:  And  probably  five  transplant  sites?

               3              MR. SPEAR:  Very likely.

               4              M. SCHERLIS:  Since we have been subjected to

               5   the discussion I feel that we have  a  right  to  participate  in

               6   response, and I must register a strong  feeling  that  if  we

               7   are talking about regional  cooperative  ventures  as  being,

               8   I assume, still one of the hallmarks of RNIP, I must

               9   express a great deal of  concern  about  having  five  transplant

              10   centers unless I can have some explanation from Dr. Hinman

              11   possibly,  or one of his staff, as far as  what  they  really

              12   project the needs for transplants in this area.

              13              1 equate in many areas of medicine, particularly

              14   in such areas as this, the fact that you have to do a certain

              15   number to maintain competency and,low morbidity and mortality.

              1 6  Maybe we shouldn't discuss this since  it  has  already  been

              17   passed upon, but since we have been subjected to the

              18   information at one end I think we can respond at the    other.

              19              MR. SPEAR:  May I comment on this, Doctor?

              20              The Bethesda Naval Hospital  has  been  designated  by

              21   the  Navy as its transplant center  for  the  Navy.  Walter  Reed

              22   has  been designated by the Army to be its transplant center

              23   for  the Army.  The representatives of these groups who were

              24   there said we want to be with you  fellows,  and  the  fact  that
  ;e -01 Reportets,  Inc.
              25   you got organ procurement going we will have to use your






                                  I      services,,  but  until  we  have  met  our  needs  with  the  military

                                  2      we  can't  do  much  in  the  community.

                                  3                           DR.  SCHERLIS-.     But  the  V.A.   hospital  works                                        with


                                         which  of  the  medical  schools?
                                  4

                                  5                           MR.  SPEAR:     George  W@-hington,   I  believe.                                           Am  I

                                  6      correct?

                                  7                           DR.  SCliERLIS:                 Aren't  there  shared  facilities  there

                                  8      in  many  of  the  areas?    I  would  assume  if  this  is  the  usual

                                  9      V.A.  organization  it  is  dependent  on  medical  school

                              10         affiliation,   and  usually  one                              would  not  choose  to  develop  two

                              11         transplant  centers,  one  at  the  affiliated  medical  school

                              12         and  the  other  the  affiliated  --  isn't  this  the  usual--


                              13                              DR.  MAYER:     Is  the  V.A.  currently  involved  in


                              14         transplantation?

                              15                              MR,  SPEAR:     Yes,  they  have  done  a  little  bit.

                              16         Only  eight  were  donein  1970,   @nd  the  total  for  the  past  five

                              17         years  in  the  D.  C.  area  is  only  20  or  30  transplants,   and

                              18         most  of  those  are  line  related,   including  military  and


                              19         nonmilitary.

                              20                              DR.  BRINDLEY:     How  many  are  there  in  Baltimore  and


                              21         Richmond  and  the  areas  around?


                              22                              MR.     SPEAR:     I  only  know  by  hearsay.                                 I  don't  know  of

                              23         any  immediate               teams,   none  we  have  supported  immediately

                              24         other  than  Richmond,  with  whom  Georgetown  has  become

    ce          I  Repoiteis,  Inc.
                              25         affiliated.     There  are  two  transplant  sites  or  renal  sites  in








               I    Bait imore


               2               DR. IIAYER: Dr. Thurman.

               3               DR. THURhiAN: The point Dr.  Scherlis  has  raised

               4    is a good  one, because do we really need  three  transplant

               5    teams in the city of Washington other than  those  that  are

               6    already established?  And we asked the same question
               7    yesterday about Philadelphia because we are  also  going  to

               8    have them coming out of our ears up there.

               9               MR. SPEAR:  I can only answer that, our own wish

               10   in this building is that there be one good one,.big one,

               11   active  one.

               12              Dr. Kountz, who is a very active transplanter, does

               13   over 100 a year personally in San Francisco, when posed

               14
                    this very question said "yes, given the @letro D. C.

               15   difficulties, complexities and population,  and  the  nature

               16   of the institutions, he would agree to it in this instance.
               17              DR.THURIIAN:  Don't -you think the last part is the

               18   most important part, because one hospital could do all you
               19   are projecting, so the nature of the difficulties is the

               20    important--

               21              MR. SPEAR:  Dr. Shapiro made  the point that three

               22   institutions of t his size and this independence must maintain

               23   their service, have transplants.   Whether we should pay

               24   for it may be another question.
        Repoitets,  Inc.
               25              DR. SCIIERLIS: I think we have to separate from






                I  this what is clearly our involvement to  make  sure  there  is

                2  an adequate delivery of such a  need  as  distinguished  from  the

                3  need of a teaching institution to  be  involved  with  certain

                4  programs as far as teaching needs are concerned.     I think therc

                5  is the probability of there being a strong distinction in

                6  this regard.

                7             DR. MAYER:  Lot me just make sure that I am clear

                8  and the committee is clear, the recommendation vis-a-vis

                9  transplantation was 106,000 in the first year in order to

              10   got -- I gather it was Georgetown moving  --  iOO,000  in  the

              11   second year to move the second one, with presumably the

              12   106,000 being pulled out of the Georgetown program, it is

              13   one year funding; and then 30,000 in  the  third  year  toget  the

              14   third one moving.

              15              I guess the question that  you  are  raising,  Leonard,

              16   is in the  transplant area the appropriateness of our

              17   suggesting funding of more than one center.

              18              DR. SCIEERLIS:  Yost and the way that we are using

              19   these funds is really as a direct means of getting three

              20   additional centers, one I guess   primed further,  and  the  other

              21   two off center. And I really  question  the  decision  of  the

              22   task force that looked at the renal problem.

              23              DR. HESS:  I can see some real practical problems

              24   in trying.to lump the military in with the civilian.  I
       1 Reporters, Inc.
              25   think there is a justification for separating those.  But if






                   we take the civilian as a separate category and the one with

               2   which we are primarily concerned, which could include the

               3   V.A. -- I don't know what the problems are in terms of

               4   cooperation between the V.A. and let's say D. C. General,

               5   but if we separate out the military and look at  that  and

               6   say that is our primary focus of concern as RUP then I

               7   don't think it makes sense to promote and facilitate

               8   unnecessary duplication.

               9            DR. @IAYER:,  All right.  Further discussion on the

               10  renal?  We will zome back to it when we come to the

               11  recommendations specifJ-aily within the whole recommendation

               12  of the project.

               13           DR. KRALEISKI:  Let me co,@.ment just briefly on your

               14  response of why yet were s,,bjected to this information.  We

               15  were directed by-Dr. Margulies when we went on  this  site

               16  visit to review this project and to bring it to this committee

               17  in the form of a recommendation one way or the  other  for

               18  this region in terms of their total program.  He,  or  his

               19  st@f, had selected site visitors to take a look at the renal

               20  program which, as I mentioned, were Dr. Kountz and Dr. Shapiro

               21  and Mr. Spear, and they met with this group in the afternoon

               22  while we were carrying on th,3 rest of the site visit.  And

               23  Dr. Shapiro believes that the program was a good one

               24  and that we should bring up i,n this form in front of  the
  e     Reporters,  Inc.
               25  group, and that was in accordance with the instructions from






               I  Dr. Margulies.  So that's why the information was being

               2  presented.

                             DR. THURMAN:  He survived it.


               4             DR. KRALEWSKI:  He did, 'yes.

               5             Okay, let me go on here Just briefly with a few

               6  other of  the accomplishments that we have noted.

               7             They have made progress in reorganizing their

               8  program.   Of course, they have brought  some  of  their  staff

               9  together.  They have reorganized RAG, they have reorganized

               10 their review of title projects, they have reorganized the

               11 evaluation of the projects  and  monitoring  of  the  projects.

               12 All of this, thougn, has  been  accomplished  recently  and  will

               13 be in effect only for tiie future.

               14            They havi voiced  some  interest  in  putting  their

               15 continuing education programs together  into  more  of  a  thrust

               16 after some discussion with us,  but  they  have  made  progress

               17 in continuing education, and particularly in terms of

               1 8regionalizing their efforts  with  the  hospitals,  because  they

               19 have been working pretty  closely  with  the  hospital  medical

               20 staff members in the region for a continuing education project.

               21            They have made progress in a patient education

               22 project through the outpatient services in the h@pitals;

               23 and they have a young gal who is a nurse o           core   staff

               24 working on that, and she is fairly offecti

       1 Reportets,  Inc.
               25            They have been pretty succ         in finding other






               I  funds for their projects once they have phased them.  With

               .2 the cutback in funds during this past year they have transferred

               3  many of their projects over to other funds.  In fact there

               4  were six or seven of them that they found other  funds  to

               5  support, six or seven projects.

               6            Now the reason they could do some of thist of course,

               7  is again through the relationship with these many,'many

               8  agencies that ar               th them on the'
                                                               i      CO  itt


               9  So locking in with those agencies, of course,  works  both

               10 ways.  It has been a limiting  factor to.them in terms  of

               11 their flexibility, but they have been able to get-the support

               12 from those agencies when they needed the dough to pick up

               13 some projects that were being phased out from  RMP  funds.

               14           They have, of course, good relationships with many

               15 of the provider agencies, again through the RAG members being

               16 part of those agencies.

               17
                            They have worked to-tr,y to develop a Comp planning

               18 B agency, not too successfully, but they have made a little

               19 proiress on it.  And they have a good relationship with

               20 the developing A agency.

               21           Their short term pay-offs I suppose in our

                  estimation woke few, with the exception of  promise  again

               23
                 from these contracts whore they could probably realize quite a

               -24 few benefits in a short period of time by allocating that mone,r
       1 Reporters,  Inc.
               25 through a contract method.




                                                                          lui


                           They have been able to develop some fairly explicit
             2       s of operating objectives for their core  staff.  Th;y
             3   are spelling out fairly precisely what kinds of activities they

                 are going to be involved with this coming -year. Again  they

                 haven't got this back down through the staff members yet  so

             6   they are tuned with it, but they are developing these
             7   instructions, and they are developing it also in terms of these

             8   contracts that they hope to let in terms of how that  will

             9   fit in with their core staff activity.  So there is a glimmer

                 there of hope in terms of control of the allocation of

             11  funds through contracts @o be able to get specific  things

             12  done that they need to further their program.

             13.           They helped develop an ahead health forum, bringing

             14 together the variou7 educational institutions in  the  region

             15  to discuss the whole problem of allied health education  and

             16  how they could cooperate, and this is making some  progress,

             17  and I think it was a useful contribution.

             18            They form,3d an JiMo subcommittee.  They are meeting

             1 9 witl,'physicians, with hospitals, they are putting out

             20  literature on it, and they are holding informational meetings.

             21  Whether that will develop to any great extent is still  an


             22  unknown factor.

             23            They have been successful, as I mentioned, in adding

             2 4 at least some minority groups @o RAG, one of them being

       Repo;tcts,  Inc.
             25  Mrs. Bullock, who we think will probably have a good influence






                  on the program in the future.
              2            Well, in my summary then, we see here an orga:nizatior
              3   that unfortunately has not lived up to the expectations, I
              4   suppose, of our last review.  They were awarded a triennium
              5   grant at fairly high level.  The performance is certainly
              6   below that level.  We see, though, that they have made some resi

              7   strides in reorganizing their program and bringing their

              8   staff closer together.

              9            They have been visited by the staff here in terms
              10  of the management review, and they have taken the suggestions
              11  from that review and attempted to integrate them into their

              12
                  organization by changing some of their organizational

              13
                  structure and by developing written job descriptions, et

              14  cetera. So they are making progress.

              1 5           And I think at the moment our question, at least
              16  in my estimation, is how we can help them further strengthen
              17  that organization and to bring it in to some kind of an

              18  appropriate level of performance.

              19
                            And that brings us again back to the kidney project
              20  because we felt, and Dr. Shaprio and Dr. Kountz felt, that the
              21  kidney project offered a great deal in this regard.  It, first

              22
                  of ail, offered a concrete kind of activity that they were goin-

              23
                  to be able to get off the ground and would give them some

              24  visibility and credibility.
  ,e   I Reportets,  Inc.
              25            Number two, they felt that the project in terms of








                                                                             ial
                   the overall program of R?&P offered a great deal  of  potent
              2    in terms of bringing these universities  together  to  start
              3    thinking about the development of programs to meet  the  needs
              4    of the region, and this would be one of the first major
              5    efforts, and they felt it would lead to  other  efforts.  They
              6    felt that it would be a project that would bring many  of  the
              7    hospitals into a regionalized kind of arrrangement,  and  that
              8    therefore it might be really a center pinning kindof
              9    activity that many other things could develop off  of  that

              10   would be very useful for the program.
              11             They felt, however, that at the momen@t. -- and we ai
              12   felt after our review -- that perhaps the RIIP program  should
              13   not run the kidney project if it was funded because  of  again

              14   the problems that they have in their organizational
              1 5  structure, but"i  probably should be run by s'omeone who is

              16   pro,,e  dir  tor in one of the hospitals.
              17             With that I will ask you, Miss Anderson, to comment

              18   on this.

              1 9            M. MAYER:  Dorothy.

              20             MISS ANDERSON:  I can only add a few things to what

              21   John has said.because he has covered the situation very

              22   well.  But I think some of his key words that you probably

              23   heard was that most all these things aie on paper  and untested

              24   and whenever we asked questions about their organization
  ceol Repofteis,  Inc.
              25   and what their plans were for the future or who  was  involved







               I   in.,various committees, what was the broad  approach,  we  would

               2   always got a flood of papers. In  fact  everybody  had  to  look

               3   up on the sheet of paper just what  the  situation  was  because

               4   they had not been so invol ved in really operating or imple-

               5   menting any of these plans.

               6              1 had an opportunity to meet with two groups, one a

               7   group of professionals and volunteers who were representing

               8   various organizations, and I asked them what  do  you  feel  the

               9   PUP contributed to the community. And  there  was  a  Dr.  Gins,

             10    who was chairman of the Departwent of Health Care

             11    Administration from Ger-ge Washington University, and   he   was

             12    very positive in his feelings of relationship with RIIP.

             13    He felt like his students had an  opportunity  to  have  contact

             14    with RUP staff, ani that the RMP staff lectured to his

             15    students.

             16              The woman from the Cancer Society  said  what  they

             17    felt was the accomplishment was that they are able to publish

             18    a catalogue of professional films that  were  available  to  the

             19    co@unit-y.  And I asked if this was used,  but  they  weren't

             20    sure about the answer.

             21          Dr. Finertu(?), who is responsible for a hypertension

             22    cliric,, said that the reason that he develo ped his clinic

             23    wasbocause of problems in the community in  regard  to  other

             24    hypertension clinics, and so his clinic now was set up
        Reportets,  Inc.
             25    according to appointment so that patiODtS wouidn  It have  to





                   wait all day.  They were playing foliony-up for patients with
              @2   hypertension, and also-that they are giving patients humane
               3   treatment, and are utilizing allied health professionals
               4   in this clinic.  And he feels that this plan, which is similar
               5   to a plan in Detroit, will be very effective here.
               6            In talking to the staff in regard to the developmental
               7   component Dr. Woodside, who is responsible for the community
               8   program aspect in this new organization, felt, too, that they
               9   needed to have a thrust as far as their direction was
               10  concerned.  It was interesting, I thought, that'some of the
               11  staff members asked us "what is a thrust."  So we had to
               12  be somewhat basic.  She felt like the new plan of organization
               13  was very good, but she had questions in her mind if someone
               14  came in with an idea with the community programs whether it
               15  would really go to her or to the coordinator  irs
               16            I had a chance also to talk to Miss Bullock,
               17  and I was impressed by her a.Lso.. She said that the community,
               18  had been studied to death, and that what the problems were
               19  were well known, and she spelled them out, about the needs
               20  for funds for education of health professionals, the need for
               21  a ladder for health professionals to grow and develop
               22  in their jobs, the need for satellite clinics in the community,
               23  and she really spelled out all what they needed whereby
               24  she felt the RMP staff had not been out in the community,

  ce-Fedefat Reportefs,  Inc.
               25  but that the community had been invited in to RMP, and she was




                                                                              106


               I    the example of how the community was invited in.

               2              DR. MAYER:  Other comments?
               3              DR. KRALEVISKI: I would like to make the recommen-
               4    dations for funding them, because again  as-I  mentioned,  what
               5    I hoped to do is somehow strengthen this  organization  and
               6    give this relatively weak program director some opportuniitiee
               7    to further strengthen his staff. And maybe  you  can't  see
               8    thist it is pretty small, so I will just flip this over and

               9    write these figures up here.
              10              This past year they had $575,.626 for core, and they
              11    have had $312,055 for projects.  Now what they are asking for
              12    here in this application was for core at $638,766.  They
              13    are asking for projects, $496,700.  They are asking for

              14    contracts at $772,061.  And then they are asking for

              15    developmental, $88,768.

              16              We believe it would be useful -- then  there  was
              17    the kidney project in addition to that where they were asking

              18    for, as I mentioned--

              19              DR. MAYER:  423.

              20              DR. KRAIX-IVSKI: It 'was over a million, and it  came

              21    down to 423.  We think that it would be useful if we

              22    would further cut back their core budget.  This has been

              23    reduced the past year over what it had been before because

              24    of the normal cutbacks across the board.  We feel if we cut

  e-Fe eai Repottets,  Inc.
              25    it back again it will give Dr. Wentz the boost  that  he  needs





                                                                             107


               I   to go through there and cut out the core positions that
               2   would strengthen that organization.  So we are recommending tilat

               3   the core be cut back to 477, and that when we do that he is
               4   going to have to discharge some people and he will have to
               5   take a hard    k.at,that,organization and come to grips with 1#z

               6   p  b.Lem or resign.
               7             We are recommending as far as the projects that we
               8   give them $205,000 so that they can continue on  with  some
               9   of them that they have going now, and specifically also will

               10  have a chance to deal with th at.nurse midwife  project  and

               11  a couple of projects such as that that seem to be worth

               12  while.

