i
                                                                            i'llil,il,,'@',,"I,     if
                                                                            III    File        '111111,
                                                                            f
                                                                                              d *











                                                   ipt@ ot@@ Yroci 4


                      DEPARTMENT OF HEALTH, EDUCATION                       AND;@,WELFAR]k



                                             PMPS COUNCIL     MEETING























                                                                   Rockville,    Ma    lahd
                                                                                    ry
                                                                   4 August    1071






                                          ACE - FEDERAL REPORTERS,      INC.

                                                   Official ReporteTs
                                                 415 Second Street, N. E.
                                                                                       Telephone:
                                                Washington, D. C. 20002-        (Code 202) 547-6222

                                               NATION-WIDE COVERAGE








     Cl,@-30 37
           r,  01-1
           q                                      DEPAR"i"4ENT  OF  !IEALTI],  EDUCATTOi.4,                          kN D    i4ELFARL'

                               2                                          Public ilcalti'l Service

                               3              !I,--alth  Services  iiid  P@ntal  Health  Adiainistration

                               4


                               5













                              I 0

                                          N-,,@TIO'.Ti%L  PDVISO,?-,Y  COUii-CIL  ON  T-IL@GIO,-:ZAL  ?,IE@DICAL  PROCRAII.'@,@'


                              12


                              1 3


                              14


                              15


                              1 6
                                                                                                           Parkla%.7n        Buildina,
                              17                                                                           Conference  Room  GIH,
                                                                                                           Rockville,  1-larvland

                              18
                                                                                                           Wednesday,  Nugust  4,  1)71

                            .19


                              20


                              2 1


                              22


                              23


                              24

    Ace - Federal Reporters,  Inc.
                              25





                                                                                                                2





                                                            C 0 N T E 11 T S

                        2  APPLICKTIOLI:                                                                        PAGE:
                        3  Al'@,3any                                                                             53

                        4 Bi-State
                                                                                                                .37

                        51 California  (S.V.)                                                                       3
                        0 Central          Yor":  (S.V.)                                                         58
                        7 Georgia  (S.V.)                                                                        39,
                        '8 Ha-,qaii                                                                              17
                        9 T.-laine                                                                              106
                        10 -@lem-jhis                                                                            68
                        11 @letro D.C.                                                                          112
                        12 @,lichigan                                                                           103
                        13 Ne,v '-@lexico                                                                       129
                        14 Northern @4e@,7 England                                                               21
                        15 L@lochester                                                                           62
                        16 Texas                                                                                 27
                        17@ Tri-Stat6                                                                           139

                        -       inia
                        18' Virg                                                                                 31

                          Wisconsin
                                                                                                                105

                        20 @'910" National Kidney Foundation                                                    141

                        2i;

                        22


                        23


                        24

   Ace-Federal Reporters,  Inc.
                        25





                                                                               3





                                       P R 0 C E E D I N G S


                 2           DR. 14ARGULIES:  I.,i the interest of sticking to various

                 3time schedules and getting our Council meeting over with

                 4promptly, we will begin now without any further hesitation.  -We

                 5do know who has the earliest kinds of leaving  schedules  and  so

                 6on, and I think we can adhere to that and not run into any

                 7difficulties.

                 8           I do.n't know when Dr. Brennan is coming. 'ge  assumed

                  he would be here and we haven't had word to the contrary, so
                 9

               @io perhaps he'll come in a little later.

                             So we will start the program review now.  we will

               12 take up those first which will make it convenient for those

               13 who have to leave earliest and I will turn that part of the

                  meeting over to Dr. Pahl.
               14
               15            DR. PAHL: Dr. Millikan, Dr.  Everist  and-Dr.  DeBakey

                 .have somewhat earlier departures, so with your permission, I
               16
               17 think we would like to rearrange the order of our reviews and
               18 start with California.  Dr. @lillikan.
                             May I also ask the annronriate staff to sit at the
               19
               20 end of the table and add their comments as before, and the
               21 regional office representatives, following their@meeting this
                  morning, will be in to also participate on the individual
               22
               23 applications.as appropriate.

                             DR. MILLIlWi4:  On June 10th and llth, 1971, there was
               24
  Ac-e--F@ral  Rdpotters,  Inc. a project visit to the California Regional Medical  Program  and
               25





                                                                                4



                 1  and you have, I believe, under the California,tab, a green
                 2 abbreviated or synopsis version of the project site visit report
                 3 There's a longer one also available that has been distributed.
                 4          In any event, there are several interesting kinds of
                 5problems that are symbolized by the  California  Regional  Medical
                 6Proaram, and I suppose one of them has to do  with  the  potential
                 7differences in opinion between project'site visitors and bet;,reen--
                 8the total concept of the Droject site visitors, and  that  of  the
                  review committee.     It also exemolifies the potential diffi-
                 9
                 io culties in the triennial review process when  we're,dealing  with.
                 11 an altered budget structure from vear to year, and that has
                 12- inhere nt in it some difficulties in the judgment process with
                 13 the rest of us because of some differences in  quality  in  the
                 14 subdivisions of the entire Regional Medical Program.
                            Now, if you look at the first page of  the  blue  sheet,
                 15
                 ,6@you'll see a series of recommendations and the first one
                 17 addresses itself to a portion of the  original  application  after
                 18 the one kind of plan and the other to a second kind  of  p  an;
                 19land ultimately you see there's a recommendation down here for
                  $6.2 million ner annum for the California Regional Medical
                 20
                 21 Program.
                 22         Noiq, I disagree with this recommendation as  a  project
                  site visitor and as a member of the Council, if  that's@wl-iere
                 23
                  weire going to stop with our potential action, and  in  trying  to
                 24
  Ace-Federal Reporters,  Inc. interpret the summary represented by the blue sheets, it seems
                 25








                   likely that a portion of this judgment to,make such a recommen-
                2 Idation  wasIarrived at because of the fact that   a couiDle of these
                3 subdivisions, which in actuality    are regions, are very poor.

                4 And  if you look at the nine that   make up California, one can

                5 see unequivocably that what's called Area  1,  Area  4  and  Area  5

                6 are among the very, very  best  in  the  United  States,  consisting

                7 of San Francisco ,oortion, the  U.C.L.A.  portion  and  the  U.S.C.

                8 portion, the latter two having been the too that combined to

                9 initiate the  action  that  has  been  consuImmated by  the  formation

               10 of the ninth area which is  the  one  at  Watts-Willowbrook  or  the

               11 Drew  School and King HosDital area.

               12            These are offset, as one looks  'at  the  total  program,

               13  by a counle of areas that among the  very  poorest,  and  this  is

               14  San Diego and Oberlinden(?), 6 and 7; and numb   er 8 has one good

               15  program and that's  the Irvine-Orange County  area.'  It  has  one

               16  good -orogram, the community stroke program, and  that  is  aioout
               171it in terms of what's actually gone on in that entire area,
               18  which, of course, is over several years.  And, as one talks

                .19 rather candidly to the Personnel  of  that  area  medical  program,
               20  they don't have much in the way of  nlans  for  anything  more,  if

                .21 you recall, at the time of our project site visit.

               22            So, I think that  while  the  California  concept  seems

               2@@ to me continues to be working, that is having nine regions
               24  reallv amalgamated under and working through a central office, I

  ikC6@Fe@ral Reporters,  Inc.
               25  think that  phenomenon  is  working  pretty  satisfactorily.  There
                   11





                                                                                 6




                 Iare certain disadvantages inherent in  the  situation  where  you
                 2@put very, very ooor quality area in combination  with  a  very,
                 3 vat-,, good one and ask peop'le to assess a budgetary outl ay  on

                  the basis of their total reaction to this.      So this is one  of

                  the problems inherent in the  California  Regional  Medical  Program

                  grant application.

                 7           Now, the next item that I have  already  mentioned  has

                 8to do with the problem which might be  a  delightful  problem  which

                 9might be created if in a year or 18 months or  two  years  we  had

               lo' a considerable change in the budget base  from  which  we  operate.

                  In other words, suppose  that  our  allocation  and  appropriations

               'I@ in Congress is actually released  and  is  considerably  increased.
               i@@iby $30, $40, $50 million; and a program  like  this  California
               14 one is locked in to its triennial review  process  to  $6.2.  Well,
               l@'we would simply keep in mind that that would be the height     of
               16 inequity, at least that's my opinion about it,  and  we  would  need

               i7 to rereview the thing.
               ]8i.          Now, there's one possibility that we  could  take  an
                  action at this point in time, because there are two nlans

                  actually in front of us, plan A and plan  B,  which  could  make
               20

                  some allowances for an altered budget structure  if  there  was  one
               21
                 'lat the end of the line.
               22
                 -           Now, the review committee has a little bit  of  a  dim
               23
               24 view of plan B. Well, I,tliink most of us  on  the  project  site

  Ace -Federal Reporters,  Inc.
                  visit seemed -- didn't see anything  very  materially  wrong  with
               25 1





                                                                                7



                  plan B at all.  I don't know what the others' reaction is, but
                 2plan B sounded like an entirely equitable plan.

                 3
                            one of the poin@ about the whole triennial review
                 4process and about the kind of internal guidelines that we
                 5approved yesterday unanimously at this table was that we are

                 f
                 0in essence giving what might be called a bloc grant.  After
                 7careful and full review and inspection and deliberation, we are
                 8saying  "For each of the three years we are going to give you
                 9tx' amount of money and you become the decision-maker as to the
                  precise way in which various portions of this money is soent.1'
                             And so what we're really talking about here in plan B

                  is an increased total funding and it was the review team's
               13 opinion that these people are highly competent to make decisions
               14 a-bout how to wisely    it was the project site  visitors' opinion
               15 that the California, the CCIU.IP and  its  subdivision.s are highly

               161 competent to make decisions and good decisions about how to

               17 spend that quantity of money.
               18            So I think that probably there would be a-series of
               191co,m.ents from staff and I don't want to belabor this issue any
               20 further, but I am summarizing my'own reaction by saying that
               21,within the context of what  II've been commenting about that I
               22'have some disagreement with these blue sheets.  There's some
               23 people here in the room who were on that project site visit and

               24 studied this thing at great length.

  Ace @-Federal  Reporters,  Inc.
               25            DR. PAHL:  Does staff have any comments to make
                  I





                                                                                8




                  relative to the discussion?


                 2           MS. SALAZAR:
                                                 I think that you can say that the

               '3 blue sheets reflects the consensus of the reviewers, as Dr..

                 4@4illikan has nointed out, with the recommendations stated on

                  the first page.  It's a rather large team, as you can tell from
               @6.this report, and has received further information since

               '7 returning.
                             DR. PAIIL:  Dr. ochsner, have you any comments as the


                 9other reviewer?

               10            DR. OCHSNER:  No, I haven't.

                             MS. KYTTLE: Dr. llillikan  did  I  understand  you

               12 correctly  when I thought I heard you  say that it  was  your
               131interpretation that Cie blue  sheet  was  recommending  $6.2?

                             DR. MILLIKAN:  Well, to go through this, they don't

                  recommend  $10.043.

                             MS. KYTTLE:  No.  I was of the opinion that the intent

                  of the blue sheet was to recommend '?B.3.

                             DR. MILLII@N:  ilinus 121.

               1'9           MS. KYTTLE:  Well, the kidney panel had met later
               26,and restored the 121 which got it to $8.3.
                             DR. MILLIKAN: Correct.  And  what  I'm  trying  to
               21
               2@ emphasize  here is that I think we either ought to make dual
                 'recommendation or say that we will bring this back to the review
               2i
                  Process if and when there is more total money in the P14P kitty
               24'-

  Ace-Federal Reporters, Inc.
               25,short of the three-year process.





