00-13
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                               t ranscript,      rocee  ing


                                                      10
                 DEPARTMENT OF HEALTH9 EDUCAT           'N AND WELFARE@.



                               REGIOZIAL,@-14EDICAL  PROGRAM SERVIC
                                                              F,


                                    -,REVIEW COIAMITTEE











                                                1100





                                             loo







                                                 Rockville, Maryland
                                                 Thursday, 13 January 1972




                                 ACE - FEDERAL REPORTERS, INC.
                                        Official Reporters
                                       415 Second Street, N. E.
                                                                   Telephone'
                                      Wasliington, D. C. 20002 (Code 202) 547-6222

                                     NATION-VIIDE COVERAGE




   4738                     DEPARTMENT OF HEALTH, EDUCATION AND WELFARE
   LLB
               2                              - - -
               3               REGIONAL MEDICAL PROGRAM SERVICE
               4                       REVIEW  COMMITTEE

               5


               6





               8


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               10
               11                                      Conference Room E,
                                                       parklawn Building,
               12                                      Rockvillep Maryland
                                                       Thursday, January 13, i97,
               13
                                             reconvened at 9,.50 a. m.,
                             The meeting was
               14
                   Dr. William Mayer presiding.
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                                                                             2



                                        C 0 N T E N T S

                2                                                        Page

                3  Consideration of applications:

                4       Western New York
                5       Florida                                           44
                6       Metropolitan D. C.                                68
                7       Susquehanna Valley                              128
                8       Intermountain                                   144
                9       Alabama                                         169
                10      New Jersey                                      174
                11      Northiands                                      186

                12


                13

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                16


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                                         P R 0 C E E D I N G B
                                         -----------
               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 substituting here for Dr. Spellman, very

              10     inadequately. He was the chairman  of  our  site  visit  team
              11     which was composed of Mrs. Mars of Council; mysel
              12     Dr. Robert Toomey, Director of the Greenville Hospital System
              13     who added a great deal to our capability, very perceptive;

              14     and Dr. Silverbiatt, coordinator  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--
              18               DR. MAYER: Henry, before we  go  on  I  just  ought to
              19     really indicate for the record that Dr. Perry has left the

              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 background, I would like to
  :e- Federal Reporters,  Inc.
              25     say something -- one of the difficulties we had at this site




                                                                           4


              1  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, Western New York
              5   and Pennsylvania that comprise this area.  And then the
              6   second day when we began talking 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 applicatio ns from this area.
              10           -They have been characterized by extreme sophistication

              11  and concentration on things like renal disease and cancer
              12  of the skin, rather small facets of a very large health care

              13  problem that they have.
              14,           The State University of New York at Buffalo is one
              15  of the strengths there.  But I note that in the Pinerican

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

              19  for 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  RMP

  ce- Federal 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.
               4            of course, there is the Roswell Par k Memorial
               5  Institute which is an outstanding cancer center, and they
               6  have been extremely hard pressed financially during the last,
               7  few years, and I think this is reflected in some of the
               8  special types of project applications which have surfaced in

               9  this area.
               10           Now there are between 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@sekvices 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  ast, between the central
                                                 p
               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 develop an
               22 application which got up here to Washington in trial form for
               23 a community health center to begin to make some progress in
               24 health services for this minority group, and they did enlist

  ce-Federal Repottefs,  Inc.
               25 @the cooperation -- there are about 17 or 18 physicians, mostly

                I





                                                                            6


                  black, who work in this community, and they had a number of
              2   meetings under Dr. Ingaills direction, and this got up here
              3   and it received some kind of pocket veto.  We  don't  know
              4   what went on. It never did surface as  a  formal  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 ms 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 HOWNY gets credit where credit is due,

              24  and Regional Medical Programs do not.

  ,ce-Fedeial Reporters,  Inc.
              25             Now this was essential in the initial  planning




                                                                           7


               I  phasest but we had considerable question that this had
               2  anything except historical significance at the present time.
               3            In addition to the hospital care activities being
               4  fragmented in the past and not serving many of the
               5  critical core areas the Regional Advisory Group has been very
               6  heavily provider oriented, chiefly by physicians; and while t-h-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. Saitz 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 RMP as of October lst.  It has not been
               22 accepted yet, and he has indicated he felt that -- we got
               23 the im ression that he will stay on until somebody can take
                        p
               24 over the reins.  He will have been with the program for five
  De-Federal      Reporters, Inc.
               25 years this spring.  But he is a surgeon.  There  is a lid on




                                                                             8


                I  all ceilings, they are kept 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, but 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 they have had a difficult time, as you c n
                10 imagine, in turning around from categorical,.and  really
                11 highly specialized categorical interests, to the new guidelines.
                12 And they had a conference in September, and they have done,
                13 1 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
                   small surgical practice in the black community.  He is on a
                18 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
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                25 integrate rehabilitation services into the continuem  of




                                                                            9


                    medical services. Then they have two sets of  objectives,
              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 to
              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 s                se flo ati
                          ome time with the         ng objectives.  They were
              10    frank about them; but these relate to political considerations,
                    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    applicants 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 in public health for years
  ,ce -Federal Reporters, Inc.
              25    preceding RMP.  The medical community is pretty well




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                   entrenched.  It has been going a long time.

              2              And so there are a lot of these subjective and
                   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  o

              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 are being formulated. But because of the  very  tight
              17   way in which the Regional Advisory Group and its program committ
              18   run this., really they sort of take along each project
              19   they think is capable of being carried out and they get that
              20   funded.  But they donit have a list of approved 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

  -ce- Federal 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   deve loped 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 Lake area
              14  health-education center in Erie, Pennsylvania, where they
              15  have pulled together five community colleges, a number of
              16  hospitals totalling 2400 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 through the State University at
  kce-Fedetal Reporters,  Inc.
              25  Buffalo and the fact that there was a good core operation,






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

              3  gotten off the ground a lot faster.
              4            Another interesting thing is there is more and more
              5  voluntary participation by various physicians, allied
              6  health professionals in the core activities.  The,y'estimate
              7  that as of last -year 40 percent of total RMP 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            Now they have this telephone lecture network which
              12  has reached now over 30,,OOO allied health professionals
              13  and physicians.  We saw that.  It has been very useful as a
                             ome 50, 60 community hospitals. 'It,,-is used
              14  tie in to s
              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 improving rapidly, and it feeds directly back to R
              24  and is participating in their evaluation activities.  As a

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              25  matter of fact,, they cut off one of their projects a year in




                                                                         13


               I  advance because they felt it was not being productive.
               2           They have given a lot of help to the CHP agencies,
               3  eJLeven,, 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 thisa

               7  little more in terms of what I said, this 1969 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 ibnercity girls.  This has been assisted by their core
               13 staff.  And they have been instrumental in getting the
               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 Northi ngt6n, at the bottom of page 12 here, a new member
               18 of the RAG.  She-had worked as a research technologist, I
               19 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
               24 Mrs. Northington's testimony. They need certainly to  expand.
  ,ce- Federal Reporters,  Inc.
               25 their RAG.




                                                                             14


                             Now we felt that Dr. Ingalls had done a  very  good
                2  job.  We don't feel that Dr. Ingalls is the world'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.  We  couldn't

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

                12 going to do more. This is getting  so  complex.  They  need
                13 to have additional staff and evaluation to help Miss Heiberg,
                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 31  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
  kce - Fedetal Reportefs,  Inc.
                25 sense of noncooperation from the testimony of the local head




                                                                           15


                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 ma4Le
                6  their decisions.  The program committee meets twice a 'year to  e-
                7  cide which programs will be funded, which will be cut  f
                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 that 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 RMP 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 Health Research, Inc., which is the grants obtaining arm
                24 for all the state agencies in New York like Roswell Park and

  @ce- Federal Reporters,  Inc.
                25 'the various public health research institutes, and so forth.




                                                                              16


                             Ana I think this together with the fact  that  they

               2   are tied in with an antequated, absolutely antequated salary
               3   basis, which has prevented 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 assisting 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            And then the other outreach is a  family  practice
               13  program, which was one of the early ones to get going at the
               14  Deaconness Hospital, 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.

               18            We felt., however, 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
               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
                   of the physicians in this one county, and has active
  ice-Fedeial Reporters,  Inc.
               25  participation from allied health. It's a  very  viable  idea,




                                                                           17


               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 didnt
               8   even have letters of approval on exterb 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 page 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                                                   tant
                   would be aided by a deputy coordinator, and assis
               19                                                    ot -- at
                   evaluator, and also having field people to cover n
               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-Federal      Repoftefs, Inc.
               25                                                    ivity in thi
                   considerable short term pay-off with continued act





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                1  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 the-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 colleges,which are resources that have not
                14 gotten involved, but which are very interested in getting

                15 more involved in allied health training.
                16           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 their RAG.
  kce -Federal Reporters,  Inc.
                25            Now the recommendations.  They are asking for the





               1  05 level, coming to page 22, a total of $1,419,000 for the
               2  fifth 'year.  And we made specific deletions on this.  We
               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-feit that this region probably should.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.  Well,
               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 Reporters,  Inc.
               25 'program development we should wait.





                                                                           zu


                           We felt that the mobile health unit which is
                2  going to cost $47,000, that RMP 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 only
                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  $1, 136,000.
                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 -- deputy coordinator, an assistant for
                12 the present evaluator, two additional members to work with the
                13 county committees as liaison, and two specialists in health
                14 matters in innercity and rural 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

                18 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 fel@ 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

  kce-Federal Repotters,  Inc.
                25 Wage and Price Board.




                                                                              21


                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 12, 18 hours a day many days.
                6  He has tried to carry too much of this on his own shoulders..
                7            We felt that the leadership role in the creation
                8  of the Lake area health education concept in Erie is a tremendous
                9  forward step, and the fact that they are profiling the
                10 health needs of all of the county systematically  with  their

                11 Chip program, very good.
                12           We think that their telephone  network  information
                13 dissemination    their regionalization needs to  be  improved
                14 further, but with their telephone net they have,got  all  the

                15 tools here.
                16           So we feel 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 who 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 position 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.
  @ce - Federal Reporters,  Inc.
                25            DR. MAYER:  Thank you very much, Henry.




                                                                            22


                I                 ts of staff before we go on?  Any additional
                             Commen


                2  comments?-
                3            All right, questions?  Jerry.
                4            DR. BESSON:  I an not sure, Henry, what your
                5  recommendation was for the diminution in support for the
                6  chronic respiratory disease program.  It is,requesting

                7  93,000 and 17,000.
                8            DR. LEMON:  Well, 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 was -- they felt it was  reallya
                12 different project, but we didn't -- to move this out into
                13 the community hospitals.  But they had not taken any steps to
                14 really determine the need for this in the community hospitals
                15 or the cooperation.  And we recommended here on number 3, this
                16 is page 22, the funding periodfor March Ist, 172  to
                17 February 28, 173 not exceed $6OiOOO, and that this really be
                is in the phase of tapering down their present training activities

                19 and evaluating what they have done.  We felt it was very
                20 important to get maximum evaluation out of this for the

                21 benefit of other RMP's to see what they have  really
                22 accomplished.  And not more than $32,000 for the subsequent

                23 -year.
                24           so instead of putting in some 600 or 700 thousand

  @ce-Fedeial Reporters,  Inc.
                25 dollars they wanted over the next triennium we recommended




                                                                              23


                   only approximately $94,000 over the next two years.
               2             -We didn't -really want to penalize them too  much
               3   be cause 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 witli

                   the function of the research foundation and their charges.

               9  What are included in those overhead costs that they pay?
              10              DR. LEMON: Bert, I may need your  help  in  this.
              11   But they process the charges    The Western New Yor4 RMP

              12   pays its own rent, does it not?
              13              MR. KLINE:  As I understood what they described,
              14   they provide recruiting services, attempt to locate personnel,
              15   they maintain all records of  expenditures,  provide  these
              16   on a periodic basis. By and large I  think  they  serve  asa
              17   resource to Western New York, and they didn't  get  into  agreat
              18   deal of detail.  But as I recall the conversation, the RMP
              19   staff 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  deant  I

  ce- Federal Reporters,  Inc.
              25   believ'
                         e,, testified -- or was in Ingalls     testified that they





                                                                            ;&4


                   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  doll ar

                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 that the state of New York accepts through the
                11 Ifeaith Research, Inc. have no overhead provision, or 8 or 10
                12 or 20 percent; and the reason that they have to charge RMP
                13 this figure is to make up for these Other low overheads
                14 so they come out with an average somewhere on the order of
                15 25 percent overhead for all of their research grants,

                16 contracts and outside  unds.
                17           DR. BESSON: Of course, the aspect of  your  site
                18 visit comment that somewhat astounded me when I read it,

                19 that RMP is really bearing the brunt of the ceilings on
                20 overhead that thestate of New York charges for entirely

                21 different programs, and this 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
  Ace -Federal Reporters,  Inc.
                25 decisions involving several other RMP grants.  All we could






                I  do was to point out two thingso that this seemed like a very
                2  high overhead figure, which, of course,, is magnified
                3  in central New York and other areas in New York; ancsecondlyp
                4  that operating as a part of Health Research, Inc. they are
                5  locked into the salary levels, but do have more flexibili  y
                6  than if they were funded via the state.  This was one of
                7  the other reasons why Health 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
                13 of someone else any more than Medicare would accept a
                14 hospitals indigent 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 RMP or any other group being

                17 involved with that group as a group.
                18           And I find that, you know, that last statement just

                19 almost 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.

  kce-   Federal    Reporters, Inc.
                25            MR. KLIn:Yes, in direct questioning this was

                I




                                                                              26



                I   brought out.
                2             DR. MAYER:  Wells then my suggestion would be that

                3   that situation needs very strongly to be reviewed.

                4             yes,, Mrs. Silsbee.

                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  exploring  it

                8   and trying to move ahead.

                9             DR. BESSON:  Would it make it any easier

                10  administratively if we with fair play of turnabout put a

                11  ceiling-on the overhead that the grantee--

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

                13            MR. CHAMBLISS:  May I comment?

                14            DR4 MAYER:  Yes.  Go ahead.

                15            MR. CHAMBLISS:  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 IISHMA,or  the

                18  individual programs of HEW. The  overhead  rates  between

                19  the universities and their foundations, or what  have  you,

                20  is negotiated by HEW.  So once the rate is established and-
                21  negotiated wherever our funds are placed in a  given  RMP
                22  that grantee overhead negotiated rate will  prevail,  and

                23
                    that is the case in this RMP.

                24            Now to speak with regard to the salary policies,
  kce- Federal Reporters,  Inc.
                25                                            t the salary
                    it has always been our policy in RMPS tha





                I    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 uponvaiich Mrs. Silsbee  makes
                5    the point that this RIIP is contemplating moving out and
                6    moving into a nonprofit corporation.  This.wouid give an
                7    opportunity then for that nonprofit corporation to  negotiate
                8    its own rate and for a restructuring of the salary levels.
                9             DR. MAYER:  Additional comments?

                10            Yes.. Iien.
                11            DR. SCHERLIS:  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 It 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
                is   five years.  I think he plans to stay in.the Buffalo area,
                19   and 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   lVdgional Advisory Group has some very dedicated people  like
                24   Dr. Felsen, who is a very capable practitioner from one

  kce - Federal Reporters,  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 working very closely with Ingalls.
              3            The other thing is Ed Merror's Department of
              4  Social and Community Medicine.,which has given extraordinarily

              5  good leadership, is a stable factor.
              6            DR. SCHERLIS:  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 real -y
              9  amounted to central laboratory 9upport at the university.
              10 And I note oh 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 they were trying to phase this out, and this is definitely on
              20 the way out.  They realize the new direction, and they 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
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              25 them a fair amount of increase for core budget here to hire so





                                                                             29


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

                2 they going to be able to f ind these people, are  they  going

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

                4  a change imminent?

                5           DR. LEMON:   I think it 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

              13  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. KRAWLEWSKI:  How much is he getting paid?

              17            DR. LEMON:  Thirty thousand.

              18            DR. KRAWIYWSKI:  We are recommending about $250,000

              19  increase  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 the

              23  assistant to the-present evaluatof"and then two additional

              24  members to work in liaison.  But the increased core would be
  -e-Fedefat Repotters,  Inc.
              25  somewhere on the order of 80, 85 thousand which we would









                I recommend.

                2            But, of course, under a triennial, as  I  understand

                .3 itt 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. KRAWLEWSKI:  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 is $343,903, and what is being

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

                16 John is making.

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

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

                19 sevent-y-two twenty-eight sevent,y-one.  That says 447 for core.

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

                21           DR. MAYER4. I see.

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

                23 requesting 587 thousand for core.  So. seeo they have

                24 already made an increase in their request.for core to provide
  ce-Fedefal Reporters,  Inc.
                25 some of the things that they need in terms  of  better  liaison




                                                                            31



                I  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,ls just a local
                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

                                                                                Is
                13 together, and-it does cover the entire local region.  And  it
                14 obviously well directed, I think. It is going  to  provide

                15 information.  it is the only activity in cancer.
                16           The model program for comprehensive family  health,

                17 that is the family practice program, 17i thousand, we  cut
                IS 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. MAYER: 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
  ce-Federal Reportefs,  Inc.
                25 is concerned. And he is raising, I  gather,  the  question  n




                                                                            32


                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 Ingalisp 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 functioning

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

                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 There is a lot going on there fu'nded through OEO, and it  is

                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

                22 a job which aren't represented on the RAG or  on'thelcore  or

                23 anywhere else.

                24           DR. MAYER:  Sister Ann.
  ce-Federal Repotters,  Inc.
                25           SISTER ANN JOSEPHINE:  Dr. Lemon, do you think.that







                                              has been coordinating all this
                   when for a while Dr. Ingall
                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 problems  You know, 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.  He is a board certified surgeon, and he,
                10 indicated he has been trying to keep his hand.in doing some
                11 after hours work in the community hospitals, but he would
                12 like to get back to his professional life.  So I think
                13 he would gradually phase back into being a practicing surgeon.
                14 I don't have any real -- Burt, what would 'you say -- I think

                15 he was anxious to let go of this thing.
                16          MR. KLINE: 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 that he would
                19 not leave certainly 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 grantee organization.
  kce-Federat Reporters,  Inc.
                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 consi deration 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 representation 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 if 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 thing.
  kce - Federal Reporters,  Inc.
                25
                   Dr. Saitz, who is a dentist, but who has really been




                                                                           35


               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. S,altz 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  thetyou feel that this region is capable of managing its own
               11  affairs presumably, because you are recommending a
               12  triennial award, which to me suggests 'your consideration
               13  of their corporation is favorable.  On the other t an, 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
               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:  Welig 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
  ,ce-Federal Repotters,  Inc.
               25  around the fact,that these are not spelled out in detail in





                                                                            36



                                                               In other
                    projects or programs that we can pinpoint
              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     specif ically allocated.
              7              And as I indicated, we were not overi-y happy with
              .8    the large sum of money that had been spent in the respiratory
              9     disease pro-ram.  And obviousi -y 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 been

              13    performed.
              14             I think with the present set-up the-y 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 the  uncertainties, like
              18    the Lake area educational program in Erie.  But it
              19    remains to be seen, you know, how well they can 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  avi
              23                                                      bei ng
                    not been spelled out that we could see.  They are
              24    developed.  I can't read the crystal ball any more than that.
  .ce-Fedeial Reporters,  Inc.
              25              DR. MAYER:  'Jerr,y.