               13            We recommend inthe contract area  --  althoug  as

               14  I previously said, there is real concern over  the  ability
               15  of this organization to handle that-kind of  activity,  but

               16  we feel, on the other hand, it would be important for

               17  Dr. Wentz if we cut back his core to.lhave@t@he opportunity,,,

               18  to-build some kinds of services through a contract group,,,and

               19  we feel that he probably will be able to do that, both

               20  because of the fact that'RAG is becoming stronger and will

               21  be able to deal with these, and because he has a@little

               22  different make up on RAG, therefore should be able to
               23  strengthen his organization and possibly develop the kinds of
               24  things that he needs to be able to develop a program:thriust
    Fede ra I  Repoi  te  r  s, Inc.
               25  through a.110C ti@            Now vm are recommending $125,000,




                                                                               108


               I ' a  substantial cutback from what he  has  asked'for.  And  this

               2   area in  here, I think it might be worthy  of  some  discussion
               3   as to  whether we should drop that a little more or keep it

               4   in that general area.

               5             Now we are recommending along with that the funding

               6   of this kidney project at about the $200,000 level, as was

               7   mentioned in this review, again because we were toldto

               8   review that kidney project in this total program context,

               9   and to look at it and to see how it fit into  this  and  if  it

              10   made a contribution.  The general conclusion of our site team

              11   was that it would make a contribution, that it would help

              12   them got that program off the ground, and that it was a

              13   reasonably priced kind of investment  in  terms  of  allocation

              14   of that money.  And that would add up to a sum of just

              15   slightly over a million dollars, as opposed to their request

              16   for 2.1 million or as opposed to their funding level that

              17   has already been approved at 1.6.

              18             MISS KERR: Are we to  assume,  John,  that  you  were

              19   suggesting nine, the developmental component?

              20             DR. KRALEWSKI:  Yes.

              21             DR. WHITE:  A point of information.  Once a triennial

              22   status has been awarded can it be retracted?

              23             DR.  MAYER:  Lot me comment on that.  Lot me remind

              24   you of how  we got into, or of what went on that led us to
  :e*1 Reportefs, Inc.
              25   approv ing  the triennium, at least as I view  it.  As  you  may






                   recall, that was early on in the triennial review processes,

               2   number  one.

               3              Number two, we had a site visit report that recommen@le,

               4   a level of funding significantly above  the  level  which  we

               5   as a committee finally recommended, that recommended the

               6   triennium and recommended the  awarding  of  the  developmental


               7   component.

               8              What this committee did then in the course of

               9   Giscussion of that site visit information  that  ivas  provided

              10   was of those three things they took away the developmental

              11   component they signifj %ntly  reduced  the  dollars,  but  we
              121  never got around to saying,, you know, no triennium.
                              Now I have to say that my guess is from John's

              14   comments -hcke, and having ---amembered the comments about  the

              15   last site visit report, is that they are further ahead now

              16   than they were when we awarded the  triennium  in  the  first

              17   piace, Phil. And if we are going to  take  it  away  I  would

              18   have to say it was our error in the first place, yoj know,

              19   ra",ier than any deterioration.

              20              Now I would guess if we got into  a  situation  in

              21   which there were significant alteration in  a  program  we  may

              22   want to do that, but I don't think we would have a very

              23   good data base in this instance to do it on that basis.  That',

              24   all I am saying.
  @e -is[ Repoi ters,  Inc.
              25              DR. WHITE:  I wasn,lt suggesting directly that this




                                                                              liu


               I   be done. I am just questioning whether it could be done.

               2             h,RS. KYTTLE:  Dr. lVhi.te, from my memory one slight

               3   modification, when the three year funding was awarded

               4   developmental component approval was withheld because of RP.G

               5   worries. It was the promise last year, and  so  we  would  not

               6   be withdrawing an approval for developmental component

               7   this year because it was not granted in the beginning.

               8             DR. MAYER:  Other staff conmients?

               9             All right, you have a recommendation before you.

              10             DR. KRALEVTSKI:  I v./ill put it.in the form of a

              11   motion,  if you would like. one  year  funding  at  $1,007,000,

              12   site visited next year again, and then the level of funds

              13   for the following year to be determined at that time.

              14             DR. @LKYER:  Is there a second to that?

              15             MISS ANDERSON:  I second it.

              16             DR. MAYER:  All right, discussion.


              17             Joe.

              18             DR. HESS:  Yes.  It seems to  me that  if we go
              19   wiih that recommendation as is we have  removed  triennium.

              20             DR. KRALEIYSKI-.  We have what?

              21             DR. HESS:  We have removed them from triennial

              22   status.  And the only thing that -- well, we also need to

              23   look at that in light of three other actions  we  have  taken.

              24   And if we do not remove them from triennial  status  it  seems
  :e -oaf Repoiteis,  Inc.
              25   to me we have to recommend a budget for the second year or the





               I    third year in the triennium, because what we are talking

               2    about now is the second year of the triennial budget,-is that

               3    not correct?

               4              DR.  MAYER:  YeB.  They already have an approved

               5    level of funding  for that third year by our previous action

               6    and Councills  action of a million one roughly.

               7              DR. HESS:   So that that's already taken care of,,

               8    the third year.

               9              DR.  MAYER:  In a sense it is, Joe.

                                          T
             10               DR. HESS:    his just doesn't abrogate, that's the

             11     point I wanted to  make.

             12               DR. @IAYER:  I would just like to make one additional

             13     comment, and I Would have to say that in the discussion we

             14     had yesterday of minority group involvement that to me this

             15     is one o,.Lv the most appalling examples, because if there were

             16     ever a region in the country where there are some

             17     unbelievable competencies existing, you know, it's this

             1 8    particular region.  And the fact that they have not accessed

             19     those competencies to me is a major concern, simply because of

             20     the obvious gap between -- you  know, the strengths are

             21     really there and they simply just need to be accessed.

             22               DR.  SCHERLIS:  I'm back on the renal bit, and

             23     also having looked at some of the projects -- they have

             24     this exercise project, is that ongoing, at about $75,000 a

        epoftets,   Inc.
             25     year, exercise  testing?





                                                                             112


               I             DR. KRALEIVSKI:  That's right.
               2             DR. SCHERLIS:  That's an interesting definition of
               3  priorities.   I am all for exercise, mind you, but I just
               4  want to mention that.                        I
               5             The other thing is looking at even the projections
               6  given by Howard University and by George Washington University
               7  in response to a direct questionnaire,  each  responded  that
               8  the number of transplants projected for each of the next three
               9  years is in the order of ten.  And how much money was piadned
               10 to be given to either Howard or G.W., $100,000?
               11            MR. SPEAR: The second year  figure  was  $100,000.
               12            DR. SCliERLIS:  That seems rather expensive just

               13 aB the basis of operation, not even including the direct
               14 cost of the procedures, namely would be $10,000 for each

               15 of the procedures done there in the  next  three  years.  And
               16 I assume that  there were some Brownie points given to the
               17 renal project  because it appeared to be a unified effort, but
               18 I guess they all agreed to sit down and ask  for  funds,  but
               19 I don't know how m@k,@po  ing they: ha e@@done of their needs
               20 in terms of being able to accomplish what has  to  be  done.'

               21            I have a great deal of reservation not on the other

               22 recommendations, although I do want to qsk -you want

               23 contracts they are proposing.  Was that clear?

               ')A I         DR. KRALE'4'SKT:  The contracts that they are proposing?
               @-I
  e - Fedeial Repotters,  Inc.
               25_1 Well, they have an array of about 45 activities listed that






                                                                              113


                1they were going to become involved in, and they ranged
                2considerably, from,helping hospitals to establish PAS
                3procedure in the hospital by talking to their, medical staff,
                4and so forth, helping dis  tribute some kind of a calendar
                5of the continuing education events  that  are  going  to  take

                6place.
                7           DR. SCHERLIS:    Do they hmie the ability to decide
                8which of these contracts should be given the highest priority

                9or the lowest priority?
                10          DR.' KRIUXWSKI:  Weil   it's a risk.  There is no
                11 question about it. But on the.  other  hand,  it  gives  them
                12 something to decide with this new organization that they-have,

                13
                  and it is a risk that we thought might be worth taking to
                14 the tune of this much money at least.
                15                                              listing are very
                             Some of the things that they are

                16
                  exciting, the medical student, nursing student thing, -you

                17 know, things such as that.

                18
                             DR. SCHERLIS:  Do you think they will choose the
                19 ones that to you are most exciting?
                20           DR. KRALEWSKI:  That's what we will find out
                21 next year.   I'm sorry to be that evasive.
                22           DR. SCIIERLIS:   I'm not too concerned about the con-
                23 tracts.   I think this may  be  j.ust what they  need  to  get
                24 moving.  But I wonder what some of the reaction of others
  ce-F6detal Repoitets,  Inc.
                                                             T Af%nlt want to pursue






                                                                             114



               I  that if I am the only one who is concerned about it.

               2            DR. MAYER:   I have the concern about the renal

               3  project only in the sense of the funding in the second and

               4  third year for two subsequent transplantation centers,

               5  the very point that you raised, Leonard.  And I think when we

               6  get to a specific recommendation what I would move,  or  would

               7  suggest that somebody move, is an amendment to it, would be

                           the first year, but take that $144,000 in the second

                  year and reduce it by the 100,000, specifically the second

               10 transplant component, which wo uld bring.that down  to  44,000,

               11 and then no funding in the third year, because the third year

               12 funding of 30,000 that was recommended by the group was

                  totally for that third transplant unit.

               14           DR. TTIURMAN:  lo@, you realize you are going to

               15
                 ,,depXry their only hope of a continuing cooperative effort?

               16           DR4 MAYE-R:  Well, I-think we need to  know that.

               1 7          DR. THURTIAN-. I am being facetious, Bill.
                                                                       4

               18           DR. MAYFR:  I think it may present an interesting

               1 9challenge to them.  They may reloolt where they want to do

               20 that transplantation under those circumstances.

             -21            DR. KRALEWSKI:  Mr. Spear, maybe you would like

               22 to comment on that because I think it is an important issue, is

               23 whether there is a willingness to cooperate on  this,  because

               24 this is much of the basis of our willingness to go along
  E!-Fedeial Reportefs, Inc.
               25 because of the fact that it seemed as though this brought about







                   a great deal of cooperation.
                2            DR. TliURbIAN:  But, John, they are talking together
                3  only because they are going to each get what they want if they

                4  wait long enough.  Judy disagrees.

                5            DR. MAYER: Mrs. Silsbee.
                6            MRS. SILSBEE:  I would like to ask a question here

                7  because at the time that Dr. Shapiro reported to the team at
                8  the site visit it sounded to me just from -your description tha-,
                9  their proposal now is different from %,hat they agreed to at th)
                10 site visit in terms of the transplantation situation, because

                11 he was excited about the fact that Iloward and George
                12 Washington had decided to get together at D. C. General and

                13 would lot Iloward use its facilities, and so forth.

                14           MR. SPEAR: I was Less surprised, I guess,  by  his
                15 reaction to the question than I was-by Dr. Kountz's,  who  I
                16 thought was wholly on one side.  I can only suggest that in
                17 retrospection as they iooked'at it they thought  well,  this

                18 is workable and if.,they,@can do it, if they mean it, then

                19 it's fair to go atorgnvith it.

                20
                             I would like to state one other thing.  The matter
                21 you were discussing, Dr. Kraiewski -- I should t hink we would
                                             if
                22
                   feel here in the R?4PS that they really mean to do  business

                23
                         t
                   and ge  a good transplant operation going there is no reason on(

                24
                   can't do it, and in the first year while they are doing one
  ,eo.,l Repoiteis, Inc.
                25 they all say they will refer their patients.   And I think if





              I    timy got one'going that is efficient and effective and does

              2    the Job they will have many more patients than they suggest,

              3    because the figures I have are similar to yours, only

              4    indicate those dialysis patients now waiting for transplant.


              5    It does not get into this whole unknown universe of people

              6    out there who are not financially able to be dialyzed, but

              7    will be transplanted.

              8              DR. SCHRRLIS:  I only have the data for each of the

              9    next three -years--

             10              MR. SPEAR:  That's all I have..  Butthere is more

             11    than I am speaking to, and there's no reason one can't

             12    satisfy.

             13              DR. MAYER:  Would someone care to make an amendment

             14    relative to, or to extend the motion as i%@. relates to

             15    transplantation in the second and third year?

             16              DR. SCHERLIS:  I would father the amendment you

             17    refused to recognize as your-own.

             18              DR. MAYER:  All right, thank you.

             19              DR. HESS:  I will second it.

             2@              DR. MAYER.,;,   amendment was that we would agree

                   to the 2  #00.0 roo   nded by the group for the kidney

             22    project  in the firs@t@ year,, we would recommend only 44,000

             23    for t  second year, which deletes the second transplantation

             24    center, and no dollars in the third year which deletes
        eporters,   Inc.
             25    the third transplantation center, but does permit support in






                    the f irst and Second years of the dialysis units.


               2              DR. BRIICDLEY:  If experience were to show that they

               3    needed to have more they could reapply for some extra

                    funding, could they not?

               5             DR. IAAYE-R:  Yes.  They have that option in the

               6    anniversary sequence that is here.

               7              DR. SCIMRLIS: With which medical  school  is  the

               8    V.A. more closely affiliated?

               9              MR. CHA?MLISS:  I believe it is George Washington

              10    University.

              11              DR. SCHE-RLIS: So they could really  share  these

              12    facilities, I assume, and that is permissable in  the  V.A.

              13    regulations, isn't it, that if you have an  affiliation  of

              14    this sort your patients--

              15              MR. CHANIBLISS:  There is a sharing provision in the

              16    V.A. regulations, yes.

              17              DR. MAYER:  Shall we vote on the amendment first?

              18              All those in favor of the amendment?

              19              (Chorus of "ayes.,,)

              20              Opposed?

              21              DR. KRALFWSKI:  No.

                              DR. BESSON: 'Will instructions go to the region about

              23  "@;this level of funding with advice  about this amendment?

              24              DR. MAYER:  Oh, I would think so,
        Reportets,   Inc.
              25              Now the discussion of the motion as amended,.furthe





                I   discussion or' comments.

                2              Yes, Jerry.

                3              DR. BESSON:   Well, I..wonder whether  it   isn't

                4   alsoeppropriate, in,spite   of the fact  that granted  the militar

                5   lives in a different) universe than the   real world,    for

                6   the Council to see about some kind of coordinative     effort

                7   with the kind of facilities that are available currently at
                8   Walter Read and whatever the other hospital is, the Naval
                9   renter.  And I think it would be perfectly appr    opriate for som,@
              10    kind of coordinative effort to take place betwee        HIJA,

              11    and the Department of lrNfense.  So I would like that our

                    motion also include a request of Council that some kind of

                    coordinative effort  be initiated as far as this transplant

                    program in this area  be concerned.


                              DR. LTAYER:  All right.  You understand that?
              161             MR. CHA-TIBLISS:  That 4D4"-t-,d be very easily covered

              17    Lis

              18              DR. @IAYE'-R:  I guess my only    I couldn't agree more
              19    that they need to look at those resources and that HSIVAA
              20    ought to use its strengthB, whatever  they  may  be  on  the
              21    federal scene, to be helpful since they are right here to do
              22    that job.  If in fact it turt.s out that both Walter Reed and
              23    the Naval Mo6ical Center acting as the centers respectively

              24
                    for the Army and the Navy  are,not  in  fact  overloaded  by
        Reportets, Inc.
              25    their own activities, then I '%,-hink it's one that oughtto be





                                                                                  JL.L




                I   encouraged to be pursued.

                2             Yes, Phil, you  had a comment.

                3             DR. WlijiT,:  May I move from the concrete to the

                4   abstract, because I think  in my mind if this action that

                5   we are contemplating occurs we are indeed jeopardizing the

                6   whole concept of a triennial review.  What we have said

                7   to this region or are saying to regions is  we  agree  that  for

                8   the next three years you are capable of managing your

                9   affairs.  But our action belies that in this case.  And

                10  if we can do it in this case then presumably we  can  do  it  in

                11  any case, and the mean4,- of a  triennial  award  is  zero.  No

                12  region will trust us.

                13;           1 think we either have to say you are no longer

                14  meritorious and we are wit-drawing it and thisis why, or

                15  we have to say okay, we made an error in judgment, but we

                16  will live with it for thenext two -years.              I

                17            IMS. KYTTLE:  There are several items that staff

                18  is charged with tt,,e responsibility of monitoring  within  the

                19  trl@3nnium, and should any of these be breached it  is  a  flag

                20  that staff is required to call  these things  to  the  attention

                21  for full review insofar as C-)uncil is concerned within

                22  a triennium.  And failure to -- well, I  think  the  words  are

                23  substantial failure to achieve what was funded and the intent

                24  of what was funded is one of.tliem.
   -01  Reporteis,  Inc.
                25            Judy will probab ly. be able to give you  much  better







                   background on what generated the decisions this round  on

                   Metro D. C. than 1, but just by our procedurairegulations

              3    they themselves would bring any region in a triennium  that

              4    is thought to be not meeting the goals that it was funded


              5    for.