                                                                                   9



                              DR. MARGULIES:  Well,  I  think  it's  very  important

                  2'right now to emphasize the fact that  we  really  need  to  make
                   decisions.  We are asking the Council to make decisions based

                   on what they think that  program  merits  without  regard  to  any
                  4
                  5assumed budgetary  restrictions  or  we're  in  bad  difficulties.
                   So I think it should be based  on  what  you  see  is  meritorious

                   and then we will have to make  a  decision  based  on  the  funds
                  7

                  8available.
                              DR. MILLIKA14: Well,  I  could  filibuster  about  this
                  9
                io $10.2 million but I don't mean to get into that kind of a
                   position.  We  heard  a  presentation  yesterday  concerning  just
                   one fragment of  the  California  Regional  Medical  Program,  and
                12
                   that's what is now called Area    9.  This is the ilatts-','Villo@,ibrook
                13
                   This is one of the most exciting developments in the American
                  @4
                15 health scene as far as I'm concerned.  That's just one       portion

                   of this thing.
                16
                              Now, generally  meritorious     if you look at   the  San
                17
                  -Jose-Valley project, the   San Fernando  Valley  project,  and  a
                18                                  1
                  ,- whole series of things in here where we have outstanding
                19
                   examples of innovative  and  initiative  kinds  of  ideas.  We  have
                20
                   some of the best coordinators in the IJ.S.A., who are not even
                21
                  Icalled RMP coordinators.  They're local area coordinators.  You
                22
                   look at Areas 1, 4 and 5, I think  they're really outstanding
                23
                   people in the whole nation.
                24
  Ace -FedwaL Repoftets, Inc., Then when you look at the  concept  of  $10  million  and
                25





                                                                            10


                  you can't helm but quietly think about some of the other lU4Ps.
                  This $10 million is relatively modest.
                  2
                           DR. PAHL:  Is there further discussion by Council or
                  3


                  staff?
                  4
                           DR. MILLIKAN:  llell, my inclination at this point in
                  5
                  ;Itime is -- Harold has made to me an extraordinarily important
                  0
                  "lbasic comment just now.  He said that we should not consider
                  7
                  these simultaneously with thinking in our minds.eye about the
                  budgetary constraints for our entire program.  well, in a
                  9
                  "'sense, that's almost impossible to do, and I think you, having
                  10
                  been through the grants game for years, understand that.
                  11
                           The review committee can't do that  either.  They
                  12
                  really can't say, "All right, we're going to forget the
                  13i
                  ,4'budgetar,y restraints in our entire review process." I don't
                  .1. believe they'll work that way.  We can't work thativay around
                  15

                  "this Co
                  -      uncil.
                  16
                            Now, if I were to forget those restraints, I'd say
                  171
                  unquestionably they should get the $10 million.  Thisis what
                  18
                  we should mass.  Now, knowing in one's mind's eye the money is
                  20 not available
                  .1.,      DR. MC PHED@L:  I agree with vou.
                  21
                  22        DR. 14ILLIKAN:  Because on the basic item of  wheIther
                  they have put together an organization and have peopled their
                  231
                  organization dith individuals competent to go through  the
                  241
  Ace-Fedefal   Repofters,   Inc. decision-making process and work with one another an  come up
                  25







                 I with a sound olan     for instance, Area 5 has a whole new
                 2 initiative'planning process going-on and has some very exciting
                 8'things they're doing and it took us an hour and a half or two
                 4'hours to look at that particular -;)ortion of the thing.  This
                 5 'is the U.S.C. part of it.  They're moving, moving, moving

                   'continually.
                 7,          So they have demonstrated unquestionably they have the
                 8 mechanisms and the Personnel to wisely use that kind of money.
                 9           DR. IIULITT:  Total population of the area  is  what?
                 16          DR. MILLIKAN:  21 million.
                             DR. KO.'4AROFF:  That raises a point I wanted to make,
                 12 that@-.iith 10 nercent of the  nation's  people,  California  is
                 13.relatively underfunded. I  don't  mean  underfunded  in  terms of
                 I1.4merit, just in comparison with other Regional'Medical Programs.
                 15          I haven't read recent grants or been on-site visits
                   recently, but I knew the program before and it seemed to me that
                 16
                   it is  an outstanding region, that we ought to at least approve
                 17
                   a level consistent with our evaluation of its merit, takina per
                 18
                   capita Population considerations.
               @19
                 26          DR. PAHL: @irs. Silsbee has a  comment  I  believe'.
                 -           MRS. SILSBEE:  It's a question of Dr. Millikan.  The
                 21
                 - last time California came  u,,o and you were looking at the whole
                 24
                 - program, there was a recommendation for about $8.3 and that they
                 23
                   Ihad  some hard decisions to make.and you wanted to get some notiOlt
                 24
  Ace@Federal Repatters, Inq' of how they went about making those decisions. And in order to
                 25




                                                                               12




                  have the record clear, I'd like to have some notion of the

                 2
                  difference in the decisions between the $10  program  and  the

                  $6.3.  Is there some indication that they made some tough ones?

                             DR. -14ILLIKAN: I can't give you -- in their  application

                  are the details.  There's some discussion of it in the project

                  site visit. I can't give you the  details  of  the  difference
               i7
                  between the $8.3 million program and the $10 million program.

                             Now, what has been accomplished out there -- for

                  instance,  there is an entirely new internal review committee

               10
                  which has  been formed and is now active.  We  had  the  opportunity

                  to meet the judge who has accepted the  chairmanship  of  that
               12 co,
                                                       -ooses
                       ttee, who is -- one of the  pur,      of founding this -- of
               131
                  having them actively internally  reviewing the phenomenon going

               14
                  on in each of the areas, is some  extra  internal  monitoring.

               1-5                                            RAG of the CCILP.IP is
                             Now, the central office and the
               16 fully aware of the problems of Areas 6','7 and 8, and they are
               17,rather intensively trying by leadership  examole  and  by  personnel
               18,from the central office going in to work with'these folks to do

               19'lsomething about the lov7 level.
               20i           Incidentally, when you'have a central  office  like  this
               2iilit's highly effective.  I couldn't helm but think about this in
               22,the Ohio State instance.  When you have a central office they

               23@can take certain kinds of actions in a portion  of  the  total
               24'region that we really can't take at the  district  level,  and  this
  Ace-Federal Reporters,  Inc.
               25-is what Mr. Ward and his personnel are doing with  Areas  6,  7  and





                                                                                                                                                               1 3



                                   1                      The  decision-making  process,  Judy,  about  their  own
                                   2   priorities,  as  far  as  I'm  concerned,  has  been  adequately  solved,
                                   3   and  they  are  now  prepared  to  struggle  with,   argue  about,  and
                                   4   ultimately  make  decisions  concerning  their  internal  priorities.
                                   5                      DR.  14ARGULIES:     I  met  with  that  committee  recently
                                   61when  T  was  out  there  and  there's  no  question  about  the  fact
                                   7   that  they're  working  hard  to  do  exactly  what  you  describe.
                                   8                      DR.  MILLIKA.N:    What  did  you  think  of  the  leadership

                                   9  of  that  committee?
                                                          DR.  IIARGULIES:     Iihink  it's  excellent.     In  fact,  they
                                   10
                                   11 lare  calling  meetings  on  their  own  more  frequently  and with                                                       nore.

                                      determination  than  they  had  expected.
                                   13                     When  I  talked  about  considerations  of  funding  level,
                                   14 I  should  have  also  said  that                           the  regions  themselves  are  in  a
                                   15 quandary  over  this  kind  of  issue  because  they  received  at  the
                                   16 time  of  the  cut  in  funding  levels  was                                  promulgated  a  very  strong
                                      suggestion  that  during  the  next  fiscal  year  they  would  be  held
                                 .17
                                      to  the  same  kind  of  funding  level  that  they  were  in  in  the
                                 .18
                                   19 Dreceding  year,  or  that  they  were  in  after  the  funding  cut  was
                                      imposed,  and  this  makes  it  difficult  for  them  to  decide  What
                                   20
                                   -  they  should  aim  for  because  they  don't  know  whether  they  s'nould
                                   21
                                      restrict  themselves  to  what  they                                think  they're  going  to  get
                                   22
                                   .  because  of  the  letter  they  received  or  whether  they  should  try
                                   23
                                   .  to  go  for  something  that  they  really  believe  that  they  can
                                   24
     Ace-@.Fedefat Reprottets,  Inc.  achieve;   and  they're  struggling  with  this  kind  of  an  issue                                                       and
                                   25





                                                                                    14



                  I  it's a difficult thing for them; and if we then modify our
                  2 judgments in addition to the jud ments they've already imposed
                                                       9

                  .3 upon themselves, it's sortof a double hazard as far as they're

                  4concerned.

                  5            I know we can't ignore the total budget.  At the same
                  6time, I don't know how we can anticipate our budget for this
                  7year because we don't know what it is, and in the absence of
                  8that kind of information, I think the most that you can do to
                  91look at the program on the basis of its merits is the closest

                  10 to a fair judgment we can ge
                  11           DR. MILLII@L:  It's kind of interesting that one of
                  12 the simple signs  of  overall  quality  of  California  in  the

                   Regional.Medical Program is-the.very fact t'.,l
                  131                                               a.@.they  have
                  14 already presented  us  with  an  alternate  plan,.  They're  so
                   effectively working  and  planning  that  they  have  two  down here.
                  16           DR. PAHL-.  Dr. Millikan, I'd like to ask you to
                  17 comment on point 2 on page 22 of the site visit report which
                  18 pints out that the $10 million plan of the region proposes
                  19 activation of some previously approved activities and so forth.

                  2b'Have conditions changed?
                  21           DR. MILLIK7uN:  This is exactly the reason that I made
                  22 the  comment   tha t I did about the relative similarity of the
                  23 triennial concept and the bloc grant concept.  You may not
                  24 recall that Yesterday I was the one that asked the question
  Ace - Federal Reporters,  Inc. hether   t                                       going
                  'Tabour w         his Council and the review committee are
                  25







                  to review brand new projects that are brought into a region
               2 lby its personnel during the triennial?  The answer is no, we're
               3i not going to review them.
               4            DR. PAHL:  Not unless there's a request from one of,

               5  the three parties.
               6            DR. 14ILLIY@.4.  All right.  But what we approved
               '7 yesterday did not include reviewing new projects, only supple-.

               'B mental and so forth.
               '9           DR. 'IkRGULIES:  You do also have,the flexibility of,
               10 making a decision at this meeting and altering it at t e next
               it one if there are changes in funding levels which you have to
               12 respond to and .,7hich -,lou cannot identify at the present moment.
               13           DR. MILLI@4:  That's right.  The only point I'm tryinc
               14 to make is that whether we're talking about the $8.3 million
               15 minus the 129, or whether we're talking about 9 of 10 or
               16 whatever, we are really talking about a sum of money that is
               17 going to be nut there, that is in California, with them as the
               18 primary decision maker about the snending at year two and year
               19 three unless some big questions are raised or whatever.  That's

               20 what I'm getting at.
               2            DR. PAHL:  That's correct.
                            DR. MILLIKAN:  And this.comment tJiat actually relates
               22

                                                                      ived one or
               23 to some activities or projects which might be conce
               24 two years ago is from a timing standpoint irrelevant.  @ly

  Ace@  Federal-   Reporters, Inc.
               25 answer is it shows lack of practical recognition of the processe





                                                                            16



                 that have been developed out there for decision making about

               2 this money'.

               @3           DR. PAHL:  Would_you care to place a motion before

               4 the Council?

                            DR. MILLIKAN:  In light of the.comments and admonition,,
               '6 concerning our philosophy as we review these grant applications,
               '7 that being that we should look at them on the basis of their

               .8 merit and that the alterations in quantities of money be a
                 portion of the staff's activities as it looks at our annual
               lolavailable budget, I move that we approve the amounts of money
               It listed under plan B with the provision that alterations in that
               12 amount be the action of staff  such alterations dependent upon

               13 staff judgment of the availability of funds.
                            DR. PAHL:  Would your motion, Dr. t4illikan, be for thal.

               -15 level of funding for the 05 and 06 years also?

               16           DR. I.IILLIKAN:  Yes.
               17           DR. PAHL:  Well, if I may just rephrase it, the motion
               18 then  -dould be for level funding for three years at $10,043,175
                 with   exact amounts to be determined on the basis of negotiation
               26 by staff during that period, and for the sum to include the
                -Ikidney project.
               21
               2@           DR. MILLIKAL4:  Right.
               23           DR. KOMAROFF:  Second.
               24'          DR. PAHL:  The motion has been made and seconded.  Is

  Ace-Fedetal Reporters,  Inc.
                 .there further discussion?
               25





                                                                               17




                            (No Response)

               2
                            DR. PAHL: If there s no  further  discussion,  I  would

               3'like to have all those in -favor of the  motion  please  respond

               4 by saying plAye. of

               ,5            ItAyesit)

               6            DR. PAHL:  Opposed?

               7            (No Response)

                            DR. PAHL:  The motion is carried.

               9            If we may now turn to the  application  from  Hawaii,
               10 with Dr. Millikan again and Dr.  Ochsher  as  backuo  reviewer.

               11           DR. MILLIKAN:   in December 1970, I believe  there  was
               12 a project site visit and  there have been,,as some of the Council
               13 members are aware, a number of problems in  the  Hawaii  Regional
               14 Medical Program. One of them concerned with  t'he  quantity  of
               15 time the program coordinator was able to devote to'  the  program
               16 and have I heard correctly that since the  application  was  sub-

               17 mitted and since the most recent project site visit there has

               18 been appointed an assistant or an associate  coordinator  at  a

               @19 full-time level?

               20           MR. MORALES: It was Mr. Livermore Tuncks(?) dho  was

               21 on core staff as a program planner has now been  put  into  the

               22 position of executive administrator, and also,  Dr.  Hasegawa  is
               23 seriousl,,- considering the Possibility of coming on board at

               24 100 percent kind of effort.

  Ptc@--Fedefal Reporters,  Inc.
               25           DR. MILLIGAN: In the application  he's  now  listed  as








                  100 percent in the application.