                                                                          37


               I            DR. BESSON:  Henryp I would like to return to this
               2  matter, even though I know that there's some constrain ts
               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, ii2l9, 60 percent.
               7  of that, 58 percent of that is never going to reach the

               8  program?
               9            DR. MAYFR:  That's a direct cost figure.

               10           DR. IYMON:  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. SCliERLIS:  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. MAYER:  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 some 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. LFMON:  I am tr-yingto justify the LeveJL,  I know
               23 from previous discussions here this is where we have problems.
               24 And you look at their present funding level, which is
  ce- Federal Reporters,  Inc.
               25 $IPIOOIOOO -- is this correct?




                                                                          38



               I           DR. MAYER:  Yes.
               2           DR. 1XMON:  Somewhere in this bail part.  We wanted to
               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. Ingalls 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
               13 potential funding agency right there.  This was the original
               14 reason for the 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 academic lid and put into an HMO, or something, where they
               20 could pay some realistic salaries -- you know, -you have to
               21 pay a little extra to live in Buffaloi  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.
  @ce- Federal Reporters,  Inc.
               25           DR. MAYER:  Sister Ann.





                                                                             39


                             SISTER ANN JOSEPHINE:  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 have.completed three years, and their
               14  plan is to fund the fourth and fifth years as originally

               15  planned.

               16            DR. MAYER:  All right, other commeDtS?

               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 HERR:  I second the motion.

               21            DR. MAYER:  Ail right, discussion?

               22            The motion was that we approve the recommendation

               23  of the site visit team.

               24            MISS KERR:  Which is not to include a developmental

  Ice-Federal Reporters, Inc.
               25  component, but at the funding level by amounts that he





                                                                           40




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

              3             Philip.
              4             DR. WHITE:  I can't accept that recommendation.
              5    I 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   where 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 visit
              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
  ,ce-Federal Repoitefs,  Inc.
              25   are going to opt one way or the other by that time in terms




                                                                              41


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

               2   can recruit, et cetera, et cetera.

               3              MRS. 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 their

               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,s

               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

               14  triennial  status is concerned.

               15             DR. MAYER:  Ali right, that's another option.

               16             DR. KRAWLEWSKI:  A question of procedure.  If  we

               17  gave them  two year funding now could they come in  or a

               18  triennial  application next year?

               19             DR. MAYER:  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                                    and I will remove it and
                              DR. BRINDLEY:  I did,
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               25  Joe make his.




                                                                              42



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

               2   recommended by the  site visit team, not  granting  triennial

               3   status, and with the provision of a site visit  in  one  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:  Ail right, further discussion of that

              10   substitute motion?


              11             Yes, Jerry.

              12             DR. BESSON:  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 committee

              17   then have any funding jurisdiction?

              18             MFTS . KYTTLE: If the requested increase  of  funds

              19   exceeds theIlevel of approval it may well  exceed  its  level

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

              21   latitude of moving 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
  ce- Federal Reporters,  Inc.
              25   that the SARP opted to send to the committee for action.    But




                                                                            43



                  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 the funding level in that second year

              12  of the triennium they would in all probability ask the

              13  review committee to look at it, number one.

              14            Number two, if in their judgment there  are  some

              15  issues that are there that are different than the basis

              16  upon which the original triennium was granted and there are

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

              18  Northiandso 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            Ail right, further comments?

              24            Henry, any comments?
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              25            DR. L;EMON:  I just might say I think it is obvious




                                                                               44


                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 health 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: Ali right. All those in  favor  of  the
                9  motion say "aye."

                10
                             (Chorus of "ayes.
                11           Opposed?
                12           (No response.)

                13
                             Henry  we thank you.

                14
                             We 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 ap the chief reviewer.
                19           The gentleman at the end of the table now, as most

                20
                   of you know is Dr. Robert Carpenter  coordinator of Western
                21 Pennsylvania Regional Medical Programs, who I didn't see
                22 flinch perceptibly when I heard all that talk about Erie, so

                23
                   1 assume there is no conflict.

                24
  kce- Federal Reporters,  Inc. DR. CARPENTER: Just my poker face. Nice to be
                25 back   with you.'




                                                                            45



               I            DR. PERRY:  From my standpoint I am especially

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

               3  will share with me how sorry we are that Al 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 Carpenter, as 'you have introduced,

              12  head of the Western Pennsylvania RMP.

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

              14  been a little shaky myself.

              15            DR. PERRY:  Reinforced by a really excellent

              16  group here from RMPS, J(,,anne 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
  ce -Federal Repotters,  Inc.
              25  relationships with Florida, a great deal of dissent between






               I   the RAG and the grantee agencyt a lack of an executive
               2   committee, other subcommittee groups to do the job; full
               3   of in-house conflicts, to a point where the dean of one  of
               4   the major medical programs was asking for the removal of the
               5   director of RMP; a move toward secession of the north Florida

               6   group area into its own RMP; an imbalance of t e areas
               7   of Florida between the southern naturally headed by the
               8   University of Miami group, the central University of Florida.

               9   And thus we went to Florida.
             10             Sometimes I think we can say miracles  wrought  by
             11    people can happen. I think we did find some  major  changes
             12    going on in Florida.  And we were excited, first of ails by

             13    a very excellent triennial application.
             14             Okay.  To some of us going down let's find the
              '15  reality on 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 glowing with tie
             22    changes that had taken place. It was not a  duplication  of
             23    national  olicies, but it was a selection of those national
                             p

             24    directions and recommendations that they felt might work

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             25    in Florida.  And I think that distinction was extremely





                                                                            47


               I  important to us as we looked at this.
               2            What are some of these changes then that have
               3  taken place?  The coordinator, Dr. Larimore, who had been
               4  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            The 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
              1 3 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 its strenghening with some really strong personnel that
              16  is going to itp this one in the middle has seemed to be a
              17  part of the major force of bringing three to talk  together.
              1 8 So there has been a drawing together of the entire state

              19  of Florida into much.more 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, Nursing

              23  Association, these were very strong.
              24            The working relationship with CHP described and in

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              25  action by the people appearing before us -- the chief of




                                                                             48


                I Florida CHP serves as a member of the RAG and as chairman.
                2 of RMP planning committee.  The RMP director is on the CHP
                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
                13 state of New York. Dr. Hilleboe was  former  commissioner  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
                16 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 some 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 McSossacks(?) is
                23 joining the staff there in evaluation.  He is looking forward
                24 to working close with the big bay, Dr. Hilleboe, that he
  4ce- Federal Reporters,  Inc.
                25 knew in New York state also, and he will be a strength




                                                                           49



                  to the program.
              2             Sidney Froberg, the nurse coordinator on the staff,
              3   1 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
              10  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
              13  looking at the new goals, which for the first time they have
              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 with good data resources for
              21  planning to the RAG, and I an 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

  ce - Federa I Repof ters, Inc.
              25  etc. have been involved here.




                                                                             50


                I           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. Hilleboe

                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

  @ce- Federal Reporters,  Inc.
                25 Gainesville with the strength and the powers that be in that






               I   situation.  Some of the projects that were closed out and
               2   that were reduced are those pro jects 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 RMP

               8   Program, Inc.
               9            These kinds of changes that have taken place through
               10  the direction, John, of -- you know, of a period of time,

               11  to Abe and to those of us who were there the first time
               12  were extremely significant, we thought, in terms of what had

               13  gone before.
               14           Continuation of support.  This has been built into tie
               15  evaLu ation approval of-oach new Project.  And listen at

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

               17  of RMP support will continue through nob-RMP support nex
               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-4unong
               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 wr tingp
               24  in all kinds of effective communication systems throughout

  ce - Federal Reporters, Inc.
               .25 -the state. I can mention some of the kinds of materials --





                                       planning  guides  for  applications,  application  materials,
                                2      staff  review checklists  --  you                          know,  in  addition  to  the
                                       panels  and  such  that  we  spoke  of.
                                3
                                4                        To  give  just  a brief  feel  on  the  kinds  of  projects
                                5      that  they        have  moved  into  this  regional  scope  I  will  mention

                                                                                                                                      riorities.
                                6      just  a  few,  but  they  do  support  their  goals  and  p
                                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  project                         has  also  established  a
                                12     network  of  six  centers  for  screening  high  risk  wo,me.,,n  for
                                13     cervical  cancer,  and  these  are  in  the  target  populations
                                14     of Jacksonville,  Miami  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  been  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     problems  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.

    A.ce- Federal Reporters, Inc.
                                25                         The  extended  campus  conce-gt  project,   involving





                   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                                           offices for the
                   that will @ done in their eight district
                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- Federal Reporters,  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   comments 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           For the weaknesses:  granted that they are doing
                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  not 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 Cuban

                22
                    population.
                23           We have recommended, however, possibly the Tampa
                24  health guides project is something they can move in here.
  @ce-FedeFal      Reporters, Inc.
                25            They are looking for some leadership people in the





                   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.  They already 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 usi as he @ntioned to
              20   you.  This project had not only 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
  ce-Federal Reporters, Inc.
              25   into that later.




                                                                             56




                              Bob.
               2              DR. CARPENTER:  Thank you.  I can't imagine what
               3    1 could add to that fine description of the region-,-

               4              DR. MAYER:  Comma, but.

               5              M. 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 back pocket and went in, and I am
               12   h&ppy to report also that at the end of the site visit I

               13   sold my gun at a five dollar profit.
               14             We found, as Warren said, much support, in
               15   watching the interactions of people and hearing their detai]Let
               16   descriptions of projects, much support for the very well

               17   written application.
               18             We were impressed, all of us, with the fact that
               19   they had arrived at a very logical arrangement to link
               20   CHP and RMP.  They simply asked the state CHP chairman  o
               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 w IJ
               24   have opportunities to refine their thinking about what,
  ,ce  -  Federal  Reporters, Inc.
               25   should be done and what can be done in Florida.  But




                                                                            57


                   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. Hilleboo  has

              11   only recently joined the program. They have  been  very

              12   effective, and it was partly because of this and partly

              13   because of the great success in phasing out projects and
              14   achieving private support that we all came away with a feelini
              15   that you could trust these people with really a good bit

              16   of money.

              17             1 was impressed that the subdivisions of  the

              18  'program, the area advisory group, the subregional groups,
              19   were led by physicians  and not old retired physicians, and
              20   not young physicians that couldn't have their  practice
              21   going well, but seasoned, active 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.
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              25             Organized medicine is also very much involved




                                                                            58


                1   through the offices of Dr. Philip Hampton, and he holds the
                2   grantee organization together and has been, I think, largely
                3   responsible for pulling the medical schools, the medical
                4   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 leaving
                7   actually he is not, he is a southern gentleman and a very
                8   talented individual, and I want him for a,RAG chairman in
                9   my region. He's really great. And the training  in  group
                10  dynamics that he lived with all 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 perkaps 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  ave
                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  area advisory groups, subregional groups, are to move into
                24  the area of area health education centers and emergency
  kce -Federal Reporters,  Inc.
                25  medical service in the coming years,




                                                                              59

                I            The renal grant I think Was a nice example  of  how
                2   well things are working.  We were faced with talented 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 were 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  quicki@y handled this, and each personls leadership role

                14  became pretty evident.
                15            So I think, as Warren said, they need to realize
                16  that there are other allied@health professions other than
                17  nurses, and they do, and Warren helped them considerably to
                18  see the importance of that, and I think that they will
                19  broaden'their representation on plaus@ing committees.
                20            They need a little bit better objectives, little moze
                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 region
  Ace-Federal Reporters,  Inc.
                25  that has the mechanism, has the leadership, and needs the




                                                                             60




                I   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 goinE
                9   to keep him from coming becaus e I know how strongly he

                10  wants to come to be there with you.
                11            I suspect he got to me because in one respect, not
                12  only because I was going to be here, but as some of  you  who
                13  may have better memories than others -- and  I am surfacing
                14  this because 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,    was
                17  one of the individuals that felt that that might be the
                18  appropriate direction that they might have to go in tie
                19  state of Florida, and I was coming off of the base of having
                20  grown up in that area and with some continuing  knowie  ge
                21  of what is going on in that area, and feeling that the
                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
  O,ce-Fedetal Reportefs,  Inc@
                25  site visit report and what has happened in the state






                   indicates to me that, by godo I am wrong once in a while.
              2    It is certainly clear from the enthusiasm of the site

              3    visit.
              4              1 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 their problems and have solved a  great  many.  Both
              12   Bland Cannon and I feel strongly that they should be approved
              13   at the level requested save for negotiation re the  renal
              14   project and approval of the 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   coordinator 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. Larimo  re.
              23             DR. CARPENTER:  My observation was that Dr. Hampton

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

  ce - Federal Repot ters,  Inc.
              25   when he was asked by Dr. Larimore to comment he did so, and





                1   very effectively.  And when something heeded to be done to
                2   put the polish on Dr. Hampton was right there to do it.
                3   1 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  adirector of AmPak.  He is highly regarded in the
                13  American Medical Association.  He is a good man to have on there

                14            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. Brindle,y.

                19            DR. BRINDLYY:  May I ask 'you a question?

                20            DR. MAYER:  Could you use the mike, please?
                21            DR. BRINDLEY:    May I ask you a question on page 7
                22  of the synopsis about one plan,"bealth care services for

                23  the underserved rural areas of the state whereby plans are
                24  to follow the Mayo, Florida experiment, whereby medical

  ,ce-Federal 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:  Beautifu 1.  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
                    Mayo, Florida.  They have introduced into this very small

                    rural community physicians--
                12            DR. BRINDLEY:  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            I)R. 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 now
  kce - Federal Reporters,  Inc.
                25  become somewhat of a referral center which has enhanced its




                                                                                64


                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              1 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 $2,213,435 including the renal.  We are
                12  recommending what they have requested from the $1,355 to
                13  $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@$196,988 plus.  And the renal project which has   bee n

                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.

                2 1            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 13
  kce- Federal Repofters,  Inc.
                25             MISS KERR:  And the t:r@.ionniai status?







                              DR. PERRY:  Yes, full approval.

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

                3             MISS KERR:  I would second it.

                4             DR. MAYER:  All right, discussion.

                5             Yes, Dr. Hinman.
                6             DR. HINMAN:  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 t his.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
                15  ahead in their other triennial as far as the total amount.
                16            DR. HINMAN:  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 thetbi,,rd -year for the kidney.

                20            DR, PERRY-. That would 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
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                25  with  them.







                           DR. MAYER: Leonard.
               2           DR. SCHERLIS: I was just going to say that perhaps
               3   we shouldn't be specific 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. HI@:  !;Im  sorry.  Ididn't hear.
               13           DR. SCHERLIS:  What has been the negotiated

               14  level at this point?
               15           DR. HINMAN:  The negotiated level at this point,
               16  my understanding it was not quite the 250; it was 223,500
               17  for the first year, 187 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.
               21           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 -yearthatthe region's
               24  approved level for the second and third year should be

  ce- Federal 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 their
                4 level of activity in the first year of the triennium and

                5 subsequent years.
                6           MRS. KYTTIZ:  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 ascends.
                12          DR. MAYER:  All right, further discussion or comments?

                13          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 my 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. beforeve break for lunch, and then after Metropolitan
                23 D. C. we break for iunch and come back and pick up those that
                24 are either anniversary before triennium or anniversary within
  @ce- Federal Reporters,  Inc.
                25 triennium after lunch.  So I think we would like  o move on




                                                                           68


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

               2            DR. KRALEWSKI:  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 soim consultants, Dr.

               6  Heustis, 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 RMPS
               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
               13 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.
               17           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 programms funded
               21 for a triennium with the recommended level for this operational
               22 year that they are in right now of a million six.  That
               23 level was funded at somewhat over 900,000 by the RMPS staff
               24 here, Dr. Margulies and his@staff, and then was cut back as a
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               25 result of the cuts across the board to 887.  So that is the




                                                                           69


               I   kind of lbnding 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.  And
               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 projects.  It also included a review,
               12  as I mentioned, of the kidney project that had been
               13  developed, started to develop two years ago, and this past
               14  year was submitted in a tentative 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  directors as a steering committee out of the board of directors
               20  of the Medical Society, and they pretty much started out to
               21  run the program from a policy 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
  ce -Federal Reporters,  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
               4   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,, their inability to get a viable program off the
               12  ground in terms of putting their projects together and
               13  developing an overall organizational thrust.  in their first
               14  year of operation, for example, it was noted that many of
               15  their projects had a hard time getting started, and in the
               16  review that took place at that time byraview committee thev

               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,
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               25  so there was a problem of control.






                            The staff that Dr. Wentz, who is the director
              2    of the program, has was pretty much inherited from the
              3    previous director, and in many cases were 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 cases
              7    appointed those staff members, so he really didn't select
              8    them.  They were appointed by these other agencies, tie-y
              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 direction.
              14            With the mission change of RMP  again there was an
              15   undue delay in their grasp of this new mission and getting
                   the mission statement out to the Regional Advisory Group.
              16
              17   As a matter of fact, they floundered around with that
              18   whole problem area for some nine or ten months, and finally
              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
              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

  ce-Federat Reporters,  Inc.
              25   programs, but they were not tied in with universities, and





                I  they were operating pretty,'much through a hospital council,
                2  and they were attempting to build the staff for these
                3  continuing education programs in their own  organization
                4  rather than using the talents that were available from the three
                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 RMPS here.
                13           Well, that was the general problem in terms  of
                14 trying to formulate a program that would meet the heeds 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 well 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.  When this was challenged
                24 during this past year they backed off completely and now are

  -ce -Federal Reporters,  Inc.
                25 referring many decisions that they should be making in terms
                I                    N





              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-,result the Regional Medical
              11  Program developed their own staff capabilities in handling

              12  fiscal management.
              13            The leadership in the program has hot 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 sonscases, and they are busy
              23  doing eheir own thing, have been for the past two or  three
              24  years, and he has just not been able to bring them into  an
  4ce-Fedefat Reportefs,  Inc.
              25  'organized group.  At least that again was a problem that was




                                                                          74


               I  being presented to RMPS here.  The staff members have pretty
               2  much their own personal interest in mind.  They have personal
               3  projects that they would like to develop, and they have not
               4  been able to relate those to an overall organizational thrust.
               5           They have right now 31 core 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 the whole administration of the program
               12 and whole complex of putting these talents together has been

               13 an ongoing problem.
               14           Weil, the third area 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
               17 attend meetings if these original members are not available.
               18 Most of these members of RAG are appointed again by
               19 interest group agencies.  That's the way their bylaws read.  Tboy
               20 have some 70 members, as I mentioned, that can be appointed.
               21 Sixt@y-five of these are appointees of various producer
               22 agencies.  So they have very little flexibility in terms of

               23 how they can change their RAG structure.
               24           The RAG group appeared to be relatively inactive also.
  ce-Federal      Reporters, Inc.
               25 We noted in the past that while they may get a large turnout





                                                                           '10


               I  for a morning meetings 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  dominated, 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 these
               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 three rubrics then, going on to some of the
               13 projects that they now have in mind and the program that seems

               14 to be developing.
               15           First of all, under administration Dr. Wentz
               16 has been able to bring the staff into his parent organization.
               17 He brought them out of the medical 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
               21 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
  ,ce-Fedetat Reporters,  Inc.
               25 organization -- and by the way, this caused him some space





                1  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 carry 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
                12 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 personnel.
                .)6         Again as I mentioned, we found at least part of
                17 the staff members, part of his staff were retired from other
                18 jobs,, and he really doesn't have a good plan in mind  as  to
                19 how to phase them out of his operation. He hopes  that  they
                20 will retire. He is hoping this will occur this coming  -year
                21 for a couple of individuals.  But 'yet  e 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
  ,ce-Fedefal Repotters,  Inc.
                25 that you would expect, if you would meet him and talk  with






                I  him f ive 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 upse t with the organization  because
                8  of the way it is kind of floating along and with their inability
                9  to even get their employees or their people that he wants  to

              10   report to them to be able to follow that channel and stop

              11   bypassing them.
              12            Okay. Well, the next thing is the  question  of  the

              13   medical society, and this has been at least partly  resolved.
              14   There is now a committee been formed between the RMP 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 shouldbe in terms of a grantee
              18   organization in fiscal management, and I am fairly  confident

              19   that that is going to improve, that relationship will improve

              20   over this coining year.