              6              DR. WHITE:  I agree, I think that's quite

              7    appropriate that there should be sonic mechanism for it.  And

              8    I can understand that there may be within a region  certain

              9    elements of the programs that would need flagging, but

             10    I think when we look at a region in which all elements

             11    of the program are flagged and where we are making substantial

             12    budgetary revisions, substantial suggestions to.them  about

             1 3   changing their personnel pattern that this is a farce.

             14              DR. MAYE, R: Well, Phil, my assumption is if we say

             15    in this situation a million dollars, of which 200,000  is

             16    to go to the renal project, that the only restraining force

             17    on that region is the 200,000 for the renal project,

             18    that they would then have freedom to expend the remainder of

             19    th;se funds in a way which they think is appropriate  for

             20    the region within the confines of things that we have

             21    approved in the past. Now I think we are laying  on  them

             22    some pretty strong suggestions, which I think is appropriate,

             23    but I think within that triennium they have that freedom.

             24    Is that not right, Mr. Chambliss?
  @-0 Reporters,  tnc.
             25              MR. CHAMBLISS: Yes, that is  correct.  They  have








                  that freedom.

              -2            MRS. KYITLX@:  Although along those lines, Dr. White,

              3   this afternoon you will be looking at anniversaries within

              4   a triennium that were not site visited, did come through

              5   the staff anniversary review panel, and are being brought  to

              6   you for information purposes, but nevertheless  include  staff

              7   anniversary review's recommendation that words go back to

              8   the region about suggestions they have within the  triennium..

              9             DR. BESSON:  I share your concern, Phil, but on the

              10  other hand I think when the anniversary.review program was

              11  first developed it really was an untested idea, and if RNIPS

              12  is anything it is an evolutionary program.  I think the

              13  notion of remanding to the regions full authority  has  really

              14  been untested, and we are in the process of testing that now,

              15            I do have one of the programs, Alabama,. to review

              16  where this very question comes up.  So I think that there

              17  are several aspects of that anniversary review that ;ire

              18  being changed as we go along.

              19            For example, we had  originally spoke of anniversary

              20  review as precluding project review, but that has become

              21  patently impossible.  We can't review program without looking

              22  at the matrix of the program which is project, and if  we  are

              23  candid about how we reach a dollar figure, which,  after  all,

              24  is the only leverage that review committee has, we reach
  -*I RepoiteFS, Inc.
              25  that dollar figure by careful scrutiny of the projects,

                I





                  the leading projects here and there, which gives us a final
              2   f igure. Now that is appropriate, I think, because we &re
                  looking at the substance of the program in terms of project.
              3
              4             The second thing that has changed since anniversary
                  review has developed has been the emergency of SARP, the
              5
              6   Staff Anniversary Review Panel, which I think gives staff
              7   a very substantial function in the review process.  And  in
              8   my particular region that I will be reviewing it will be
              9   for review committee's function alone.  We have no ac  on
              io  to take on it, and staff I think has been very close to
              11  the problem, nas appropriately, I think, recommended a change
              121 in funding level.  But they retain, as I understood your
              13  comments a little whilb ago, Mrs. K;ttle, the option of

                  bringing it to review committee for action,
              14
              151           1 think it would be well for the review committee
             .16  to have sume clearcut idea of standard operating  procedure
              17  vis-a-vis the entire anniversary review process.  But I
              18  don't share your concern that we are going back on our
              19  ori@ginal intent. I think the intent is that we do have  an
              20  obligation to monitor tha region and make sure that they are

              21  accountable.

              22            DR. MAYER: Phil.
              23            DR. WHITE I have no problem with the con--ept  of
              24  surveillance, and I have no problem with the concept of a
  :e-01 Reporters, Inc.
              25  close scrutiny of the application, including ail elements






                I            MRS. SLOAN: Could I make Just one comment that may

                2  be helpful in the kidney disease area?  The National Kidney

                3  Foundation has brought together a committee to develop

                4  guidelines in the field of kidney disease, in  stage  kidney

                5  disease, comparable to those which we have  been  developing

                6  for the Secretary's list under section 907.  They have made

                7  the recommendation that unless a proposed transplant facility

                8  could project a volume of transplants of 50 cases  per  year

                9  that it was not an appropriate place to have a transplan

                10 program in term-- of the safety of the patients and  keeping

                11 the team sharp and act4ve.

                12           But rather than saying that neither G.W. nor

                   Howard could hope to have a transpant program in the future,

                14 if 'you could tie this in some way to the projected load

                15 as this would increase within the District you might eventually

                16 be able to jus@ fy,three transplant facilities. @I think the

                17 hope of having one;l@@@eventually as-part of the medical s hoo  s

                18 program of all three medical schools has been a very

                19 im*iortant@part of bringing this amount of cooperation

                20 together.

                21           SISTER ANN JOSEPHTISE-:  May I ask just one question

                22 relative to this and maybe relative to Dr. Margulies'

                23 remarks thi6 morning?  I recognize that a significant sum

                24 of money has been appropriated at the present time for
  .ce eal Reporte(s,  Inc.
                25 treatment of renal disease and that there is going to  be  a





                   of the application which incorporates project, at the
               2   time we come to these decisions, That doesn't bother  ine.

               3   What bothers me is that by our actions here in  reference

               4   to Metro D. C. we are saying %ye didn't really mean to
               5   give you triennial status last -year and therefore we are
               6   going to be meddling in -your affairs, we are not going to
               7   tell -you you are no longer triennial, but indeed  we are not
               8   going to let you behave in that fashion. And  I  think  this
               9   is ridiculous, that we either say you don't or -you do,  and
               10  I think thing this precludes the staff raising  flags  about
               11  certain kinds of program elements. But when  you  have  this

               12  substantial amount of concern it's a totally different kind

               13  of picture.
               14            DR. BESSON:  Viall, the other aspect of this, Phil,

               1.5, is that we make decisions very often on promise,  and  t  re
                   is p6 ve y@@obv@ious@@gu.,I@f between promise and performance @ki
               17  as is manifest here.  Viell, I think it is appropriate for
               18  regions to,know that they are accountable for their promises,
               19  and I think it is perfectly appropriate for RMPS  to  hold

               20  them accountable with performance, so that if this is going

               21  to be interpreted by regions peripherally that  they  have
               22  to measure up, well, that's fine.  Thre's  nothing  wrong with

               23  that.  I can live with that very easil-@.

               24            DR. MAYER:  I guess what I was trying to say

         Reporters, Inc.
               25  earlier, Phil    maybe I wasn't communicating clearly






                  enough -- is that what we are doing is arriving at a
              2   suggested-funding level as it relates to the second yeiLr of
              3   the triennium.  What they do is still a matter of significant

              4   judgment on their part about that.

              5              Yes, Sister..
              6              SISTER ANN JOSEPHINE-.  Let me ask a question I
              7   think is related to this,   I would' like to ask what has

              8   happened to the management audit that was inaugurated?

              9              MR. CHAMBI,ISS:  That's a good question, Sister.

              10  Those are  going forward and the pace is being intensified.

              11  This region has already had a management audit of its

              12  activities.
              13             SISTER ANN JOSEPHINE:  Has the management audit

              14  prepared them for possibly recommendations that will

              15  indicate they are not living up to their commitment?

              16             MR. CTIAMBLISS:  The management audit did in fact

              17  point out  their weaknesses, which some of the areas you dis-

              18  cussed broadly were touched on.

              19             DR. KRALEIOSKI:  And as I mentioned in the accomplish-

              20  ments section hero, they have i mplemented some of those

              21  suggestions, particularly the ones dealing with personnel
                  policies and the ones dealing with their organizational chart.

              23             MR  CHAMBLISS-.  And pulling the core back in.

              24             DR. @ALEWSKI:  Pulling the core back in.

       Reportefs,  Inc.
              25             SISTER ANN JOSEPIIINT,  Pursuing this a little furthe






               I  are there capabilities in the staff review that

               2  unsatisfactory performance can be flagged early enough so

               3  that a management audit could be made and be helpful, be

               4  supportive maybe to the recommendations of a site visit

               5  team and prepare the region for the recommendations that

               6  will be made?  It would seem to me if these things occurred

               7  simultaneously then it would begin to be effective in the

               8  total process.

               9             MR. CHA@MLISS:  The management audits are now on a

             10   schedule for covering all the regions.  It so happens we have
             11   passed this one already.  But certainly if there are elements

             12   in the program that need management audit attention at any
             13   point in the program I think the management audit team would

             14   get back in.

             15              DR. BESSON: Was the management audit available to

             16   the site visit team prior to its--

             17              MR. CHAlfl3LISS: In fact it was.

             18              DR. BESSON:  Is it available here in the books?

             19              MR. CHAI@ABLISS: It may not be in your books, but

             20   it was made available to all the members of the site visit

             21   team prior to the site visit.

             22              DR. BESSON:  I have never seen one.  I wonder whether

             23   we could see one.

             24              MR. CHPIABLISS:  No problem at all.
  -I*, Reporters,  Inc.
             25              DR. MAYER:  Any further questions on the motion?





              I   pu@h for transplant and renal dialysis.  However,  it  may
              2   well be that when we find out how many candidates do  O)tist
              3   if the program is expanded and the fantastic cost  of  the
              4   program, we will find that we won't be so energetic in
              5   pursuing this whole thing. In fact I have  real  fears  that
              6   we will move in the area of a philosophy comparable to
              7   euthanasia as we begin to look at  these  candidates.  And
              8   I wonder if we shouldn't take into thinking --  there  isn't

              9   anything we can do about the policy, I know; but  even  as
              10  we develop our own philosophy here, that we may  not  always

              11  be this enthusiastic about developing all  these  centers,
              12  and maybe heed to look realistically at what is a realistic
              13  case load to support a center, and this would be of great

              14  concern to me.

              15             DR. MAYER: All right, further conbnents?

              16             Everyone understand the motion?

              17             All those in favor of the motion say "aye."

              18             (Chorus of "ayes.,)

              19             Opposed?

              20             DR. WHITE:  Aye.

              21             DR. MAYER:  All right.  It will be duly recorded.

              22             Lot me suggest that we make every effort to be back
              23  here by about a quarter of 2:00 if we possibly can in order to.

              24  got through the remainder.
   OReportets, Inc.
              25             (Whereupon, at 1:15 p.m., the meeting recessed,   0

                  reconvene  at 1:45 p.m.)



                                                                         VLAI,@ILI                                                                                                                               0










































                     0                                                                                 0                                                                                   0








                                       AF'IT,,Rl@DON SESS ION

              2                                            (JL:45 P.M.)

              3             DR. MAYER:  We are going to. make one small

              4    modification in the schedule and move to Susquehanna Valley

              5    and honor the plane J. Warren has to make to Buffalo

              6    this evening.

              7             DR. PERRY:  Thank -you, Bill, and special thanks

              8    to Miss Kerr for permitting me to go ahead first.

              9             Susquehanna Valley RMP is currently in its 03
              10   operational -year. It is functioning at.$480,405, and they

              11   submitted an 04 request for a million four.
              121          DR. SCHERLIS: May I interrupt -you just a  moment?
              13   Do -you want us to fill out for the others coming up the

              14   same forms, or are they only necessary for the ones we

              15   have the regular review of?

              16            MRS. KYTTLE: The rating sheets should  be  filled

              17   out for your anniversary prior to the triennium.
              18            DR. SCHERLIS:  Intermountain and Susquehanna?

              19            MRS. KYTTLE:  No, Intermountain and Susquehanna are

              20   regions that are anniversaries prior to their triennium.
              21   They have not received a prior rating from this committee.
              22   SARP rated, and I have the ways in which the SARP members

              23   arrived at that rating, and I was trying to get back before
              24   you started to talk this over with you a bit.  This is what
  :e-*,al Reportefs,  Inc.
              25   we wore kicking around.







                              For anniversaries prior to triennium they  need  to

               2   go to Council with a firm recommendation of a rating.
               3              We were wonderi ng what the comniittee's  assessment

               4   would be of a procedure van creb,y SARP would rate; if you would

               5   wish, vie would show -you how SARP arrived incrementally at

               6   the total rating on the pink street you have before  -you.  If

               7   you would want to affirm the rating that SARP  has  given,  or

               8   if you would want to change it; we are not trying to color

               9   your thoughts in that line.

              10              MISS KERR: I would have only  one  comment  relative

              11   to your oliestion, Lorr,"ne, and that is that I personally
              121  on Intermountain have no handle other than  the  written  word
                   which the staff review and SARP has given me, plus this,

              14   plus their application, ar4 my interpretation may not be

              15   a fair one.  Now I will be asking for imput from the staff

              16   members involved, but since I have never been  to  this  region

              17   on a site visit I have to depend largely on the written

              18   word.  And I just want to throw that in as a potential

              19   fo' perhaps not a fair evaluation or interpretation from me to

              20   this group.

              21              MR. CHA-TIBLISS: WeLl, we would certainly hope  that

              22   an overview of the region could be augmented by knowledge

              23   that resides either on the committee or in the staff on

              24   which you could base some rating.
  111.1 Repotteis,  Inc.
              25              MISS JERR: And so -you are suggesting then  that  we
                 I








                     do rate?

                2               MRS. KYTTLE,:  Well, now this is what I want to
                3    ask you then,  Therefore just thinking of Intermountain at

                4    this time rather than the larger question, would the

                5    specific ratings of the Staff Anniversary Review panel

                6    assist you?  Would you like to see them.

                7               MISS KERP,.:  I would like to -- after the presentation

                8    and after the discussion if there are discrepancies maybe,

                9    if there are some major questions or gaps.

                10              MRS. KYTTLE:  That's a good base.  All of the

                11   anniversaries have been reviewed, even those within the

                12   triennium, and,have been assigned ratings.

                .13
                                MISS KE@RR:  Could you report to us afterwards what

                14   the average was or what the number assigned to that was, and

                15   then we can--

                16                              Individually?
                                MRS. KYTTLE:

                17              MISS KERR:   N6, as-a group.

                18              MRS. KYTTLE: I can do both.

                19              DR. MAYER:  Lot me try a suggestion, that since

                20   SP.RP will have arrived at some    ratings o n the anniversaries

                21   prior to triennium, and I assume -- will they have done

                .22  anything on anniversaries within the triennium?

                23
                                MRS. KYTTLE:  Both.

                24              DR. MAYER:  All right' they have done both,        I
        Repoiters,  Inc.
                25   guess, just to throw   it out for discussion, that perhaps if







                    this group had those ratings available to them to look

                    at while we are going through the  review  process  that  we

              3     might wantto raise some discussions about particular areas

              4     which we may have some feelings of gross discrepancy, but

              5     that we would not attempt to evolve a separate rating for

              6     those that are anniversaries or anniversaries within


              7     triennium.


              8               Now how does that grab the committee?  Is it

              9     appropriate?

              10              MRS. KYTTLE.:  Could I add something to that?  In

              11    an effort to get -your feeling of -- you know, this is

              1 2   only our second, and really the first full time that we have

              13    seen anniversaries in this light -- in our effort to got to

              14    you materials that would help you in -your reviews of

              15    anniversaries that had this prior review, these ratings Come Ln

              1 6   two forms individually, both raw and weighted.  And I would

              17    like to get your feeling about  whether  both  documents  or

              18    either document sent to you at the  time  the  other  papers

              1 9   areagnt to you would be of assistance to you.

              20              DR. PERRY:   I think I would have been  happy  to. have

              21    seen them. I have th total that came in --  'you  know,  on.

              22    the pink sheet.   I would have been very pleased to have

              23    seen the other.

              24              Again as Billy has said here, I have been to that
  -*I Repoiters,  Inc.
              25    region, but I am responding at this  point  to  the  printed






              I  word, and that kind of revieNv from those people that have been

              2  much closer I think would be of assistance to us.

              3            MRS. KYTTLE: Mr. Chambliss, in an effort to assist

              4  the discussion may I pass them out now, so it would perhaps

              5   generate--

              6            MR. CHAIMLISS:  Indeed so.  I should think so,  And

              7  we would like to say that the SARP ratings are in no wise--

              8           MIS$ KERR:  Are binding?

              9            MR. CHAMBLISS:  Beg your pardon?

             10            MISS KERR:  Are bindi ng?

             11            MR. CHAMBLISS:  No, indeed, they are not.

             12            MISS KERR:  In no wise are binding?

             13            MR. CHANIBLISS:  Yes, they are simply for your

             14  augmentation if you choose to use them.  What,we are trying

             15  to do is to get as many regions rated. as we can; as we can

             16  get them through the process, then our basis for

             17  comparison will be much greater.

             18            MISS KERR:  Well, in essence then unless we have any

             19  glar'ing opposition to this we are really supporting SARP's

             20  rating which will then be its of ficial rating for the

             21  moment?

             22            MR. CHA.KIBLISS: If that is your pleasure, all right.

             23  But again that is left to this committee.

             24            MISS KE-RR:  That's what I mean, unless there is.
  @e*1 Reportefs,  Inc.
             25            MR. CHA?,IBLISS: Yes.
                I






                           MRS. XYTTLE, : It would constitute either -your
               2  modification or your affirmation of a rating that would hold

               3  until the next anniversary.
               4           DR. BESSON:  But that would be for the raw data
               5  rather than the final figure? We Would have an opportunity
               6  to inspect the raw data rather than just the single weighted

               7  score?
               8           DR. MAYER:  Right.  Yes.  I gather that's what they

               9  wore saying.
               10           All right, why don't we just move along and try it
               11 and see how it works, ar, I guess it's like everything else
               12 in here, policy finally evolves out of dealing with the real

               13 world.
               14           DR. PERRY:  Susquqhaiina Valley, as I started to

               15 say, is currently on its 03 operational year.
               16           Geographically this is the central Pennsylvania
               17 area, with Harrisburg, Hershey as.the focal point.
               18           I did have the opportunity of participating in the

               1 9las" site visit here at this region.  At that time -- and
               20 Susquehanna has quite a history of problems -- there was,

               21 the site visit group believed
                                                 a lack of strong leadership

               22 anywhere, the coordinator, RAG, medical school relationship,

               23 and so forth.
               24           There were some major questions asked about the
  ,ce-Oal Reporters,  Inc.
               25 relationship bet@yeen the region, if you recall, andthe grantee,







                  the Pennsylvania Medical Society.