                 2           MR. MORALES:  I understand he still hasn't.

                   -         DR. MILLIK@,,I: @lie reason I asked this question  is

                 4'a series of project site visitors over many, many months, over
               '5 three years or so, have all  recommended  that  the  coordinator
                 6be full-time and/or have an associate  or  assistant  or  deputy
               @7 coordinator who can devote a significant amount of time to this
               @8'activity, and that had not taken place at the time of the last

               @9 oroject site visit and was mentioned as a matter of great
               10 concern by the project site visitors.  So that is now cleared


               12            Another problem has to do .qith the allocation of money
               131time and effort that are devoted to the Basin      the   Pacific
               14 Basin, and the Hawaii R:4P is responsible for that activity.  Now'
               15 as I get the general scene, when discussion goes on in the
               16 Hawaii Regional Medical Program RAG there is a friendly feeling
               17 toward devoting activitv and money to the  Basin,  but  when  it
               18 gets down to actuallv saying that "x" amount of money is going
                  to be used for this purpose, why, the amount of money gets

               20 smallers so it almost dwindles away.
               21            Now, there's some problems,  of  course.  The  trans-
               22 portation  allocation must be pretty  significant  because  it's
               2@ costly to  fly back and forth to the Pacific area, and I wonder
                 3
                  if any thought has been  iven any Dldce along the line to maybe
               24                          9

  Ace-Federal Reporters, Inc.
                  in this instance helping, in a sense, the Hawaii RAG by putting





                                                                              19



                  a little bit of earmarked, $30,000 or $40,000 or something like
               2 that, for the Basin?  Would that be possible?

               3
                            DR. IIARGULIES:  it could certainly come in the form
               41of a strong recommendation which would produce about the same
                  effect.

               6            DR. MILLIKAN:  I don't know how the others feel about
               7  it, but from what I've kind of heard, it would seem  in  this
                  narticular kind of situation this .qould assist the Hawaii RAG

                  a little'bit and Hasegawa if there was some very strong
               10 recommendation like that from this end of the line, just set
               11, that aside, so to soeak, and use it that way and not get into
               12 this interminable discussion and when you  finally  get  down
               13 to money matters about whether they're going to put any money

               14 out there in the Basin.
               15           1 don't know whether staff has any comme'nts  about

               16 this.
               17i          MR. MORALES:  I think that this would be very helpful
               18 to the region because Dr. Hasegawa has a concern and has had
               191for years now that funds that he receives for Hawaii  can  be
               20'easily depleted in the trust territory which is 3 million
               21'square miles of area which he's responsible for, and the budget
               22,tliat is reflect in the blue sheet is a recommendation by
               23 committee course is keening really a tight rein on what fun s
               24 Hasegawa will have for Hawaii itself, and if an additional

  Ace @cFefal  Reportets,  Inc
               25 $30,000 was awarded for the trust territory then he will know





                                                                                                                                                     20



                                 I what  he  will  have  to  @vork  with  within  Hawaii  and,  in  addition,
                                 2 can  continue  on with  activities  and  possibly  expand  his

                                 '3@lactivities  a  little  bit  as,far  as  core  staff  and  planning  in  the

                                 4 trust  territory  with  this  $30,000.

                                                      DR.  MILLIKAN:    The  review  committee  has  recommended,

                                                                                                                                      5  and  06
                                 0 as  you  see  on  the  blue  sheet,  awards  for  the    04,  0
                                 7 years  $1.6,  $1.4  and  $1.3,  and  since  this  principal  issue  of
                                   the  leadership  appears  at  least  to  be  temporarily  solved,  I
                                   favor  or would  move  the  recommendations  of  the  review  committee
                                 lolwith  the  conditions  as  stipulated  bv  the  committee  at  the
                                   bottom  of  the  first  page  of  the  blue                             sheet.

                                                      DR.  OCHSI'IER:    I  second  that

                                                      DR.  PAHL:    Dr.  Millikan,  in  order  to  clarify  the
                                   motion,  would  the  funds  which  you wish  to  have'for  the  Basin  be

                                   in  addition  to
                                 16@                  DR.  MILLIKAN:    I  recommend  $30,000  addition  to  be
                                 17 with  a  strong  recommendation  or  however  one  wishes  to  phrase  thal
                                   that  this  monev  be  allocated  for  use  only  in  activities  in  the
                                 18

                                   Pacific  Basin.
                                 2'04                 DR.  PAHL:    The  motion,  then,  is  for  approval  of  the
                                 21 Hawaii  application  for  one  vear  funding  at  $1,072,000  plus  an

                                                                                                                                      hat  that
                                 -22 additional  $30,000  with  the  strong  recommendation  t
                                   money  be,utilized  for  support  of  activities  in  the  trust  region
                                 23
                                 241and with  the  additional  advice  as  specified  on  page  1  of  the
    Ace -Federal  Reporters,  Inc,.
                                 '6,committee I s  report?
                                 2




                                                                             21




                             DR. MILLII<M  Correct.
                 2           DR. PAHL:  The motion has been made.  Is there a

                  second?

                             DR. OCIISNER:  I second it.
                 5           DR. PAHL:  Is there further discussion?
                 0           (No Response)
                             DR. PAHL:  If not, all in favor of the motion Please
                 7

                 8signify by saying "Aye.

                 9            Ayes
                 10          DR. PAHL:  Opposed?

                             (No Response)

                             DR. PAHL:  The motion,is carried.
                 1 2
                 13          If we may noa turn to Dr. '.-Ilillikan's last application,

                  Northern New England.
                 14
                             DR. MILLIKAN:  Herb, I'm in a considerable quandary
                 15
                  about this.  I have never been on a project site visit here.
                 16
                  I've heard discussions of it since the original visits of the
                 17
                  TPi.,l contract which was discussed and reviewed a number of years
                 18
                 -ago, and T)erl-iaos @like DeBalrey can help out if real precise
                 19
                  recall is necessary.   I've seen the application itself and the
                 20
                  only portion of that application that I can see that makes any
                 21
                 %, impact on people is the kidney portion, and this is one   off
                 22
                 23 the   record
                             (Discussion off the record)
                 24

  Ace@@ial Reporters,  Inc-
                 25          DR. I.IARGULIES:  Clark, one event has occurred and I





                                                                                   22




                                                       'th it, which  has  been  the
                   don't know how  familiar  you  are  wi

                   award to that area of funds for an experimental health
                 2
                 ""'delivery system, and this has brought together potentially the
                   'kind of data base which they have developed with the combination

                   of other -                           erimental  system  with  CHP
                            ,,)otentialities for  an  exp
                   combination and so fortli, which may make the activities they
                   have been carrying out a  little  more  meaningful  in  terms  of

                   actual Droject development.
                 8
                 9            How you can judge that at this early point, I don't
                   know, but  I think it's a point of information which is signifi-
                 10


                   cant.
                 11
                              DR. MILLIKA14:  Right.  What I'm really saying is I
                 12
                 13 don't feel competent because of my biases to make any particular
                   recommendation about this one.  This  oo s  o-me  i e a
                 14
                   ithat as manv of us conceive of ',UIP has been essentially unpro-
                 15
                   ductive, and this data base business       I  thought  the  other
                 16
                   day when I  was  reading  through  the full application, this is a
                 17
                   little  bit  like  a  registry.  Their data base  situation  is  a
                 18
                 - little bit like  a  registry  that  is not a part of some plan.  It
                   is just collecting figures like crazy and apparently in this
                 20
                 . data base they have almost every kind of a number that you
                 21
                   could ever want but what's ever been done with them or really
                 22
                 23 going to be done with them, I don't have the foggiest notion;
                   and I found no evidence  in  the  application  that  there's  any
                 24
  Ptce- Federal Repo( ters, Inc., reason to think that any kind of care of people has been
                 25 II





                                                                        23




                  influenced in any fashion by all the years of existence of this

               2
                  P14P.  To me, it's just amazing.  I think somebody has been on

               3
                  a site visit -- you've been up there

               4
                            DR. KO.',4AROFF:  Yes.
               51
                            DR. MILLIK2Ui:  Well, you may have an entirely

               6
                 1different look at it and I think somebody else ought to talk

               7
                  about it.

               8
                            DR. PAHL: Dr. Komaroff, would you care to  make  a

               9
                  comment?


               10
                            DR. KOr4AROFF: I felt the  same frustration, that this

               11
                  was a very excellent data collecting operation that was stymied
               121more for reasons of personality than  phil.osophy, from actually
                 I
               13lutilizing or even planning for the utilization of the  data,

                  and I think that ,.ias the consensus of the site visitors last

               15 December.
               16           Frankly, the problem, as it did in several occasions
               17 yesterday, seems to rest with the leadership of one man  who
               18 has a lot of strengths, but whose  proble.m is in making
                  connections with Deople that really count, and that means in

               20. this case the medical society, the medical school and even the

               21 @school of public health which lies a block away.

               22,          At that time, in December, there were really  very
               23 poor relationships and the RMP staff, extremely competent and
               24 imaginative in many ways, was operating or appeared to be
  Ace@Federat Reporters, Inc.
               25:operating in a vacuum; and the question was where they  were





                                                                            24



               1  going to go from there and how adequately they were going to
               2 serve the broker role that they seemed to feel was their

               inappropriate one.

                           DR. PAIIL:  Dr. Roth, do you have any comments as

                 backup revie@-7er?
                           DR. ROTH:  No.  The only attention that I have really
               7"oaid to it is its eventual gearing in with the New England
               6'Regional I@idney Program, that part of it, but I thin  Dr.
                 Millikan sort of excluded that and talked about that separately.
                           DR. MILLIKAN:  That is the plan it looks to me like
                 is going to have real impact on people, a cooperative arrange-
                 ment for the bettering of the care of people of this region, in
               13 this instance, with reference to kidney disease.
                           DR. PAHL:  Is there further discussion from Council
               141
                 or staff on the basic oroposal or the site visit?- Mr.  Colburn
               15
                 and Miss Houseal are here.  Do you have any comments?
               16
                           MISS HOUSEAL:    In answer to what's happened since
               17
               1 the sitelvisit, I believe the region has been working with the
                 medical society in developing a peer review mechanism.  I don't
               19
               26!know who will be funding this, but they are getting together
                -with more of the statewide organizations than they did I believe
               21
                 at the time of the site visit.
               22
                           MR. COLBURN:  I think since the site visit, the data
               23
                 base has had somewhat of an imnact on health planning in the
               24
  Ace-Federal Reporters,  Inc. region. They're getting a $460,000 award R&D for this data
               25




                                                                               25



                  I base and this peer review, which is going to be monitored by the
                  2 medical societies.  So there has been a strengthening and it


                  '3 has status.

                  4          DR. MILLIKNQ:  From what I hear is they're sort of
                  5getting other grants to do the things that ordinarily  IU-IP  might

                  6do.

                  7@         MR. COLBURTN:  They have had an impact also on
                  8'formulating B agencies in the state.  They just got planning

                  9awards for two B agencies.
                  101        DR. KO@,IA-ROFF:  one interesting thing that'they were
                  11 doing, a private general Practitioner, Gene Bont, had opened
                  12@up his practice to both quality audit and financial cost benefit
                  15'studies in a rural general practice situation, using  paramedics
                  1'4 personnel for a certain group of Datients and'not for others,
                  l@ using the problem oriented record, and this was just an
                  1'6 inspiration at the time we were there but  hadn't  gotten  off  the
                  17 ground.  Do you know what's going on with that?
                  18         MR. COLBURIN: I really don't. Dr.  Shyer  I  think  was
                  19 coordinating that and he's left and I  haven't  seen  the  progress

                  20 reports.
                  211        DR. PAHL: Mrs. Silsbee informs  me  that  the  regional
                  office representative, Mr. William @,IcKenna, knows a  great  deal
                  22
                  23 of this and is at a meeting for a few more  minutes  and  will  be
                  ,,. returning.  Perhaps we could either defer the application or
                  24
  Ace Feder-a.1   Reporteis,   Inc. go on to the kidney aspect.
                  251





                                                                            26



                            MR. MILLIKAN:  Well, I'll make the motion that
               2 because I  don't think we can phase this out or anything like
               3 that -- I  would move the a_doption or move that we approve the
               4 recommendations of the review committee, including recording
               5 the six items of their critique, under critique, with these
               o  items being kent very strongly in mind as we address ourselves
               7  ultimately to the acceptance of the triennial review application
               8  from them when it comes sooner or later, and that hopefullynie're
               9  able via the appropriate administrative leadership to see to
               10 it that some of the real concepts of ITMP are gotten into their

               11 program.
               12           DR. PAHL:  All right.%  The motion has been made to
               13jacce-ot the recommendations of the review committee, including
               14 the points made under the critique in the blue summary sheet
               15 and with the further advice as stated by Dr. ?4illikan.
               16           Is there a second to the motion?
               17           DR. SCHREINER:  Second.
               18           DR. PAHL: The motion has been made  and  seconded.  Is
               19 there further discussion?
               20           DR. MILLIKAN:  I think the problem here is exemplified
               21 if one reads those points, that here is a region which has  been
               22 active from ear ly on in the 'iistory of this division with the
               23 absence of a good set of goals,@objectives and idriorites.  They
                  could simply sit down and write those out from 40 other  regions
               24

  Ace -Federal  Reporters,  Inc
               25 if you don't have any ideas of your own.  That's pretty close to




                                                                              27



                  unacceotable, you see, to be in existence for five years and
                21not have any good goals or objectives.  I think that's the
                31review committee's statement.  If you look at number 5, the
                4 lack of a data collection strategy, and all they've been doing
                5 is collecting data for five years and they don't have any
                6 strategy for the use of any of it, according to the review.
                7            DR. PAHL:  I'm glad you didn't say the goals and
                8 Plans of 55 other region-@.  PerhaDs 40 or so.  Is there further

                  discussion?