              21             The newly elected president of the medical  society

              22   assured us that he is going to tive them his fullest

              23   cooperation to expand RMP, and that in his estimation it  was
              24   perfectly agreeable to let RAG be the policymaking body and
  ce -Federal Reporters,  Inc.
              25   for the medical society to act in a different capacity.






                I           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 Regional Advisory Group has been totally
                7  reorganized, and they have organized it now into a number of
                8  working committees, and Dr. Wentz believes that these  working
                9  committees will involve RAG more actively in the  decision-
                10 making, and therefore will be helpful in getting them to  come

                11 to meetings and take an active role in the program.
                12          They have been only minimally effective in involving
                13 minority groups into this debisionmaking structure, although
                14 they have added one black woman -- her name is Mrs. Bullock
                15 to the group, and she was very impressive to us.  Unfortunatel3.,"
                16 they didn't invite her to the site visit meeting, bug 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 invited 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 about the program. They  have  not
                22 involved her in the decisionmaking process as of yet.  Bu t

                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
  ,ce    -    Federal    Reporters, Inc.
                25 'beneficial influence to the program.






                                  airman of the RAG group that is now chairman
                            The ch
                2  of the group,, and he 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.  Yet
                7  every one of his working committees are headed by physicians,
                8  and they are pretty much representing interest group agencies,
                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
                11 program,, will be able to alter those committees or be
                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 me
                15 three times.  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 4Ln aggressive kind of guy who will

                20 make changes.  Again it is of -yet untested@.
                21           Twenty-ihree out of the 110 RAG members and
                22 alternates are minority members.  But with the exception of
                23 aboutthribe of them they are a relatively passive group, and
                24 it would appear to us that they were handpicked -- maybe that'i

  @ce-Fedefal Repoitefs,  Inc
                25 being a little too unkind, but they were brought in there with









                                                                        Mrs.
                   the idea that they weren't going to cause any waves
                2  Bullock, on the other hand, will cause waves, and again we

                3  pin a lot of hopes on this gai.
                4           All right, the program in itself, they have broadly
                5  stated goals and objectives that kind of go along with
                6  what everyone else things should be done and reflect the
                7  national interest.  Their projects that they have developed,
                8  however, don't really fall into these general areas,
                9  although the areas are so broad that -you could fit everything
                10 into them, I suppose.  They have few new projects.  As a
                11 matter of fact, the application we have in'front of us here,
                12 all of the projects have been previously approved.  So

                13 there's no now projects in it whatsoever.
                14           They have 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'sp
                19 dealing 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 And as a matter of fact, in loooking at the projects that
                23 they are'requesting funds for here, with the RAG group that
                24 was in front of us that day we were asking them what they
  kce -Federal Reporters,  Inc.
                25 thought of these projects and the priorities, and they





                I  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
                I Imeeting the day we site visited them that probably they were
                12 going to be effective in reallocating those priorities  in
                13 a more meaningful manner. So we did get 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 progr
                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

                23
                   raised the issue of trying to put these together into some
                24 kind of a continuing education thrust it was really a new
  Lce -Federal Reporters,  Inc.
                25 thought, and they really had not done that at all in the past.






                I             They have totally reorganized their review procedure,
                2   and they have an office that they call an office of Program
                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 the3Lr contracts they are asking for money

                12  to involve medical Students and nursing Students and other

                13  health students into a program in the poverty areas for
                14  two purposes, one, to get them to appreciate the problems;
                15  and number two, to get 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.

                19            The HMO projects that they have in mind in terms
                20  of giving groups of physicians some help, providing them
                21  information with the HMO 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 embryonic stage of development.  Their organi-

  kce-Fedefal Reporters,  Inc.
                25  zation was certainly minimal in terms of its capabilities at

                 I




                                                                               83


                I   the moment.  It looked as though RAG had some promise in
                2   terms of decisionmaiking. 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 this time I can got you to comment on it
                12  since you sat in on the meeting with them, Mr. Spear.
                13            MR. SPEAR:  My naturally poor enunciation is further
                14  burdened by some oral surgery yesterday, so if -you don't

                15  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.
                18  The history is one burdened with poor organization, poor
                19  planning, selfish interests expressed.  And at the last
                20  Council meeting, one of the last projects in hand  Counc I
                21  said let's take one more look, 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
                               It was not the first time this had been attempted
  kce- Federal Reporters,  Inc.
                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  nephrology

              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 clearl)

              13
                    through Dr. Argie's efforts as well as the RMP, had  done
              14    its work and gotten its marbles lined up pretty well.  There

              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 MWRP.

              20
                              Shall I go ahead and say what came up later,

              21    Dr. Kralowski?

              22              DR. KRAL;EWSKI:  Yes.

              23
                              MR. SPEAR: The plan that came forward  was  for
              24    a total request of $524,000  a little more, about 525,
  -ce-Federal Reportets,  Inc.
              25
                    including the indirect.  This is a reductionfrom the






                   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 UpshOr Street clinic to be installed by Howard
               10  University, and a community home dialysis unit at the D. C.
               11  General Hospital, and an outer center home dialysis center

               12  to be placed in Northern Virginia.

               13             Let's talk about these separately.

               14             The transplantation component was a  request  for

               15  $183pOOO,  and is focused on Georgetown University, and
               16  includes an appropriate number of staff and some very minimal

               17  other cost elements that need to go into this.  And rather
               18  than detail it for you, let me give you the reviewer's commentt,,.

               19  These 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 RMP.  The
               24  concept of the administrative coordinator.is an error.  The
  ce-Fedeial Repotters,  Inc.
              .25  proposal places this individual in the RMP offices to keep







               I   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 ways 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

             22    doctor who I am told is quite capable and has been receiving

             23    a year's training in Minnesota. George Washington  wants  to

             24    get a transplant and get going.
  :e- Federal Reporters,  Inc.
             25              So that in looking to the future what  the reviewers




                                                                            87



               1  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 invol ved.  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 f irst 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 ball 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   by the region.

             12             The neighborhood dialysis center at the Upshur

             13   clinic was essentially a reiteration of the plan we saw in the

             14   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

             18   region had only shown a definite focus on transplantation

             19   and had demonstrated the desire to got 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
  ,e- Federal Reporters, Inc.
             25   of the community.




                                                                            88



               1            The region suggests that there are on the order of

               2  150 patients    this was the 1970 figure -- on dialysis in the

               3  region being treated through seven centers.  The  gap  lies

               4  in the innercity where there is little, if any, resource

               5  for the innercity residents.  These dialysis centers,

               6  essentially the Upshur clinic and the one at D. C. General,

               7  would start moving on that need.

               8            The Upshur 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 would 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  Medicaid 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  home environment would not permit them to.perform  this  at
  .e- Federal Reporters,  Inc.
              25  home.




                                                                            89


                            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 augment 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 home tra*ning unit

              11   in Howard 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 r6im ursemen

              22
                   for evening physicians and the technician services.  Since
              23   the Upshur patients will be trained in self dialysis supplies

              24
                   should not be reflected in the budget.  The reviewers believe
  ce -Federal Reporters,  Inc.
              25   the remodeling cost to be wholly out of line."  They  were




                                                                           90


                1  $3OvOOOo 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 water 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 $2,0

                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. MAYER:  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 co  nts.  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

  -ce-Federat Repottets,  Inc.
                25 levels given by the applicant was whoiiy underutilizing the






               I   center, and they say even though at that 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 compu er
               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 $410000 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  Georgetown 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 urged 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 enough supported, financially
  ce   -   Federaf   Reporters, Inc.
               25  supported patients to help cover the West Virginia  load,





                  which is estimated to be about 25 percent of the predicted 10a(.
               2           The request is for two part time doctors, and 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 laia out.
               10          The total request as recommended by.the reviewers:
               11 year 1. 202,265; year 2, 144,000; year 3. 30,000.
               12           DR. MAYER:  Thank you.  And just point out that
               13 the 202 000 in the first year was comparable to a reques
               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. KRALEWSKI:  Okay, want me to continue on here
               19 then just briefly with some of the accomplishments,

               20 and one of the major accomplishments--
               21           DR. SCHERLIS:  Can we ask questions about the renal
               22 study while it is still fresh in our minds?
               23           DR. KRALFWSKI:  All right, if you wish.  That's fine.

               24           DR. MAYER:  Go ahead, Leonard.
  ,ce -Federal Reporters,  Inc.
               25           DR. SCHERLIS:  I was just scanning the available






                   application, and no mention was made in the discussion of
               2   the facilities at the V.A., hospital or at Bethesda Naval

               3   Medical Center, and I gather there are already going on

               4  active transplant units there. Are we thinking in terms

               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

               12  that it was pushed aside.
               13            DR. SCHERLIS:  Lots of problems with the military?

               14            MR. SPEAR:  Yes.  It simply was not addressed.

               15  It was discussed, the desire to get 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  may 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.
  e- Federal Reporters,  Inc.
               25            DR. SCHERLIS:  One transplant site?




                                                                             94


                             MR. SPEAR:  I'm sorry# one ti sue typing site.
                                                          s

              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    1 assume, still one of the hallmarks of RMP, 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.
              16   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

  ce-Fedefal Reporters,  Inc.
              25   you got organ procurement going we will have  o use -your




                                                                            95


               1   services, but until we have met our needs with the military

               2   WO can't do much in the community.

               3             DR. SCHERLIS: But the V.A. hospital  works  with

               4   which of the medical schools?

               5             MR. SPEAR: George Washington, I  believe.  Am  1

               6   correct?

               7             DR. SCHERLIS:  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 - Federal Reporters,  Inc.
              25   affiliated.  There are two transplant sites or renai sites in








                    Bait imore

               2               M. MAYER: Dr. Thurman.
               3               DR. THURMAN-,  The point Dr. Scherlis has raised
               4    is a good  one, because do we really need three transplan
               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, g3Lven the Metro D. C.
               15   difficulties, complexities and population, and the   nature
               16   of the institutions, he would agree to it in this instance.
               17              DR.THURMAN:  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              MP,. 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.
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               25              M. SCHERLIS:  I think we have to separate from





                                                                           U't



               1  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 there
               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   get -- I gather it was Georgetown moving -- IQO,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             1 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. SCHERLIS:  Yes, 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
  e - Fedetal Repottets, Inc.
             25   think there is a justification for separating those.  But if





               I  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. Genera
               5  but if we separate out the military and look at that and
               6  say that is our primary focus of concern as RMP then I
               7  donit think it makes sense to promote and facilitate

               8  unnecessary duplication.
               9            DR. MAYER.-  Ali right.  Further discussion on the

               10 renal?  We will come back to it when we come to the
               11 recommendations specifically within the whole recommendation

               12 of the project.
               13           DR. KRALEWSKI:  Let me comment just briefly on your
               14 response of why you were subjected to this information.   e
               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 staff,, 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 the rest of the site visit.  And

               23 Dr. Shapiro believes that the program was a good one
               24 and that we should bring up in this form in front of the

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               25 'group, and that was in accordance with the instructions from




                                                                              99


                  Dr. Margulies.  So that's why the information was being

              2   presented.

              3              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 the projects, they have reorganized the
              11  evaluation of the projects and  monitoring  of  the  projects.
              12  All of this,, though, has been  accomplished  recently  and  will

              13  be in effect only for the future.
              14             They have 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
              18  regionalizing 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 hospitals;
              23  and they have a young gai who is a  nurse  on  their  core  staff

              24  working on that, and she is fairly effective.

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              25             They have been pretty successful in finding other




                                                                             100


                   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 this, of course,

               7   is again through the relationship with these many, many
               8   agencies that are locked in with them on their RAG committee.
               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 try to develop a Comp planning
               18  B agency, not too successfully, but they have made a little

               19
                   progress on it.  And they have a good relationship with

               20  the developing A agency.

               21            Their short term pay-offs I suppose in our

               22  estimation were few, with the exception of promise again

               23 from these contracts where they could probably realize quite a

               24  few benefits in a short period of time by.allocating that money
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                                                                           101

               I           They have been able to develop some fairly explicit
               2  kinds of operating objectives for their core  staff.  They
               3  are spelling out fairly precisely what kinds of activities the@
               4  are going to be involved with this coming -year. Again  they
               5  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 act ivity.  So there is a glimmer
               10 there of hope in terms of control of the allocation of
               11 funds through contracts to be able to get specific  things

               12 done that they need to further their program.
               13          They helped develop an allied health forum, bringing
               14 together the various 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 formed an HMO subcommittee.  They are meeting
               19 with 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

               24 at least some minority groups to RAG, one of them being

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               25 Mrs. Bullock, who we think will probably have a good influence




                                                                          luz



               I  on the program in the future.
               2           well$ in my summary then, we see here an organization
               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 real
               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.
               15          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 all, offered a concrete kind of activity that they were going
               23 to be able to get off the ground and would give them some

               24 visibility and credibility.
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               25           Number two, they felt that the project in terms of





                                                                           J6   --



                  the overall program of RMP offered a great deal of  potential
               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 mdme n t. -- and we al
               12 felt after our review -- that perhaps the RMP program  should
               13 not run the kidney project if it was funded because of  again
               14 the problems that they have in their organizational
               15 structure, but it probably should be run by s6meone who is
               16 project directorIin one of the hospitals.
               17           With that I will ask you, Miss Anderson, to comment

               18 on this.

               19           DR. 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 are on paper and untested
               24 and whenever we asked questions about  their  organization

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                                                                              104



               I   in.,various committees, what was the broad approach, we  would

               2   always get 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 involved 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  feet  the

               9   RMP contributed to the community. And there was  a  Dr.  Gins,

               10  who was chairman of the Department of Health Care

               11  Administration from George Washington University, and  he  was

               12  very positive in his feelings of relationship with RUP.

               13  He felt like his students had an opportunity to  have  contact

               14  with RMP staff, and 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

               1 8 a catalogue of professional films that were available  to  the
               19  community. 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  clinic,, said that the reason that he develo ped his clinic

               23  wasbacause of problems in the community in  regard  to  otier

               24  hypertension clinics, and so his clinic now was set up
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               25  according to appointment so that patients  wouldn't  have  to

                I





                                                                           Iva

               I   wait all day.  They were playing follow 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 first.
               16            1 had a chance also to talk to Miss Bullocko
               17  and I was impressed by her also.  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,

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               25  but that the community had been invited in to RMP, and she was




                                                                            106


                   the example of how the community was invited in.

              2              DR. MAYER:  Other comments?
              3              DR. KRALEWSKI: I would like to make the recommen-
              4    dations for funding them, because again as I mentioned,  what
              5    1 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 f igures 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  or

             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. KRALEWSKI: 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

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             25    it back again it will give Dr. Wentz the boost that he  needs





                                                                            iul


               I   to go through there and Cut Out the core positions that
               2   would strengthen that organization.  So we are recommending tiiat

               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 look at that organization and come to grips with ;hai

               6   problem 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 that 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 have the  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 thrust
  :e - Federa I Repor te rs, Inc.
               25  through allocation of core.  Now we are recommending $125,000,




                                                                          io8


               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 get 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:  Let me comment on that.  Let me remind
               24 you of how we got into, or of what went on that led us to
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               25 approving the triennium# at least as I view it., As you may




                                                                           109


               1  recall, that was early on in the  trienniIal review processes,

               2  number one.
               3            Number two,, we had a site visit report that recommended
               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  discussion of that site visit information that was provided
               10 was of those three things they took away the developmental
               11 component, they significantly reduced the dollars, but we
               12 never got around to saying, you know, no triennium.
               13           Now I have to say that my guess is from John's
               14 comments here  and having remembered 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 place, Phil.  And if we are going to take it away I would
               18 have to say it was our error in the first place, you know,

               19 rather 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'i

               24 all I am saying.
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               25           DR. WHITE:  I wasn't suggesting directly that this

                I




                                                                               110


                   be done. I am just questioning whether it Could be done.
               2              NM . KYTTLE:  Dr. White, from my memory one slight
               3   modification, when the three year funding was awarded
               4   developmental component approval was withheld because of RAG
               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 comments?

                                                               tion before you.
               9              All right, you have a recommends
               10             DR. KRALEWSKI:  I will 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. MAYER-  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  with that  recommendation as is we have removed    triennium.

               20             DR. KRALEWSKI:  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-Federal Reporters,  Inc.
               25  to me we have to recommend a budget for the second year or the






                    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:  Yes.  They already have an approved
              5     level of funding for that third year by our previous action
              6     and Councille 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               M. HESS:    his just doesn't abrogate, that's the

             11     point I wanted to make.
             12               M. MAYER:  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 of 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               M. 8CHERLIS:  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

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             25    ;year, exercise testing?






               I            DR. KRALEWSKI:  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.
               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-planned
               10 to be given to either Howard or G.W., $100,000?
               11           MR. SPEAR:  The second year figure was $JLOO,000.
               12           DR. SCHERLIS:  That seems rather expensive just
               13 as 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
               1 8I guess they all agreed to sit down and ask, for funds, but
               19 1 don't know how much pooling they have done of their needs
               20 in terms of being able to accomplish what has to be done.
               21           1 have a great deal of reservation not on the other
               22 recommendations, although I do want to ask you want
               23 contracts they are proposing.  Was that clear?
               24           DR. KRALEWSKI-.  The contracts that they are proposing?