             2             The weakness of the RAG was emphasized  time  and

             3    again. Continuing emphasis in the region had  been  placed

             4    on categorical and what appeared to be quite separate

             5    projects with no evidence of program planning.

             6             The noninvolvement of the Hershey @ledical School

             7    although repeatedly requested liaison had been requested and

             8    had been looked at, was noticeably consistently missing.

             9             The absence of nursing andallied health imput, and

             10   although their continuing education program in that area

             11   emphasized this, there was no voice and little  relationship

             12   in any decisionmaking or committee relationship.
             13            There was a concentration on subregional development,

             14   And although there was recognition of thisstrong relationship

             15   of individuals throughout the region.in various  sections,

             16   there was little,, if any, regional direction.

             17            There were questions raised about how decisions were

             18   made by the RAG because there was evidence that  practically

             19   nothing had been turned down in the history of the  program.

             20            Okay, that's a pretty dark and bleak  picture  that

             21   1 painted here. But at this point there seems to  be  some

             22   light on the horizon, and in terms of these kinds of negative

             23   statements I would like to attempt to indicate what in the

             24   written report Susquehanna has moved on so far to remedy some
  -01 Repot ters, Inc.
             25   of these weaknesses.





               I           Number one, and of primary importance    and all of
               2  us,I'guess, recognize the importance of leadership in a
               3  program -- the replacement of the lay coordinator with a
               4  physician who will assume this post January lst, just a
               5  week or so ago, is of major impact here and major import.  We

               6  hope impact.
               7           At the time of the site visit great concern     and
               8  it has been expressed for several times    at the capacity
               9  of the past coordinator, recently past, to speak up and to
               10 be heard in any way with the Pennsylvania Medical Society.
               11 He had formerly functioned as the executive director of the
               12 Pennsylvania Medical Society.  When he moved to the other
               13 position they were not sure in any way that he had a really

               14 major leadership role and voice to make.
               15           As-of January I Dr. Joseph.T. ichter will be
               16 taking -- I'm not sure I pronounced the name right, I-c-h-t-e-Y
               17 a pediatrician, attended the University of North Carolina,
               18 got his M.D. at the University of Pennsylvania, has accepted
               19 the.position and is on staff in the region.

               20           There is a vacancy on the core staff for the
               21 position of Assistant Director for Program Services.  The
               22 nursing staff position is still open, has not been filled.

               23 So there is a capacity, an opportunity for the new man  o
               24 make some appointments that should strengthen core and give
  @e-Oal Repoiters,  Inc.
               25 him a working relationship there in the program.






                           The core staff, those of us that met them -- and I
                  recall several of them.very well -- and this is in the
             3    report of the staff review, the staff anniversary review
             4    that has been handed to me -- great confidence in a competent
             5    though small core staff.  This core has carried on in t
             6    past few years, and some of us wonder how, with some of the
             7    lack of leadership that I think some of us feel has been
             8    present there.  Even during this last matter of months
             9    I am sure it has been core and such that has developed the
             10   application,that has put some of this together. There are

             11   some strong evidences there of change.
             12             Number twop in relation to RAG, RAG has also
             13   appointed a new chairman.  In the staff report, those who
             14   have knorn him and met him and seen him in action -- and
             15   again I recall who he is -- another,member that I had lunch
                  with,today indicated she remembered him also -- the new
             17   chairman of the RAG, again showing change in response to

             18   some new actions there.
             19             RAG for the first time has appointed a planning
             20   committee.  This had been recommended at our last site
             21   visit.  So a planning committee for the first time has come

             22   up.
             23             The new RAG chairman has expressed the desire which.--
             24   you know, this goes back to the early statement I made -- but
  D-*, Reportefs,  Inc.
             25   to spell out the specific relationship between the grantee

               I




                                                                                 137



                 I  agency and the RAG.

                                                      id it taite to get  to   that?
                 2             Okay, how many years d

                 3  But they are willing to spell that relationship out.

                 4             in relation to the approval of programs and the

                 5  assigning of priorities and such, we still have major question3,

                 6  and I believe these are some of the things that the new RAG an]

                 7  certainly the new director of the program must get involved

                 8  in at once.

                 9             The repnrt indicates that RAG is studying its

                 10 composition.  This is another   positive.. Many of us were

                 11 concerned about the con.,asition of that RAG.
                 121           Although the nonwhite population is six percent, the@E
                    are none on the core, none on the project staff,     one  of  34

                 .14 on the '.RAG, two of 493 on -ther groups and committees.  There
                 15 are some opportunities certainly for action there.

                 16            There is still a major question of relationship

                 17 'that has not been spelled out yet with Hershey Medical School,

                 18 although we have the fixst evidence indicated here that
                 19 th.y will consider -- and I am sure this is true since indeed

                 20 a position has been found for this physicianpa faculty
                 21 appointment for the physici&j coordinator,  We hope this

                 22 moves ahead so  there  is  a  definite  relationship  there.  We

                 23 will have to wait and  see  if  this  indeed  does  happen.  But

                 24 again this indication from Hershey that they are willing to
  ,e - ,I Reporters,  Inc.
                 25 look this way is strong.






                            If you recall from our past review,,it has  not  been

              2   statements'of negativism from Hershey, for they have  been  the

              3 location for quite a few continuing  education  programs  --  I

              4 remember specifically a  physician  assistant,  well  attended

              5  conference that they have had, programs of this kind.  it

              6   has been the great involvement that Hershey has  been  involved

              7   in in getting started itself, and their unwillingness to

              8   commit meager resources and such to anything  else  at  this

              9   period of time. They have not looked at it as  a  unit  where

              10  could strengthen each other together, which, of  course,  would

              I I have been ideal.

              12            Although regionwide planning is badly needed  --  and

              13  I spoke of the 'disparate-ptojects and the problems in  terms

              14  of putting a region together -- the new coordinator  --  and

              15  I am sure he will find this out very soon --  has  available

              16  some very excellent resources in the very active local

              17  advisory groups. They speak quite openly about  --  they  are

              18  a grass roots group, everything happens in their program and

              19  has'in the past in the grass roots.

              20            Many of us were extremely impressed with the young

              21  physicians that we met from the various district committees.

              22  Here is a resource that the new director, the RAG  needs  to

              23  bring in spelling out a role, a leadership role, the ways in

              24  which these men can become a much more positive influence.  In

       I Reporters,  Inc.
              25  the past they had very little relationship to the region other





                   than what they could do out in their  district,  and  in  that
                2  case it was a separate kind of approach, These  people  'need
                3  to be brought into a total relationship.  But there's strength

                4  and there's resources there to work with.
                5           At the last meeting there was no data base of
                6  any kind, the last site visit, there was no data base of any
                7  kind;reported in the proceedings here and in the application, end
                8  it is a bright spot certainly, in,cooperation viith,-alsocial
                9  epidemiologist from Hersey a data base for the region has

                10 been developed and published.

                11          What is needed certainly, I believe, is a major
                12 commitment of assistance from RMPS here.  This has been
                13 spelled out in the recommendations made.   I see a comment here
                14 that Harold has put on the outside of these,,Iliet's  get  in
                15 touch with this man immediately and work with him as closely
                16 as we can," and from comments that were made  -yesterday  the
                17 approach has already been made.   I notice someone, they said, fr(
                18 the staff is there today.  He is willing, eager  to  come  in
                19 and'work with RIEPS.  He wants to take a little more time to

                20 assess his own resources, his own region,  before  he  starts

                21 to move.
                22           In terms of recommendations -- and to go down the

                23 line of all of these I think in the period of time that
                24 we have,it is going to be a repeat of what we found in that
  :e -of Reporters,  Inc.
                25 region before.  I think the important thing to  make  of  the







              I   recommendations    and  here  I  am  leaning  very  heavily  on

              2   the staff review recommendations, and I do concur certainly


              3   with them.

              4             Number one, to provide an initial award for the  04

              5   year of $480,405. This was the commitment for the 04  -year

              6   as well as the current level of funding, the exact  amount.

              7             I think it needs to be made clear, as the  staff

              8   has recommended, and looks like an excellent way of  doing

              9   this -- made clear to the region and to this new  coordinator

            10    and to the RAG that's trying to make all kinds of  changes

            11    that this amount can be allocated by the region in the most

            12    effective way possible to chart this new course for the region.

            13             Number two,  to recommend that the director of

            14    RLII>S be given the authority,to allocate up to 100,000 to

            15    this region during the 04 year if it is determined by staff

            16    that this can be effectively used for regional and  program

            17    development. That total, were it to be given, would  be  up

            18    to an amount then of about $580,000. Regional  and  program

            19    development certainly deserves this.  They have the programs,

            20    the staff -- and those of us who recall the projects  that

            21    are already in operation, we are not too impressed with  some

            22    of them, some of them have had minimal effectiveness in

            23    various ways, but this would put the RAG and the director  on

            24    the basis of an opportunity to move ahead and change.
       eportets,  Inc.
                            I feel that it is absolutely crucial that RMPS




                                                                             141


              I  'move with this individual in every way possible in terms

                  of whatever assistance can be given.

              3             We would also disapprove the developmental component.

              4             And I would like to have Judy, any of the other people

              5   who are familiar with the region, to respond to this since there
              6   was not a site visit, anything that I might have missed in the

              7   recommendation.

              8             MRS. SILSBEE:  You didn't miss anything.  Dr. Ichter

              9   is on board.  I understand he does have a Hershey faculty
             10   appointment, and as soon as he gets his feet wet and  goes  to

             11   St. Louis he wants to talk to Dr. Margulies.

             12             DR. MAYER:   All right, comments?

             1 3            1 have one to mal4ie, I would just like to suggest

             -.14 that in recommendation number two, that is the availability

             15   of iOO,000 in the 04 year, that it be clear that in making

             16   those dollars available there  is no implied.commitment in the

             17   05 year above and beyond the $580,000 issue.  Because what
             18   I am saying is if they com,.nit.that, all tha t 100,000 in the
             19   last quarter, you know,  in theory one could be caught in  the
             20   begining of the 05-year with an $880,000 kind  of  commitment,
             21   and I just think care needs to be given in dealing with that.

             @22            DR. SCIIERLIS:  For my own information would

             23   Dr. White comment on project number 28?

             24             DR. WHITE:   Later.
       Reporters,  Inc.
             25             DR. SCHE@RLIS:  What's tliv-t?







                             DR. WHITE   Later.  I haven't looked at it.

              2              DR. SCIIERLIS:  It's just a small paragraph.

              3              DR. WHITE:  I don't even see it.

              4              DR. MAYER:  What page are -you on?

              5              DR. SCHERLIS:  Last page of the orange sheets.

              6              DR. WHITE:  Ridiculous.


              7              DR. SCHERLIS:  What?

              8              DR. IYHIIT, Ridiculous.

              9              DR. SCI-EERLIS:  Thank you.

              10             DR. PEITRY:  These ar e the recommendations that have

              11  been made  also by -- an  I recall this specifically -- by

              12  the Last program.   This was the project,..'if -you go back

              1.@ into this region, that concentrated completely on
              14  coronary ani all ti,ese var-,tus -- and- we have been criticizing

              15  them right down the line.  This is one of the reasons why

              16  in the committing of the money we are saying for god's sake,

              17  let's look at new objectives, new-goals, in terms of what you

              18  are coming up with.

              19    .*
                             DR. SCHERLIS:  In view of Dr. White Is rather

              20  prolonged discussion, would it be incumbent upon us to say

              21  since we are attaching no sti,ings to the funds, we nevertheless

              22  do not think that project number 28 should be funded under

              23  any circumstances?

              @24            DR. PERRY:  I would-be happy to have that included.
  :e   f Repotters,  Inc.
              25             DR. SC@RLIS:  I gather this is Dr. White's





                                                                            J.



                  reaction,  Is that correct?

              2             'DR. VIHITE: I think it, is.
              3              DR. PERRY:  A footnote, "ridiculous."
              4              DR. WtkYER:  All right, additional comments?
                             I gather you are moving then the recommendations of
              5

              6   SARP.
              7              DR. PERRY:  (Nods.)  So'move.
              8              DR. MAYER:  All right.  Further discussion?

              9              All those in favor?
             10              (Chorus of "ayes.")

             11              Opposed?

             12              (No response.)
             13              MRS. KYTTLE,:  This includes affirmation of the

             14    rating?
             15              DR. PERRY:  I have not had a chance to look at the
             16    rating. That was 244, if we  look at this on the scale this
             17    places them in the two and a-half C category.  Unless therets
             18    some recommendation for change I would certain reaffirm

             19    that rating.
             20              DR. MAYER:  All right, are -you willing to accept
             21    then the ratirg, overall rating granted by SARP?

             22              DR. PERRY:  I am.
             23              DR. IIAYER: I see heads going up and down instead

             24    of sideways, so we will assume that we have consensus.

  :e   I Reporters,  Inc.
             25              I would like to then move to Intermountain,


















                a                                                              0                                                             0




                                                                               144



                    Elizabeth.

               2              MISS KERR:  I would 'again make it clear I have not'

               3    visited Intermountain, nor have I before reviewed  any  of

               4    their materials. The secondary reporter is  not  here,  Mr.

               5    Spellman.    don't know whether he had or not.   But I


               6    would like to have--


               7              DR. MAYER:  Just docunient,in the record that

               8    Sister Ann is leaving.

               9              MISS KERR:  So I would hope that Harold O'Flaherty

              10    and Dick Clanton, who are familiar with the area,  or  any

              11    others around this table who have made visits,  will  feel

              12    free to put in anything that they would desire when I

              13    get through.

              14              The Intermountain Regional Medical Program,   the

              15    grantee institution is the University of Utah.  The Regional

              16    Medical Program consists of a geographical area  of  Utah,

              17    parts of Nevada, Montana, Idaho, Wyoming,  Colorado,  which

              18    covers 546,000 miles, and I think we must keep this in mind

              19    when we look at the core and a few other things  that  seem

              20    to be quite sizeable.

              21              Thei,e are two and aquarter million people, about

              22    fifty percent of whom live in urban areas,  and  therefore

              23    the greater portion is.arid, mountainous, sparsely populated.

              24              The Intermountain  Reg.ional Medical Program is
        Repotters,  Inc.
              25    presently in its fifth operational year.  It is not within







              I   a triennium.  It  is presently funded at direct cost of

              2   $2,478,645, with  an indirect cost of $904,419, which kind

              3   of startled me.   And they are funded through March 31st of

              4   172.


              5             This particular anniversary application re-quests

              6   continued support for core and 21 projects ongoing, support

              7   for initiation of seven new projects, a developmental component,

              8   totaling $3,025,219.

              9             This anniversary proposal had a staff  review  on  the

             10   14th of December and was reviewed by  Staff  Anniversary  Review

             11   Panel oh the 20th of December, and recommended approval.

             12             As far as the goals, objectives  and priorities of

             13   this region are concerned, they certainly used the right

             14   words, and are therefore in writing compatible with national

             15   priorities. But the  relationship  of.the  operational  projects

             16   to the goals and objectives are rather fuzzy at this time.

             17             It appears that the-goals, objectives and

             18   priorities speak to such factors as improving health care

             19   delivery, accessability, and so forth, but  on closer

             20   speculation most of the projects are  still  basically  oriented

             21   to continuing education.

             22             Apparently Intermountain Regional Medical Program

             23   continues to demonstrate outstanding progress.  Each of the

             24   projects that have been funded appear to be accomplish their
        eporters,  Inc.
             25   stated  objectives.







                            It is felt that the present coordinator, Dr.

               2  Satovick, has really done an outstanding job in terms i3f

               3  filling the position of the former coordinator and in  terms

               4  of preserving and even strengthening the autonomy of the

               5  Regional Medical Program.  There have been a minimum of

               6  problems in the transition and in the program as it is ongoing.

               7           Apparently they have a very  strong  staff.  There

               8  has been considerable improvement in involving the  outside

               9  organizations in planning and in carrying out program components,

             10             I go to the core staff, which.consists of 30

             11   people, most of whom are full time, but all of whom are  at

             12   least 60 percent time or more.  Twent,y-four of core staff

             13   are men, and their are three Orientals.

             14            Then in looking at.RAG, let me say first  that  RAG

             15   consists of 30 people.  Now they still have 30 people on

             16   their RAG, although the representation has been changed

             17   to involve more consumer input, and just a slight token,  I

             18   should say, of minority representation, in that on the  RAG

             19   they have at the moment 28 active appointments, 23 of  whom

             20   are men and two with Spanish surnames. But I think  we  need

             21   to say here that in this particular area we do not find as man3

             22   blacks and we do not find as many chicanos, and So forth, so

             23   perhaps we have to take this in consideration, too, when  we

             24   are looking at the minority representation.  But it does look
  -JOR,porters,  Inc.
             25   a little low.






                             The RAG membership, though it  has  become  more

              2    representative of the community at large and is seemingly better

              3    informed about the role and the program  of  the  Regional

              4    Medical Program, there is still concern that the RAG is not

              5    as active as it would like to be seen.  The comment here was

              6    made that this is duo primarily to the fact that there is

              7    difficulty in the RAG membership relating with core staff.