                             (No Response)
                             DR. PAHL:  If not, all those in favor of the motion
                121 please signif'y by saying "Aye.",

                13            Ayes
                             DR. PAHL:  Opposed?

                             (No Response)
                15
                             DR. PAHL:  The motion is carried.
                16
                             I would like now to turn to the application from
                17
                  Texas, with Dr. Everist as princi-.?al reviewer.
                             DR. EVFRIST:  For those Council members who remember
                19
                  the early  history of Texas TMP, this review will be refreshing.
                20
                  For newer  members, it will be a revelation.
                21
                             By using the most euphemistic recordable descriptions
                22
                  of the first three years of the'Texas Regional Medical Program,
                23
                      could say that they were disharmonious, disgruntled, dis-
                24
  Ace - Federa( Reportets, Inc. believing and distressful.
                25





                                                                               2 8




                                                                       eting   for
                            There were a variety of organizations comp
                  2whatever i't was they felt PJIP could deliver. By  some  strange
                  3alchemy, the current coordinator, Dr. Charles lAcCall, has
                  4enticed a phoenix out of the ashes.   Texas is still not a
                  5"showolace for R!-IP, but it certainly has seen the light of the

                  ;/' 1970s on the horizon.
                  0
                  7         Texas has about five percent of the nation's popula-
                  8tion scattered over an area of 267,000 square miles and they
                  'have recently rediscovered subregionalization.  In the nast,
                  idITexas has had difficulty measuring its goals and priorities
                  with the national goals and priorities.  The fault was probably
                  12 bilateral, but that was the past and the future  looks  better.
                            The grantee institution is now the University of
                  Texas system with offices in Austin, and is also now the fiscal
                  14
                  15 agent, and they are requesting triennial review with a total of
                  Ia three-year funding of $5,632,416.  This would include a ten
                  16
                  17,percent developmental component for three years, core, and three
                  new -,orojects; one aoproved unfunded, plus  eight  continuation
                  18
                  ?rojects for one year; two for two years; and two renewa
                .19

                  projects for one year.
                  20
                             They are also requesting earmarked kidney  disease
                  21
                  funds on  a non-comneting basis for  a period of three years.
                  2@
                             The project orientation which currently entraps a fair
                  23
                  24 amount of the substance of the Texas MNIP has not been signally
  Ace-Federal   Reporters,   InG. successful with perhaps two exceptions. The newer programmatic
                  25i                                            'I




                                                                                 29



                  'Encroach seems to have a regional concept well in hand and   shows

                 2  true concern for the deficiencies in the health delivery
                 3il-ystam, especially for cannulas and  blocks.  Examples  of  this
                 41!.-tre an attempt to imorove the quality of care given by black
                  physicians, the high priority   placed on a  project  called  GRO,
                 0to provide in-service training in small rural hospitals and the
                 ,-F'@c,,,--@ioloyment of a regional staff, now three, potentially ten,
                 8,,and selecting these employees from local, knowledgeable,

                 91,c@ffective people.
                             The managerial hierarchy of  the  program  would  seem
                 1111-Lo be most adequate and@the new coordinator almost beyond


                             The review committee has solved the very sticky
                 141,lDroblem of how to react to the past and a goo(f future is garnered
                 1'5@'from their site Visit and a written pronosal.
                             They recommended $1,590,000 a year@for   two  years  to
                 i7lim,nrove the developmental component. They are  not  placed  on
                 i,@;@-xic-nnial review but a site visit will be made at the end of
                 ig,,one year.  This is only $125,000 less  than  they  requested  for
                       first year  and a little than.$300,000  under  their  request

                 21 for the third year.
                 22          The committee has expressed  their  faith  by  allowing
                 2@l@he developmental component while at the same time they h   ave
                  !,,-,',,,-IoT?ted a "wait and see" attitude.
        a! PC, r I,@@
                             I, therefore, recommend approval for  two  years  at  a






                I funding level of $1,590,000 including the developmental funding.
                2           DR. PAHL:  Thank you.  Before we place the motion
                3before the Council, perhapa.we might ask Mr. Friedlander if

                4there are any comments he would like to make.
                5           MR. FRItDLA14DER:  After years of listening to Dr..
                6Everist-do such a magnificent and incisive  job of reviewing
                7the review committee's recommendations,'I couldn't possibly add

                8anything.
                            DR. PAHL:  The motion has been made for acceptance
                10 of the comriittee's funding recommendations.  Is there a second

                Ilito the motion?
                2           DR. FRIEDLA14DER:  Second.
                13          DR. PAHL:  Is there further discussion?  i-ir. Posta,

                14 do you !lave anything?

                            MR. POSTA:  That suits us fine.

                            DR. PAHL:  If there's no further discussion, all those

                17 in favor of the motion please say IlAye.11

                            IlAyesit)
                18-

                            DR. PAHL:  OT3!Dosed?

                2b          (No Response)
                            DR. PAHL:  The motion is carried.
                21
                            DR. MARGULIES:  I wonder if I could just make one
                22
                @",co=ent at this point.  The reviling of this region with its
                3
                24'past history and present status which came through with the kind

  Ace   -   Fedeial   Repotters, in@-
                25 of enthusiastic summary in review committee as it has in Council,




                                                                             31



                 I again illustrates what we keep talking about with the TU4Ps from
                 2one moment to the next, and that is what kind of  leadership  is

                 '3 iDresent and @qhat that leadership can achieve, and this is an

                 @4 ideal exaTinle of what a difference it makes and we have some

                  other examples of what a difference it makes which are less

                 '6 pleasing,.
                 '7'        DR. PAHL:  If we may now go to the application from

                 8Virginia,, Dr. DeBakey.
                 .9         DR. DE,BAKEY:  Well, the only thing to go by is the
                 10 recommendation of the review committee on the blue sheet, and  I
                  vrould be inclined to go along .,7ith their recommended funding.
                 12 I must say that I had some feeling that this may be  inadequate.
                 l3tIs there someone here that has better information than is
                 14 available in these sheets-about the reason @qhy'they have cut
                 15 back on some of the support, particularly in relation to supplier

                 16 and equipment?
                 17         DR. EVERIST:  it's two centers.
                 18         DR. DE BAKEY:  I know that, but  I'm talking about

                  the

                            DR. PAHL:  -L@Ir. Spear, could you perhaps comment on
                 201
                 21the funding recommendations?
                 22'        MR. SPEAR:  The Virginia TU4P has had a.great potential
                  for activities in renal disease-and the application that was
                 23
                  received reflected at least some very good things that needed
  Ace-Fedetal  Reporters,  Inc.- t  be done, but the nanel was unsatisfied with the kinds of
                 250

                 t ,





                                                                                 32



                I descriptions that were  given  about  the  activities.  Their  goals

                2 were not @ell described in  some  respects.  There  was  some  clear

                3"duplication of effort described,  and  the  central  difficulty  was

                4 '@ona, not unusual in many regions, that there was a need for

                5 further cooperation and coordination among the activities

                  'involved  in  re nal disease.
                '6
                '7           The activities related particularly   to a dialysis
                8  activity, the @anel was willing to act on with    some  specificity

                   and the review reflects that.  The knowledge of    the panel  about

                  'the four Possibilities in the region led them to desire that
                I 0

                   there be some conversation to see what are the  base  needs,  that

                   can be met within the application that was   submitted.
                13           They were just unwilling to make   some decisions on som@
                14 I'-oarts of the a-onlication without further discussion face to face.
                             DR.  DE BAKEY: Well, the reason  1  questioned  this  is
                15
                  !because I get  the impression that they felt that this was in
                16
                   good hands, and certainly Dr. Hume is able  to  give  good  leader-
                17
                   ship for this, there's no question about that.
                18
               .19           MR. SPEAR:  Yes.
                             DR. DE BAKEY:  And it seems to me that cutting back on
                20
                   some of the funding that this is going to jeopardize their
                21
                   ability  to do the job well, particularly when  you  have  as  good
                22
                   leadership as you have in the renal disease area as exists
                -23

                   there.
                24

  kce -Federal Reporters,  Inc.
                25           MR. SPEAR:  I think the key statement there is that




                                                                                  33




                   I  those funds be used as a base for discussion.  This much could

                   2 clearly b6 approved with no difficulties; that there  might  be

                   3 a need for more was well @cognized, but it needs to be

                   4clarified.

                   5         DR. EVERIST:  There's a site visit coming up next

                   6month in Virginia and there could well be a  kidney  man  put  on

                   7the site visit team and recommendations given.
                   8         DR. DE BAVEY:  Well, I certainly would go along with

                   9that.  That's a good suggestion in my opinion.

                             I certainly would be willing to anDro've  this,  but  I
                10
                   think @ie,ought to take into consideration that there is  a
                12 possibility, perhaps after the site visit in another month, and
                13 we have an opportunity to review this again  and  bring  it  back
                   to the Council, if the site visit demonstrates there   is a need

                   for the additional funding, I t hink we ought to be open to

                16 orovide it.
                             I just am a little concerned about cutting back on
                17
                18 the funding of a groun of peole that I have great confidence
                   in and admiration for in terms of what they're able to do in
                19
                26 1this  area.
                   I         DR. MARGULIES:  I got the impression when   we discussed
                21
                   11 this earlier after they had been down there, r4ike, that the
                22
                   @l
                   Ipeonle were there but they really hadn't gotten together.  There
                23
                   were some terrible gaffes in which an  application  was  in  with
                24
  Aoe@-Federal   Reporters,   Inc. somebody's name on it and he discovered his  name  on  there  for
                25





                                                                                     34




                 I the first time  when  the  application  was  in.  It's  that  kind  of

                 2  disjointed effort.  It's there but it hasn't been pulled

                 3 Altogether.

                 4             DR. DE BAKEY:   I was on a project site visit     in

                 5  Virginia well over a year ago, and at that time I got the

                 6 "distinct impression th  at there  were  some  polarizations  as  well

                 7 "in certain parts of the state,  but  it  seemed  to  me  that  much

                 8 "of this has improved,  that  they  were  getting  together  and  were

                 9 "trying to work it  out,  and  particularly  the  renal  program  is

                 10"'one which was receiving  the  support  of  everybody.  So  I  was

                 ]]-"particularly anxious to see if maybe this would be a good

                 12'1'mechanisnL to demonstrate how they could work together to helo

                        the  people  and  particularly  people  that  are,in  need   the

                 l@4 'patients that need this type of management.

                               DR. SCHREINER:  May I ask what the status of      Droject

                 l@@'12, ,)rocurement, what the status of the funds was?

                 17            MR.  SPEAR:  Yes.  I  wanted  to  comment  on  that.  We

                 1 8'have been -,3roviding funds for the organ procurement development

                    in that area and, in fact, that's  the  key  point  for  the  whole

                 10 southeast area of the country,    and we have just orovided a
                 21 third vear of funding for organ    procurement     development
                 22' activity which is expected probably to be the final funding, but
                 23 we wanted to look at it again  at  the  end  of  the  third  year.
                @24            DR. SCHREINER: I think,  just  to  back  up  what  @like is

  Ace-Federal Reporters, Inc.
                 251saying, that at least in that particular program it      's fuhctionin





                                                                                                                                               35


                                I    pretty well.    If  that  goes  down  the  drain,  that's  the  hub  of
                                2    the whole  12  or  13  university  network  that's  getting  the

                                3"typing  and  kidney
                                4                    DR.  PAHL:    Dr.  Merrill,  did  you have  a  comment  to

                                5' m@ze?
                                0                    DR.  MERRILL:    I  just wondered,  this  is  labeled
                                7Virginia         Regional  Medical  Program  and  I  would  assume,  as
                                'Dr.  Schreiner  just mentioned,  that  it  deals  with  patients  from
                                9   areas  other  than Virginia,  and  I  gather  that's  perfectly
                                lb"ap-,?ror)riate  for  this  program;  is  that  correct?

                                1                    DR.  PAHL:    Yes.
                                12                   DR.  @IE-@ILL:    I  notice  also  that  there  is  a  salary
                                I  for  a physician  part-time  in here.    Does  this  represent  a
                                3
                                14 departure  from  the  policy which we  discussed yesterday?
                                                     MR.  SPEAR:    You're  looking  at  the  figures                               here?
                                15

                                                     DR.  MERRILL:    Yes.
                                16
                                                     MR.  SPEAR:    The  proposal,  among  the  other  things  it
                                171
                                18 talked  about,  was  the  development  of  two  satellite  dialysis
                                   units  and  the  key  to  these  units  was  that  one  was  to  be  for
                                19
                                20 paying patients  and  one was  to  be  for  indigent  patients.  One
                                -  was  to be  relatively  fancy  and  one was  to  be  relatively  plain;
                                21
                                   and  the  nanel  couldn't  accept  that  philosophy.    So  this  repre-
                                22
                                2'3 sents  their  judgement  of  faults  that would be  encountered were
                                24 a  single  dialysis  satellite  were  to  pick  up both  the  paying  an@
     Acc,@'Fe@at Reporters,  Inc.  the  indigent  people.
                                25




                                                                            36


               I            DR. MERRILL:  But the services of Physicians who
               2 would be essentially rendering service to patients is included

               3  in  that?