  :e -Federal Reporters,  Inc.
               25 Well, they have an array of about 45 activities listed that
                I






                I  they were going to become involved in, and they ranged
                2  considerably, from:helping hospitals to establish PAS
                3  procedure in the hospital by talking to their medical staff,
                4  and so forth, helping distribute some kind of a calendar
                5  of the continuing education events that are going to take

                6  place.
                7            DR. SCHERLIS:    Do they have the ability to decide
                8  which of these contracts should be given the highest priority

                9  or the lowest priority?

                10           DR. KRALENSKI:  Well   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 the-y-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           Some of the things that they are listing are very

                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. SCHERLIS:  I'm not too concerned about the con-

                23 tracts.   I think this may be just what they need to get

                24
                   moving.  But I wonder what some of the reaction of others
  ce Federal Reporters,  Inc.
                25 might be as far as the renal project.  I don't want  o pursue




                                                                             114



               1  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  got to a specific recommendation what I would move,  or  would

               7  suggest that somebody move, is an amendment to it, would be

               8  $202,000 the first year, but take that $144,000 in the second

               9  year and reduce it by the lOOpO 00, 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

               13 totally for that third transplant unit.

               14           DR. THURMAN:  But you realize-you are going to

               15 destroy their only hope of a continuing cooperative effort?

               16           DR. MAYER:  Well, I think we need to  know that.

               17           DR. THURNIAN:  I am being facetious, Bill.

               18           DR. MAYER:  I think it may present an interesting

               19 challenge to  them.  TheIy may relook where they want to do

               20 that transplantation under those circumstances.

               21           DR. KRALEWSKI:  Mr. Spear, maybe you would I ke

               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
  ce -Federal Reporters,  Inc.
               25 because of the fact that it seemed as though  this brought about







                1  a great deal of cooperation.
                2           DR. THURMAN: 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 as  a que tion 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 what they agreed to at t
                10 site visit in terms of the transplantation situation, because
                11 he was excited about the fact that Howard and George
                12 Washington had decided to get together at D. C. General and
                13 would let Howard 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                                                  t that in
                   thought was wholly on one side.  I can only sugges
                17 retrospection as they looked at it they thought well, this

                18
                   is workable.and ifz%they.@can do its if they mean it, then

                19 it's fair to go alongwith it.
                20           1 would like to state one other thing. The  mat  er
                21 you were discussing, Dr. KraleWSki -- I should think we would
                22                           if
                   feel here in the RMPS that they really mean to do business

                23
                   and get a good transplant operation going there is no reason one

                24
                   can't do it, and in the first -year while they are doing one
  @ce -Federal Repoiters,  Inc.
                25 they all say they will refer their patients. And I  think  if







                   they get 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. SCHERLIS:  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 canit

             12    satisfy.

             13              DR. MAYER:  Would someone care to make an amendment

             14    relative to, or to extend the motion as it 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.

             20              DR. MAYER:, The amendment was that we would agree

             21    to the 202,000 recommended by the group for the kidney

             22    project in the first -year, we would recommend only 44,000

             23    for the  se cond 'year, which deletes the second transplantation

             24    center, and no dollars in the third year which deletes
   Federal Reporters,  Inc.
             25    @the third transplantation center, but does permit support in
                I







                   the first and second years of the dialysis units.

              2               DR. BRINDLEY:  if experience were to show that they

              3    needed to have more they could reapply for some extra

              4    funding, could they not?

              5             DR. MAYER:  Yes.    They have that option in the

              6    anniversary sequence that is here.

              7               DR. SCHERLIS: With which medical  school  is  the

              8    V.A, more  closely affiliated?

              9               MR. CHAMBLISS.  I believe it is George Washington

              10   University.

              11              DR. SCHERLIS: 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. CHAMBLISS:  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. KRALEWSKI:  No.

              22              DR. BESSON: "will instructions go to the region about

              23   this level of funding with advice  about this amendment?

              24              DR. MAYER:  Ohv I would think so.
  ;e -Federal Reporters,  Inc.
              25              Now the discussion of the motion as amended,.furthe




                                                                            118




                  discussion or comments.


               2            Yes, Jerry.

               3            DR. BESSON:  Well, I wonder whether it isn't

               4  alsoappropriate, in,spite of the fact that granted the militarr

               5  lives in a different universe than the real world, for

               6  the Council to see about some kind of coordibative effort

               7  with the kind of facilities that are available currently  at

               8  Walter Reed and whatever the other hospital is, the Naval

               9  Center.  And I think it would be perfectly appr opriate for som4.-

             10   kind of coordinative effort to take place between RSHMA

             11   and the Department of Defense.  So I would like that our

             12   motion also include a request of Council that some kind of

             13   coordinative effort be initiated as far as this transplant

             14   program in this area be concerned.

             15             DR. MAYER:  All right.  You understand that?

             16             MR. CHAMBLISS: That could be very  easily  covered

             17   in the post Council advice letter.

             18             DR. MAYER:  I guess my only -- I couldn't agree more

             19   that they need to look at those resources and that HSHMA
             20   ought to use its strengths, 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 turns out that both Walter Reed and
             23   the Naval Medical Center acting as the centers  respectively
             24   for the Army and the Navy are not in fact overloaded by
  ,-Federal Reporters,  Inc.
             25   their own activities, then I think it's one that oughtfo  be
               I




                                                                               119



                   encouraged to be pursued,

               2              yes, phil, you had a comment.
               3              DR. WHITE: 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 thi s 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 ye  can  do  it  in

               11  any case, and the meaning 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  meritorio Ius and we are withdrawing 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.

               17             MRS. KYTTLE:  There are several items that staff
               18  in charged with the responsibility  of  monitoring  within  the
               19  triennium, 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 Council 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 f unded is one of them.
  e-Federal Repofters,  Inc.
               25             Judy will probably be able to give  you  much  better




                                                                            120


               I   background on what generated the decisions this round on

               2   Metro D. C. than I, but just by our  proceduraireguiations
               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 some 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

               13  changing their personnel pattern that this is a farce.

               14            DR. MAYER: 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  those 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?

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               25            MR. CHAMBLISS:  Yes, that is correct.  They have




                                                                                 121




                    that freedom.
                2             MRS . KYTTLE:  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 staf f annivers ary review panel,. and are@be:Lng-brought.-to,
                6   you for information purposes, but nevertheless ineludeistaff-
                7   anniversary review's recoi ly, r ndation. 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 an,niversary@review@program was@.
                I I first developed it really was an. u-nt.ested@ idea,. and,-' if@@ RMPS"
                12  is anything it is an evolutionary program..  r.'tlii-nk- the
                13  notion of remanding to the regions fuiti authori-ty,has--really-

                14  been untested, and we are in@ the procesEr of,' testi-n@ t-hat', now.
                15            1 do have one of t@be pr@ams,. Alabama.- .. tD(@rev,ievr%

                16  where this very question comes ug..  So, L,' think-- that'. there;

                17  are several aspects of that anniversary review. t-h-et" pxe.-

                18  being changed as we go along..
                19            For example, we had originally spoke@of-anniversar-y

                20  review as precluding project review, but that haS7become
                @l  patently impossible.  We can't review program wit-hout-.Iooking
                22  at the matrix of the program which. is project,,, arrd,-, if-'We axe

                23  candid about how we reach a dollar figure , which-- after@ ail,
                24  is the only leverage that review committee has-, we reach-
  e  -  Fedeta  I  Repor  te   is, Inc.
                25  that dollar figure by careful scrutiny of the proje@c.,ts,





                   the leading projects here and there, which gives us a  final
               2   figure.  Now that is appropriate, I think, because we are.
                   looking at the substance of the program in terms of project@.
               3
               4            The second thing that has changed since anniversary
               5   review has developed has been the emergency of S@ARP,. the.
               6   Staff Anniversary Review Panel, which I think gives@ staff
                   a very substantial function in the review 'process-.. And-@ i"n'.
               7
                   my particular region that I will be reviewing it will beF
               8
               9   for review tommittee's function alone.  We have no-action-,
               10  to take on it, and staff I think has been very, close- toe
               11  the problem, has appropriately, I think, recommended a c-hange
               12  in funding Level.  But they retain, as I anderstoodyour-
               13  comments a little while ago, Mrs. Kyttle, the option of'
               14  bringing it to review committee. for action.
               15            1 think it would be well for the review, comittee(-
               16  to have some clearcut idea of standard operating  procedure-
               17  vis-a-vis the entire anniversary review process.,  But r
               18  don't share your concern that we are going back oitour-
               19  original intent. I think the intent is that  we  do,have  an
               20  obligation to monitor the region and make sure that they are

               21  accountab.Le..
               22            DR. MAYER: Phil.
               23            DR. WHITE I have no problem with  the  concept  of
               24  surveillance, and I have no problem with the concept of a

  @e - Federal Reporters,  Inc.
               25  close scrutiny of the application, including ail elements.




                                                                            123


               I   of the. application which incorporates project, at the
               2   time we come toIthese decisions.  That doesn't bother me.
               3   What bothers me is that by our actions here in reference
               4   to Metro D. C. we are saying we 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.  An  r think-.t.his
               9   is ridiculous, that we either say you don't or 'you7do@,, and"
               10  I think thing this precludes the staff raising-flags--,about,
               11  certain kinds of program elements.  But when yott have. this@
               12  substantial amount of concern it's a totally different kind.'

               13
                   of picture.
               14            DR. BESSON:  Well, the other aspect of t.his@,, Phil.,,
               15  is that we make decisions very often on, promise@,, andit.here,
               16  is a very obvious gulf between promise and performance-,.
               17  as is manifest here.  Well, I think it is appropr@iate@f-or,
               18  regions to,know that they are accountable for their,promises,
               19  and I think it is perfectly appropriate for RMPS tothold
               20  them accountable with performance, so that if this is going,
               21  to be interpreted by regions peripherally that the-y-have
               22  to measure up,, well, that's fine.  Thre's nothing wrong with

               23  that.  I can live with that very easily.
               24            DR. MAYER:   I guess what I was trying- to@ say

  4e -Federal Reporters,  Inc.
               25  earlier,, Phil    maybe I wasn't communicating clearly




                                                                             i24


                   enough    is that what we are doing is arriving at a
               2   suggested funding level as it relates to the second @year@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. CHAMBLISS:  That's a good question, Sis@tei-..
               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 au-d,6it
               14  prepared them for possibly recommendations that wiLl
               15  indicate they are not living up to their commitment?,
               16            MR. CRAMBLISS:  The manageimnt audit did in, fact
               17  point out their weaknesses, which so= of the are-as@ you, dis-.

               18  cussed broadly were touched on.
               19            M. KRALEWSKI:  And as I mentioned in@ the accomplish-
               20  ments section here, they have implemented some of those
               21  suggestions, particularly the ones @Ling with personnel
               22  policies and the ones dealing with timir organizational chart.
               23            MR. CHAMBLISS:  And Pulling the core back in.
               24            M. KRALEWSKI:  Pulling the core back in..

  e - Federal Reporters,  Inc.
               25            SISTER ANN JOSEPHINE:  Pursuing this a little furt,he






               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 :tnthe@

               8   total process.
               9            MR. CHAMBLISS:  The management audits are now@on,&-
               10  schedule for covering all the regions.  It so. happens,@ we7 have-
               11  passed this one already.  But certainly if there@ are-.eiements@
               12  in the program that need management audit attention:at any@
               13  point in the program I think the management audit team would.

               14  got back in.
               15            DR. BESSON:  Was the management audit ava:L.Labl:er. to-

               16  the site visit team prior to its--

               17            MR. CHAMBLISS:  In fact it was.
               18            DR. BESSON:  Is it available here in, the books?,:
               19            MR. CHAMBLISS:,  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.  r wonder whether

               23  we could see one.

               24            MR. CHAMBLISS:  No problem at all.

  e-   Federal    Reporters, Inc.
               25            DR. MAYER:  Any further questions  an the@motion?




                                                                             126


                             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 comittee 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 facti@.j-t7
                8  could project a volume of transplants of 50 cases  per-year-
                9  that it was not an appropriate place to have a transplant
                10 program in terms of the safety of the patients:  and,keeplng

                11 the team sharp and active.

                12           But rather than saying that neither G.W',- nor,
                13 Howard could hope to have  a transplant 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 justify three transplant facilities.,  r-, think-. the-
                17 hope of having one eventually as part of the medicaL schoal's;
                18 program of all three medical schools has been a very-
                19 important part of bringing this amount of cooperation

                20 together.
                21           SISTER ANN JOSEPHINE:  May r ask just oniw question

                22 relative to this and maybe relative 1-10 Dr. Margulies"

                23 remarks this morning?  I recognize @t a significant sum
                24 of money has been appropriated at tlw present time. for
  kce- Federal Reportefs,  Inc.
                25 treatment of renal disease and that there is goin@ to; be  a





                   push for transplant -arid renal dialysis.,  However, it may
               2   veLl be that when we find out how many  candidates  do  eXiSt@
               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 r have, real fearw    that,
                   we will move in the area of a philosophy comparable to@
               6
               7   euthanasia as we begin to look at these candidates..  And.
               8   1 wonder if we shouldn't take into thinking - therer isrn-;It.
               9   anything we can do about the policy, I know;: but evLe-n,: as@,
               10  we develop our own philosophy here, that we may: not., always.
               11  be this enthusiastic about developing alL.tilese-centers,,
               12  and maybe need to look realistically at what is7a real.@istlc.-
               13  case load to support a center, and this would,be ckf great,,

               14  concern to me.
               15            DR. MAYER:  Ali right, further co=eLnts-?.@
               16            Everyone understand the motion?
               17            All  those in favor of the motion, say@ "gy4r-..

               18             (Chorus of "ayer,.,I)

               19            Opposed?

               20            DR. WHITE:  Aye.
               21             DR. MAYER:  All right.  It will be- d'ui@y recorded-.,
               22             Let me suggest that we make every effort to be-back
               23  here by about a quarter of 2:00 if we possibiy-can :Ln@order.-t'O

               24  get through the remainder.

  -Federal Reporters,  Inc.
               25             (Whereupon, at 1:15 pm., the meeting@recessed, to@

                   reconvene  at 1:45 p.m.)




                                                                                128



                                         AFTERNOON SESSION
                2                                              (1:45 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!Buffaloi.

                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 currentlyin,    its- 03-
                10  operational -year.  It is functioning at $480;,,405,,, and@. they
                11  submitted an 04 request for  a  million  four.
                12           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 shou,id@ be filled
                17  out for -your anniversary prior to the triennium
                18            DR. SCHERLIS:    Intermountain and SusqLuehanna?@'
                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 'whic6 the- SARP members
                23  arrived at that rating, and I was trying to,get back,before-
                24  you started to talk this over with ym a bit.  This-is what
  ce-Federal Reporters,  Inc.
                25  we were kicking around.






                               For anniversaries prior  to  triennium  they  need  to

                2    go to Council with a firm recommendation of a rating..
                3              We  were  wondering  what  the  committees  assessment
                4    would be of a procedure whereby SARP would rate; if you would.
                5    wish,, we would show you how SARP arrived  incrementally-  at,
                6    the total rating on the pink sheet you have before -you@',   I:t
                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 relat ve
                11   to your question, Lorraine, and  that  is  that  I  personally
                12   on Intermountain have no handle other  than  the  written,  word

                13   which the staff review and SARP has given me, prius t-iiis@,,
                14   plus their application, and my interpretation may not. be-
                15   a fair one.  Now I will be asking for imput from the, s@taff'
                16   members involved, but since I have Never been to, t@-  region@.

                17   on a site visit I have to depend largely on tbLe written.

                18   word.  And I just -want to throw that in as a potential
                19   for perhaps not a fair evaluation or interpretation. from me to

                20   this group.
                21              MR. CHAMBLISS:  Well, we would certainly hope that

                22   an overview of the region  could  be  au  ented  by  knowledge
                                                             gm

                23   that resides either on the committee or in the staff on.

                24   which you could base some rating.
  ice - Federal Reporters,  Inc.
                25              MISS KERR:  And so you   am suggesting then, that we




                                                                            130




               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 Pane.I.
               6   assist you?  Would you like to see them.
               7             MISS KERR:  I would like to -- after the@ presentati:(in-

               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, oven those within the

               12  triennium, and have been assigned ratings.
               -13           MISS KERR:  Could you report to us afterwards-what,
               14  the average was or what the number assigned to4that was,. and.'

               15  then we can--

               16
                             MRS. KYTTLE:  Individually?

               17            MISS KERR:  No, as a group.

               18            MRS. KYTTLE: I can do both.
               19            DR. MAYER:  Let me try a suggestion,. that since
               20  SP.RP will have arrived at some ratings on 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.  r
  :e- Federal Reporters,  Inc.
               25  guess, just to throw it out for discussion, that perhaps if'






               I    this group had those ratings available to them-to-look

               2    at while we are going through the review process@ that we

               3    might wantto raise some discussions about particulaxareas
               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?  14@it

               9    appropriate?
               10             MRS. KYTTLE:  Could  I add something to@ that-?  Ln

               11   an effort to get your feeling  of - you@ know,, this- is:
               12   only our second, and really the first full time that we have.@
               13   seen anniversaries in this light - in our effort to;ge@t to
               14   you materials that would help you in you.r!revtews-of
               15   anniversaries that had this prior review, these, ratings come.- Ln'

               16   two forms individually, both raw and weighted'.,  An-& rwou.id

               17   like to get your  feeling  about whether both- documents. or--

               18   either document sent to -you  at the time the other- papers

               19   are wnt 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, r have been to that
   Federal Reporters,  Inc.
               25   region, but I am responding at this point to the pr:Lnted-@




                                                                     132


             I  word, and that kind of review 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. CRAMBLISS:  Indeed so.  I should think so.  An&
             7 we would like to say that the SARP ratings are in na wise-

             8          MISS KERR:  Are binding?

             9            MR. CHAMBLISS:  Beg your pardon?

             10           MISS KERR-.  Are binding?
             11           MR. CHAMBLISS:  No, indeed, they are not.

             12           MISS KERR:  In no wise are binding?
             13           MR. CRAMBLISS:  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 c"@
             16 get them through the process, then our basis for

             17 comparison will be much greater.
             18           MISS KERR-:  We.L.L, in essence then unless we. have any,
             19 glaring opposition to this we are reaJLI@y supporting SARP's
             20 rating which will then be its official rating for the

             21  moment?
             22           MR. CHAMBLISS:  If that is your pleasure all right..

             23  But  again that is left to this commi e.
             24           MISS KERR:  That's what I w*an, unless there is..

  ce-Fedetat Repottefs,  Inc.
             25           MR. CHAMBLISS: Yes.





                I-         MRS. KYTTLE: It would constitute either -your
                2 modification or  y.our affirmation of a rating that would hold@

                3 until the next anniversary.
                4          DR. BESSON:  But that would be for   the raw data
                  rather than the final figure?  We would have  anop  rtunity-
                5                                                    Po
                6 to inspect the raw data rather than just the  single- weighte(t-

                7 score?
                8           DR. MAYER:  Right.  Yes.  I gather that""hat they-

                9 were saying.
                10          All right, why don't we just move aiong.and tr-y@:Lt.
                11 and see how it works, and I guess it's Li-Ice every-thing'alse.-
                12 in here, policy f inall-y evolves out of dealing with-- the real,.