              8    This was not enlarged upon, and somebody may want  to  speak  to

              9    this.  I assumed that because the core is active, is

             10    aggressive, is able, that perhaps the RAG sits  back  and  isn't

             11    quite as prominent in docisionmaking as perhaps  we  would  like

             12    to see them.
             13,             Tiie education planning'an-I evaluation  section

             14    appears to have a preat deal of vi sibility.  Their major

             15    contribution.has been to @sist those people directing

             .16   education-..I projects, and they he-ve been particularly helpful

             17    in the specifications of educational objectives and in

             18    evaluating educational programs.

             19              However, when we look at  the  total  evaluation

             20    program it seems that the majority of their work has been done

             21    in the area of educational programs, and little in'total

             22    program evaluation.

             23              Thcugh they do have some hard data, it appears

             24    that the region has established a systematic process for painnin,

       Repo(ters,  Inc.
             25    proposals or developing propoqui objectives -- it does not





                   appear that they have used these data to establish their

               2   priorities.
               3             The region has made considerable progress in the

               4   development of subregional centers despite budgetary
               5   cutbacks, and they at the present momemt have apparently what
               6   individuals they title coordinators in Grand Junction,
               7   Colorado, Pocatello, Idaho, and Provo, Utah.  In these three

               8   areas it is foreseen that there is great potential for area

               9   health education center development, and they are looking in.

               10
                   this direction.
               11            Apparently the Regional Medical Program is directly

               12  involved with many activities of other health planning

               1 3 agencies in the region, though it se0iiis that again CHP

               1 4
                   perhaps because of the visibility and the action and the
               15  positive movement of the core staff of RMP seems not to be
               1 6 as active as one would hope that the CIIP might be.

               1 7           The ongoing projects, of which there are  21, two

               18
                   of which are to be phased out at the end of March,  are indeed

               19
                   quite categorically oriented and continuing education

               20  oriented.

               21            The new projects, the seven hew proposed projects

               22
                   seem to fall more in line with the new direction that RMP

               23
                   is taking and is encouraging.

               24            In looking at the strengths  of this region,
  ,e   I Reporters,  Inc.
               25  certainly this new coordinator is leaving his mark at the





                  present time, and it is predicted that he will continue to.
              2   It is felt he has good administrative ability.  It was felt

              3   that the core staff is one with.a high level of competency

              4   and hard working, with broad vision.

              5             The development of subregional centers which may

              6   Lead to ABEC'S, at least there is activity out in these

              7   centers that is active and has visibility, and this, too,

              8   would be considered a strength.

              9
                            The Regional Medical program has had an impact on

              10  the improvement uf care of the people in the region.
              11  There are a few areas, ',)wever, that need to be strengthened.

              12            As I mentioned before, at the present moment it

              13
                  still appears that their overall pr"gram is still pretty

              14
                  much projnct orien'-ed.
              15            If some of you caught my early remarks,,you will notc

              16  that the indirect costs of $904,4.L9, recognizing that we have
              17  nothing to do about this', but it is a sizeable amount of
              18  indirect cost, and it is up to sixty some percent -- I have

              19  forgotten just the exact amount.

              20
                            Again they need to strengthen the relationships and

              21
                  show them more clearly betwep-n their goals, objectives and

              22
                  priorities as they have writ,".-en them in light of the new
              23  mission and what really actually exists at the moment.

              24
                            Evaluation procedures need to be improved in other
       I Repoftets,  Inc.
              25  areas than that in which they are doing an acceptable job,







               I  which is the educational evaluation.

               2            The region has not done too well to seek out other

               3  sources of support for the continuation of its projects.

               4            The staff group in its review -- and I concur with

               5  this -- is that rather than the 3,025,000 which was requested

               6  for the sixth operational year, because of the areals needs to

               7  strengthen their activities in those areas  identified,  and

               8  yet to give them an opportunity to do so, it was  felt  that

               9  the funding allocation be kept at the same level as  it  was

             10   last year rather than to increase it to.the $3,025,000,

             11   which would remain then 9.t $2,478,650.  This was the

             12   recommendation of the staff.  It also was the recommendation

             13   of SA11P, and I would go along with .'iiis.

             14             The staf-" review recommended $75,000 for the

             15   developmental component.  The SARP group -- and this was

             16   the only area in which there was any marked difference of

             17   opinion relative to their reviews-- the SARP group recommends

             18   that this region perhaps if it had more flexibility with more

             19   developmental funds could be a little bit more effective

             20   in moving ahead to accomplish the strengthening of those areas

             21   identified as needing this, and recommended ten  percent  of

             22   the former level of direct fLnding, which comes then to

             23   $247,864.

             24             As a reviewer with no more familiarity than I
       Reporters,  Inc.
             25   have with this area, I agree .-hey have many strengths.  I





                                      think  they  have  to  take  a  hard  look  at  turninr,  the  corner
                             2        further  and  looking  at  their  projects  and  relating  them

                             3        to their new priorities.
                             4                             And  perhaps  I  zu-a  getting  just  a  little  bit  squeamish,
                                      because as I sit on this committee at times I think -- and 1
                             5
                             6        use the word "hard-nosed," but I don't really mean it,that

                             7        derogatorily, but I think sometimes we get a little generous
                             8        and then a litttle bit later wonder if we really did the

                             9        right thing.
                            I 0                            So what I am saying                      is I personally would rather
                            11        myself recommend the developmental component which would be

                            12        a part of the total level of funding at $150,000 rather

                            13        than the $247,00.  But I do recommend the developmental

                            14        component.               I recommend it at that level.

                            1 5                            1 would be :glad to hear from the rest of you, and

                            16        I  would  be  willing  to  consider  changing  my  mind.

                            1  7                           DR. ILKYL-R:  Comments fro,.u staff?

                            18                             VOICE,:  I would only comment that the rationale

                            19        for holding the developmental component at $75,000 was to

                            20        maintain the existing level across the board.  That was the

                            21        only rationale.

                           .22                             MISS KERR:  Yes, and I think this is what I

                            23        assumed.  Yet I also gathered from the SARP report that that

                            24        review group felt that it might-give them opportunity to move

    e           Repofters,  Inc.
                            25        out faster to do things if they had more.







                                            I'm sorry.    w
                             MRS. KYTTLE:                  as involved in something

              2     else and Missed part of your conversation. Are  you  on

              3     item 2 of the things that require committee action?  Says

              4     Council approval at a $75,000 limit, staff  recommended

              5     that that limit be maintained, but the staff  anniversary

              6     review panel recommended that the allowable ten percent be

              7     approved within the 2.4 recommended.  Are you saying    and

              8     1 missed it -- that you do go along with recommendation

              9     number two or you do not?

              10             DR. MAYER:   N , she is saying.--

              11             MISS ]ORR:  I compromise.

              12             DR. MAYER:  She is saying  a third proposal, which

              13    is to limit it to 150,000.

              14             MISS KERR: I believe that the  75,000  may  keep

              15    them down a little bit too much.  I believe the 247,000 is

              16    probably more than is necessary to get them to move until

              17    such time as we can look at it again.

              18             MRS. KYTTLE: Mike Posta, who  isn't  here  today

              19,   be@ause of illness, and who is chief of the desk under which

              20    this region-falls, had a conversation with the  region,
              21    part of which I participated in, because the region was callirg

              22    to ask what latitude it had to redesign and put  monies

              23    into different places that had generated since this appii-

              24
                    cation had been developed, and part of their concern was that
   101 Repoitets,  Inc.
              25    they had opportunities to move in developmental component






                   kinds of ways. And, curiously, this region  has  funded  a
               2   great deal of its development component through grant
               3   generated income.  One large component that has generated thi3
               4   income has generated so much that it is phasing out  and  it
               5   is continuing most of its activities under its own  steaii
               6   and others.  And when that component went they were going

               7   to have to redesign some of their inonies.to fund even  up

               8   to the $75,000 approval that they had been given, because

               9   the grant generated income that had substantiated  the  fund

               10  was going around 58-60,000 dollars,

               11            Mike Posta tells me that they were  talking  about

               12  activities that would more than double the $58,000 that
               13  they had.  Now whether they would double the 75,000 I don't

               14  know.

               15            Did he have a chance to get into that with you,

               16  Dick?

               17            VOICE:  No, he didn't.

               18            MRS. KYTTLE:  So apparently the region at this time

               19  stands ready to use about 125,000.

               20            DR. MAYER., Which would be within  the  $i5o"ooo

               21  restraint ttiEt is being suggested.

               22            MISS KERR:   I guess I had the feeling we have gone

               23  on promises so long, but.you know -- I 'm really questioning

               24  whether we should do that as much as we have.  And this
  (1-01 Reporteis,  Inc.
               25  gives them more latitude than they %,ouid have had with  the






                   75vOOO.

               2              DR. MAYER:  Yes, Leonard.
   0
               3              DR. SCIIERLIS:  I hate to bring up individual

               4   projects,  but there is a small bookkeeping item of $333,000

               5   for multiphasic screening with a comment made in the SARP

               6   review that the slowness of the multiphasic screening

               7   activity raised doubt about the relationships between the

               8   medical school, county and community it was designed to serve,

               9   and the IRMP.

              10              I was wondering do 'you have any comments upon how

              11   well that  program is moving or what it means in terms of

              12   the present attitudes toward multiphasic screening?  I know

              13   it is only a small iter, in their to4-al budget.

              14              DR. MAYER:  Dick, would you care to comment?

              15              IM, CLA-MPTON:  iLtis was also a concern of staff.
              161             DR. SCHERLIS:  Could staff tell us a little bit

              17   about it?
              18              MR. CLAMPTON:  The indication is they hope to

              19   begin operations in this  project as of this month, January

              20   of 172.  However--

              21              DR. SCHERLIS:  This is the third -year, isn't it?


              22              DR. MAYE-R:  No.

              23              @IR. CLAMPTON: Well, they have been toolin,-, up during

              24   that period, but they will be going operationally supposedly

  E!   I Reporters,  Inc.
              25   this month.  This has all been a tooling up process.






                              DR. SCIIERLIS: Have they already  spent  two  times

                @2  333 prior to this third year?  What kinds of tools are   they
                3   tooling up?  I don't mean to be facetious on this, but   it's

                4   obvious that we are talking about an expenditure that is

                5   going to run a million dollars by the time it is completed,

                6   I hate to hear at this point in time that  they  are  tooling

                7   up.

                8             ims. KYITLE,: This is part  of  the  Intermountain

                9   i)rograxn that has generated carryover every year.  They money

                10  was awarded, and I believe historically  they  had  troubles

                11 with the county on zonir- exceptions,  and  that  carried  over
                121 one year because they needed to rennovate and  werenl!t  very
                13  successful with exceptions that they needed.

                14            T know tie chart- show that monie s were awarded, bul

                15  they  were not expended. They  were  carried  over.  Some  of

                16  the  money reinvested in this pro4ect is the same money

                17  that was awarded the year before.  Not all; some.

                18            DR. SCHERLIS:   I would suggest as a logistical

                19
                    pi y  that this be a device that every  RMP  follow;  namely,
                20  to have an expensive project funded, because  it  then  gives

                21
                    a utilizable source of funds to be  used  for  developmental

                22  component.

                23
                1             MRS. KYTRLE: I think it was a  model  cities  joint

                24
                    endeavor.
  le Oal      Repoiteis, Inc.
                25            MR. CHA@IBLISS:  Yes, I think the committee should




                                                                             156


              I   know that, as Mrs. K-yttle points out, this was a model cities

              2   project.

              3             We have undergone some concern about  this  project

              4   not getting movin- before now.  It relates very directly

              5   to the same kind of problem that was encountered  at  Meharry

              6   of muitiphasic screening,  And here again, if you recall,

              7   there is a policy determination on the  multiph@-ic  screening

              8   to see how they are going to move before we get  much  further

              9   into this, and we are beginning, I believe, to see some of

             10   these answers fail out now.


             11
                            DR. MAYER:  A  you recall, Leonard, when we approved
             121  that one we approved it with really that thought in mind,
             13   and it looked like one of the better multiphasic screening

             14   Proposals that we l.ad, and 4t also was involved in a

             15,  joint effort with model cities in terms of the population

             16   served, et cetera, et cetera. But -your point is  well  taken

             17   about the built in developmental component.

             18             DR. SCHERLIS: I am just wondering  what  should  we

             19   do ".t this point in time about the third year coming up,  let

             20   it go at 333? What was SARP's reaction  to  this?  Aside  from

             21   having some negative gut reaction, what logistical--

             22             IIR. CHAIFBLISS:  MAybe I can share our reaction with

             23   you.  That sentence that you read does encapsulate our

             24   feeling here, and we raised a-further policy issue about
   ORepotteis,  Inc.
             25   the interface between technology and service.   That wELs




                                                                             157



                   encompassed in that discussion.

              2              DR. SCliERLIS: I guess the real meaning of my

              3    question more directly is do you translate that into  'your

              4    final dollar and cents recommendation for the region.  Was

              5    that part of -your consideration or not?  Or did  ou just

              6    say we will keep that at 333,000?  1 was curious.
              7              MRS. ICYTTLE:  With a funding level recommended of
              8    2.4 something is going to have io give.  I don't know whether

              9    it will give out of muitiph,,tsic screening or not.

             10                                             gative to decide,
                             MISS YXRR:  This is their prero

             11    isn't it?
             121             DR. BESS:  But I wonder if something shouldn't
                   be said about this in the advice letter, because  again  if

             14    .:rou loob, at everything OISL this seems to be funded
             15    disproportionately high.

             16              DR. AIAYEil: The question that I had is what  are

             17    the implications of the recommendation, and I am asking it

             is    vis-a-vis the comments tiiat Dr. Margulies made yesterday

             19    relative to potential add on dollars going in.  If we took

             20    no action the region's request for the 06 -year -- well, the

             21    region's approved level for -'@he 06 -year by Council as it now
             22    exists on a previous action in the triennium was 2,687,000,

             23    and we are now recommending 2,478,000 as a  funding  level.

             24    What does that mean in terms of recommendation that goes to
  @-01 Reportets,  Inc.
             25    Council, and is this really a suggestion that you lower the





                                                                               .L.JO



                I  previous Council approval of the  06  year  by  approximately

                2  200,000 or not?   I just need to understand the implications

                3  of the motion.

                4             MRS. KYTTLE:   It Is afunding level, not an approved


                5  level that we are making,

                6             DR. MAYER:   All right, fine.  Did  you  hear  the

                7  response,  that it was a funding level we are talking about

                8  and not--

                9             DR. BESSON: I think the  point  of  this  question

              .10  really revolves about how these figures.were arrived at,

              11   and it really takes a little bit  of  scrutiny  to  determine
              121  how 3.025 is cut down to 2.478.  But it seems to me that
                   that figure is arrived at not arbitrarily, but by    looking over

              14   each individual pr@ject an-' saying this is not appropriate

              15   and this is..

              16              Am I incorrect in that, Lorraine?

              17
                              MRS. KYTTLE: Well, I'm  not  chairman  of  SARP.  I'm

              18   Exec Sec of SARP, but this is how I recz@,11 the  figLre  was

              19   ar4ived at. Some calculations  were  instituted,  and  when  you

              20   started adding this and subtracting that  the  members  of  SARP

              21   concluded finally that if you sent them the message that

              22   two projects that have been criticized before stand criticized

              23   again, and if you send them the message that they have turned

              24   off one that we wanted turned off, and if you send them the
  :e   1 Repotters,  Inc.
              25   message that some of the new activities that they are






                I  proposing are looked upon much more favorably than some

                2  of the continuations like, I believe it  was  project  i8,  and

                3  say you get the same amount of-money next-year as you had

                4  last year, and within that framework to make your decisions,

                5  that they felt they were coming to  about  the  same  amount

                6  of money.

                7             DR. BESSON: Well, it would  be  very  heopful  if

                8  we could have the basis on which SARP arrives at its funding

                9  level because this is really the way we operate here,    too.

              10   We start with a number and then add and subtract to it.  Now

              11   as I look over the ite,q requiring committee action, I see

              12   that there are suggestions based  on  approval  or  disapproval

              13
                   of individual projects, and as I hove looked over some of

              14
                   the now prnjGcts ',hat you gay are more in keeping with

              15
                   the new missions I may disagree  with  some  of  those.  But
              161
                   I think in the light of the  question  raised  about  multi-

              17
                  'phasic screening it would be  important  for  review  committee

              18   to know whether that was "deleted" or whether that was

              19   a!-ov!ed to stand.

              20
                              MR. CHfilIBLISS:  It was allowed to stand.

              21
                              DR. BESSON:  Well, then it might be appropriate for

              22   us to know a little bit morG detail as to how SARP arrived
              23   at its funding level recommended.  Maybe that's a loss to

              24
                   us now, but in the future I think it would be helpful.
       I Reporters,  Inc.
              25              DR. MAYER:   I thini, the point you are making is  a





                  valid one, Jerry, and I would like to suggest that it really

              2   would be helpful to this committee that when SARP does
              3   arrive at recommendations concerning funding level that
              4   you know, we went through this process just now, we have been
              5   going through that process for six years -iow, and we would
              6   hope that something akin to -- if SARP is going to replace

              7   our activities, that something akin to the procedures
              8   being used here are also being used there, and that  that

              9   information be brought to us.