                            MR. SPEAR:  Yes.
               4
                            DR. PAHL:  Dr. DeBakey, was that in the form of a
               5
               6  specific motion for concurrence with the corimitteels.recommen-
               7  dation but that should be subsequent should the site visit
               8  indicate a need for additional funds that this request will be
                  brought back before the Council?
               9

                            DR. DE BAKEY:  Yes.
               10
               11           DR. PAHL:  Is. there a second?
                            DR. EVERIST:  Second,
               12
                            DR. PAHL:  Is there further discussion?
               13i
                            .(No Response)
               14
                            DR. PAHL:  If not, all in favor of the motion olease
               15
               16 say  Aye.
               17            IsAyesig)
               18           DR. PAHL:  Opposed?
               19           (No Response)
                            DR. PAHL:  The motion is carried.
               20
                            DR. DE BAKEY:  I think Dr. Everist's suggestion to
               21
                  have someone from the kidney disease Danel on the project site
               22
                  visit would be desirable.
               23
                            DR. PAII:  Yes, we will have aonrogriate representa-
               24
  Ace-Federal Reporters,  Inc. tion from the staff and the kidney disease panel on the site
               25





                                                                               37



                            Now, we're hoping for Dr. Brennan still  nerhaps  to
                2 make it to the meeting so with your permission I would like to
                3 take up the Bi-State application with Dr. ochsner as principal
                4 reviewer, and we'll hold the New York applications pending the

                5 arrival of Dr. Brennan or at your pleasure.
                6           DR. OCIISNER: I haven't made a site visit  there  and
                7 I don't know when the last site visit to Bi-State was made.  I,
                8 -Cnink you're all aware of the fact.that this is one of  those
                9 hodgepodge regions in which it involves  a  large  metropolitan
                10 Area, St. Louis, and two fine medical schools and then  a  very
                11 large rural area in southern Illinois.
                12          Apparently they have a strong coordinator.  They
                13 have difficulties because of the type of arrangement  with  the
                14 many diversified interests, but apparently they're doing a

                15 fairlv good job.
                16          I would recommend @qhat the review committee
                17 recommended, that there be an additional year instead  of  the
                18 three years requested, and this be in the  amount  of$924,113.
                19          DR. PAHL:  And your recommendation includes the
                20' concurrence with the committee's disapproval of  the  develop-
                  mental 'Com-oonent and the other funding relative to the projects.
                211          -
                22           DR. OCHSNE'-R:  Yes.
                23           DR. PAHL:  Dr. DeBakey, you were backup reviewer.  Do
                24 you have any special  comments?
  Ace -Fed6fal Reporters,  Inc. DR. DE BAKEY: No. I would agree with that.
                25





                                                                                       38



                 I             DR. SCHREIL4ER: I wanted  to  ask,.  what's  the  status
                 2  of the ord,-3osal that they  were  Preparing  on  a  multi-regional

                 3  renal training program?  Does anyone kAow?
                 4             DR. OCHSNER:  I  don't  know  what  the  status  is  about
                 5  that.  All I know is what they've got here.
                 6             MR. JEWELL: We  do  know  there  is  an  application  in
                 7  the mill. They have  not  yet  formally  submitted  it  to  us  but
                 8  they are awaiting word as to when the     doors open for 910

                 9 consideration.
                               DR. SCH-REINER: I knew  that  they  were  working  on  a
                 101
                 11  very comprehensive Droposal.
                 12           DR.!4ARGULIES: Yes.  That  was  Missouri-,  Bi-State  and
                    Ka,-isas.  They have been 1,7orking on it'.     get  the   impression
                 13
                    from  talking  with  the  coordinators  separately  that  they're
                    finding this more difficult to do this together than they       had
                 15
                    anticipated and I have the feeling that they will come in       more
                 16
                    separately with their  applications  and  try  to  join  in  some way,
                 17   -
                    but that's not necessarily true.  I think that, again, this
                 18
                    might be affected  considerably  by  level  of  funding  in  the  way
                @19
                    in which we come back to them because the idea of combining over
                 20
                    that area is very sensible.
                 21
                 22            DR. SCIIPEINER:  It had some very exciting aspects in'
                    one Dlace  where I thought  we  could  exert  a  little  leverage
                 23

                    maybe.
                 24
  Ace-Federal Reporters, Inc.  DR. IIARGULIES:   Yes.
                 25





                                                                                        39



                  I             DR. PAHL:  The motion has been made.  Is there a

                  2  second to'the motion?

                  3             DR. DE BAKEY:    IL second it.
                  4             DR. PAHL:  Any further discussion?  Does the staff

                     have further discussion on this ap?lication?

                  6             (!lo Response)
                  7             DR. PAHL:  If not, all in favor of the motion please,

                  8 say  lokye.11

                  '9            ("Ayes")

                  10            DR. PAHL:  Opposed?

                  11            (No Response)

                                             -he motion  is carried.
                  121           DR. PAHL:
                  131           We may now   turn to the Georgia application with
                  14 Dr. Cannon as Drincipal reviewer and Dr. Schreiner as backup

                  15 reviewer.
                  16            DR. CAIINOII:  The Georgia application has been studied
                  17 both by the site visitors and the review committee and they
                  1 8turned in almost identical recommendations to approve the
                     number of people approved in the recommendations that are before

                     you and we've had a significant study.
                  20
                                Now, there is one question concerning policy that we
                  21
                     might take a minute to discuss.  Both the site visitors and the
                  22
                     review committee were anxious that,some way be worked out to
                  23
                  24 fund a program to stimulate underprivileged students in high
  Ace @Federat Reporters,  Inc'                                This received a gold star
                  25.1 school into the health care system.




                                                                               4 0



                 I both by the site visitors and by the  review  committee.  However,
                 2 it's been the policy of this Council not to fund programs in

                 3 career oriented programs.
                 4           In other words, sometime ago when we were discussing
                 5 applications referable to different stratas in the personnel
                 6 training of health care workers, we put a limit on the funding
                 710f the schools.  Isn't that correct?
                 '8          DR. MARGULIES:  That's ri ht and, of course, that
                                                      9
                 9 issue came up during the discussion of  that  particular  activitv
                 10 but the people who looked at it were so impressed by its
                   potential that they felt that this was one time when it could
                 12 be described in different manners or one in which you took
                 13 advantage of the fact that you make-your own rules  and  have  the
                 14 opportunity to make exceptions to them if you find it wise.
                 15          DR. CANNON:  it's a very small amount of money,
                 16 $23,000, in comparison to an application which is asking for
                 17 $3.7 -million per year at least, but it would require some change
                   of polic        uld like to have the staff  that  recommended  the
                 18        Y.  I wo
                   Council reconsider it express their oninion.
                 19
                             DR. K014AROFF:  Is this-something that could be
                 20
                 '.' accomplished out of core without calling it  a  separate  project?
                 21

                             DR. CANNG,-i-.  It could be.
                 22
                             DR. KO,'AAROFF:  Thus without violating policy.
                 2i
                             DR. I,.IARGULIES:  Well, you can, but I don't think @-ic
                 24
  Ace-Federal Reporters,  Inc' need it's our policy and I think that we deal with  it  as  our
                 25





                                                                                41




                            DR. EVERIST:  we don't need to change our policy.

                2           DR. 14ARGULIES: Miss Nelson, do you  want  to  comment


                3 on this?

                4           MISS NELSON:  I was going to comment that on  our

                5 policy, the last sentence, we do state that RMP funds may also
                0 be used in Dlanning health careers recruitment activities.  This
                7 is in spite of the fact that we said we didn't  fund  operational
                8 programs. It may be used in Dlanning  health  career  recruitment

                9 activities as a oart of and coordinated with  the  overall  man-

                10 power strategy for the region, and do you see this as a  part  of

                11- that endeavor in Georgia?

                12          DR. EVERIST:  It's a moot question.

                13          DR. PAIIL:  We can waive it.

                14          DR. EVERIST:  Sure.  We can waive our own policy   and

                15' just make an exception,.
                16'         DR. CiViNON:  Well, I believe that we're making a
                17' mountain out of a,molehill because I think we  could  very  well
                18 work out the funding on this.  I think we'd sort of want to make

                  an issue on it to see if there was going to be a policy change

                2-O' by the Council.
                2"l'        -My feeling is that we ought to express  our  interest
                22 but tell them that our policy is unchanged at the  present  time.
                28@ I think he's well aware of it. I kind of  have  a  feeling  that
                24 we're kind of making an issue about whether %,ie're going to

  Ace.-Federal  Reporters,  Inc.
                25 change our policy or not.





                                                                             42



               I           DR. IIARGULIES:  I think we can describe it as some-
               2 thing @7hich Council regarded as a good thing to do so long as it
               3  was done in a manner consistent with our policy, and he'll

               4  understand what he then needs to do.
               5           DR. CA--NNO!i:  All right.  Now, as to the overall prograli,
               .6 you will note that both the site visitors and the review
               7  committee have recommended funding of $2.8 million per  year
               ,8 instead of the requested $3.9, $4.3, and $3.9, and ver y clearly
               @9 set out the reasons for deletion of this amount of money from
               10 that requested, and they were on the basis of programs in which
               11 they dithheld funds or thought they had little or no relation"
               12 ship to the overall program and not likely to remain  viable
               13 without future support from T.U4P, and that they could be incor-

               14 porated in other projects.
               1,5          For instance, they have two respiratory projects that
               16 deal with respiratory disease, one in pediatrics and one  in
               17 adult respiratory diseases; and the fourth reason, it would be
               18 more appropriately funded  from other sources of support.
               19           There is one question @ihen you're tabulating the funds
               20 how both the site visitors and the review committee come  up
               21@ with $2.8 million. There is a questionable item  and  that's
               22@ under project 6, communications network, a request for $160,000
               2@' and T presume that the recommendation is that this not be funded
               24 Now, I could not tell from what was given to me either on the

  Ace-Federal  Reporters,  l.ncl.
               26 blue sheet  or the site team report whether the recommendation





                                                                                    4 3





                    was for deletion of this amount.

                2              DR. PAHL:  Mr. Nash, c an you heln us out on that?

                3              MR. NASH:  Yes. @The recommendation was not including

                4  funds for   that Droject.
                5              DR. C@4NON:  Then, if you turn on the yellow sheet,
                6   to run down the projects that funding was changed, the state-
                7   wide cancer program with a cut of about 60 T)ercent of the funds,
                '8  and then the respiratory center and the facilities for respira-
                9   tory diseases were merged and that funding was cut.  There was
                10  another merger of patient and family education with the learning
                11' resources and that funding was cut.  Then the kidney disease

                12  program was dropped or cut.
                f3             DR. ?,IARGULIES: Bland, could I      I just got a letter
                14  yesterday  and was waiting to get to this   kidney one.  This is
                15  one letter from Albert Tuttle and the other from, Gordan Barrow
                16  about the kidnev oroposal.  They feel that this had an inade-
                17  quate review  and they feel   very  strongly   about it.  There was
                18  not a site visit, and   they felt that  to  look  at it from our
                19  point oil- view was out of context to  the  rest  of the activities
                20  which are going  on  down  there.  And  I  indicated that we would be
                21  ha-oov to withdraw  that  particular  proposal  from consideration
                22  at this time until we could  have  a  site  visit  to satisfy their

                23  requirements.
                2@4            DR. CAZINON:  Well, what about the ad hoc panel on

  Ace.-Federal Reoorters, Inc.
                25  renal disease?





                                                                             4 4



                            DR. 14ARGULIES:  Well, the ad hoc panel did not make a

                 2 site visit and they felt that they had based their judgment on
                  incomplete information and they would like to have them look at
                  it more fully, and I thought their objection was valid as I

                  .4ent over it with the kidney division.  So they prefer not to
                 ,Ihave any consideration of it at this time.
                            DR. SCHREINER:  While you on it, I had planned to make
                 8some comments on that area.  one of the problems and f think
                  we commented on this in the orientation sessions -- it's a
                 10 minor problem.  The ad hoc kidney 'review committee is very good,
                  however it is pretty heavily loaded with four transplant
                  surgeons and sometimes their decisions.reflect the surgical

                  prejudices.
                 13
                 1.4        Now, they just sort of took a sort of black or white
                  approach to the fact that there wasn't a surgeon there, and at
                 15
                  the time they considered it there Hasn't.  They were in the
                 16
                  nrocess of recruiting a new chairman in the department of

                 I8surgery.
                            DR. DE BAKEY;  They've got one there now.
                 19
                            DR. SCHREINER:  And they got a very fine one who has
                 20

                 @ i
                  also committed himself to a transplant program, and he's very
                 2 1
                  cooperative and very academic surgeon, and I would think that
                 22
                  that .,7as probably a kind of hasty comment that was made.
                 23
                 24         The other problem was that all our negotiations were
  Ace - Fedefal Reporteis,  Inc' with the young fellow who ran the dialysis unit who is a very
                 25





                                                                                    45



                    dynamic person who is leaving for   personal reasons, and they
                 2 sort of took that as a comment that the whole thing was going
                 3 to collaose, whereas the ftct is tha@ the dialysis center at
                 AlGreeley(?) is the closest of  any  unit  in  the  whole  South  to
                 '6 fulfill the criteria that the NIII study  group  set  up  on  the
                 6  ideal nedhrology center, and it was partly set up ..7ith IV-.IP
                 7  funds.  I think it would be a little unfair to pull the rug out

                 8  from under it.
                              DP,.. CA14NON: This gives some  insight as to the
                 10 strength of our representation in the kidney -- very logical
                 11 objections -- and I'll be discussing this further on another

                 12 resort that I have.
                 13;          Well, let's delete that from our consideration and
                 14 say that such projects as physiology for nursing and nursing
                 15 instructors and projects  for  dietitians  and  so  forth,  there  were
                 16-ino other projects in,question or programs in question except
                 17 one, and both the review committee and site visit team said
                 18 that a plan for  a  health  maintenance  program  at  Stenhens  County,
                 119@ which is a county of  about  20,000  people,  will  not  be  considered
                 2'0' for funding on the basis  that  we  no  longer  are  funding  new
                 2-ilmultip@hasic screening testing.
                 22            For those of you aho are not aware, this is a small
                 2'3- rural county and has an  ongoing  program  such  as  this,  you  should
                 24 look to Iuca, Mississippi.  If    you go down to Iuk-ai  @,iississippil

   Ace.-Federal   Reporters,   Inc.
                 25 1they have a program similar to   the one  that  was  recommended  here





                                                                             4 6




                                                     to bringing those peoole who
                  in Stenhens County.  It is the key
               2@ haven't had health care into a hea lth care system.  It's a
               3 1.-gimmick and it works very-,yell with a followulo of health care.
               4 And we can't really analyze that on paper, as Clemmons'
               5 'committee did, as to the valu,e of multiphasic screening because
               6,5it,s the byproduct of the technique that accomplishes something

               7 that we in -@.IP want to accomk-)lisli.