                13 world.
                14          DR. PERRY: Susquehanna Valley, as 1,  s@tarted@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          1 did have the opportunity of participating in the.-
                19 Last 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@le-aders
                22 anywhere, the coordinator, RAG, medical school relationshipr,.

                23 and so forth.
                24           There were some major  questions  asked-about-the

  -e-Fedetal Repotteis, Inc.
                25 relationship between the region, if -you recall,. andthe grantee,




                                                                                    134



                    the Pennsylvania Medica.L Society.

                               The weakness of  the  RAG  was  emphasized  time  and,
                 2
                 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 piann:ing.-
                 6             The noninvolvement of the Hershey, Me-dica.L School
                                                        aison had 'seen, requested added,
                 7  although repeatedly requested li
                 8  had been looked at, was noticeably consistently, Aging.
                 9             The absence of nursing and4lLiied health. i:mpu-t@,. ancL
                 10 although their continuing education program in-t.hat area
                 11 emphasized this, there  was  no  voice  and  Little@  re-laUonshiP."
                 12 in any decisionmaking or committee relationship.,
                 13            There was a concentration am subregional development.
                 14 And although there was recognition of thls-strong relationship
                 15 of individuals throughout the  region  !rL@  vwl@Gus  sections-,.
                 16 there was little, if any,, regiona.L dilrec+-ioal.,
                 17            There were questions raised about-- how,@ do@-- tons were@
                 18 made  by  the  RAG  because  there  was  ev@nce  that  practically..
                 19 nothing had been turned down in the btstory- 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 t,.* indicate what it- the

                 24 written report Susquehanna has moved am, so far- t(y@ remedy- some

  ce -Federal Reporters,  Inc.
                 25 of these weaknesses.




                                                                                 i3 5



                              Number onef,'and of primary importance       and all of
                 2  us,l'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 JLst,, 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 concer@n@       and-
                 8  it has been expressed for several times       at thoF 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  dire@tor-of   the
                 12 Pennsylvania Medical Society.  When he moved ta the. others
                 13 position they were not sure in any way that he: had@ a rea.L'ly,,
                 14 major leadership role and voice to make.
                 15           As of January I Dr. Joseph T.    Ichter wil-L, be@
                 16 taking -- I'm not sure I pronounced the    name, right,, r-c--h@-t@--3r - -
                 17 a pediatrician, attended the University    of North4 Carolina,.
                 18 got his M.D. at the University of Pennsy]Lvania,. has-accepted
                 19 the position and is on staff in the region.
                 20            There is  a vacancy on the core staf f  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 to
                 24 make some appointments that should  strengthen  core  and'gi,vle
  ce- Federal Reporters,  Inc.
                 25 him a working relationship there in the program.




                                                                              136


                            The core at-           of us that met them     and  I
                                        aff, those
                2   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 the
                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   1 am sure it hits 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 two, in relation to RAG, RAG has a.Lso.
                13  appointed a new chairman.  In the staff report, those,who@
                14  have known him and met him and seen him in act@ioa    and
                15  again I recall who he is -- another member that r  hadi.unch@
                16  with,today indicated she remembered him also     the, new
                17  chairman of the RAG, again showing change in response t(y,

                18  some new actions there.
                19           RAG for the first time has appointed a planning7
                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
  .e-Fedetal Report6rs,  Inc.
                25  to  spell  out  the  specific  relatiobship  between  the:grantee




                                                                                137


                I   agency and the RAG.-
                2             Okay, how many years did it take to get to that@?
                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,questi-oni,
                6   and I believe these are some of the things that@ the new RAG an I
                7   certainly the new director of the program   must get inva.Lved.

                8   in at once.
                9             The report indicates that RAG is stud'y-ing-tts
                10  composition.  This is another positive.  Many of us-were-
                I I concerned about the composition of that RAG.,
                12            Although the nonwhite population  is@  air  percent,, the.e
                13  are none on the core, none on the projec@t staff,, one of-  3,t
                14  on the RAG, two of 493 on other groups and committees-..  The.re@
                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- MtyditaL. S-chool@,
                18  although we have the first evidence indicated@here that.
                19  they will consider     and I am sure this is true since indeed.
                20  a position has been found for this physician a faculty
                21  appointment for the physician 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
  ce- Federal  Reporters,  Inc'
                25  look this way is strong.




                                                                                                                                                      138


                                                      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 c                        ontinuing education programs
                               4 remember specifically a physician assistant, well attended
                               5    conference  that  they  have  had,  programs  of  this  kind.,    rt
                               6    has  been  the  great  involvement  that  Hershe-y  has  been.involved
                               7    in  in  getting  started  itself,  and  their  unw-iiiingness@t.a.
                               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,, wouid.@

                               I 1  have  been  ideal.
                               12                     Although  regionwide  planning  is  badi-y-needed. --and
                               13   1  spoke  of  the  disparate -projects  and  the@  prob.levis  i@n,. terms-
                               14    of  putting  a region  together  --  the  new coordinator  - and,
                               15     1  am  sure  he  will  find  this  out  very soon                                     has,  avai-,Lable@
                               16    some  very excellent  resources  in  the  very  activeolocal
                               17 advisory groups. They speak quite open,ty about -- they7 am,
                               18 a grass roots group, everything happens in their4program an

                               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.     I'a
    ce- Federal Reporters,  Inc.
                               25   the  past  they  had  very  little  relationship  to  the  region-other




                                                                             139


                I  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.-an,y.@;
                7  kind; reported in the proceedings here and@ in- the- appJLlcation7,. and
                8  it is a bright spot certainly, in,cooperation w:Lth,"asoci&L
                9  epidemiologist from Hersey a data base for-t-he@region has7.

                10 been developed and published.
                11          What is needed certainly,, r. believe,, i;w- @major.
                12 commitment of assistance from RMPS here..  This@has@been
                13 spelled out in the recommendations made.   1: see@ a comment. here.
                14 that Harold has put on the outside of these,, "Let-lie@ get, i@n-
                15 touch with this man immediately and, work,. withi him, as:@ clo-sel-y,-
                16 as we can," and from comments that were: made -yesterday - the
                17 approach has already been made.  I ooticef- someone7,. t;hey said@-@ . f rot
                18 the staf f is there - today.  He is willing,, eager@ to come@ in
                19 and work with RMPS.  He wants to take a little more time    to@@
                20 assess his own reso urces, 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
                   vm haveit is going to be a repeat of what we found     in that@.

  ,e-Fedetal Repofters,  Inc.
                25 region before.   I think the important thing to make-  of the




                                                                                 140


                I   recommendations -- and here I am leaDing 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-Of4

                5   year of $480,405.  This was the commitment for the 04V year.@.-

                6   as well as the current level of funding, the exact amount...

                7             1 think it needs to be made clear, as-  the@  staf:U

                8   has recommended, and looks like an excellent way,  of  d.aimg@

                9   this -- made clear to the region and to.  this  new  coordinator,

                10  and to the RAG that's trying t  o 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'           'i6

                14  RMPS be given the authority to allocate, U'4p@ to.' ioo,ooQ@ t!OL

                15  this region during the 04 -year if it iz determined. by@ sta- -

                16  that this can be effectively used for regional and,.program

                17  development.  That total, were it to be given@,, woul   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  t.hat@

                21  are already in operation, we are not too impressed  wit.  -  some

                22  of them, some of them have had minimal ef fectiveness in-

                23  various ways, but this would put the  RAG  and  the  director  on

                24  the basis of an opportunity to move &Mad and change.
  @-Federal Reportets,  Inc.
                25             I feel that it is absolutely crucial. that: RMPS




                                                                                 141


                I   move with this individual in every way possible in     term

                2   of whatever assis tance can be given.
                3             We would  also  disapprove  the  developmental  component-.
                4             And I would I ike to have Judy,. any- of. ther. other- peopJ e
                5   who are familiar with the region,. to respo-ndlta:this since there
                6   was not a site visit, anything that- r might have- missed-- in@. the-

                7   recommendation.
                8             MS.  SILSBEE: You didn"t miss-  anything.  IW,-.  iic:hter-
                9   is on board.  I understand he, does have a H#rshe,y-facu-ity-
                10  appointment, and as soon as he gets his fee-t wet.- and, goes--- to.
                11  St. Louis he wants to talk to Dr. Margulies.,

                12            DR. MAYER:    All right, comments?
                13            1 have one to make     I would Just   @e-, to, suggest-.
                .14 that in recommendation number two.,, that is the,- availability
                15  of 100 p 000 in the 04 year, that it be clear, that,,- i-n @, making
                16  those dollars available there is no, impFLied.. ammitment-. in.-  the
                17  05 year above and beyond the $580;,.OOO@ issue-.,  Btycause, what'
                18  1 am saying is if they commit that,. all that 100,00O.in-the
                19  last quarter, you know, in theory one@ could@ be- caugh@t-, in7 the
                20  begining of the 05 year with an $880,000 kind of commitment,
                21  and I just think care needs to be given inideal.:Lng-wit-h that'.
                22            DR. SCHERLIS:  For my own information-would,-

                23  Dr. White  comment on project number 28?

                24             DR. WHITE:  Later.

  e-Fedetal Repofters,  Inc.
                25             DR. SCHERLIS:  What's that?






                             DR. WHITE@.  Later.  I haven't looked at: it.

              2              DR. SCifERLIS:  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. WHITE:  Ridiculous.

              9              DR. SCHERLIS:  Thank you.

              10             DR. PERRY:  These are the recommendations-thathave--
              11  been made  also by -- and I recall this specifically --by.-

              12  the last program.  This was the project,-. if-you:gobaek-

              13  into this region, that concentrated completety,on-,
              14  coronary and all these various    and we have bean-@ criticizing-
              15  them right down the line.  This is am, of them,, reasons, why-
              16  in the committing of the money we are Saying for.- god@li3@ sakcr.,,

              17  let Is look at new objectives. new go&Ls-, tn@ terms of- what, -you@-.

              18  are coming up with-.

              19             DR. SCHERLIS:  In view of llr, White's rather
              20  prolonged discussio n. would it be incumbent upon us to say
              21  since we are attaching no strings to the funds., we neverthelesE

              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- Federal Repoiters,  Inc.
              25             DR. SCHERLIS:  I gather this is Dr-.. White"s




                                                                           143


                  reaction.  Is that correct?
              2              DR. WHITE: I think it is.
              3              DR. PERRY:  A footnote, "ridiculous."
              4              DR. MAYER:  All right, additional comments?,
              5              1 gather you are moving then the recommendations of

              6   SARP.
              7              DR. PERRY:  (Nods.)  So move.
              8              DR. MAYER:  All right.  Further discussions?,
              9              All those in favor?

              10             (Chorus of "ayes.

                             Opposed?

              12             (No response.)
              13             MRS. KYTRLE:  This includes affirmation of the

              14   rating?
              15             DR. PERRY:  I have not had a chance to L-oolL 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.  Utiess- therel'si
              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 rating,overall rating granted by SARP?

              22             DR. PERRY:  I am.
              23             'DR. MAYER:  I see heads going up and down instead
              24   of sideways, so we will assume that we have consensus..

  ce-Federal Repofters,  Inc.
              25              1 would like to then move to Intermountain,,




                                                                                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.  I don't know whether he had or not.,  But L

              6     would like to have--

              7               DR. MAYER:  Just document in the@recard that,,

              8     Sister Ann is leaving.

              9               MISS KERR:  So I would hope -that WarcFid., G"Fl'aherty,

              10    and Dick Clanton, who are familiar with  the  area,,  or,any

              11    others around this table who have made visits,. will  fuel,,

              12    free to put in anything that they would desire when.r

              13    get through.

              14              The Intermountain  Regional  Medical.  Progrma,.the

              15    grantee institution is the Universit@y of Utah@.,  The:.Regidnal@
              16    Medical Program consists of a  geographical  area  of@Utah.,
              17    parts of Nevada, Montana, Idaho, Wyonting-,,, Co,.L-orada,, which--
              18    covers 546,000 miles, and I think we must keep this Ln@mind-

              19    when we look at the core and  a  few  other  things  thatseem

              20    to be quite sizeab le.

              21              There are two and a quarter mil.Lion.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 Regional Medical Program is

  .e-Federal Reporters,  Inc.
              25    presently  in its fifth operational year..  It is not within




                                                                                   145


                I   a triennium.  It is-p'resently 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-reFqueErta

                6   continued support for core and 21 projects ongoing, support

                7   for initiation of seven new projects, a devel-opmental-component,

                8   totalling $3,025,219.

                9             This anniversary proposal had a staff review on-the--

                10  14th of December and was reviewed by Staff Anntve.rsary@Revt-ew

                    Panel on the 20th of December, and recommended approvals.,

                12            As far as the goals, objectives and'@ priorities-  of-.'

                13  this region are concerned, the-  certainly used. the right
                                                    y

                14  words, and are therefore in writin compatible-  with.  nati:ona.Ll
                                                         9

                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 heal.th   care@

                19  delivery, acdessability, 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
  --Federal Reporters,  Inc.
                25  stated objectives.




                                                                                 146



                              It is felt that the present coordinator, Dr.

               2   S&tovick, has really done an outstanding job in terms of
               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  s@taff.  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   peoples most of whom are full time, but  all  of  whom  are  at-
              12   least 60 percent time or more.     Twenty-fout of'core.  staff

              13   are men, and their are three Orientals.

              14              Then in looking at RAG, let me say first that RAG7

              15   consists of 30 people.  Now they still have 30-peoplel,on.

              16   their RAG, although the representation has bee:a changed

              17   to involve more consumer input, and just a slight taken@.,.  r.!

              18   should say,,  of  minority  repre,sentation, 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,, sa

              23   perhaps we have to take this in consideration, too@,. when we

              24   are looking at the minority representation.  But it does look

  e-Fedeial Repotters,  Inc.
              25   a little low.




                                                                                147'



                              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-I

              5    as active as it would like to be seen..,  The comment., herre-- w@-
              6    made that this is due primarily ta the faxt- that- the-re@, is
              7    dif f iculty in the RAG membership relating., with'. core-@ Staff.,

              8    This was not enlarged upon, and somebod-y-may!want,taispeak-to@

              9    this.   I assumed that because the, core@ is active-,. is-

              10   aggressive, is able, that perhaps the RAG@ sits@ back- and-- is'n'

              11   quite as prominent in decisionmak-ing as. perhaps-, we@. would-., like--@

              12   to see them.

              13              The education planning and evaluation seCtiAOn.

              14   appears to have a great deal of visibility
                                                                   Their- major.

              15   contribution has been to assist those  pe.opla@  direeting-

              .16  educational projects, and they have., been, particularly,'heipflUl.

              17   in the specifications of educational objoctives- 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'tot'al,

              22   program evaluation.

              23              Though they do have some hard@ data,. it, appears

              24   that the region has established a systematic process for painnLng

   Federal Reporters,  Inc.
              25   proposals or developing proposal objectives - fLt@ does not,




                                                                             148


                I   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.Junct.ion,
                7   Colorado, Pocatello, Idaho, and Provo, Utah@..  rn@the,se-t4ree
                8   areas it is foreseen that there is great potential.'for-area
                9   health education center development, an4 they-are@looking in.

                10  this direction.
                11           Apparently the Regional Medical Programlis directly
                12  involved with many activities of other health-p-l-anning

                13
                    agencies in the region, though it seems that again CHP
                14  perhaps because of the@ visibility and the action@ and. the-
                15  positive movement of the core staff of RMPI@seems not,ta@be,,
                16  as active as one would hope that the CHPmight be.-.
                17            The ongoing projects, of whi!ch@ there- arer@ 2J:,. t-woc
                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. new 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,
  ce-Fedefat Repotters,  Inc.
                25  certainly this new coordinator is leaving his mark- at@ the




                                                                            149


                I ' 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 AHEC'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@imp@t on-
                10 the improvement of care of the people in the region@..
                11 There are a few areas, however, that need to be strengthened.,
                12          As I mentioned before, at the present moment it

                13
                   still appears that their overall program is still pretty-

                14
                   much project oriented.
                15          If some of you caught my eari-y remarks,, youi w:L.LI;, note
                16 that the indirect costs of $004,419, 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 @ thave

                19 forgotten just the exact amount.

                20
                             Again they need to strengthen the relationships and
                21 show them more clearly between their goals, objectives and

                22
                   priorities as they have written 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-
  ce- Federal Reporters,  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-odt.other

              3   sources of support for the continuation of its projects.

              4              The staff group in its review -- an-d r- concur- with.

              5   this -- is that rather than the 3,025,000 whichwas:requested'

              6   for the sixth operational year, because of the- area.1s- needs to

              7   strengthen their activities in those areas  ident-if:Led@ . and@

              8   yet to give them an opportunity to de so, it was feltthat.

              9   the funding allocation be kept at the same level as i--t was

             10   last -year rather than to increase it to the $3,,,025,000,

             11   which would remain then at $2,478,650.  This, was the@

             12   recommendation of the staff.  It also was the recommendation

             13   of SARP, and I would go along with tk@z

             14              The staff review recommended $75@,.000, f-or@ the

             15   developmental component.  The SARP group@    anxT-, thiis@@ was-

             16   the only area in which there was any marked dtf ference. o:E

             17   opinion relative to their reviews--  CW SARR group recommends,

             18   that this region perhaps if it had mme f lexibilli.ty- 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 recomwnded ten percent. of

             22   the former level of direct funding# vkich comes then. to

             23   $2479864.

             24              As a reviewer with no more familiarity than I'

  e - Federal Reporters,  Inc.
             25   have with  this area., I agree they haw many strengths.,  I'





               I   think,they have to take a hard look at turn.ing@the corner
               2   further and looking at their projects and relating them

               3   to their new priorities.
               4             And perhaps I am getting just a little bi-.t-squeamiB,h,
               5   because as I sit on this committee at times r think-. - and, I"
               6   use the word "hard-nosed," but I don"t really mean -it@that
               7   derogatorily, but I think sometimes we- get a.Li-.tt.Le.@generous
               8   and then a litttle bit later wonder if we@ really- d@id@ the-

               9   right thing.
               10            So what I am saying is I personally, wo,u7id' rathe@r@
               11  myself recommend the developmental component which,would;be-
               12  a part of the total level of funding at $150,00.0@rather-
               13  than the $247,00.  But I do recommend the developmental

               14  component.  I recommend it at that level.
               15            1 would b6:glad to hear front the res-.t- of y-,au,@. and"

               16  1 would be willing to consider changing my mind.,

               17            DR. ILKYER: Comments from s.taff?@
               18            VOICE: -1 would only comment that the rationale
               19  for holding the developmental component at $75,,OOO 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 IC
               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 Federal Reporters,  Inc.
               25  out f aster to do things if they had more..