              10            Yes, Harold, do 'you want to comment?
              11            MR. O'FLAHERTY:  I was going to say in response to

              12  the question there has been a concern, particularly  over
              13  the last year, with the Intermountain R@IP that they  ave
              14  shown a very lack of being able to make any hard  funding
              15  decisions.  A lot of their ideas --.as has been pointed out,
              16  they have come up with new ideas that are valid, they have
              17  a lot of palatability in the region, but nevertheless we have
              18  activities that have been going on out there for up to five

              19  years, and we felt that to increase the funding level over
              20  this past year would in some ways put a commendation to

              21  this process.

              22
                            The group did not feel that they were ready, the
              23  Regional Advisory Group was ready to make some of these hard
              24  decisions that had to be made in this region and to turn off
  e -01 Reporters,  Inc.
              25  some of these old activities that should have demonstrated






                  their utility or nonutility to the s stem at this juncture.
                                                      y

              2   So we felt it would be a disservice almost to aggrandize

              3   them in this capacity to add to the past kear's level.

              4             DR. NIAYE, R: I think one can just look at the fact

              5   that the dollars are precisely the same as last year and

              6   assume that. I think the issue is we would hope  that  SARP

              7   is arriving at those conclusions on a more exploicit  basis

              8   by looking at projects and finding out what projects they

              9   think ought to be phased out, et cetera, et cetera, and then

             10   adding on those that need to be approved, and that level

             11   may not be 2.4, that level might bei.9 million or 2.39

             12   million or some other such figure.  And it is that explicit-

             13   ness that I think we would like to see incorporated into the

             14   SARP process as well as our own.

             15             Is that, Jerry, adequate paraphrasing?

             16             DR. BESSON:  Well, I know it is incorporated in

             17       SARP thinking, but I think it should be made  available

             18   to review committee. I'm asking that it be  made  explicit.

             19             DR. MAYER:  Well, I was taking it one step further,

             20   assuming that the level came out exactly right, they didn't

             21   go through the process that we have gone through.  Now

             22   that's just putting two and two together. That may  not  be

             23   right.  So I think there's a second component to it,

             24   not only should we know about it, we think it should be done.
       Reporters,  Inc.
             25             Yes, Elizabeth.
               I







                            MISS KERR:  I Would like to also make two more


              2   comments.

              3             In looking at the mean weights given by the review

              4  panel they are strikingly similar  to what I would have  felt

              5   viDs reasonable, and you all can make your own decisions,

              6   having read the material.  But I think they point out very well

              7   where the weaknesses are.  And it shows it a little bit above

              8   satisfactory, and that's about where I would, as a  reviewer

              9   on paper, put it.

             10             I also want to make one other.comment; since  this

             11   is our first go through after having a SARP procedure, to

             12   me it was very helpful.  I do agree with what you are saying,

             13   however, Jerry, that some of these details maybe if shared

             14   with us Would be good. But I do want to say.it  does  appear

             15   to me that the SARP procedure is helpful to the reviewers.

             16             DR. MAYER: All right, further comments?

             17             DR. THURMP.N: I second the motion for 150,000.

             18             DR. MAYER: So what we are suggesting is  the  SARP

             19  recommendations with the exception that instead of not to

             20  exceed ten percent under item 2 of the recommendation we

             21   are saying not to exceed $150,000 in the 05 year vis-a-vis

             22   the developmental component.

             23             All right, further comnietits?

             24             Yes, Jerry.
  :e   I Repottets,  Inc.
             25             DR. BESSON:. I also Wonder a little bit about  the





                                                                              Iva


                   letters of transmittal of our decisions here. if  the  area  is

                2 to have a litie bit of a sense of what  the  messages  arb@that

                3  we arc transmitting they have to be something less than

                4  cryptic, and I think they may be quite cryptic if we just give

                5  them a number without backing up how we arrived at the number.

                6  The region may take refuge in considering that these ar e  just

                7  funding constraints because RMPS doesn't have enough money this

                8  year and say "well, we are doing exactly what's expected of us,

                9  and if only R!,APS had a little more money we could have some

               10  more," but that may not be what .,,e intend.

               11            Is there any way that review committee can have some

               12  feedback as to exactly what's told the region after we come

               13 to sort of very thearia.L decision here and say  well,  somebody

               14  is going to let the region know what the messages are

               15  that we are transmitting.

               16            MRS. KYITLE: Dr. Besson, we had copies  of  all  the

               17  advice letters from the last review cycle ready, and I had hopeJ

               18 we would got them ready to give them to you today,  and  it  is

                   only that the same people are involved in ail of this are

               20  the same people that were invol ved in all that that  we  didn't

               21  get them to you. If you don't catch a very  fast  train  going

               22  home it will be there waiting for-you, copies of the advice

               23  letters that generated from the last cycle.

               24            MR. CffiUfl3LISS: If I may add on to that, that is
  'Cleat Repofteis,  Inc.
               25  now a matter of policy, that the members of the Advisory






                                                                   4

                   C@uncil, the 'members of the site visit team,- and the

               2   consultants, along with the chairman of the RAG and the

               3   granl-lee institution, will get copies of the post Council advice

               4   letters.  So this information will be widely disseminated.

               5             DR. BESSON: Will those letters of advice

               6   incorporate the kinds of specific comments that we make about

               7   projects, that project number 28 for Susquehanna Valley

               8   is ridiculous?

               9             MR. CHA-@IBLISS:  Yes, indeed,

             10              DR. BESSON: I mean maybe dressed up  a  little  bit.

             11              MR. CHMU3LISS:  Vie won't say it in that way, but

             12    we will make it very clear to them, your concerns.

             13              DR. MAYER:  It will also say if,you have  any

             14    questions about what that word means just write Dr. Philip

             15    White, Marquette University.

             16              (Laughter.)

             17
                             MISS KERR: One of-the things  we  haven't  discussed

             18    at ail is the mini'report of the mini-SARP review committee

             19    on'renal disease application which is incorporated in the

             20    total amount, but I don't want to lot it pass by  without  any

             21    reference to it.  And that is that on 25B you will notice

             22
                   in the peach colored sheets -- 25A, rather, is control of chroii

             23
                   renal disease, and the part of this in the application  is  an
             24    ongoing program, but the committee wished to point out
        Reporters,  Inc.
             25    it says "the directions the regions appears to be going






               I   appear to be nonproductive, and would give  a  low  rating

               2   if so asked regarding this activit,y.@, Furthermore, the'
   0
               3   progress report is not  satisfactory because of its incomplete-
   0
               4   ness and brevity.  Relative to 25B in the ALG portion, it

               5   would have to be deferred pending the R@@o policy decision on

               6   this.

               7             Relative to section 25B, again  it  indicates  that

               8   there has been some new information fed into  RMPS  as  of

               9   December 9th relative to the activities for the renal control,

              10   and I do not have this information.

              11         @IR. GROSS:  The new information  related only to

              12   supplemental activities, namely, 25B.   It  was  basically

              13   a more detailed description of what they  were  applying  for

              14   and the reasons for it.  If you would like, at the present timD

              15   I can give you what my reactions were as a staff reviewer

              16   in more detail of the supplemental activity,

              17             My recommendations were that this not be approved

              18   as.well because of the following reasons.  First of all, it

              19   appeared -- first of all, what was requested  was  the  funds

              20   for hiring an organ profusion technician as well as an organ

              21   procurement technician, and thirdly, the  ALG  aspects  of

              22   the program.  The ALG might be mentioned first   because  the

              23
                   decision there is a little simpler.  R.@IPS has yet to make'a

              24   policy decision on that.  I think any decision regarding
  e    I Repotters, Inc.
              25   funding of that has to be deferred.






                             The objections that I had to the first two  portions,

              2    tiD profusion technician and the organ procurement  technician,

              3    were not that such a need is probably not justified in an

              4    absolute sense, but that poor planning I think was

              5    demonstrated in the fact that these profusion machines

              6    had already been purchased, and it has been clearly

              7    demonstrated that the ancillary personnel for such a  profusion

              8    approach to organ procurement are also a necessary part

              9    and should have been employed initially, and why they would

              10   have purchased the machine and now are.requesting the

              1 1  necessar,%, personnel is @yond me,

              12             A.nd secondly, that this sort of piecemeal support

                   of a program "- I mean asking for supplemental activity

              14   and just v,,intihg, you irnol- a couple of desks sort of thing,  c

              15   coupie of technicians here and there. without clear evidence

              16   of how they are going to be utilized, was lacking.

              17             Thirdly, it has been demonstrated in many areas

              18   that third party support can be generated for organ

              19   procurement if a single cost isid3ntified.  Many insurance

              20   carriers are now in several areas willing to pick up the tn-b.

              21   for this.  The precedent haE- been set.  So I am not sure

              22   the actual fiscal need for this is there.

              23             And fourthly, in their application they did not

              24   make any mention of why RMPS-specificall-y was needed for
  C,Oal Repottets,  Inc.
              2 5  support of these individuals.  In other words, why other

                I







                   so      of funding, of which there are many  potential  ones,
                     urces


              2    weren't available.

              3              So for all of these reasons, pririarily poor planning

              4    reasons and poor justification reasons, I didn't  think  that

              5    25B was worthy of  approval.

              6              DR. IDAYER:  Thank you, Dr. Gross..

              7              MISS  KERR:  Thank you, This  is  helpful.  I  don't

              8    think this alters the  level of funding we are recommending, bu,:

              9    1 am wondering if we don't want to in the advice  letter,  or

              10   least include in this some of our discussion relative to this.

              11             DR. hlAYER: lYell, I assume that -- my  assumption

              12   is that advice letter comes not only from information surfaced

              13   here, but in these instances by SARP and elsewhere.
              14             Yeso Joe.

              15             DR. HESS:  I had a question that may have relevance

              16   for the advice letter.  Did you a-i you reviewed the

              17   application have the feeling that-they are  really  reaching

              18   out into some of the far areas away from Salt Lake City

              19   to address some of the problems in Wyoming, Montana, et
              20   cetera?  The majority of these projects are University of
              21   Utah based and Salt Lake City focused, many of them are,
              .22  although they have established some regional off'          ently
                                                                   ices   appar

              23   in trio or three other locations--

              24
                             MISS KERR:  Urban areLqs again.
  ,e   1 Repottets, Inc.
              25             DR. HESS:  Yes.  But in this area some of the real




                                                                           168


               1  problenrare rural problems.  And my question is are they

               2  really making an honest to good ness attempt to cover the

               3  problems in the total region for which they are responsible.

               4             MISS ICERR:  If -you are asking for my reaction, I

               5  feel they are not getting to the rural areas.  There is not

               6  the evidence that they are.

               7             DR. HESS: What aboutthe staff reviewers?

               8             DR. @IAYER:  Someone from staff want to make a


               9  comment?

             10              The question is to what degree are they  relating

             11   to the rural component of Intermountain region.

             12              MR. CHk@.U3LISS:  Out of SARP came the view that you

             13   hold, that there needs to be much more outreac   n  erms

             14   of their program.

             15              DR. HESS:  If that is indeed true I would suggest

             16   a recommendation to that effect be incorporated in the


             17   advice letter.

             18              DR. MAYER:  Ali right, everyone understand the

             19   motion?


             20              All those in favor?

             21              (Chorus of "ayes.")

             22              Opposed?

             23              (No response.)

             24              Thank you, Elizabeth.
       I Repoitets,  Inc.
             25              We move on then to Alabama.

















                                                                                                                                          es







               I              DR. BESSON:  We should be able to complete Alaban-a
               2    in five minutes. it doesn't require  any  committee  action.

               3              DR. MAYER:  It didn't take the big eight much longei


               4    either, Jerry.

               5              (Laughter.)


               6              DR. BESSON:   But I will just give  the  committee

               7    a bird's eye view of the Alaba-sna program, and I am interested

               8    in knowing why SARP felt that -- it took the option that'


               9    this didn't review review committee action and others in


              10    the same general, category did, not that I doh't share

              I I   SARP's view, but in jupt elucidating the modus  operandi  of

              12    Anniversary Review CoAnmittee.

              13              '.ehis is Alabamals first ..iniversary application in

              14    the triennium.. Tii region is requesting some  two  million.

                    The Council has previously approved.at the time of the trienn'
              15                                                                   lull


              16    application for the upcoming year 1.6 million, and the Staff

              17    Anniversary Review Panel recommends 1.15 million.

              18              1 won't detail the -- oh, the 1.15 million is made

              19    up,-- the request is made up of continuation of core for

              20    the fourth year, six ongoing projects, two approved and

              21    unfunded projects, and eight new unfunded projects.  They

              22    are not new, they had previously been approved.

              23              Tha major concern that staff has with-the Alabama

              24    region is that in spite of the fact that there is  a  strong
  @A*Reportefs, Inc.
              25    RAG and that their priorities are well ordered, they have





                    great difficulty in relating projects to priorities, and

               2    the director feels that a staff tactical review of the

               3    Alabama region is necessary.

               4              In looking over the program I concur with SPRP's

               5    recommendation that the committee has no need for action.

               6              DR. MAYER: Further comments from those that

               7    participated in the SARP review on the staff?

               8              Anyone want to coriment on Dr. Margulies' comments,

               9    which  was simply that that letter of advice was very

              10    important and that some of these issues needed  to get

                    incorporated in it, perhaps even some direct staff discussion.

              12              Comments from the committee?

              13              Jerry, would you phrase your question again for

              14    staff,  or I can try.to paraphrase it.

              15              DR. BVSSON:  I have no question.

              16              DR. @LKYER:  Well, I thought the question -- at least

              17    I heard you ask a question which said--

              18              DR. BESSON: Oh, yes, the question I have is      and

              19    this  came up before -- whether staff could outline for

              20    review committee exactly what  its modus operandi is

              21    vis-a-vis anniversary review,  which ones they choose the

              22    option to present to review committee and which not.

              23                                     pect to procedures any
                              MRS. KYITI;E:  With res

              24    anniversary in its triennium need only .get Council approval
        I Repoiters,  Inc.
              25    by regulation.  By agreement -- and Dr. Pahl outlined this





               I    at the last committee -- anniversaries within the triennium
               2    that are going on their way to Council still stop off'at
               3    committee prior to going to Council , so that if committee
               4    has something before it for information only that nevertheless
               5    jars it, it can make noises at that time.
               6             With respect to Alabama, though, Dr. Besson, the
                    secretary of SARP asked the specific question on Alabama
               8    as to whether SARP would want to refer Alabama to committee
               9    for action, and SARP decided it did not.
               10            Anniversaries prior to the triennium do come to comiii
               11   for action, as our agreement that Dr. Pahi outlined.  This
               12   is an anniversary within a triennium, and it comes to you as

               13   information on its way to Council.
               14            DR. MAYER:  I gather they -- perhaps need to clarifl,
               15   the question of what Jerry was saying, was on what basis do
               16   you make this decision that you pop some here for action

               17   and some for information.
               18            TARS. KYTTLE:  Changes in program direction or
               19   methods of operation, such as what brings Northiands to -you
               20   for action even though it's an anniversary within a
               21   triennium; failures in staff's view to meet the standards
               22   that the region set for itself in the first place, which
               23   brought Metro D. C. to you with a site visit.  Those are the.

               24   two primary reasons.
  ice*,,l Reporters, Inc. ,
               25             im. CHAIMLISS:  Or they are askingfor funds in







              I addition to--
              2           MRS. KYTTLE: They go to Council, by regulation stop

              3 off at committee.
              4           DR. MAYER:  You mean those that are requesting
              5  no, wait a minute.  I think what Mr. Chambiiss was suggesting
              6 was that those that rere asking for dollars in the anniversary
              7 within the triennium, for dollars above those previously
              8 approved by Council, don't those come here?
              9           MRS. KYTTLE:  No, sir.  An anniversary within its
              10 triennium that doesn't ask for any more money than its
              11 approved tevei Council h-s delegated to staff.
              12          DR. MAYER:  No, you missed the question.  The
              13 question was those that are a--,king f-,r more money than was
              14 approved b-v Council. do thev not come  here?
              15          MRS. KYTTLE: Witnin a  triennium?
              16          i)R. MAYER: Within a triennium  an anniversary request
              17  that  asks for more dollars than approved  by Council.
              18          VOICE:  Funded level or Council approved level?

              19          DR. MAYER:  Council approved level.

              20          MRS. KYTTLE:  No, not within the triennium.
              21          DR. MAYER-  Well, by George, I think it ought to.
              22 You  R-now, if I were a Council member I would sure want the

              23 advice   of this committee on those.
              24          DR. BESSON:  It would be nice if we could have these

       Reporters,  Inc.
              25 all spelled out for our next,review committee meeting so we





                                                                           J. f
                                                                 4



                                   -y what we are sup
                  would know exacti                 posed to do.

                           @IRS. KYTTIX,:  They are spelled out insofar @C,
              2
              3   Council is concerned.  Council has delegated to the Director
              4   to make continuation awards within the triennium and  just
              5   advise Council unless the region asks for more money than its

              6   approved level.
              7             DR. BESSON:  lYell, that's what he just described.
              8             MRS. KYTTLE:  Yes.  Now in setting up the procedures tc
              9   operate under that delegation    and this is what I understood
             10   Dr. Pahl to present to committee last time -- anniversaries
             11   prior to the triennium, in an effort to keep your workload
             12   on trienniums the point of action primarily, under Councills
             j3   delegation we would deal only N@ith Council and advise committee
             14   after the fact of what Council had recommended within  the

             15   triennium.  It was at the last committee meeting that
             16   Dr. Pahl agreed to advise you prior to the Council rather than

             17   after the Council.