               8            So I would suggest that some further consideration

               9 be given to the Stephens County health maintenance  program  so
               10 that it could be placed in a different context of its  primary
               11' purpose, and 1 do not believe that we should exclude funding
               12' for that program; but, as I say, site visitors and reviewers

               13 have suggested that we do so.
               1-4          DR. KONIAROFF: Are adequate provisions for  referral

               1,5 and continuing care provided in this?
               16           DR. CANNON:  As near as I can tell from the material

               1 7sent to me from Georgia -- Georgia has a very unique way  of

               18 getting their information with forms and things, so that  we
               19,4may not have all the information you want from them.  Relying
               20" on the site group, maybe they could tell us.  Did-you look into

               21 that program?
               22'          MR. NASH: No. We didn!t really look  at  any  of.the
               23 projects there from a technical aspect.  They do have followup
               24 built in the program. I think the reason the  site  visitors

  Ace-Federal Reporters, Inc.
               26 recommended no funds for this project was based upon the





                                                                                   47



                    policy or recommendation of Council that no further multiphasic
                2@  screening be approved and be supported.
                3             DR. C2VINON:  Well, I would recommend that some way
                4  we would not change our policy    for multiphasic screening, new
                5 'programs, but that we would suT3-port an activity such as this
                6 "which accomplished the  goal  that's  more  important  than  finding
                7"'out whether multiphasic screening is  a  wise  program  to  support.

                8@  financially.
                9             You see, if we pass this, the way I look at it, we've
                10' already acted against the  recommendations  of  the  Brennan  repor

                11"which we-accepted.
                12            DR. %IARGULIES:  Well, those recommendations were
                131 saying -- and I think this may be at  least  part  of  the  resolu-
                14  tion of the issue that you raised -- they said that these
                15  should be suspended until there can  be  a  more  adequate  evalua-
                16'1 tion of the usefulness of  these  kinds  of  screening  activities,
                17  and I think that if you want to take action on that pending
                1'8 -that evaluation, and we can then sp end more  time  with  them  to
                    see whether this fits in with the other kinds of issues or not,
                    it gives us at least a way of responding.
                201
                21            We don't knod how  long  the  evaluation  will  take,  of
                22" course, and .ihat the nature of it will be, but there is an
                23' intensive effort going on all through IISI-lHi-\ to take a look  at
                24  this multinhasic  screening issue because it's all over the place

  Ace @Federal  Repofters,  Inc.
                25  and we may have  some kind of basis in the near future    of being




                                                                                4 8



                   able to lift our kind of prohibition on it.
               2             DR. MILLIKA!I:  Could we then amend the motion to
                   include such a phrase as continued support for this activity
                   you mentioned pending evaluation and appropriate further
               4

               5   judgment concerning it?
               '6            DR. CA'.4NO14:  I would accept that.
               7             DR. DE BAKEY:  Bland, you have some personal
               8   experience with this?
               9                    :4 O.,:4: Only in Ilikai, I went down about amonth
                             DR. CA-N
                   ago, a little more than a month ago, to Iuka, Mississippi,
               10
                   because I had heard so much about Iuka, Mississibpi,and its

               12  program.
               13            DR. DE BAKEY:  How did you happen to hear about it,
               14 because I  never heard about it?
               15            DR. MILLIK2U4:  Haven't you, really?
                             DR. DE BAKEY:  l@o.  That's why I'm interested.
               16
                             DRi CN@NON:.  Well, it's a community on the periphery
               17
               18  of the Regional medical Programs in Memphis, and if there's
                   anything that sneaks well for working in outlying regions, I
               19
               20 Ithink this is the one place I would point  to.  And  I  wonderedI
                   if the staff of EUIPS has this impression. Would  you  speak  to
               21
               22  it?
               23            MR. RUSSELL:  Yes.  I'think you'd have to-kno@-i Dr.
                  .,Cosby who heads up the mobile multiphasic screening unit in.
               24
  Ace -Federal  Reporters,  Inc. Iuka.
                          This was about ayear ago tliat,Dr. Cannon, it actually
               25





                                                                            49



               I  got started and underway, a year or a year and a half ago.  As
               2 a result of the mobile unit and the interest of the  general
               3 practitioners in the area, they have stimulated a tremendous
               4 amount of interest, not only in the mobile unit but they are
               5 bringing in other programs.  They got the local mayors involved.

               6 It's really delightful.
               7            DR. C)UINON:  The main thing is bringing people in for
               8  health care that's never seen a Physician.
               9            DR. EVERIST:  I'm not sure it's appropriate to  be
               lo@ discussing this because we are going to be discussing this in th2
               li' Memphis region in just a little bit, and I personally have some
               12 different ideas about :[,uk--a County.
               .13          DR. MARGULIES:  Dr4 Everist, in his quiet way,  is
               I14saying that this part of the discussion is out of order because

                  weire going to get to that next.
               15
                                                                 Memphis.   I
               16           DR. CA.NNON:  Well, I'm not discussing           m
                  telling you the value of a program @qhich uses multiphasic
               17
                  screening, that @.ie call multiphasic screening programs really
               18
                  ought no4- to be called that.  They're using multiphasic
               19
                  screening to effect a program in getting started, a health care
               20
                  system for neople that otherwise don't get in the system, and I
               21
                  say it's qrong to exclude funding of those programs on the
               22
                  basis of the Brennan's Committee rpeort.
               23
                            DR. DE BAKEY:  You're making a generalization, it
               24
  Ac-e-federat Roofters,  Inc.. seems to me, and I'm not sure that that's correct. Multiphasic
               25





                                                                               50



                  screening has been around for a long time.'  It doesn't always
                 2do  what  yo u say it does.  So it depends on who does it and how

                 3it's   done.

                 4           DR. MILLIKAN:  I thought he was not making a
                 5generalization.  I thought he was making it specific.
                 6           DR. CA14NON:  I wasn't generalizing, because it's

                 7Dr. Cosby  that makes it r.;ork down there.
                 8           DR. DE BAKEY:  is this Stephens County you're talking


                 9 about?


                 10          DR. CANNON:  Yes.

                 11          DR. DE BAKEY:  And I:.ul,.a,, is in Stephens County?
                 12          DR. CANNON:  No.  Stephens County is in Georgia.

                 13 -lukais in Mississippi.
                 14          DR. DE BAKEY:  What do we know about Stephens County?
                 15          DR. C2U4NON:  What I know is only there is a multi-
                 16 sTDecialty group that is prepared to take over this health
                 l@ program for the community of which 25 percent of the population
                                                                           p

                  is below T)overty level.  Now, if the 25 percent below poverty

                  level are brouaht in for the first two
                                                           years, no charge, for

                  their screening and positives will be   referred to n
                 26'                                                  Lhysicians
                 2),' if they don't have a physician,with no charge health care will

                 2@' rendered for those two years.
                 2           DR. DE BA.KEY:  Fine.  That's a good objective.
                 2 4'        DR. CANNON:  And then, after that, it's supposed to
  kce- Federal Reporters, ln@.,
                 251generate it's own support.  But to call it a multiphasic





                                                                           51



                  screening program isn't     because multiphasic screening is
                2 Idone in a lot of different ways.  It doesn't always have to
                3
                  have a big computer.  It @n be done with a small laboratory and

                4 one  doctor.

                             Well, again, I would recommend that we fund it and

                  not call it a multiphasic screening program

                7            DR. MILLIKT,:,I:  With this amendment?

                8            DR. CANNON:  Yes, with the amendment that t7hen this
                9 is finally decided it would be reviewed.  So, if we now sum this
                10 up, there's a recommendation for $2.8 million without a
                  decision on the program 36, which is kidney disease, which is
                12' requesting a quarter of a million dollars, because that's still
                131in limbo; but adding a sufficient amount .@ihich is $107,000 to
                14 take care of the beginning of the Stephens County program whici'l

                15 would bring it to a-)out $2.9 million.
               @16           If you will accent that, I will move that the $2.9

                17 million would be the anpropriate funding.

                18@          DR. MILLIK@.-I:  Second the motion.


                             DR. CANNON:  Per year.

                20           DR. PAHL:  Is there discussion by the Concil?  Dr.
                2T, Cannon, the requested amount for that project 39 in the third
                22' year drops precipitously to $16,000, and I didn't know whether
                23 your motion basically was to $2. 9 million for each of the three

                24, years or to reflect the requested amounts.
  Ace.. Federal  Reporters,  Inc.
                251          DR. CANNON:  In the absence of my portable computer,
                                      k





                                                                              52




                  I tried with my pen to tabulate the amounts that were  deleted

                 2
                  by both groups and I couldn't come up with $2.8 million.  It
                 3
                  wouldn't work out correctly. And I got within $100,000  and  I

                 4.
                 .thought that was pretty good, and so I thought if they went

                 5
                  $100,000 more than what they recommended it @-iouldn't be too

                 6
                  bad.  Now, if you can figure out a closer figure on that
                 7          DR. PAHL:  I'll take your Dortable computer.
                 81
                            DR. SCHREI@.4ER:  The point you were making is that the

                 9
                  third year recommendation would drop off by roughly

                            DR. CA14NON:  $16,000.

                            DR. SCHREI@IER: $84,00@.

                            DR. PAHL:  The recommendation would be for $2.9
                  million for each of the first two years and the $1.9  million,

                 1,4
                  plus the requested amount for project 39 for the third year.
                 15         DR. CA14NON:  I think the staff could figure out these

                 16
                  amounts and I think they know the intent of Council.

                 17
                            DR. PAHL:  All right.  The motion has been made and

                  seconded.  Is there any further discussion?

                 19@
                                NASH:  I have a.question.  Does your motion includot

                 20
                  the recommendations made by the site visitors and review
                  committee regarding the other projects and the no funding

                 22
                  recommended?

                 23
                            DR. CIL'INOII:  Yes.  That's what I went through.

                 24         MR. NASH:  With the exception of kidney.
  Ace-Federal  Reporters,  Inc.
                 25                                xception of kidney  nd the
                            DR. CANNON:  With the e                    a





                                                                                                                                 53




                              excention of the SteT)hens  Co@nty project.
                          2                     DR.  PAHL:    All  in  favor of the motion please  say  "Aye.',

                          3
                                                  Ayes

                          4,                    DR.  PAHL:    opposed?

                                                (No Resnonse)

                                                DR.  PAHL:    The motion           is  carried.

                          7                     DR.  IIARGULIES:    I want to remind us  all that because,

                          8
                              we're still  in the  transitional oeriod that these  comments

                          9"in the  form of            recommendations  and  advice  and so  forth  are
                          10 advice  rather than requirements.    I  think we  all  understand that

                              but  I have to keeD reminding us  of that from time  to time.

                          12                    DR.  PAHL:    Perhaps we            could have our coffee brea_-c

                          1:3 @no,,,7 and reconvene.

                          14                    DR.  '4ARGULIES:    One  thing we  do want to get done befor-t
                          15  anybody is  ready to leave  is have  any  further consideration of
                          16 'the  review criteria which we discussed yes                           -terday,  so we may
                          1'7 interrupt the  review if necessary  for that purpose  to make  sure
                          18  that the majority of the Deoole  are here  or as many people  are

                              here  as  there  are now.


                          20'4                  (Recess)

                          21                    DR.  PAHL:    if we        may  come  to order,  I believe what
                          22  we would like  to do is  return to our original  agenda and take
                          23' up the  three New York applications  starting with Albany.    Dr.
                          24  Brennan is not with us  and we will  call on \-Irs.  Wyckoff  for

    Ace -Federal  Reporters,  Inc'
                          25@l the orincipal  review.