                1            MRS. KYTTLE:  I'm sorry.  I was involved in something

                2   else and missed part of your conversation.  Are YoLt 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 sayinir - 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 KERR:  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, thcr 24,7i,,@000, is
                16  probably more than is necessary to get theuL ta- movel@ untix

                17
                    such time as we can look at it again.

                18            MRS. KYTTLE:  Mike Posta,,who isn,"t here  o ay
                19, because of illness , and who is chief of the desk. under@ which,
                20  this tegion-falls, had a conversation with the region,
                21  part of which I participated in, because the, region-. was call@irg
                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
  ,e Federal       Reporters, Inc.
                25  they had opportunities to move in developmental.component






               I   kinds-of ways. And, curiously, this region  has-  funded  a
               2   groat deal of its development component througiL grant
               3   generated income.  One large component that has generated thi-3
               4   income has generated so much that it is phasing out and,tt
                                                                           st@
               5   is continuing most of its activities under its own.
               6   and others.  And when that component went they were going
               7   to have to redesign some of their moiies.to fund even  u-p-
               8   to the $75,000 approval that they had been given, 'oecaus.e
               9   the grant generated income that had substantiated the furyd@

               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,,OOO@that
               13  they had.  Now whether they would double the 75,000@l d@on-l't

               14  know.
               15             Did he have a chance to get into that wi.th@@ @you-.,,

               16  Dick?

               17             VOICE:  No, he didn't.
               18             MRS. KYrrLE:  So apparently the region: at this time-

               19  stands ready to use about 125,000.
               20             DR. MAYER: Which would be within the  $150-1@000

               21  restraint  thaLis being suggested.
               22             MISS KERR:  I guess I had the feeling we- have gone
               23  on promises so long, but you know -- I'm reali-y, questioning
               24  whether we should do that as much as we have.  And-this

  ;e - Federal Reporters,  Inc.
               25  gives them more latitude than they would have had-with,the




                                                                              154



                   75tOOO.

              2               DR. MAYER:  Yes, Leonard.
              3               M. SCHERLIS:  I hate to bring up individual.
              4    projects,  but there is a small bookkeeping item, of@- $333, 000@'
              5    for multiphasic screening with a comen.t made- in the- SARP
              6    review that the slowness of the multi.phasic screening-
                   activity raised doubt about the relationships, betwee:n-@the
              7
              8    medical school, county and community it was@ designs to-, serve:,

              9    and the IRMP.
              10              I was wondering do you have any@ comments, upoir@ how-@
              I I  well that program is moving or  what it means.-- in-@ terms, of.@
              12   the present attitudes toward mult@iphasic@ screening?,  I. know,

              13   it is only a small item in their total budget,..
              14              DR. MAYER:  Dick, would you care. ta. comment,?'
              15              MR. CLAMPTON:  This was- also.. a concern- of@- staf:f@'..
              16              M. SCHERLIS:  Could staff teLl. u.s           blt@,

              17   about it?
              18              MR. CLAMPTON:  The indication,is they@hope-t-o

              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. MAYER:  No.
              23              MR. CLAMPTON: Well, they have been@ tooling up duriDg

              24   that period, but they will be going operationally supposedly

  'e-Federal Reporters,  Inc.
              25   this month.  This has all been a tooling up.process..






                              DR. SCHERLIS:  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 the-y@are tooling-

                7  up.
                8             MRS. KYTTLE:  This is part of the, ]En-.termountain
                9  program that has generated carr,yover every-year.,  They,money-
                10 was awarded, and I believe historically they-had troubles

                11 with the county on zoning exceptions, and that carried@over,,.
                12 one year because they needed to rennovate and, weren.A@t- @ver-y@

                13
                   successful with exceptions that they needed.,
                14            1 know the charts show that moni-es@were@awarded-,.bul
                15 they  were not expended.  They were carried over.. Somer--O-fL'

                16
                   the  money reinvested in this project is the same money

                17 that was awarded the year before.  Not al.L,;: some..

                              DR. SCHERLIS:  I would suggest as@ a, logistical
                19 play  that this be a device that every RMP fol:.Low;, 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
                              MRS. KYTRLE: I think it was a model cities-,Joint,

                24 endeavor.
  :e   -    Fedefal    Repoftets, Inc.
                25            MR. CHAMBLISS4  Yes, I think the committee-,should




                                                                            156


               I  know that, as Mrs. Xyttle points out, this was a model. cities

               2  project.
               3            We.have undergone some concern about this project,

               4  not getting moving before now.  It relates very directly

               5  to the same kind of problem that was encountered@at Maharry-

               6  of multiphasic screening,  And here again, if -youirecall,
               7  there is a policy determination on the muit"phaste screenin
               8  to see how they are going to move before we get mtich@further,
               9  into this, and we are beginning, I believe, ta see, some of,

               10 these answers fall out how.

               11           DR. MAYER:  As you recall, Leonard,, whe-n.,we approved

               12 that one we approved it with really that thought in.@mind@,

               13 and it looked like one of the better inuitiphasic:screening,

               14
                  proposals that we had, and it also was involved@inl&
               15 joint effort with model cities in terms of the, populations
               16 served, et cetera, et cetera.  But your point is- we.Lt, takein',

               17 about the built in developmental component.

               18           DR. SCHERLIS:  I am just wondering what should we.

               19 do at this point in time about the third year coming up, I
               20 it go at 333?  What was SARP's reaction to this?  Aside from
               21 having some negative gut reaction, what logistical--
               22           MR. CHAMBLISS:  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
  -Federal Reporters,  Inc.
               25 the interface between technology and service..  T at was




                                                                                 157



                I   encompassed in that discussion.
                2             DR. SCHERLIS:  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@'you. @st'.
                6   say we will keep that at 333,000?  1 was curious..
                7             MRS. KYTTLE:  With a funding level recomw.,nded of@
                8   2.4 something is going to have   to giire-..  r,, don@t"t know- whe@ther.-

                9   it will give out of multiphasic screening or- not..

                10
                              MISS KERR: This is  their  prerogative  to@.  decide,

                11  isn't it?
                12            DR. HESS:  But I wonder if something shouldn't,
                13  be said about this in the advice letter,, beeause@ agaity  if-@
                    you look at everything  else  ttLi.a seem to. be funded

                15
                    disproportionately high.

                16            m@,
                                   MAYER:  The question; tbat. r had" is-- what, arms
                17  the implications of the recommandatim,, and@, r.- ant- asking- it-.

                18  vis-a-vis the comments that Dr. Margulies made yesterday

                19  relative to potential add on dollars going in.,  U ww- took.

                20
                    no action the region Is request for tln, 06 'year -- we-II, the
                21  region's approved level for the 06 -year b,y Council as it,@ now
                22  exists on a previous action in the, triennium was 2,687-,000,

                23
                    and we  are now recommending 2,478,009 as  a.  funding  level..
                24  What does that mean in terms of rec       ndation that goes to
  e -Federal Reporters, Inc.
                25  Council, and is this really a suggestion that you lower the




                                                                             i58


                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's a funding level,, not an-@ approved.

                5  level that we are making.
                6            DR. MAYER:   All right, fine.  Did you,hearrthe
                7  response, that it was a funding level we are@ talk-ing'about,

                8  and not--

                9            M. 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.
                12 how 3.025 is cut down to 2.478.  But it seems to@me that
                13 that figure is arrived at not arbitrarily, bu,t by looking over
                14 each individual project and saying this is not appropriate

                15 and this is.

                16           Am I incorrect in that, Lorraine?
                17           MRS. KYTTLLE:  Welip IluL not chairmaa. of S7ARP-.,  Vtw

                18 Exec Sec of SARP, -but this is how I recall the f igur e was

                19 arrived at.  Some calculations were instituted,, and-. when- you
                20 started adding this and subtracting that the members of SARP
                21 concluded f inally that if you sent them the message that,
                22 two projects that have been criticized before s@tand-critic ze
                23 again, and'if you send them the mes@e that the,y-have turned
                24 off on                           f, and if          them the
                         e that we wanted turned of           Tou,send

  ce-Fedefal Reporters,  Inc.
                25 message that some of the now activities that they are




                                                                                    159


                     proposing  are   looked upon much more favorably than some

               2     of  the   continuations like, I believe it was project 18,    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  heopfu@JL  i-f

               8     we  could  have the basis on which SARP arrives at its@fu.nding-

               9     level   because this is really the way we operate here,, too..

               10    We  start  with a number and then add and subtract to,,Lt..  Now

                     as I look over the items requiring committee action-., rsee-@

               12
                     that there are suggestions based on approval or disapproval

               13
                     of individual projects, and as I have looked@over-some-of-

               14
                     the new projects that you say are more in-keeping with@.

               15    the new missions I may disagree with  some  of'  tboose-..  But

               16    1 think  in  the light of the question, raised about  mul..,ti.-

               17    phasic screening it would    be important for review committee

               18
                     to know whether that was    "deleted" or whether that was.

               19
                     allowed to stand.

               20
                                MR. CHAMBLISS:  It was allowed to stand.

               21               DR. BESSON:  Well, then it might be' appropriate for

               22
                     us to know a little bit more detail as tohow'SARp.arri,vad

               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.
  @e-Federal Repofters, Inc.
               25               DR.   MAYER:  I think the point you are making is a




                                                                                160


                 I  valid onev Jerryp and' I would like to suggest that it really
                 2  would be helpful  to this committee that when BARP 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 now, 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 RMP that  t@he-y'  have
                 14 shown a very lack of being  able  to  @-e  any  hard  funding
                 15 decisions.  A lot of their ideas -- an has bee.rr pointed   out?
                 16 they have come up with new ideas thaA: are valid,. t@he-y have
                 17 a lot of palatability in the region, but nevertheless     we-, hava
                 18 activities that have been going on @- 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 t@o make  some-  of  these  hard
                 24 decisions that had to be made in tM* region  and  to,  turn;  off'
  ce -Federal Reporters, Inc.
                 25 some of these old activities that should have demonstrated






                     their.utility or nanutility to the system at this      juncture.

               2     So we felt it would be a disservice almost taF@ aggrandize

               3     them in this capacity to add to the past @ear-'s Level.

               4               DR. MAYER:  I think one can@ just took, at'. I the - fAct-I

               5     that the dollars are precisely the same- as least. year, anc]L-,

               6     assume that. I think the  issue  is  we  would  hope  that.S@ARP-
               7     is arriving at those conclusions on a more. expio-icit.  basis,--
               8     by looking at projects and finding out what projects,- they-,
               9     think ought to be phased out, et cetera,, et cfrtera,. and: then@-

              10     adding on those that need to be approved,, and@that lovel@
              11     may not be 2.4, that level might bet.,9- mi!,IE@ion; or- Z'.39
              12     million or some other such figure..  And, it is- that, expliditl--.

              13     ness that I think we would like ta see-, incorporated i@nto- t-he@

              14     SARP process as well as our own..

              15                Is that,, Jerry, adequate paraphrasing?-,

              16               DR. BESSON:  Well, I Itnow- it is i-'nuorporate-d@ in:-.

              17     the SARP thinking, but I think it shoulder 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 Is just putting two and two together., That, may, not,.  be,

              23     right.  So I think there's a second component to i@t.,
              24     not only should we know about it, we think it should be done.
  a -Federal Reporters,  Inc.
              25                Yes, Elizabeth.




                                                                                162



                              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  f@l-t-

               5   was reasonable, and you all can make your own.decisions,,
               6   having read the material.  But I think they point out very-wel-I
               7   where the weaknesses are.  And it shows it a I:,.ittLe, 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 i  s. ared

               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 commen@ts?'

               17             DR. THURMAN: I second the motion for, 15'0@,OGO,..

               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 comments?

               24             Yes,, Jerry.

  ,e -
    Federal Reporters,  Inc.
               25             DR. BESSON:, I also wonder a little  bit  a  out  t




                                                                              163


               I  letters of transmittal of our decisions here.  if the area is
               2  to have a iitle bit of a sense of what the messages ar6 that-.
               3  we are 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 aV the: number,..
               6   The region may take refuge in considering that theser ar   just-,
               7   funding constraints because RMPS doesn"t liave-enough;money, t-his,
               8   year and say "well, we are doing exactly what's- expecte-d@ of- us--,
               9   and if only RWS had a little more money- we could haver, Some

               10  more," but that may not be what we intend..
               11            Is there any way that revieWL committee can-, have some@

               12  feedback as to exactly what's told the region@after,we Comes
               13  to sort of very theorial decision here: and say- wei'i,, somebody,

               14  is going to let the region know what the messages are:

               15  that we are transmitting.
               16            MRS. KYTTLE:  Dr. BeEson, we had@ copies- of-- al-L the-.
               17  advice letters from the last review cycle: ready,,, land-, Ii had,@, hope I-

               18  we would get them ready to give them to. -you- today,@ and- i-t-@ is-

               19  only that the same people are involved in all of tbia-are.
               20  the same people that were involved 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. CHAMBLISS:  If I may add on to%that, that.is

  kce- Federal Reporters,  Inc.
               25  now a matter of policy, that the members of the Advisory,




                                                                                    164


                I   Council, the members of the site visit team, and the

                2   consultants, along with the chairman of the RAG and the

                3   grantee 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 Va@y;

                8   is ridiculous?


                9              MR. CHAMBLISS:  Yes, indeed.

                10             DR. BESSON:  I mean   maybe dressed up; a little  bi-t.,

                11             MR. CHAM13LISS:  We 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.. phkilip-.

                15  White, Marquette Univers ty.

                16             (Laughter.)

                17             MISS KERR:   One of the things we haven.,"t  discusse-d@

                18  at all 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  let  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 chroi,ic

                23  renal disease, and the part  of  this  in  the  application  is  an

                24
                    ongoing program, but the committee wished to point out
  ,e-Fedeial Reporters,  Inc.
                25  it says "the directions the regions appears tobe going-




                                                                                       165


                      appear to be nonproductive, and would give a low rating
                2     if so asked regarding this activit-y.@, Furthermore, the
                3     progress report is not satisfactory because of its incomplete-
                4     ness and brevity.  Relative to 25B in the ALG@portion, L@t
                5     would have to be deferred pending the RMM policy de-cision.ow

                6     this.
                7               Relative to section 25B, again it indi-eates-that.-
                8     there has been some now information fed tnto@ RMPS asF of@
                9     December 9th relative to the activities for,the-renalfcontrol-@,

                10    and I do not have this information.

                11          MR. GROSS:  The new information  rekated. only,' tck
                12    supplemental activities, namely, 25B.  rt was basically
                13    a more detailed description of what the-y were applying       for-
                14    and the reasons for it.  If you would like,: at the.: present-. tim3
                15    1 can give you what my reactions were as. oL- staf-il- re@vi-ewer,-

                16    in more detail of the supplemental activity,,..
                17               My recommendations were that tli'iS7   not be- approve-d-:
                18    as well because of the following reasons.. First- of.'@ all-,.  i-t@
                19    appeared -- f irst 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.  RMPS has       yet tcy makw.  &
                24    policy decision on that.      I think any,, decision regarding
  @e -Federal Reporters,  inc.
                25    funding of that has to be deferred.






                              The objections that I had to the f irst two portions,

              2     the 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     ha4 already been purchased, and it has been clearly
              7     demonstrated that the ancillary personnel for-such.&.-profus-ior,.

              8     approach to organ procurement are also a necessar-y-part-.

              9     and should have been employed initially, and@why,they would-.

              10    have purchased the machine and now are requesting-the@

              11    necessary personnel is beyond me.
              12              knd secondly, t@at this sort of piecemeal support,

              13    of a program -- I mean asking for supplemental activity
              14    and just wanting, you know, a couple of desks. sort, of. thi@ng@,, e
              15    couple of technicians here and there, withou-.t crew evidence.

              16    of how they are going to be utilized, was LacK-i-ng

              17              Thirdly, it has been demonstrated iii; many- areas-

              18    that third party support can be generated, for,organ,

              19    procurement if a single cost isidentified.,  Many insurance
              20    carriers are now in several areas willing to pick up-the tab,

              21    for this.  The precedent has been set.  So I am not sure.

              22    the actual fiscal need for this is there..

              23              'And fourthly, in their application they- di-d not,

              24    make any mention of why RMM specifically was needed for
  ce-Fedetal Repotters,  Inc.
              25    support of these individuals.   In other words., why other







               I  sources of funding, -of which there are many potential. ones,


               2  weren't available.

               3            So.for all of these reasons, primarily poor planning

               4  reasons and poor justification reasons, r dtdb.lt tht-nk-that.

               5  25B was worthy of  approval.

               6            DR.  MAYER:  Thank you, Dr. Gross.

               7            MISS  KERR:  Thank you.  This is helpful.,  17 don It'.

               8  think this alters the  level of funding we are-recomme-ndi-ng- bu-1;@

               9  1 am wondering if we don't want to in:the advise  ietter,.or

               10 least include in this some of our discussionrre.Lat@ive ta this@.

                            DR. MAYER:  Well , I assume that - my- assumption

               12 is that advice letter comes not oni-y from@informat:Lon.,surf@aced

               13 here, but in these instances by SARP and elsewhere..

               14           Yesg Joe.

               15           DR. HESS:  I had a question: that may, have-; r!elevance@-.-

               16 for the advice letter.  Did you as you" reviewed the:

               17 application have the feeling that they- are-,, really,? reachin@g@

               18 out into some of the far areas away from Salt Lake@- City.

               19 to address some of the problems in@Wyaming,, Montana,.et

               20 cetera?  The majority of these projects are Universit-y-of

                  Utah based and Salt Lake City foc@used,. many qf them,ar-e,

               22 although they have established some  regi.Lonat offices apparently

               23 in two or three other locations--

               24
                            MISS KERR: Urban  areas  again.
  ,e-Federat Reporters,  Inc.
               25           DR. HESS:  Yes.  But in this area some of the real




                                                                            i68



                                                                       they
                I  probiensare rural problems.  And my question is- are
                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 KERR:  if you are asking for my reaction, r
                5  feel they are not getting to the rural areas.  There is.-nat

                6  the evidence that they are.
                7            DR. HESS:  What aboutthe staff reviewers?-

                8            DR. MAYER:  Someone from staff want ta make-&

                9  comment?
                10           The question is to what degree are they  relat.ing--

                11 to the rural component of Intermountain region..
                12           MR. CHJLMBLI    Out of SARP came the view that-you
                13 hold, that there needs to be much more outreach in terms-

                14 of their program,
                15           DR. HESS:  If that is indeed true I woul-d@ suggest,

                16 a recommendation to that effect be incorporated,in.the

                17 advice letter.

                18           DR. MAYER:  All right, everyone understand'the-

                19 motion?


                20           Ali those in favor?

                21           (Chorus of "ayes. 11)

                22           Opposed?

                23           '(No response.)

                24           Thank you, Elizabeth.

  ce-Fedetat Reportefs,  Inc.
                25           We move on then to Alabama.




                                                                                   169


                I              DR. BESSON-: We should  be  able  to  complete  Alabama

                2   in five minutes.  It doesn't require any committee action.