             18             Did I get that wrong?

             19             IIR. CHA1,113LISS:  No, I think that--

             20             DR . 14AYER:  You got that right, but I can assure

             21   you that if Dr. Pahl suggested that those that were  above

             22   the funding level already approved by this committee and

             23   Council were going to pass by this committee without even a

             24   blip I would have come out of my'seat.  So I suspect he
  e-01 Reporters,  Inc.
             25   didn't communicate that to us, or I was gathering wool when






                   he did.  And I think that's an issue that needs to be

               2   clarified because I think it's important.
               3             DR. THURI,,IAII:  Bill, he did sp--ak to that when those-

               4  of us who wer new were indoctrinated.  He said exactly as
               5  Mrs. Kyttle has said, but we did not know enough to say anythinr
               6  back.  I am speaking of those of us who were new to this

               7    committee.


               8             DR. MAYER: I see.

               9             DR. THIJRIIAN: Because as she has phrased it is
               10  exactly as it was phrased in that indoctrination session,

               11  and Dr. Pahi conducted that.

               12            DR. MAYER:  I guess then what I would like to
               13  request, if the committee concurs, that further staff dis-

               14  cussion occur about that one particular issue, because
               15  otherwise, 'you know, a region could,request two mil in the
               16  second year of its thing and it wouldn't fly by here at all.
               17  You know.  And I suspect that -you might like to know how

               18  that two mil is being spent.

               19            okay, further comments on Alabama?

               20            New Jersey.  Dorothy.

               21            MISS ANDERSON:  Yes, New Jersey -- this again is

               22  for your  information.  No action is required.
               23            This is a review that was done by staff.    I -was not
               24  there, and so I am just reporting to you the result of their
  kc Olal Reporters,  Inc.
               25  findings.


   r        NEW JERSEY
















            so                                                                                                   #a






               I              Apparently this programi triennial review came
               2   through with awards for funding for only one year, an@ someho,@.
               3   the second and third year fundings were overlooked.  So

               4   consequently this is the m ain purpose for it coming in at

               5   this   time,
               6              In reviewing the original request for this program
               7   1 was very much impressed upon the action within this RAG

               8   organization.  The New Jersey RAG is really a group of core

               9   people and active committee members who are involved in
              10   changing and improving the health care delivery system in their

              I I  community.

              12              New Jersey, as you know, is one of the most defisely

              l@   populated states in the United Sta@t.@s, and it faces

              14   intensification of the pro-lenis that other urban areas have.

              15              Their greatest problem they found was basic health

              16   care, and in recognizing this they designed their goals in

              17  @this direction.

              18              Their first priority of the region revolves around

              19   im-roving accessibility, quality, quantity of health services

              20   for the urban disadvantaged.

              21              You will be interested to know that 80 percent of

              22   the money requested in the past has gone for community


              23   programs.

              24              For two years the urban health component of this

       I Reporteis, Inc.
              25   RMP has had staff active in the model city programs in the





               I   Siate, and the accomplishment-sof the urban health coordinators

               2   are impressive.  I think there'.s 17 urban health coordinators

               3   at 17 different locations.

               4             A hospital based family he.alth service in

               5   Now Brunswick has been developed, and a consumer health radio

               6   series has begun this 'year. It was interesting they surviewed

               7   and found that people really learn more from the radio than

               8   they do from the T.V., and the people in the underserved areas

               9   had their radios on most of the time.

              10             Next year they would like .to see the initiation of

              11   a comprehensive family health service in Newark, and a

              12   community health improvement project.

              13             ,this latter activity is L7questing $50,000 to

              14   $100,000 to be divided among the 17 cooperating cities on

              15   a matching basis according to size,.need, and available

              16   resources to support the development of primary ambulatory cars

              17   centers.

              18             What's interesting is the fact that this RNIP is

              19   reA.Ily working with many of the local, federal and state

              20   agencies in cooperation in developing these various programs

              21   and resources.

              22             Now in reviewing this in the past the staff was

              23   cautious abcut their approach, and thought maybe tLey should

              24   try it in only one or two cities.  But because of the good
  ce   I Reporters,  Inc.
              25   background activity that has taken place and enthusiasm of
                I






                I  the  staff  they  feel  like  they  don't  hesitate  to  recommend

                2  the go signal for all 17 locations that are being discussed.

                3             The core staff is made up of 15 people and six

                4  clerks, but the project core has 53 people and 40 clerks.

                5             Some of the concerns the panel had were, one,

                6  what is the rationale behind assigning project status to
                71 the urban health component rather than including it as part
                8  of core where this function would seem to lie logically.

                9  The staff also felt that in a project ac- limited, and whereby

              10   if you had core activities it  could go.on for a much longer
              11   period of time, and I think many other RIIP's are u4..-ilizing

              12   their core in % smiliar method.

              13              It was noticed with some condern that this massive

              14   effort in  urban health has an entirely white professional

              15   core staff.- And I could not find any indication of any plans

              16   for hiring minority members.  On the urban health component st

              17   there are three blacks and three Spanish surname professional

              18   personnel.

              19              The New Jersey program was commended by the review

              20   panel for the success it has shown in garnering funds from

              21   other sources, particularly the large amounts of federal and

              22   state money which had been funneled into the model cities

              23   area and the considerable support which had been received from

              24   the State Health Department.
  :e   I Reporters,  Inc.
              25              Their RAG -- as I go down the line, their RAG and





                                 I       their  grantee  organization  are  identical  bodies,   and  it
                                 2       seemed  like  this  might  be  a  possible  conflict,  but  thdy
                                 3       assured the staff there is no conflict of interest in this

                                 4       set-up.
                                 5                          There are 27 members of RAG,                                  and five of these

                                 6       members are black minority members.
                                 7                          The overall panel assessment of the New Jersey
                                 8       Regional Iledical Program was that it is an excellent program
                                 9       which has become a potent force                                    in medicine in New Jersey.
                                 10      The goals and activities of the program are geared to the
                                 11      unique requirements of the area, with a primary emphasis on
                                 12      improving health care for the urban disadvantaged. There
                                 13      are too@ numerous less expensive efforts directed toward
                                 14      increasing the effectiveness and efficiency of existing
                                 15      facilities  and  services  and  increasing  the  skills  and

                                 16      knowledge of health practitioners.
                                 17                          They had a program that I was looking at in more
                                 18      detail which I thought might be combined, the one -- oh. dear
                                 19      where is that -- one in regard to medical audit in hospitals,
                                 20      and they discussed the possibility of expanding this, and
                                 21      1 think it would be very worth while to expand it beyond
                                 22      just the medical physician component, but also to the other
                                 23      allied health members who are involved in medical care.
                                 24                            In terms of arriving at reasonable funding level

    ce          I Repotteis,  Inc.
                                 25      for the          next -year based on the success of the program to





                                      dat              the  b                                                         for  the  future,   the
                                          o  and                 right  prospects  it  holds
                                 2    panel  thought  that  the  current  level  of  $1,087,904  was
                                 3    entirely  inadequate,   and  they  are  consequently  recommending
                                 4    $2,990,000  for  this,   the  third  and  fourth  year.
                                 5                       DR.  MAYER:               Ail  right,   lot  me  see  if  I  am  clear.                                    1
                                      guess  I  need  to  have  a  better  feeling.     In  other  words,   this
                                 7    committee  recommended,   I  gather,  with  Council  approval,   that
                                 8    they  be  funded  in  the  03  year,   the  first  -year  of  their

                                 9    triennium,   for  2.9  million.

                                 10                       MISS  AlxTp-,RSON:    Yes.

                                 11                       MRS.  KYTTLE:     2.99.
                                 12                       DR.  MAYER:     2.99?    That  was  our  previous
                                 13     recommendation,   too?    All  right.     And  then  by  a-decrea.-,e  in
                                 14   the  funding  process  by  staff  or  some  other  device                                                      was

                                 15   cut  back  to  the  million  225?
                                 16                       Eileen,  you  want  to  tell  us  --  you  know,   I'm  just
                                 17   trying              what  the  action  that  we  are  saying  on  the  surface
                                 18   would  look  like  we  are  saying  okay,  SARP  has  just  said  throw
                                 19   in  another  1.7  mil,   and  that,  -you  know,  on  the  surface  gives
                                 20   me  a  little  trouble.,  so  I  gather  the  story  has  to  be  a  little

                                 21   more  complicated  than  that.
                                 22                        VOICE:     There  are                 two  problems.     When  the  region
                                 23   came  in  with  the  triennial  application  'it  was  at  a  point  where
                                 24   core  was  in  its  third  year  of  continuation,   had  one  year's

    Ile       ral Repottets,  Inc.
                                 25   commitment  remaining.     And  the  region  as  well  requested  only





                   on -year for its developmental component.  And we weren't
                   operating then nearly as cleverly as we are now, and the
              @2
                   region didn't picli it up either.  So when the committee made
               3
                   a recommendation as to an approved level core, the developmental
               4
               5   component, and certain continuing parts of the program were nol
               6   taken into consideration in arriving at a dollar amount
               7   for the second and third years of the triennium.
                             Now for the 03  year, although the committee recommoid.
               8
                   e,l 2.99 million the region was actually funded at just a
               9
               10  couple of dollars over a million.
                             So what SARP 49 suggesting is that Council restore for
               12  the  second and third years of the triennium the approved
               J'3 level  that was given for the first -,)ar, the rationale being
               14  that that is the irtent of the previous reviewers, and
               15  recomrionding as well that the region be given lots of extra
               16  money in terms of actual funding, actually 2.9 million which
               17  is what is requested in the application.
               18            One thin- I did want to comment when -you were
                   describing the community health improvement pro-ram, that
               19
                   request -- the entire request is for $900,000.  It is to be
               20
               21  utilized in lumps of betweeen $50,000 and $100,000 to each
               22  of 17 model Cities.  But the total request is for $900,000.
               23            DR. MP.YER:  Yes, Len.
               24            DR. SCIIERLIS:  Ilow did the decrease from 2.9 to

  e    I Reoofters, Inc.
               25  1.2 actually take place.  I'm curious.  That's a tremendous





                                                                           A-   W.L





                1 drop, and--
                2      MRS. SILSBEE:That.was the level at which they were,
                3 and there was no more money; had to keep it at the'same level

                4 and actually cut it back.

                5           DR. SCHERLIS:  In other words, that was just
                6 keeping it where they were.  Funds were not available at

                7 that time.
                8           DR., MAYER: I gather they came through here with

                9 a triennial request before we Nvere establishing prior  -y

                10 ranking.


                11          VOICE:  Yes.

                12          DR. MAYER:' What is the impression of staff,  going

                13  back through our minutes, of Nvb.ere we would have put that,

                14 A, B or C?
                15          Mi KRALEI@SKI:  I wonder if I might comment on this

                16 since I Site visited last time.

                17          DR. MAYER:  Ali right.

                18          DR. KRAIXVISKI: I think it is a very good  program.

                19  Th@re is some of the best leadership there that I have seen

                20 in a corporation.  Dr. Florin was a good guy.  Dr. Hartman
                21 is a good administrator, and he really keeps track of  what's
                22 going on in that place.  So I think, from my estimation at
               .23 least, we probably would have rated this thing one of the

                24 top progra.,as.
  A    rat       Reporters, tn c.
                25          Now on this funding, though, it seems to me that they






                     were operating at a higher level than that 1.1 or 2 or
                2    whatever it was, and I suspect..that that  was  a  cutbacli,  as

                3    a matter of fact, in their operational level, because as

                4    I recall, I don't believe that our recommended level of

                5    funding was twice as much as  what  they  were  getting  at  the

                6    present time, going from one to three.  I might be wrong on

                7    that.

                8              MRS. SILSBEE:    it was 1.3.

                9              DR. KRALEWSKR:  They  had  a  lot  of  programs  going

               10  when I visited them, and particularly a lot of exciting

               11    programs going with the core city.  They were making a good

               12    contribution, there was no question about it.

               13              They had a numl3er of  good  staff  people  on  board,

               14    and I' don It know if they still have them or not.    Maybe becaut; 3

               15    of the cutback they have had to--

               16              DR.  HESS:  According to the  slieet  here,  when  you

               17    visited them,  John, they were operating their funding

               18    ..Level at 1.3, and then they were cut back to 1.2 for

               19    budgetary reasons.

               20              VOICE:  The cut brought them back to about

               21    $1,087,000, and then at the end of f@scai '7i we gave     them a

               22    supplemental award to bring them up to 1.2.

               23              DR. MAYER:  lVe actually recommended a JL20 percent

               24    increase?

  ce    I Repoiters,  tnc.
               25              DR. SCIIERLIS:  You must be a good salesman.






                              DR. MAYER:  You're powerful, John.

              2               (laughter.)
              3               DR. KRALEIYSICI: As I said, I don't recall recommend-
              4     ing an increase of that magnitude, but perhaps we did.   But
              5     the impressions that I again give to the group were that
              6     we did rate the program. very highly.  They really had been

              7     able to switch over to the new RIVIP mission very rapidly;
              8     they had a good staff, they were involved in the real gut

              9     issues of that region, and they were producing.  And so we

              10    recormeded a substantial incr case, and.j gather that the
              11    group here -- I don't remember just all the discussion that

              12    took place, but anyway it was roughly--

              13              DR. SCHERLIS: I was on a site visit with Dr. Florin

              14    and I was very impressed with his ability.

              15              DR. MAYER:  The rating by. SARP at least is 4i2o

              16    which is off of the scale, you know, of the sheet here.

              17              So all right, I feel better about all that.

              18              Other comments that anyone has?

              19              DR. KRALEUSKI:  If we are going to give them roughi5

              20    a million nine -- a million seven increase?

              21              VOICE:  That's what we recommended.

              22              DR. KRALEIVSKI:  You have been in touch with them,
              23    I am sure, in between.  Are they capa@le of handling that

              24    influx of money all of a sudden?  What I am worried about is

       I Reporters,  Inc.
              25    if they have lost some of their staff--
                I









                                                                    ney,
                            VOICE:  No, the largest chunk of this mo

               2  percent--

               3            DR . ICR.'KLE I'@ K IThe model cities?

               4            VOICE:  Eighty pe rcent of the request is for  urban

               5  health, and they do have lots of people,

               6            DR. KRALEWSKI:  Do they still have those individuals

               7  on their staff yet, the guys who were operating in the  model

               8  cities program and were funded part by--

               9            VOICE:  Yes.

               10           MRS. SILSBEE:  They also have some that were used as

               11 staff  the+ were put in '.; the state.

               12           DR. SCHERLIS: I think it should be emphasized  that

               I  this was the level of your original request anyway.

               14           D-.t. MAYEI..: Sorr', Len, I missed that.

               15           DR.' SCHERLIS:  It was the level of the original

               16  request of the sit3 visit and of this committee, is that

               17  right.

               18           DR. KRALEWSKI:  That's right.  But my question is

               19  whE.her it's the same organization now that it was during that

               20  visit.

               21
                            DR. SCHERLIS:  And they reassure us that it is.

               22
                            tM. CHP2,IBLISS: Doctor, you raised tha question
               23 about whether that staff that has been working i'6 urban health

               24 is still there, and I think the answer is yes.
  "real Reporters,  Inc.
               25           Furthermore, that staff, as you probably  recognize





               I   it's called an urban state. The whole state itself is  just
               2   like one big -- I won't say a ghetto, but it's just onb big
               3   rundown state. And the idea coming out of the staff was  to

               4   the effect that that urban core group would be made a part
               5   of the core, and that they would no longer be supported under
               6   a project as they had been, and that was one of the

               7   recommendations coming out of SARP.

               8            DR. MAYER:  okay, further comments relative to

               9   'Llow Jersey?
               10           All right, I will move on then to Notthiands  RMP.
               11  The Northiands RIIP is r euthemism for the state of Minnesota.

               12  It started out originally as being more than that, but
               13  they finally retracted it back and dut it in the state
               14  border, with 3.8 million people.  It has been operational

               15  since March of 1969.

               16           The triennium was approved at our last January,
               17  -February review cycle a year ago, I participated in the
               18  triennial review rite visit along with Al Putinan in December
               19  of'1970, just a little over a year ago. There has  been  no
               20  site visit since that point in time, but there has  been  a
               21  management assessment team from staff in there within the last

               22  month or so.
               23           We approved, as well as did Council, the trienn ial
               24  application and the developmental component, with a  budget
  ,4b, Reporters,  Inc.
               25  of $1,157,000.  They were approved py the Council in the 04



                                                                                                                                                             m


                                                                                                                                   I
















                0                                                              0                                                             0






                     year, that is this next coming year, which is the second

                2    year of the triennium which we are reviewing, a level        of

                3    $ip45OpOOO,  with  committed  funds  for  that  year  the  same  as

                4    the existing year, that is     $1,157,000.

                5               They  are requesting  in  the  04  year,  that  is  this
                6    coming year or   the second -year of the triennium, too million

                7    on in direct cost, including 309,000 for a kidney project, or

                8    roughly a million eight plus the kidney project, that million

                9    3ight  being  roughly  about  700,000  above  the  current   funding

               10    level.

               11               From an  orga,-4.zational  standpoint  this  is  one  of

               12    the regions that has a board of trustees and a RAG which

               l@    have had pro  brews initially on  who  a  on  first,  the'.board  of

               14    trustees or the Ri'-G.   It 1-ioked  like  we  were  resolving  When

               15    we were  there  in favor of the RAG assuming the  responsibility.

               16    The subsequent year seems to have proved this out in

               17    terms of  responsibility,  and  they  now  are  in  the  process  of

               18    merging the two groups, with a meeting at the end of this

               19    me-Ith to finalize that.