                                                                                                                               54




                                                                                                        n trouble.  It had
                           I                  @IRS.  VIYCKOFF:   Albany seems  to be  1
                           2   a review committee  report  sad.   they seemed to be pretty
                           3     irritated   with Albany  ancl there's  quite  a management problem
                           4     there.   Both the  review committee  and the  site visitors  seem
                                 to  feel that they desperately need the help of  a deputy
                           6     coordinator who is  someone who can bring administrative                                  ability

                           7     into this  situation.
                                               This  is  atriennial  application.but the  critique here
                           9     seems  to be  centered  around the  fact  that it's  nothing but the
                           10    renewal of ongoing pro]ects with  75 percent of its  activities
                           11-   within the  core budget  and most of its  operational project
                           12    money eaten up by the  continuation of its  two-,viay  radio project
                           13'   x.:hich is  something they seem to  set score by  that has  60
                           ]4i:  hospitals  now equinped dith  th4-s  two-way radio system and a lot'
                           15    of money is  used to keep up this  equipment  and  continue
                           1X    operation of this program.   The hospitals  are not yet willing
                                 they say,  to absorb this  and need three more years  of time  to
                           17

                           18    do this.
                                                The review committee  recommends  that this Albany
                                 !OIP be  funded at  $900,000  for one  additional year,  with  a
                           20
                           2i.   followup  site visit in a year to check the  region's progress
                           22    with  regard to         numerous  and specific recommended changes.   iiow,
                           23    they have been          very  adamant  about these  changes  and I  think
                                 perhans  it would help if we put  them into our recommendations
                           24

     Ace - Fede rat Reporters,       Inc.
                           25    so they have this  leverage to work with.





                                                                             55



                            The necessary changes are:  (A) mechanisms for the
               2 phase-out  of PJ-.IP support to be developed for this two-way
               3 'radio and coronary training activity 4ith the understanding
               4  that R:4P funds will not be forthcoming for longer than 12
               5  months and no more than one-year terminal support for coronary
                  training; that the -,@G and its executive committee must become
               7  a policy-making body which actively review and evaluate ongoing
                  proposed activities and they need education as to their
               9  responsibilities.  They suggest that a conference seminar might
               10 be a way of doing this.  That the planning and review sub-
                  committee of the executive committee be com.3osed of only
                  executive committee m@L ers, now rather fuz@-y being composed of
               12
               13 staff and a lot of extraneous people that should not be voting
                  on it, and that all deliberations of the executive committee
                  must be reviewed and considered by the Regional Advisory
               15

                  Committee.
               16
                            They feel that the functional review procedure needs
               17
                  to be straightened out.   They have a situation where the
               18
                  present consulting groups have been established to serve both
               19
                  technical review and orogram development, so that there has to
               20
                  be a means of separating these functions so that technical
               21,
               22 review -people   review is not performed by the same group that
                  develops the activity.  This is@a plain conflict of interest
               23

                  situation.
               24

  Ace-Federal Repofters,  Inc.
               25           They also recommend that efforts be made to include





                                                                                    56





                                                                  eonle fr
                    in the technical review process qualified p            om   outside
                2 the Albany and Albany '.-',Iedical College  area.  Now,  this  area
                3'evidently has  some  of  the  zame  excellent  data  base  collection
                4   which has been going on in the neighboring region but it

                :6  has-,i't been applied -- the same problem.
                6              They feel that strenuous efforts must be made to fill
                7   the core position of the nurse coordinator and they need a set,
                8   of operating objectives which are quantified and measurable,
                .9  time dependent, and ranked in oriority order.
                10             They also have some  suggested   considerations   here
                11@ which I think don't need  to  go  into  the  recommendation,  but
                12  @,,7hich-could be @lorked out by the staff.
                13             So, in view of this situation which I think ought to
                14, be discussed along with the other New York regions to see wheth&@-
                1-5 or not there is a Possibility of combination, I would like to
                16, move approval of the review committee's recommendation that this
                    project be funded for only one year more for $900,000.
                ,7
                               DR. FRIEDLATNDER:  Second.
                               DR. PAHL:  Is  there  other  discussion  from  staff  or

                2b  Council?
                               .!.IS. FAATZ.  Well, I think  what  was  important  about
                    Alban-,? is that there is hope  that  the  Recommendations  of  the
                2@'
                2@' site team  which  the  review  co   :ttoe
                                                            .,,#dopted are specific enough
                2-4 lthat in a year's time when the site    team  goes  back  there's

  Ace-Fedeial   Reporters,   Inc.
                2'6 really not much question about what     has to have  been  done  as




                                                                                                                                                                     57




                                       there    as  there  has  been  in  the  past.

                                                           DR.   PAHL:     Thank  you.

                                @3,
                                                           DR.  14ARGULIES:     Zld  like  to  just  add  to  that  that
                                4    these  recommendations  really  should  be  supported  by  a  good  bit
                                5    of  interim  effort  on  the  part  of  the  staff;   and  quite  fra                                                       nkly,
                                       we  are  always  in  the  uncomfortable  situation  regarding  a
                                '7     coordinator  and  the  kind  of  leadership  he  provides  because  we
                                18     have  a  relatively  laissez-faire  attitude,  but  there  seems  to  be
                                '9'    no  question  about  what's  needed  in  Albany,   as  there  will  be  in
                                10  @some  of  these  other  programs,   and  I  think  we  might  be  able  to
                                                     a  little  more                firmness           to  our  concern  over  that
                                12-!reconmendation  than  a                          deTDuty         coordinator.'    I  think  there  are

                             :,,,T,,3  other  alternatives  which  we  could  suggest.
                                14                           MRS.  WYCKOFF:     Well,  if  they  could                                  unfreeze  all  the
                                15     money  they've  got  tied  up  in  that  two-way  radio  thing
                                I   6                        DR.  PAHL:     The  motion  has  been  made'to  accent  the
                                171 co@mn,'ittee's  recommendations  on  the  Albany  application.     Is
                                1   8  there  a  second  to  the  motion?

                                .19                          MR.  MILLIKAN:     Second.
                                20                           DR.  PAHL:     Any  further  discussion?
                                21                           DR.  MILLIKAN:     Did  you  want  to  hear  discussion  of  the

                                22     others  before  the  vote?
                                28                           MRS.  WYCKOFF:     Do  you  think  it  would  help  matters  to
                                24     discuss  the  Rochester  one  before  a  final  vote?

    Ace-Fedefat Reporters,  Inc.
                                2S                           DR.  MARGULIES:     I  rather  doubt  it.     I  think  there's





                                                                              58




                I not much that we can do now except look at each one separately.-

                2           DR. PAHL:  All those in favor of the motion.please

                3 say ItAye.11

                4            IlAyesil)

                5           DR. PAHL:  Opposed?

                6
                            (No Response)
                71'
                            DR. PAHL:  The motion is carried.

                8           We will now turn to the Central New York  application

                9 with Mr. Friedlander as principal reviewer and Dr. Cannon as

              10  backup.

              11,           MR. FRIEDLANDER: Well, Central New York  at  Syracuse

              12  has essentially the same problems it seems as Albany has for  a

              13  different set of reasons. I think while Albany  has  regressed,

              14  we might say, I think Syracuse has sort of just treaded  water

              15  and done more of the same, but it's not really much of a  sur-

              16  prise.
              17            It seems to me that the review committee's  critique
              18'lwhich really reflects the observations of the site visit  team
              19 ireally summarize what you find in reading the  application.  It
              20 might be eiell to run through a fod of these because they are
              21  all reflected in the conditions under which the funding is

              22  recommended.

              23            The fact that the objectives are described in  terms
              241 of activities rather than anticipated accomplishments, this  is

  kce- Federal Reporters, Inc.
              25' sort -- you  et the vague feeling that they Ire talking about
                              9





                                                                                59



                   activities but there's no connection with accomplishments.  They
                2 refer to the Regional Advisory Group as  a  viable  entity  with
                3 fairly good leadership. @ guess we get  into  some  more  of  this
                4  middle-level kind of quality. Suffers from  a  lack  of  allied
                @5 personnel, consumer representation, particularly inner-city and

                6  rural community, model cities, etc.

                7
                             The review committee believes that the Regional
                :8 Advisory Group -- and I think this  is  also  substantiated  when
                '9 you read the application -- needs to assume  a  greater  role  in
                I0 giving leadership to ti-ie T31anning and operational activities
                   of the program. They seem to be set  aside  from  the  program.
                12 It all seems to be project oriented and that the Regional
                1'3 Advisory Group has not assume  responsibility  for  developing  d

                14 regional plan.
                15           The executive committee of the Regional   Advisory
                16 Group, too, needs to expand its  membership  to  include  broader
                   representation from low economic consumer groups, rural physiciai!
                   young activist physicians,  allied  health  Personnel,  etc.  The

                   same nroblem exists here.
                             And then the concern expressed over the.membership of
                2-1 the Regional i'.iedical Program's committees, which consists
                22' primarily of Physicians  and  little  interrelationship  existing
                23 between those committees and indeed  --  between  the  committees
                2@ themselves and between the  committees  and  the  health  related

  Ace-Federal  Reporters,  Inc.
                25' groups in the community.  They constantly refer in their summary




                                                                                60



                I of their activities of having  working  relationships  with  various
                2  of the community health related grouses but nothing seems to

                '3 'happen.
                4            The review committee also -- and I think with faints

                5  Draise -- the present core staff is good but small in number.
                0'Then they  have the same problem here that Albany reflects, is th..z
                '7 'recommendation that someone needs to be there to help the
                8  coordinator Micros been there for quite a while but he's a nice
                   fellow and if he got some help maybe they could move.  It's a

                1'0- very similar kind of thing.
                1,14         Then the other criticism which  seems appropriate
                12 this  again, is reflected in the recommendation -- the activities
                13 Previously funded by the Regional Medical  Program  have  not  been
                14 absorbed into the local health system with the exception of the'

                T5 home health aid program.
                T6           No@q, in Syracuse, I guess the thing  that's   comparable
                   to the t-.,7o-T,,7ay radio in Albany is the nurse education program,
                17
                1 8but this one seems to be an extremely good  Drogram  but  seems  to
                ]@Ibe operating in a kind of vacuum for its own purposes and has
                26' no relationship to the -- or very little to the other allied

                   health activities in the area.
                22           The question of evaluation, you  get  this  from  reading
                23 the application as well, but you wonder about this.  Thev have
                24 three evaluators and there's  no  relationship  among  them.  There

  Ace - Fedefat Repoftefs, Inc,
                25 doesn't seem to be any  interrelationship  between  the  evaluating
                   I





                                                                              61


                 1 group and the core staff.  They all seem to operate separate
                 2 from each other; and also the fact that there are three part-tim(
                 3 evaluators, three T)hysiciaLns who obviously have other interests
                 4 in the community.  But the region does express an interest in.
                 5 evaluation but doesn't seem to be doing much about  it.
                 O'          on the basis of these kinds of  observations, it seems
                 '71that the ten conditions under ahich the.recommendation is made
                 B'seem to be appropriate.  The fundin         hdation  is that
                                                      g recomme

                        be a $200,000 addition to the current funding and that
                 10 this $200,000 be utilized to develop activities that will help
                 11, to improve delivery of health services to the urban and rural
                 12 poor which a-,)pear to be two real priorities for the region.
                 1'3         On the basis of this, I would move that the
                   recommendation for one year funding of @'850,000 with the listed'

                   conditions be approved, and also that the contingent on, as
                   recommended by the review committee, a staff followup visit
                 l@@lsix months following the award of this application to evaluate
                 18 the progress that's been made in meeting the conditions.

                             DR. PAHL:  Thank.  Dr. Cannon?

                             DR. CAN'@iON:  I support the comments given.
                 20
                 21i         DR. PAHL:  The motion has been made.  Is there a

                 2@ second?
                 23          MRS. 7,IYCKOFF:  Second
                 24          DR. PAHL:  Is there further discussion from Council
  Ace - Federal Reportets,  InC.1
                 25or staff?





                                                                                         6 2




                                (No Response)
                   2            DR. PAHL:  If not, all those in favor of the motion

                   3 please say I$Aye. 11

                   4             I'Ayesit)

                   5            DR. PAHL:     O;Dposed?

                   6'           (Rio '.Response)
                   7            DR. PAHL:  The motion is carried.

                                Ttle now turn to the Rochester application, Dr.