                3              DR. MAYER:  It didn't take the big eight much iongei

                4   either,, Jerry.

                5              (Laughter.)

                6              DR. BESSON:    But I will  just  give  the@committee-

                7   a bird's eye view of the Alabama program,    and@ I-' am, interested

                8   in knowing why SARP felt that -- it took the option@that,

                9   this didntt review review committee action and others in

                10  the same general category did, not that I don't share-

                11  SARP's view, but in just elucidating  the  modus  operandi-..O:t

                12  Anniversary Review Committee.

                13             This is  Alabamals  first  anniversary  appi-icationiin

                14  the triennium. The region is requesting some,  two  m:ti..Lion.,

                15  The Council has previously approved at the- time, of ther@ trie-nniu@

                16  application for the upcoming year 1.6 million,, and  the  S.-taff'

                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             The major concern that staff has with, the Alabama

                24  region is  that in spite of the fact  that  there  is  a  strong
  ,e -Federal Reporters,  Inc.
                25  RAG and that their priorities are well ordered@,. they have




                                                                                170


                I   great. dif f iCulty in relating projects to priorities, an
                2   the director feels that a staff tactical review of the

                3   Alabama region is necessary.
                4              In looking over the program I concur@withiSARP'si
                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 comment on Dr. Margulies" comme@nts,,

                9   which  was simply that that letter o  adv ce was very,
                10  important  and that some of these issues needed to get
                11  incorporated in it, perhaps even some direct Ertaff'discussion.

                12             Comments from the committee?
                13             Jerry, would you phrase -your questioaagain@for,

                14  staff,  or I can try to paraphrase it.

                15             DR. BESSON:  I have no question.
                16             DR. KAYER:  Welig I thought the  question     at-least@

                17  1 heard you ask a question which said--
                18             DR. BESSON: Oh, yes, the question I have      --and'

                19  this  came up before -- whether  staff  could  outline  or

                20  review committee e xactly what its modus @randi is
                21  vis-a-vis anniversary review, which ones they choose the
                22  option to present to review committee and which not..

                23
                               MRS. KY7TLE: With  respect  to  procedures  any

                24                                             t Council approval'
                    anniversary in its triennium need only ge
  4ce-Fedefal      Repofters, Inc.
                25  by regulation.  By agreement -- and Dr. Pahl outlined this





                    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
                    jars it, it can make noises at that time.
                5
                6            With respect to Alabama, though, Dr. Besson, the
                7   secretary of SARP asked the specific question on Alabama
                8   as to whether SARP would want to refer Alabama top committees
                9   for action, and SARP decided it did not.
                10            Anniversaries prior to the. triennium do come tai C-Ormkit,
                11  for action, as our agreement that Dr., Pahl 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 c,larif,
                15  the question of what Jerry was sayimg, was on what basis. do@
                16  you make this decision that you pop some here for  action,

                17  and some for information.
                18            MRS. KY-TTLE:  Changes in lprogram direction or
                19  methods of operation, such as what lwings Northiands to  -you
                20  for action even though it's an anniwarsar@ within a
                21  triennium; failures in staff Is 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 sfite visit.  Those are the

                24  two primary reasons.

  kce -Federal Reporters,  Inc.
                25             MR. CHAMBLISS: or they me  askingfor  funds  in








                 addition to--
                2          MRS. KYITLE: They go to Council, by regulation stop

                3of f at committee.
                4          DR. MAYER:  You mean those that are requesting
                5no, wait a minute.  I think what Mr. Chambliss was suggesting@
                6was that those that were asking for dollars in the anniversary-
                7within the triennium, for dollars above those previously
                8approved 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 level Council has delegated to staff.
                12          DR. MAYER:  No, you missed the question.  The
                13 question was those that are asking for more money than was
                14 approved b Council, do they  not  come  here?
                            y
                15          MRS. KYTTIY,-. Within a  triennium?
                16                                   ennium  an anniversary@ request
                            M. MAYER:  Within a tri
                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 know, if I were a Council member I would sure want the

                23 advice of this committee on those.
                24           M. BESSON:  It would be   nice if we c%ould have these

  @ce-Federat Reporters,  Inc.
                25 all spelled out for our next review committee meeting so we-





                I  would know exactly what we are supposed to do.
                2            MRS. KYTTLE:  They are spelled out insofar as
                3  Council is concerned.  Council has delegated to-t-ho. Director4
                4  to make continuation awards within the triennium andL  J,ust@.
                5  advise Council unless the region asks for,more money:than its,

                6  approved level.
                7            DR. BESSON-.  Well, t-hat"s what- he, just, described-.
                8            MRS. KY7TLE:  Yes.  Now: in setting- u.p-@ them procedures to
                9  operate under that delegation      and, this@@ i@s- what@L 17 understood@-
                10 Dr. Pahl to present to committee-last time@. - anniversaries
                   prior to the triennium, in an effort to- keepr,, -yGur-- workload-.
                12 on trienniums the point of action, primarily,, unde-r-@Counci-JL Is
                13 delegation we would deal only witit Council and@adv.ise.--committee
                14 after the fact of what Council @  recommended@  withiir@  the-
                15 'triennium.  It was at the last committees mee-ting- tha@,
                16 Dr. Pahl agreed to advise you prior- to@ the@ CounciL.  rather than-

                17 af ter the Council.

                18            Did I get that wrong?,
                19            MR. CHAMBLISS:  No,, I think that--
                20            DR . MAYER:   You got  that right, but r can assure
                2 1you that  if Dr. Pahl suggested that those that.  werer  above
                22 the funding level already approved by this:commit,tee and
                23 Council were going to pass by this cm  ittee@ wi@'t@hoat,. even-
                24 blip I would have come out of my seat.,  Sol r@ suspect he

  ,e-Fedetal Reporters, Inc.
                25 didn't communicate that to us, or I was gathering wool.@when




                                                                                                                                                    174


                                I  he  did..    And  I  think  that's  an  issue  that  needs -to  be
                                2    clarified  because  I  think  it's  important.
                                3                      DR.  THURMAN:    Bill,  he  did  speak  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, anyt
                                6    back.     I  am speaking  of  those  of  us  who  were  new@ to@ this

                                7    committee.


                                8                       DR.  MAYER:   I  see.
                                9                       DR.  THURMAN:  - Because  as  she  has  phrased@  it  is
                                10    exactly  as  it  was  phrased  in  that  indoctrination  seseTion,

                                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  issues,  because.
                                15     otherwise,  you  know,  a  region  could  request  tvo@ mit  :Ln-. thiw
                                16  second  year  of  its  thing  and  it  wouldn't  fly by-here at atil"
                                17     You  know.    And  I  suspect  that  -you  might  Laker  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  staf f..    r- was  not
                                24    there,  and  so  I  am  just  reporting  to  you  the  result-of  their-
    kce- Federal Reporters,  Inc.
                                25   findings.




                                                                               175


                              Apparent.Ly this program triennial review came
              2     through with awards for funding for only one year, and.somehoa
              3     the second and third 'year fundings were overlooked.  So
              4     consequently this is the main 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

              11    community.
              12              New Jersey, as you know, is one of the most de6s-ei'
              13    populated states in the United States, and it faces
             .14    intens if icat ion of the proglems that other urban, areas: have-.,
              15              Their greatest problem they found was basici hea.L@'th,@
              16    care,   and in recognizing this they designed their goals,,in.

              17    this direction.
              18              Their first priority of the region revolves aroond-
              19    improving 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

  e  -Federal   Reporters, Inc.
              25    RMP has had staff active in the model city programs- in@the




                                                                             176


                I  state, and the accomplishments of 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 health service in
                5  New 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 u@nderserved 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 Newarit,, and" a.

                12 community health improvement project.
                13           This latter activity is requesting $50,.000,; to-
                14 $100,000 to be divided among the 17 cooperating clities- on
                15 a matching basis according to size, need, and available:
                16 resources to support the development of primar-y- ambulatory cars

                17 centers.
                             What's interesting is the fact that  this RMP'is

                19 really 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 about their approach, and thought maybe they should
                24 try it in only one or two cities.  Ebt because of the- good
  ce-Federal Reporters,  Inc.
                25 background activity that has taken place and@ enthusiasm of




                                                                              177


                1   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 an-d;40 clerks.
                5            Some of the concerns the pane.L had were,. one-,.
                6   what is the rationale behind assigning project status to
                7   the urban health component rather than including i,t-- as@ part',
                8   of core where this function would seem to@lie logically.
                9   The staff also felt that in a project as limited, and-.whereb,y
                10  if you had core activities it  could go on for-a much-longer
                11  period of time, and I think many other RhM!"s- are- uti-A@,,izing-

                12  their core in a smiliar method.
                13            It was noticed with some condern that thia--massive
                14  effort in urban health has an entirely wh@ite. p=fess:Lanaill-
                15  core staff.  And I could not f ind any 3"Lndica@-. n, aE. any,@ plans:
                16  for hiring minority members.  on the urban., hea.Lth. component s:taf:
                17  there are three blacks and three Spanish, surname: profess:Lon.&...

                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 amou,nts,of federaland.
                22  state money which had been funneled int o the model!. cities
                23  area and the considerable support which had been rece-ived-fxom

                24  the State Health Department.
  ce Fedetal Reportets,  Inc.
                25            Their RAG -- as I  go down the line,, their- RAG and





                                                                              Ito


                1   their-grantee organization are identical bodies-, and it
                2   seemed like this might be a possible conflict, but they
                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  the-se
                6   members are black minority members.
                7            The overall panel assessment of the New,Jerse,y
                8   Regional Medical Program was that it is an excellent program
                9   which has become a potent force  in medicine in IR'ew Jersey.,
                10  The goals and activities of the program are  geared  to,the
                11  unique requirements of the area, with a primary emphasis oni
                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 sitills, 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-I
                20  and they discussed the possibility of  expanding  this,  an
                21  I think it would be very worth while to expand it  be-yond@
                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@

  kce- Federal Reporters,  Inc.
                25  for the next year based on the success of  the  program  to




                                                                             1.79


                  date and the bright prospects it holds for the future,- the
                  panel thought tha t the current level of $1,087,904 was
               2
               3  entirely inadequate, and they are consequently recommending-
               4  $2,990,000 for this, the third and fourth year.
               5            DR. MAYER:  Ali right, let me see if I,' am-,ciear...  I-,
               6  guess I need to have a better feeling.  In other, wcFrds,,. this-
               7  committee recommended, I gather,, with Cotr@ncil. approval:.,. tha-t.
               8  they be funded in the 03 year, the first -year, of' ther.-ir,

               9  triennium, for 2.9 million.

               10           MISS ANDERSON:  Yes.
               11           MRS. KYTTLE:  2.99.
               12           DR. MAYER:  2.99?   That was our previous
               13  recommendation, too?  All right.  And then  by &.@decrease i-n@
               14  the funding process by staff or-some Others device i.,t was,

               15  cut back to the million 225?
               16            Eileen, you want to tell us     'you k-now@l,  jus,t,
               17  trying -- what the action that we are sa@T on@ the-- aurfac@e-
               18  would look like we -are saying okay, SMP 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- @yearlis
  4ce-Fedetat Repotters,  Inc.
               25  co  itment remaining.  And the region as well requested only
                     mm





                   on year for its developmental component.  And we weren't,
                   operating then nearly as cleverly as we are now,, ard the
                2
                   region didn't pick it up either.. So@when  the  committee  made
                3
                4  a recommendation as to an approved level. core, the-development@d
                5  component, and certain continuing partEF of the program wereinol;
                6  taken into consideration in arriving-at a-dol@,Lar-amouxit--
                7  for the second and third years of theL triennium.,
                             Now for the 03  -year, although, the- committees recomme i d -
                8
                9  ed 2.99 million the region was actually funded" at,- J-ust,,@
                10 couple of dollars over a million.,
                             So what SARP is suggest in67, is- that- Cck-unaii-! restore:- fr
                12 the second and third years of the triennium the-approved..
                13 level that was given for the. first yearl,, the ratJbnale-be:ing-
                14 that that is the intent of the previous reviewers,,and-
                15 recommending as well that the regioir be@ g:Lveni iiats-I of-r extr@.
                16 money in terms of actual fu-nding,, actuaL@l:y-27,.,97,mi:IjLiarr@wllich@
                   is what is requested in the application;..
                17
                18           One thing I did want to comment when 'yotrwe@re@
                19 describing the community health improvement pr@am-,, t'i
                20 request -- the entire request is for $900,000..  I.t'.is,to  be
                21 utilized in lumps of betweeen $50,000@and.$IOG,000 t-o.-!each
                22 of 17 model cities, But the total request is  :Eor--$900@-iOOO.
                23            DR. MAYER:  Yes, Len.
                24            DR. SCHERLIS:  How did the decrease from @,9.,-,to-

  ,e- Federal Reporters,  Inc.
                25 1.2 actually  take  place.  I'm  curious.  Thatlg:a  tremendous








                 1drop,, and--
                 2     MRS. siLSBEE:That was the level at which they were,
                 3and there was no more money; had to keep it at the same level

                 4and actually cut it back.
                 5          DR. SCHERLIS:  In other words,, that was@ @st-
                 6keeping it where they were.  Funds were not avai@l:abiaat,

                 7that time.
                 8           DR., MAYER:  I gather they Came through-@ here- with@-,
                 9a triennial request before we were establishin&r priority,

                 10 ranking,

                 11          VOICE:  Yes.
                 12          DR. MAYER:' What is the impression: of staff,, gOiDg-
                 13  back through our minutes, of where we wou.Ld@ have put- that.,.

                 14  At B or C?

                                                                             this.-
                 15          DR. KRALEWSKI:  I wonder if I might  coment. on:

                 16  since I site visited last time.

                 17          DR. MAYER:  All right.

                 18          DR. KRAI-XWSKI:  I think it is a, very good program.
                 19  There is some of the best -Leadership there that r have seen
                 20 in a corporation. Dr. Florin was a good guy.  Dr. Hartman
                 21 is a good administrator, and he reaLl'y keeps track@ o:t whati.ts
                 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 programs.
  Ace-Fedefal      Repoftefs, Inc.
                 25          Now on this funding, though,,, it seems to me. that"L they




                                                                             182


                I   were operating at a higher level than that 1.1 or 2 or
                2   whatever it was' and I suspect that that was a cutback, as
                3   a matter of fact, in their operational level, because as
                4   I recall, Idon't believe that our "commended 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. KRALEWSKI:  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,  good,
                12  contribution, there was no question about it.
                13            They had a number of good staff people on, board,,
                14  and I' don't know if they still- have then or not..  Mixybe. bee-aus3

                15  of the cutback they have had to--

                16            DR. HESS:  According to tin sheet here,, when,@ -you-.

                17  visited them, John, they were operating their fund@ing,
                18  level at 1.3, and -then they were cut back to I..2 for

                19  budgetary reasons.

                20            VOICE:  The cut brought tia-m back to about
                21  $1,087,000, and then at the end of fiscal v7l we gave them a
                22  supplemental award to bring them up to 1.2.
                23            'DR. MAYER:  We actually recommended a 120., percent

                24  increase?

  Ice -Federal Reporters,  Inc.
                25            DR. SCHERLIS:  You must -br, a good salesman.





                I             DR. MAYER:  You're powerful, John.

                2             (.Laughter.)
                3             D@. KRALEWSKI: 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@@werer that,
                6   we did rate the program very highly.  They reaii,y-had been,
                7   able to switch over to the new RMP mission@ very- rapidly;-.
                8   they had a good staff, they were involved., :La the@ real gttt.
                9   issues of that region, and they were producing-..  And-so-we-
                10  recozmeaed a substantial increase, and I gether- that, the
                11  group here -- I don't  remember just alL the-dmscussion that,

                12  took place, but anyway it was roughly--
                13            DR. SCHERLIS: I was on a site Visit withi Dr.. Florin

                14  and I was very impressed with his abilit:y.,
                15            DR. MAYER:  The rating by SARP) at. Le:ast@ iis 4jL2,'p:
                16  which is off of the scale, you know, of the shoethere@..
                17            So all right, I feel better abou-t at.It that-@
                18            Other comments that anyone has?
                19            DR. KRALEWSKI:  If we are going to@give them roughl5

                20  a million nine    a million seven increase?

                21            VOICE:  That's what we recommended.,
                22            DR. KRALEWSKI:  You have been in: touch@ with them,
                23  I am sure.' in between.  Are they capable of handling that
                24  influx of money all of a sudden?  lbat- I am worri-ed@about is

  ce- Federal Reporters,  Inc.
                25  if they have lost some of their staff--




                                                                                     184


                  I            V016E:  No, the largest chunk of this-money, 80

                  2percent--

                  3            DR, KRALEWSKI:  The model cities?
                  4            VOICE: Eighty percent  of  the  request  is@  for,  urban

                  5  health, and they do have lots of people.
                  6            DR. KRALEWSKI:  Do they still have-those iad@ividuals@
                  7on their staff yet, the guys who were, operating in'.  thef-  model.'

                  8cities program   and were funded part by--

                  9            VOICE:  Yes.

                  10           MRS. SILSBEE:  They also have some that w@@ use         as.

                  11  staff that were put in by the state.

                  12                                               be emphasized  t@hat,
                               DR. SCHERLIS: I think it should,

                  13  this was the level of your original request anyway-.,

                  14
                               DR. MAYER:  Sorry, Len, I missed that..
                  15           DR. SCHERLIS-.  rtwas the level. of the@ original
                  16  request of the site visit and of this committee-,, i-ff. that,

                  17  right.
                  18           DR. KRALEWSKI:  That Is right.  But my@ question @ is
                  19  whether it's the same organization now that it was during that

                  20  visit.

                  21
                               DR. SCHERLIS:  And they reassure us that t,

                  22
                               MR. CHAMBLISS:  Doctor, -you raised.the qpestion

                  23
                    about whether that staff that has been working i@ urban health

                  24 is still there, and I think the answer is 'yes.
  kce-Federat Reporters,  Inc.
                  25           Furthermore, that  staff,,  as  you-  probably  recognize





                                                                                  Lou


                 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  one  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  s-uppor@d-,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:tcy-@

                 9   New Jersey?
                 10            All right, I will move on   then to  NorthiAnds  RMPI.
                     The Northiands RMP  is a euthemism for the@  state  of  Minnesota.
                 12  It started out originally as being more than that,, but
                 13  they finally retracted it back and put it in the@s-tate
                 14  border, with 3.8 million people.    It has bee,ni; o-perational-

                 15  since March of 1969.
                 16            The triennium was approved at our: last January-.,
                 17  February review cycle a year ago.  I partic@ipated. @. them
                 18  triennial review site visit along  with  A.L  Putman  in,@Decomber
                 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  triennial
                 24  application and  the  developmental  component,  with  a  budget
  ce-Fedeial      Repofters, Inc.
                 25  of $1,157,000.  They were approved b         Council in-the 04
                                                           ,y the




                                                                                  I as b



                     year,.that is this-next coming -year, which is the second
                 2   year of the triennium which we are reviewing, a level of
                 3   $1,450,000,.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 thi-s'
                 6   coming year or  the second year of the triennium, twolmiii:L-on

                                                                           project.,. or-
                 7   on in direct cost, including 309,000 for a kidney
                 8   roughly a million eight, plus the kidney project, that mi-i@i@i:on-
                 9   eight being roughly about 700,000 above the current fundkng,

                 10  level.