               20               As far as the cccxdinator and staff, we      were

               21    impressed when we were out there with Dr. Winston Miller,

               22    the  coordinator,  and  his  ke),  staff.  They  were  very  strong

               23    and effective.    And we  v,,ere  particularly  impressed  with  the

               24    system that they had evolved.of monitoring the achievement of
  ;,*,I Reportets,  Inc.
               25    staff  and  accounting  for  the  tine  and  expenditure  of  staff






                    in light of preestablished goals for each of those individual,,.

              2     That is one of the mos.t effective management tools   that

              3     I have seen actually functioning for quite a while.

              4              As far as their goals and priorities, one of the

              5     key issues when we were out there expressed by the tiorthiands

              6     staff and the RAG is the difficulty they may have in

              7     turning this region around towards now goals in  light  o

              8     the existing commitment they had for some fair.ly effective

              9     ongoing projects established under the earlier goals.

              10             They have accomplished this in a rather interesting

                    way, which I suspect, Jerry, is the reason why  this  one

              12    is brought to our attention for action when the  others  were

              13    not, rather than simply for information as was  the  case

              14    in Alabama and Ilew Jersey.

              15              What they evidently did is as follows:  The

              16    RAG charged their three planning, review  and  management

              17    committees, which are the education, health manpower and

              18    health services development, to develop essentially.what

              19    we@e prospecti for the next -year's activity. What  they  did

              20    essentially was develop 29 contract offerings of about

              21    $25,000 each which were sent out on a mailing list of over

              22    7@000 people in the state of Minnesota.  From  that  they  got

              23    back 68 applications:ftom 38 different organizations.

              24    Forty-three of these were approved and, if you  will  forgive
  '40al Reporters, Inc.
              25    me, prioritized, and were included in the appiicatio n.

                I






                             This somewhat unusual approach on the surface looltcd

               2  like that what  they were doing was really creating contracts,

               3  but as you really look at it, essentially what they have
   io
               4  done is decided what it is they waDt  to  do  in  the  region  and

               5  they have just  simply  developed  a  communications  device  that

               6  has been more effective than some in getting projects back into


               7  the region to work on.

               8             They did provide some freedoms in that they suggested

               9  that there might be some variations on the prospecti that they

              10  sent out that could be accepted, as weil.as a few came in which

              11  addressed themselves to the  goal  but  were  different  than  the

              12  original 29.

              13             These projects or  contracts  have  been  reviewed  in

              14  detai I by staff, by SARP, and by the   kidney review panel.

              15             I might comment first  on  the  kidney  proposal  which

              16  they had which was divided into three components, a

              17  professional  and  public  education  component,  a  hypertension

              18  screening component, and a transplantation, tissue

              19  typing, dialysis, blood bank component.  The kidney review

              20  panel recommended not  only  disapproval  of  the  entire  kidney
              21  Project, but actually  recommended  disapproval  of  each  of  the

              22  individual components of it.  And I see no reason to disagree,

              23  and it would save me some major problems as well.

              24
                             SARP recommended that they  be  funded  at  the  1.450
  el.,  Reporters,  Inc.
              25  level, which is equal to the,level already approved by us







               I  and approved by Council for the 04 year,  This is roughly
               2  $300,000 above the current level of funding, but significant'
                                                                                  y

               3  below that which they have requested.  This would enable

               4  them to continue their core operation at approximately the

               5  existing level of funding at the  developmental  component  of

               6  $115,000 which we have previously approved, both ourselves

               7  and Council, but which had not been funded  by  Northlands  due

               8  to the previous commitments they had on ongoing projects.

               9             It would also enable them to continue some of their.

             10   ongoing projects and studies, and at the same time add 15

             11   of their top priority rank projects that came out of the

             12   prospecti as well as eight in the Second priority.

             13              All of this is possible with the addition  of  only

             14   $300,000 because they are phasing out  eight  ongoing  projects

              .15 this current .-Year.

             16              1 have some of the same concerns that SARP mentioned


             17   as they went through it, that it may be  difficult  to  manage

             18   as many as 23 small contracts or projects  as  a  problem.  The

             19   only feeling I had of a 'positive nature was that if  they  can

             20   apply the same techniques that they have used for the

             21   internal management of their staff to mana-ing those projects

             22   then I think they will be able to handle them.

             23              I also concur with the comments of SARP  that  they

             24   need to place emphasis on initiatin- fairly early on'in
  @40   Repottets,   Inc.
             25   those individual contracts emphasis to pick up support for






               1  them at the completion of their funding.
               2           So I especially  concur with the SARP recommen dations
               3  that they be approved for funding at the 1.45 level, and
               4  that there be no kidney proposal accepted at this time.

               5            John is the second reviewer.
               6           DR. KRALr@,IVSKI:  I can't add a great deal to that.
               7  In looking over these projects and not having site visited thi3

               8  region, it appears that these projects would make a

               9  contribution to achieving their goals.
               10           It looks as thoufrh the RAG is.active in the decision-
               11 making prr-:ess, and the----fore would apparently help formulate

               12 this list in the order that it is in.
                            I think the critical issue is Nvhether the organization

               14 -I.s capable adminisLrativel-I of handling this kind of
               15 activity, and I think if we look at the fact that at least
               16 the reports that c=e from the site visitors, the reports that
               17 we have had in writing and verbal, indicate that this is a

               lp strong area.  The administrative staff is well organ ze
               19 ane they have done a good job in r-inning their project so far.
               20           So I think on that ba sis probably we could conclude
               21 that they will be able to ha,-die this kind of decentralized
               22 activity, particularly since they have been able to develop
               23 some pretty good control mechanisms on staff activity and core

               24 activity.
      'I Reporters,  Inc.
               25           So I would concur with the recommendations -you have




                I Just made, and would put that in the form of a notion if you

                2 wish.

                3            DR 711URMAN: Second.


                4            DR. MAYER:  Len.
                5                                             omment, and that
                             DR. SCHERLIS:  I only have one c
                6  is they must be blessed with a great gift of wisdom to be
                7  able to give a priority rating to 43 projects and ass ign
                8  ranks to each of them.  I think that that is a very, very
                9  difficult feat, and it would be very interesting to see how
                10 they arrived at -.t.  I would concur with what you said, but

                11
                   I think it is amazing t- have a group be able to assign

                12
                   priorities to 43 discrete items and quite diversified projects

                13
                   like this in that manner.

                14
                             IIRS . n@LE:   I think it is interesting because
                                                                     to
                15 I think the committees did the first ranking and then they

                16 were interdigitated.

                17
                             DR. MAYER:  There Nveren't just 43, there were really
                18 68, because there were 25 of them that they bounced out

                19
                   as 3aying no go, they are not good enough.
                20           DR. B E.S@S ON   I'm fascinated by this approach,
                21 and I think that the idea of setting priorities first and then

                22
                   having people devise project!3 that,you say yes or no, whether
                23 they meet with your priorities, is the very reverse of the way

                24
                   we have been seeing the whole thing operate right along,

       ial  Reportcrs,  Inc.
                25  and I think is a very interesting approach. That's really






                   what we're doing Vis-a-vis the region.  And while we say
              2    yes or no'to funding, they just-have the same kind of decision
              3    to make, yes or no, to awarding a contract.  I think it is

              4    a very interesting approach, and it will be  interesting

              5    to see how they develop.

              6              DR. @LKYE, RAdditional comments from staff who were

              7    at the SARP review?

              8              All right, the mot ion then is to accept the

              9    recommendations of SARP at 1.45 level with no kidney  ef fort

              10   included in,'it.

              11             All those in favor?

              12             (Chorus of "&yes.")

              13
                             opposed?

              14             (No response.)

              15             I would like to take a couple of minutes to see

              16   if there are any further comments about the  Connecticut

              17   activity.  As we indicated to you -yesterday, there were some

              18   materials that were incorporated in the back of -your book

              19   which we suggested that you might want to take a look at

              20   for further discussion.

              21             Yes, Joe.

             .22             DR. HESS:  I read iiith some interest the comment

              23
                   here that Council believes the question concerning investing

              24   heavily in a state so Y,,iealthy in resources is completely
       I Repoitets,  Inc.
              25   irrelevant, and I wonder if that is an overstatement oftheir





                   views or if they really believe that,  because it is hard for
              2    me to accept that as being valid from  an advisory body'of.a

              3    federal governmental agency.
              4              Now to say that we should look purely at the merits,
              5    or let's say the RIIP should look purely and only at the merits
              6    of the program and have a system where the excellent programs
              7    get more and more money, and by and large the areas that have
                   excellent programs have already got more resources to begin
              8
              9    withp this only tends to increase the disparity between
              10   the upper and lower ends of the scale of health care around thE
                   country.  And it seems to me that that is in a sense going
              12   contrary to one of the basic purposes of the federal
              13   government in this country, and I just have a great deal of
              .14  difficulty in understanding or accepting what I read into that

              15   kind of a comment.
              16             DR. MAYER:  Would someone at  the Council meeting car(
              17   to elaborate on what they thought the  intent of that
              18   statement, whether that was a fair statement of   how they
              19   felt about it?  Is there someone here on   staff  who was at

              20   the Council meeting?

              21             ?.M. CHAMMLISS:  Judy.
              22             DR. MAYER:  Judy,  the question  that  is being raised
              23   is the issue -chat on the Connecticut  proposal  in which the
              24   Council altered the recommendations of this group, was that
  'Ibal Repotters,  Inc.
              25   one sentence statement that said "the Council believes that th(






                   qu              in- investing heavily
                    estion concern                       in a state so wealthy

                   in resources is completely irrelevant," and Joe has raised
             .2
             3     some questions about did they really say that, and if they dil,

             4     did they really mean it.
             5               MRS. SIILSBEE-. I think they did really say that.
             6               DR. SCIIERLIS: My reaction to that might be that it
             7     was posed to us that one of the reasons we were interested in
             8     the approach of Now Jersey was because that is such a rundown
             9     --tate, and I would suggest that we can't do both of these
                   things as appro@hes in a logical manner simultaneously.
             10
             11    Either we exclude -- arl I would call for a revision of
             12    my New Jersey vote if that approach is not to be relevant.
                             I think just as we can lo@k at a have-not state

             14    and feel very strc;..igly tha+ we might apply other standards,
             15    we have a right to look at a have state and have certain
             16    standards.  Is my point of view is out of line with Council
             17    program?  If so, all my votes should be reconsidered.
             18              Would ycu care to res pond to that interesting

             19    po-nt, Judy?
             20              MRS. SILSBEE:  I think perhaps the Council and
             21    committee should get together on the subject of Connecticut

             22    because we can't act as go-betweens.
             2 3             M. SCIIE-RLIS:  We have been told to emphasize

             24    urban problems and dense populations.
  @4DReporters,  Inc.
             25              MRS. S11.13BEE:  Couicil is looking at the Colitiecticul





                I   program as a different type of program and they feel that
                2   it needs support as a different type of pro-ram.
                3             DR. SCI-IERLIS: I guess the statement is what

                4   troubles me.

                5             DR. MAYER:  Yes, Jerry.
                6             DR. BESSON:  Well, I think there may be a source of
                7   confusion here as to what deserves support.  I think R?,IPS
                8   has continually from the beginning awarded a meritorious
                9   program.  Now whether a program that is meritorious involves
                10  a have-not area or a have area is what I think they considered

                11  to be irrelevant, and - can live with that.
                12            DR. SCIIERLIS: I can live with that.
                              DR. BESSON:  And I think that's all they are saying,
                14  that ConLeoticut is a ver@ meritorious program, and if that's
                15  the case the fact that they have a higher per capita income
                16  and a higher dollar am,3unt from RTIPS and everything else,
                17  that is irrelevant.  That's the only way I interpret it.
                18            DR. SCIERLIS: Is that the way you interpret it?

                19                                            ms with
                              DR. MAYER:  Joe has SOM3  proble        thatg I

                20  think, if I heard him clearly.
                211           DR. HESS:  That's right,  'I certainly do, because
                22  I fully concur with the need for a  meritorious program for
                23  funding, but I think there comes a  point where some regions

                24
                    you know, we have got to anticipate some leveling off as we
  ,c  eal Reporters,  Inc.
                25  try to -- let's say the have regions in terms of funding, and







               I    not a continual escalation of funding just because t ey

               2    are meritorious, because there's only X number of dollars

               3    in any one year to spend, and I think that sure, we would

               4    like to see excellent RI.IP's in every region of the

               5    country and we are working toward getting that by  a  variety

               6    of mechanisms which we use here. But I  think  that  there

               7    will need to come a point where there needs to be kind  of  a

               8    damper on the have regions 'who are excellent; otherwise  you

               9    sort of say the sky is the limit and you end  up  spending

              10    proportionately more money on the have.regions,than the

              11    have-not even though the have-nots may be on the way to

              12    developing better programs.

             .13              DR. DESSON:  Okay, Joe, but this is the first time

              14    we are beginning to speak of a rational way of  comparing.

              15    regions.  Up until now our decisions were completely

              16    dependent on the time of day and how tired we were and who hac

              17    more money, and it was all very haphazard.  But  now  that

              18    we have an order of relative ranking for the first time we
              19    @e being able to use them     I notice that the use  of  PPBS

              20    in New Jersey is commended, as though that's  something  that

              21    was discovered yesterday.  Well, that has been around for

              22    a long time, and why RMPS has never used it I  will  never

              23    understand.

              24              But there we are, we are just -- r,.,@LP is being dragged
  C40al Reportefs, Inc.
              25    clutching and screaming into the current era. Unfortunately,





              I  the kind of thing that -you are asking for, we are just

              2  beginning to do it.

              3          DR, MAYER:  Comments?
              4          VOICE: Yes, I  th.ink the comment about the relevancy
              5  in relationship to the state developing resources is due to
              6  the fact that possibly the state that is wealthy in resources
              7  may very viell be the best place to demonstrate or experiment
              8  with some of this.  I think this is part of the reason for
              9  the statement, justification for the statement.
              10         DR. BESSON:  I have difficulty living with that
              11 Connecticut decision for an entirely different reason, and
              121 that is the big concern that we had here was -yes, they were
              13 asking for a lot of money, but if t'-',s was a surreptitious
              14 way of supporting rpdical schools that was a bottomless pit,
              15 and if -je were going to get into that then we really wouldn't
              16 have any vtoney for health care delivery changes.  And for
              17 the Council to consider that the only notion that apparently

              18 made them reverse our decision was that this was an
              19 innovative program, I think Connecticut has been extremely cleNe,
              20 in using cliches in just the right way to push the right buttor
              21 here in RMPS, and that'-- unfortunate because I think the
              22 emphasis in Connecticut for the amount of money that is being

              2 3spent is somewhat misdirected.
              24          DR. MAYER: I'm delighted that we made as strong a
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              25 point of the two or three iss,ies which we made on this one,











                   n
                   amel-y the concerns about support of faculty and the need to
               2   revolve that, and where do those medical schools stand 'in
               3   terms of picking up their responsibilities, number one, at
               4   some tii-ne in the future; and the second issue which relates tc
               !5  the longstanding concerns relative to organized medicine in
               6   that state, and then the issue that Joe has raised that we

               7   discussed at soma length previously.
               8            I just hope that since I won't be here beyond the
               9   next meeting, that that has gotten so well documented in
               10  people's thinking that three -years from now somebody will
               11, be looking at how much of the lederal dollar through RNIP
               1 2 is going into facilities of those medical schools, and somebody
               1 3 will also be looking at the time of the next triennium beyond
               14 -the surface about how are they really rciating to organized

               15  meqicine in that state.

               16            Other comments?
               17            I would just like to make one other additional

               18  comment on something that would be helpful at least to me as

               19  an 'individual. I asked the question initially when me
               20  started on these priority rankings were they the summation
               21  of the weighted, and the answer was yes, they were the

               .22
                   summation of the weighted.  I would like to see a correlation

               23  between the summation of the weighted and the overall
               24  assessments and how that works out, and I hope somebody is

  c    at Repoitets,  Inc.
               25  looking at that because I sure would like a report of that






                   to find out how high that correlation really is.     And I
                @2 would like to have some of that data so I could look back
                3  and think, you know, maybe  that overall assessment component

                4  is meaniDgfUl.  And I hope some further detailed analysis

                5  of this interms of what weights ought to go and are they

                6  related to overall assessment  or not by factor and subfactor

                7  is going on.

                8             But I think for now what I would like  to  know  is

                9  the sums of all of the above, plus the   overall weighting

                10 and how that looKs at the next meeting..

                              DR. SCIMRLIS:  Maybe we will find one of the members

                   of this committee always is right at that average point and

                13, we can let him cast all our votes.


                14            /Laughte.-

                15            M. MAYER:  Right.  You  know,  Harris  and  Gallup,

                16 they learned that a long time ago.
                17            Any other items of business to come before the group?

                18            Yes, tlr. Chambiiss.

                19            MR. CHPIIBLISS:  The queFtion was raised initially

                20 at the beginning of the review   about travel and  about  your

                21 reimbursement, and I simpi'y,'-fouid like to say that we  have

                22 checked with our travel office.    All of the payments from

                23 October forward are now at the Treasury,  and  you  should  be

                24 getting them within two week,-,.
  ,4bl Reporters,  Inc.
                25            I know you have heard that before, but I do






               I    understand that they are in fact there.  And perhaps but

               2    for the holidays you would have heard from them.

               3               DR. SCI-EERLIS:  Which Treasury is that?

               4               (Laughter.)

               5               DR. t@IAYER:  Of the United States, that is.

               6               MR. CIWMLISS:  The disbursement office of the

               7    Treasury.

               8               DR. IIAYER:  Any other items of business?

               9               Thank you very much.

             10                (Whereupon, at 3:50 o'clock p.m., the meeting was

             11     adjourned.)

             12


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