                               From an organi
                                              zatiobal standpoint this is:-- one- of'

                 12  the regions that has a board of trustees and a RAG which.
                 13  have had problems initially on whols oa first,. t'he'board    of
                 14  trustees or the RAG.  It looked like we were-resolving when',
                     we were there in favor of  the  RAG  assuming  the  responsibility.
                 15
                 16  The subsequent year seems to have proved this out tn@
                 17  terms of responsibility, and they now are in.., the, process-
                 18  merging the two groups, with a meeting at the. end@oft,his

                 19  month to finalize that.
                 20            As far as the   c=dinator and staff,, we were
                 21  impressed when we were out there with Dr. Winston.Miller,:
                 22  the coordinator, and his key staff.  They were very,strong@
                 23  and effective.  And we were particularly impressed     with the
                 24  system that they had  evolved  of  monitoring  the  achievement  of
  .e-Fedetal Reportets,  Inc.
                 25  staff and accounting for the time and expenditure of staff@





                I   in light of preestablished goals for each of those individuals.
                2   That is one of the most effective management tools that.
                3   1 have seen,actually functioning for quite a while.
                4             As far as their goals and priorities,, one- o:U the-
                5   key issues when we were out there expressed' by., the Northi-ands,,
                6   staff and the RAG is the difficulty they may have in
                7   turning this region around towards new goals, in,, light o:U
                8   the existing commitment they had for some fairly effective.
                9   ongoing projects established under the earlier- goals..
                10            They have accomplished this in a. rather- interesting
                11  way, which I suspect, Jerry, is the reason; why,- this- one-
                12  is brought to our attention for action when the others@ wer-er
                13  not, rather than simply for information as wzw the case

                14  in Alabama and New Jersey.


                15
                              What they evidently did is as foil-tuwu-:  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  were prospecti for the next year's act@'iv-it-y-.,  What t@hey-@d:id
                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-,OOO people in the state of Minnesota.,  From that.- they got-
                23  back 68 applications from 38 dif fe're@zt organizations..
                24  Forty-three of these were approved and, if you- wi'l,ll forgive
  ce -Federal Reporters,  Inc.
                25  me, prioritized, and were included to the application.
                 I                                          .I




                                                                                188


                I           This somewhat unusual approach on the sur    face looked
                2  like that what they were doing  was  really  creating  contracts,
                3  but as you really look at it, essentially what. they have
                4  done is decided what it is they want tol 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-in-t-o

                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 well as@a,few aame,:Ln which.
                11 addressed themselves to the  goal  but  were  different  than.thw

                12 original 29.
                13           These  projects or contracts have- been-,reviewed  ill
                14 detail by staff, by BARP, and by the kidney- review panel.@',
                15           1 might comment first on the lti,.dney, proposaL  which
                16 they had which was divided into three components-,, a-
                17 professional and public education component,..  a;-h@rteins@ion,
                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 nolreason t.o-@d sagree,

                23 and it would save me some major problems as well.
                24            SARP recommended that they be funded  at  the  l@.450

  ,e-Fedeial Repoiters,  Inc.
                25 level, which is equal to the level already,approved        us




                                                                                   189


                 I  and approved by Council for the 04 year.  This. is roughly
                 2  $300,000 above the current level of funding, but significantly
                 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 compone.nt,o-f-
                 6  $115,000 which we have previously approved,. both ourselves

                 7  and Council, but which had not been fu,nded@   by, Northi@ands  due-

                 8  to the previous commitments they had on@ongoing projects:.

                 9             It would also enable them to continue some o-f-' their,
                 10 ongoing projects and studies, and at the s@ 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@ addi-tion@ of'oryly@

                 14 $300,000 because they are phasing out eig)xt- ongo-i@ng-,  projects.

                 15 this current year.

                 16            1 have some of  the same concerns that. MP--, me-ntix)ne-d--

                 17 as they went through it,   that it may be- (fiffic@u t twma-nage-

                 18 as man  as 23 small contracts or projects as a,,pr
                          y                                               ob tem.  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 man-aging-those projec-ts@

                 22 then I think they will be able to handle them..

                 23            r also concur with the comments of SARP that they-

                 24 need to place emphasis on initiating fairly early on@in
  @e-Federal Repoiters,  Inc.
                 25 those individual contracts emphasis to@pick up support       for,




                                                                            190


                I  them at the completion of their funding.
                2           So I especially concur with the SARP recommendations
                3  that they be.approved for funding at the 1.45 levei,.and-
                4  that there be no kidney proposal accepted at this tJme.;

                5           John is the second reviewer.,
                6           DR. KRALEWSKI:  I can"t add a great- dtLal.' ta that-..
                7  In looking over these projects and not h-av:in@ %!',to viis-ite-d@. thi;
                8  region,, it appears that these projects would.. makeL, a.,
                9  contribution to achieving their goals.,
                10          It looks a s though the RAG is- active in the-decision-
                11 making process, and therefore would apparentl,ylheip-@fbrmulate

                12 this list in the order that it is in.
                13           1 think the critical issue  is whether,the, organization
                14 is capable administratively of hand-ling this kind4l or
                15 activity, and I think if we look at the. fact that, at, least-.-
                16 the reports that came from the site visitors,,, the. recpprts- that
                17 we have had in writing and verbal,, indicate@ that@ this-- is &
                18 strong area.  The administrative staff is weil,.organized@,,
                19 and they have done a good job in running their-project@so,.f-ar.
                20           So I thin k on that basis probably we could conclude
                21 that they will be able to handle this k@ind.of decentralized
                22 activity, particularly since they have been.able to develop
                23 some pretty good control mechanisms an staff act.ivity-and'core

                24 activity.
  ,e -Federal Reporters,  Inc.
                25           So I would concur with the recommendations -you have




                              I just  made,  and  would  put  that  in  the  form of  amotion  if  -you

                              2 wish.

                              3                    DR,TMMMAN:    Second.

                              4                    DR.  MAYER:    Len.
                              5                     DR.  SCHERLIS:    I             only  have  one  comment,,  and  that-
                              6     is  they  must  be  blessed  with  a great  gift  of wisdom to be
                              7     able  to give  a          priority  rating  to 43  projects  an@d'assign.
                              8     ranks  to each          of  them.    I  think  that  that  is  a.ve.ry,,.                          very-
                              9     difficult  feat,  and  it  would  be  very  interesting  to  s-eer  how
                              10    they  arrived  at  it.                I  would  c      oncur witk what  you7 said,,. btlt-
                              11    I  think  it  is  amazing  to  have  a group be  able:toas,-wign@

                              12
                                    priorities         to 43  discrete  items  and  quite  diversifie4t projects

                            .13     like  this       in  that  manner.

                              14
                                                     MRS.  KYTTLE:    I             think  it        is  interesting because,
                              15    I  think  the  committees  did  the  first  r@- @ing, amc!4, then, they

                              16    were  interdigitated.

                              17
                                                      DR.  MAYER:    There  weren"t @just  43.,  there@ werel@ really

                              18
                                    68,  because  there 'were  25 of  them that  they- bounced. out,

                              19
                                    as  saying  no  go,  they  are  not  good  enough..
                              20                      DR.  B'E S@S DN                I Im  f ascinated  by  this  approach,
                              21    and  I  think  that  the  idea of  setting priorities  first@.and  then
                              22    having  people  devise  projects  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  al'ango'.

    ce-Fedetat Reportefs,  Inc.
                              25     and  I  think  is  a very  interesting  approach..    That's  really




                                                                              iL 92



                   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 ofdecision
                3  to make,, yes- or no, to awarding a contract'.  IC think- it-, is@
                4  a very interesting approach, and it will be, i,nte-reatJ-ng7

                5  to see how they develop.
                6             DR. MAYER: Additional comments from. staff-; who were@

                7  at the SARP review?
                8             All right, the motion then is to: accept. th@e.,-
                9  recommendations of SARP at 1.45 level   with-, no@ kidney,- ef f 6rt-.

                I 0included in it.

                              All those in favor?

                1 2                      tia-ye s
                              (Chorus of

                13
                              Opposed?

                14            (No response.)

                15
                              I would like to take@ a. couple o:f mi:nutes@ tcr-@see,-
                16  if there are any further comments about the-.Connectiout.
                17  activity. As we indicated to you- 'yesterday,, t-bere7 wem- some@
                18  materials that were incorporated in@ the back@of-your.-book@
                19  which we suggested that you might want to take7 a look- at

                20  for further discussion.

                21            Yes, Joe.
                22            DR. HESS:  I read with some interest,, the-.cromment@.

                23
                    here   that Council  believes  the  question  concerning  investing
                24  heavily in a state so wealthy in resources is completely
  ce - Fedeial Repottefs,  Inc.
                25  irrelevant, and I wonder if that is  an  ove:rst:atement-@oftheir




                                                                                    193


                     views or if they really believe that,  because  it-  is  hard  for
                 2   me to accept that as being valid fron 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 RMP 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
                 8   excellent programs have alread'y got more resources-! to@ begi-n-@
                 9   with, this only tends to increase the disparity between,
                 10  the upper and lower ends of the scale of health,. care- around@@ thiE
                 11  country.  And it seems to me that that. is ixy &, 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-
                                                                               into t hat
                 @14 dif f iculty in understanding or accepktng- what 1, read.

                 15  kind of a comment.
                 16             DR. MAYER:  Would someone at, the. Council- meeting, car(
                 17  to elaborate on what they thought the in.,t@ent of that,
                 18  statement, whether that was a fair statement of      how they,
                 19  felt about it?  Is there someone here on,     s@taf fwho was - at@.

                 20  the Council meet36Lng?

                 2 1            MR.       LISS:  Judy.
                 22             DR.  MAYER:  Judy, the que@n      that   is being raised
                 23  is the issue   that on  the  Connecticut  proposal  in which the
                 24  Council altered the recommendations of. this group, was that'@

  kce -Federal Reporters,  Inc.
                 25  one sentence statement that said "tire Council believes that, th







                                                                              we al t h-y
                I    question concerning-investing heavily in a state sa
                2    in resources is completely irrelOvant,",and Joe, has raised-
                3    some questions about did they really say- that, and-- if-- they, di 1,

                4    did they really mean it.
                5              MRS. SILSBEE:  I think the@y@ did'. real'.Uy days that-.
                6              DR. SCHERLIS:  My reaction to- that might- be. t@hat- it
                7    was posed to us that one of the reasons me weriy- :Ln@este@d@- in

                                                                     ijw. such% &@ rundown
                8    the approach of New Jersey was because that
                9    state, and I would suggest that we cw"t dt)- both-- cyf@ t-@e,
                     things  as  approaches  in  a  logical  manner-simultaneausi-F
                10
                     Either we exclude -- and I wou-id call f@ a. rev%isibri of-.@'

                                                                           re
                12   my Now Jersey vote if that approach@is not to be,       I-evant,-
                13             1 think just as we cani look,. at a  have@tL,  S  'a
                     and feel very strongly that we might ap                tandards,,
                14                                              pty- other-@ s
                15   we have a right to took at: & !rave, state@ and: have@ Certain
                16   standards.  Is my point of view- is out of li@ne-, with:-.Counc@il.
                17   program?  If so, all my votes S-hou@ld@ be@ reconsidered-,.,
                18              Would -you  care  t*,  respond.to  that.intercating

                19   point, Judy?
                20              MRS. SILSBEE:  I think perhaps the Counci@i@and
                21   committee should get together on the subject of Connecticut-

                22   because we can't act as go-betweens.,
                23              DR. SCHERLIS:  We have been@ told to@ emphasize-

                24   urban problems and dense populations.

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                25              MRS. SILSBEE:  Council is looking at@the Connecticu





                    program as a different type of program and they_feel that
                2   it needs support as a different type of program.
                3            DR. SCHERLIS:  I guess the statement is what'.

                4   troubles me.

                5            DR. MAYER:  Yes, Jerry.
                6            M. BESSON:  Well, I think there, may. be- w source- of
                7   confusion here as to what deserves support.  r- th@-. RWSI-
                8   has continually from the beginning awarded@a meritorious
                9   program.  Now whether a program that is meri-toriousiinvolves,
                10  a have-not area or a have area is what r th:ink--th4wy,considered
                11  to be irrelevant, and I can live with. that..
                12           M. SCHERLIS:  I can live with.. that...
                13           M. BESSON:  And I think that Is- all the-y@- am saying,
                14  that Connecticut is a very meritorious programs,. and@ if," that .1s@
                15  the case the fact that they have a iti@gher@per-capita@.income
                16                        unt from RMPS and'. eve-ryt-hing- elaiw,
                    and a higher dollar amo
                17  that is irrelevant.  That's the on-L-y- wayz IC' :Lntorprert. it-.,
                18            DR. SCHERLIS: Is that the. way, you i,nter:pre-t-, it-?'
                19            M. MAYER:  Joe has some  problems with that-,,, I-

                20  think,  if I heard him clearly.
                21                                                     because
                              DR. HESS:  That's right, r certai-ni@y-do
                22  1 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 level@ing@off as,we
  ce-Fedefat Reporters, Inc.
                25  try to -- let's say the have regions in terms of funding,. and






                     not a continual escalation of funding just because they

               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 RMP's in every region of the
               5     country and we are working toward getting that by,  a- varJ-e-ty-
               6     of mechanisms which we use here.  But  I  think  that  there
               7     will need to come a point where there needs t* be K-,ind, 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  spe-nding
               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. BESSON:  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 c:omgietely,
               16    dependent on the time of day and how tired we, were and@ who. haV
               17    more money, and it was all very haphazard.:. But, now-  that

               18    we have an order of relative ranking, for the first ti-me@ we
               19    are being able to use them -- I notite that  the  use  of  PPBS
               20    in New Jersey is commended, as  though  that's  something  that
               21    was discovered yesterday.  Well, that has beenaround 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 -- RMP@ is being dragged-

  ce -Federal Reporters,  Inc.
               25    clutching and screaming into the current era.,  Unfort.unatel,yr







                                                              we are just.
                I  the kind of thing that- you are asking for,

                2  beginning to do it.
                3           DR. MAYER:  Comments?
                4           VOICE:  Yesp I think the comment about the relevancy
                5  in relationship to the state developing resources is due--to@
                   the fact that possibly the state that is wealthy,-in,resources-
                6
                7  may very well be the best place to demonstrate or experiment'.
                8  with some of this.  I think this is part of the-reaso-n for--
                9  the statement, justification for the statement..
                10          DR. BESSON:   I have difficulty living, wi,t@h@ that.
                11 Connecticut decision for an entirely different reason,,and,::
                12 that is the big concern that we had he,re@was yes-,they--were,
                13 asking for a lot of money, but if this was a surreptitious
                14 way of supporting medical schools that was a bottomless pit,,
                15 and if we were going to get into that then. we@ reality-, would@,n@-I t-.-
                16 have any money for health care delivery changes'..  And-,fbr.-
                17 the Council to consider that the cal-y notion-,that apparently-,-
                18 made them reverse our decision was that this was an-
                19 innovative program, I think Connecticut has beeiT extremel,ycle%er
                20 in using cliches in just the right way to push the right; buttot
                21 'here in RMPS, and that's unfortunate because. 1, think@the
                22 emphasis in Connecticut for the amount of money that is being
                23 spent 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 issues which we made on   this@one,




                                                                                       198

                  I   namel-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 time in the future; and the second issue whichj,rolates to
                  5   the longstanding concerns  relative  to  organized@  med.i.cine@  in-
                  6   that state, and then the issue that Joe has. raised,that we
                  7   discussed at some length previously.
                  8              I just hope that since T,, woty."t ber he-rw beyond I  the
                  9   next meeting, that that has gotten so we.Li documented. in
                  10  people's  thinking  that  three  'years  from  now   somebody-wiii
                  11  be looking at how much of the, federal dollar through:RMP
                  12  is going into facilities of those, medical, schools-,. and-- somebody
                  13  will also be looking at the t.ime@ of the next triennium beyond
                  14  -the surface about how are they -really  rel'ati@ng@@  to:  organized

                  15  me4icine in that state.
                  16             Other comments?
                  17             1 would just like tot  make  one  at.her-  addi,@-nai,i
                  18  comment on something that would be         lpftti: at@ least. to, me- as
                  19  an individual.   I asked the ques@tion initiail;y-when,wo-
                  20  started  on  these  priority  rankings  ve-re  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  ccvrrelat ion
                  23  between the summation of the weighted and' the overall.
                  24  assessments and how  that  works  out,  and,  I,,  hope  somebody  is

  .ce-Federal Reportets,  Inc.
                  25  looking at that  because  I  sure  would  like  a  repo-rt@  of  that




                                                                                199


                I   to f ind out how high -t hat corre I at ion 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 meaningf ujL.  And I hope some f urthe-r det@ai-le-d@; analysis
                5   of this interms of what weights ought- to go-@ and@ aiw..- they
                6   related to overall assessment  or-not by factor-and--laubfiLctor

                7   is going on.
                8             But I think for now what I- wouild7@ @e- to-@, know @ is---
                9   the sums of all of t he above, plus the overaiT-.. weighting

                10  and how that looks at the next meeting-.
                I I           DR. SCHERLIS:  Maybe@ we wiLl, find', one of.' t-hir-- member-c.
                12  of this committee always is, right at that@. average poin@t@. and

                13  we can let him cast all ou7r wotes.,

                14            (Laughter.)
                15            M. MAYER:  RiLght.,  You, k     Harris, an-d-.4 Ga;l.i u p@

                16  they learned that a long times aga@..
                17            Any other items of business to-@ ooze--. bef are,., the- grou p?

                18            Yes,, Mr.. Chambliss.,
                19            MR. CHAMBLISS:  The questtm.was raised@initiall-y
                20  at the beginning of the review about travel  and  about,your
                21  reimbursement, and I simpi-ywould like to say  that@-we-have
                22  checked with our travel office.,  All of the-paymen-ts--ftom
                23  October forward are now at  the  Treas@,  and-,you:should-be

                24  getting them within two weeks.
  e-Federal Repoiters,  Inc.
                25             1 know -you have@ heard that bef@ore,, btLt. I', do,




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                  understand that they'are in fact there.  And perhaps but
             2    for the holidays you would have heard from them.
             3               DR. SCHERLIS:  Which Treasury is that?

             4               (Laughter.)
             5               DR. MAYER:  Of the United@States., that
             6               MR. CHAMBLISS:  The disbursement. office-ot the,

             7    Treasury.
             8               DR. MAYER:  Any other items of business?'

             9               Thank you very much.

                             (Whereupon
             10                          at 3:50 o'clock p@..mi..,, the- meeting was!

             11    adjourned.)

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