                     @'-IcPhedran the Drincipal reviewer.
                   i@o          DR. MC PHEDRA24:  The Rochester Regional Medical
                     Program  was  site  visited   June 24-25, and the recommendations of
                   -the  site  visitors   were   agreed upon by the subse  quent    review

                      'committee.
                   13
                   14           Specifically, the recommendation was for this upcoming'
                   15 04 year $800,000, with this year only, and a folloTvup site

                   16 visit after that year.

                   i .
                   17           For   comparison,   the third  year  was  $895,000  for   a
                   18 12-month   period.   It   actually had been an 18-month period with
                     a funding of $1.45 million.
                   19
                                The sane problems    of essentially no program but
                   2 0
                     rather a   collection of projects continues in this region.  That
                   21
                   2@ is, it's  a  problem  that  has  been  identified  before.  A   site
                   "lvis't   team in April 1970 -- and'I think a subsequent management
                   23
                   2@ assessment visit, although I can't find that at the moment
  Ace-Federal Repoiters, Inc., made the peculiar recommendation that a deputy coordinator be
                   25





                                                                             63




                                                    ction and strength.  It
                  appointed to give the program dire'                       is

               2                                             titute for an
                  hard to view this as other than a poor subs
                  entirely ne@,; direction.  Some progress has been made, however,
                  and even the conditions suggested in the critique on the blue

               5  sheet I think reflect the progress that was seen in the last
               .Iyear.  For example, the second condition particularly, was that
               '7 the region would have in this 04 year flexibility in budget
               6 rearrangment to build its core staff, develop a revised form

                t
               9  of regional leadership, etc., and this condition was thought
               101reasonable by the review committee because of  changeIs in the
               11 region; for example, diversification o'L the Regional Advisory
               12 Grou-P and improvement of that, and creation of an active
               13 executive committee of the Regional Advisory Group which
               14'a,opeared to provide increased strength for the program.
               15           Also, other hopeful signs were some objectives and
                                                              I
               I;loriorities had been set and listed which wasn't the case before,
               17,and another asset was that the program had a good reputation
               18 with Physicians and nurses in the area; but one wonders whether

                                                                     d be bent to
                  this wasn't to some extent because the program coul
               26 almost anybody's purposes, at least according to the critique

               21 here.
               2@'          Developmental component was requested but specifical y

               28 denied in the critique.
               24           I move acceptance of the review committee's recommen-

  Ace@Federal ReOofters, Inc.
               25 1dations of $800,000 -- I'm sorry, I left out one thing.  The





                                                                                 64



                   condition in the recommendation is that the kidney project
                2 is excluded from funding within the $800,000 level, but it's
                '3 'stated that if ,-armarked funds become available  there  is no
                @-objection to increased award of funding for this activity.  This
                -5 project, however, did receive an.unfavorable review from the
                6 ad hoc kidney panel and I wonder  whether  that  is  a  wise
                7  reco=....-andation.  If.the review was unfavorable and if the
                8- program is in difficulty, I'm asking for advice here, wouldn't
                   it be better to suggest that that be left out unless -- and they
                10' be discouraged from putting this into operation -- unless it
                   would cripnle the whole  regional kidney program.  I'd like to
                   have sor.,ic advice and help from staff and others about that.
  0
                              DR. MERRILL:  Is that kidney program in this yellow

                14 sheet here somewhere, a summary of it?
                 -            DR. PAHL:  Mr. Spear, would you be able to give us
                15
                16 any information on the Rochester kidney proposal as it was
                   reviewed by the ad hoc panel?
                              MR. SPEAR: I don't think it is, Dr. 1,1,--rrill.
                18
                              DR. PAIIL:  IIrs. Silsbee has a comment while you're
                19
                20 looking.
                 -            MRS. SILSBEE:  Dr. 14errill, that application had come
                21
                22 in the cycle before this one and the kidney panel reviewed it
                 " several months ago before this application came in.  The region
                23
                   at the time they submitted tft,is application didn't know the
                24

  Ace-Fedetal Repofters,  lnr,,.
                25 fate of the kidney  project so it was not included in this,





                                                                              65




                  yellow sheet.
                 2           DR. SCHREINER:  I don't understand that.

                 3           DR. PAHL:  The description of the kidney proj ect is

                 4 not included in the materials before you at this time because
                 ,-5 it was reviewed earlier.  I think the question that Dr. McPhedra:i
                 6 had was why did the ad hoc panel find this proposal unsatisfac-
                 7tory, an d then is this a @.7ise thing to include it in the

                 8present recommendation.
                 9           DR. L@-IC PI.IEDI.Wi:  Not exactly.  I'm taking it as given
                 10 that the ad hoc panel found it unsatisfactory, and I'm
                 11 wondering why, if that was.the case, why the review committee
                 12 felt that if earmarked funds became availble there's no objec-
                 13 tion to an increased award to permit funding of this activity.
                 14          MS. FAA7iZ:  The site team didn't feel very strongly
                  about this one way or the other.    They had the recommendations
                 16 of the ad hoc kidney panel and the ad hoc kidney panel objected
                 17 to this oro-oosal primarily because it seemed to be a number of
                 18 years behind the times.  The site team, as I say, did not feel

                 19 strongly about it.
                 20          1 think the thinking was that perhaps if earmarked
                 21 funds became available and there was nowhere else to put them --
                 22' it was a very wishy-washy kind of recommendation.
                 23          DR. 14C PHEDPAil:  Well, that's the way it seemed to me
                 24; and that's ,.ihy I wonder if we shouldn't -- I think we shoul

  Ace@Fedeial  Repofters,  Inc.
                 25 exclude it.  We should go along with the recommendations of the




                                                                                 66




                   Iad hoc kidney panel ,orol)ably.
                   21
                             DR. SCHREINER:  One of the comments that I've been
                   3making lately is this whol-e ad hoc kidney panel mechanism
                   4serves to really cut us off from the kind of information we got
                   5from the very simplified decision mal-,ing., '@le have very  little

                   6
                   1onnortunity to look over their shoulder.  You know,osomebody

                   ,7
                   left the program so  somebody says the whole program was out,
                   a $300,000 program and one man left the pro ram and they thought
                                                                 9

                   '9 it would collaose.
                             I'm not sure that we're getting    the input to review
                   the kinds of things that we do want, a lot of things based on
                   12 outside experience and the other people, because there's enough
                   13i'nforntation here.  I'm totally in the dark,  They've got a good
                   14'dialysis program un there if we could develop that in some way.
                   1-5 They probably don't have transplantation and this probably
                   16 influenced the recommendation of the committee.
                   17         DR. @,IARGULIES:  I think your criticism is absolutely
                   18 valid.  @le have not supplied Council or the review people at
                   19 all adequately with the reports of the  ad  hoc  panel  as  to  the
                   20@lb             they made their decision or what their
                    asis upon which
                   21 criticisms were, and I think this has been part of  the  ad  hoc

                   22 arrangement itself.
                   23         That's easily corrected, particularly now that we
                   24 have that level of interest on  the  Council.  I  think  we  won't
                   i
  Ace  -Federal  Reporters,   Inc.
                   25 have any further difficulty with it.




                                                                             6 7



                           DR. MC PFIEDIWI: Well, Ifll just say that I'm in the
               2 dark about it and I just need somebody else to help me decide.

               13           MRS. SILSBEE.;  DX. .,IcPhedran, I think the reason why

               4  the committee was so wishy-washy about this is that if the
               '5 kidney redevelopment was an agency by which the broader program.
               '6 could be brought together, then they would feel that that could
               @7 proceed.  But they didn't knoii on the basis of the ad hoc

               '8 1 panel's considerations.
                            MR. SPEAR:  Mr. Stolof is at the mike and he was

               10 involved in the review of that project.
                            MR. STOLOF:  I can sneak only as was told to us by
               121 the reviews.  The emphasis of the Rochester project which was a
               13 par t of an overall plan to seek to strongly stress sharing and
               14 rather than procuring more organs they were sharing -- they
               16@were setting their mechanisms programmed around the international
                  sharing o-le organs rather than stressing procuring more organs
               17 to be used.  I think this is why the nanel met with disfavor
               l@ on the project and it felt that due to the state of the art of
               l@ the tissue typing they questioned the Rochester proposal because
               20 it o7as basing the majority of 'its sharing on tissue typing

               2-1 findings.
               2@           DR. PAHL:  Dr. PlcPhedran, do you wish to
               2@           DR.,MC PHEDP@I:  Well, I just think I'll have to move
               @"4 adoption of the review committee's report, perhaps leaving in

  Ace Federal  Reporters,  Inc.
               25 the third wishy-washy conditions, being unable to come to grips





                                                                             6 8




                  with it any better than this.
                  2         DR. MARGULIES:  I think that since this is so unsatis-
                  3factory, what we really should do is provide at least some
                  4members of the Council, perhaps Dr. Merrill and Dr. Schreiner,
                  5 @with enoug,i information so that we can come back and take
                  @6 another look at this particular activity at the next meeting of
                  27 the Council because I think it's all out of phase and it's

                  8vague and generally unsatisfactory.
                  9         DR. MILLIX-AN:  Would you accept that as an amendment?
                  10        DR. MC PHEDP,7@N:  Yes, I would.
                  11,       DR. MILLIK)V4:  I amend your motion.
                  12        DR. MC PIIED@l-.  You're amending my motion.  I accept.

                            MR. MILLIKEN:  Second th
                  13,                               e amendment.
                  14        DR. PAHL:  The motion has been amended and seconded
                  to aiDorove the com-mittee's recommendations and defer any
                  16 action until next Council meeting on the ],,idney project.  Is

                  there further discussion on this motion?

                  18        (No Response)
                            DR. PAIIL:  If not, all in favor please say "Aye."

                  20          Ayes
                  21        DR. PAIIL:  Opposed?
                  2@        (No Response)
                            DR. PAIIL:  The motion'is carried.
                  23
                            Because Dr. Everist will have to be leaving before too
                  24

  Ace-Federal         Reporters, Inc..
                  25 long, T wonder if we might skip to.the Memohis application with




                                                                                6 9



                   Mrs. Vlyckoff as the principal reviewer and'Dr. Everist as
                2 backuo reviewer.
                3@                                     request for $2,754,000 f
                            MRS. V-7YCKOFF:  T-kis is a                         or
                4  the fourth year of operation.  They want $2.5 million for the
                5  'fifth year and $2.3 million for the sixth year, making a   total
                   of $7.7 for the three-year period.  The current level of

                   support is now $1,512,795.
                             1.  They want authority for a developmental component

                '9 in the event new funds become available
                10           2.  They request continuation of 5 projects within
                11 the currently approved period, amounting to.a total of

                12 $461,046.
                13           3.  -,hey ask for $799,548 for core  and  $524,283  for
                14 continuation of 7 projects beyond the approved period.  They
                15 want $969,356 for 12 new projects for each of three years.
                16 They will -chase out three previously supported programs.
                17           There is a difference of onition between the site
                18 visitors and the review committee on  the  amount  recommended  to
                19 the llemohis @IP.  The site visitors recommended $2 million for
                20 each year, maki ng a total of $6 million over  the  three  years.
                21@ The review committee recommended a cut to $1,627  iOOO.for  each
                22 of the three years, a total of $4,950,000.  The review committee
                23 cut core funds from $799,548 to $600,000.    Then they cut all
                24 projects, continuation, new and  renewal,  from  $1,954,685  down
  Ace-Federal   Reporters,   Inc.
                25 to $1,027,000.  The review committee's total recommendation, low





                                                                               70



                I  as it is, is still above the current direct cost level of

                2  $1,512,795.

                3           For those of yoia-,viho do not know the Memphis region,

                4 it is important to understand the extraordinary character of

                5 its composition.  The @MP geographical boundaries cover

                  T3ortions of 75 counties in five states:  Tennessee, Arkansas,

                @7 Mississippi, Yentucky and Missouri.  The area is a medical
                @8 marketing natural watershed.  It is served by the University of

                  Tennessee Medical School.

                10          As you may remember, the original idea of  IUIP  was
                  that it would operate largely outside of  the  political  sub-
                121divisions of government and be designed to serve the natural

                13,groupj-ngs of providers, educational institutions, and
                14 voluntary health agencies. Now things have  changed  and  RDIP

                15 must cooperate with Comnrehansive Health Planning and   other

                16 government agencies that are structured along the lines of
                17 political subdivisions.  ilem-ohis Tu..IP has had a heroic task

                IS in trying to work out  these  relationships.  Therefore,  when

                19 site visitors and review committee and staff say that the

                20@ organizational structure of Memphis l.UIP is "complex," "cumber-

                21 some," and "com-lolicated," it must be understood that they are
                22 struggling with an enormously difficult problem.  lqlien,  for

                23, examnle, HS@-IA issues a seemingly simply requirement that @lPs

                24 must submit their proposed projects to CIIP for comment and

  Ace-Federal Reporters,  Inc.
                251revie@,i and receive at least an acknowledgement from them, in




                                                                                 71




                   Memphis, this means getting answers from five  state  CHP  "Al'
                  2agencies,  and innumerable "B" agencies, and then going to three

                   HEW regional offices.
                .@4          On top of this there is the elaborate structure of

                  5the @lid-South Medical Center Council which  is  designated  as  the

                @6 RAG for the MMIP.  It covers 75 counties, has 156 members,

                  751 percent consumers. It is the  grantee  agency  for  the  new

                .8 Exoerimental Health Planning and Delivery System Contract ,,7itil

                @9'tlie National Center for Health Services Research and Development,

                10'.for $728,000. However, this body meets  only  once  a  year  and  if

                   you will look at the chart at the back of the site visit reporti
                   you will get some idea of this unusual arrangement.  I think

                   you have that chart which mav help you  because  this  gets  very

                14 complicated.
                15           The.site visitors tried to  find  out  exactly  where  the

                16 decisions were made and this was not easy.  On Daper, the

                17 Medical Center Board of Directors,  consisting  of  45  members

                18 elected at the annual meeting of the ,,lid-South  Medical  Center
                19 council appears as the final authority for the iU-,IP.  It consists
                20'of 18 providers, 27 consumers, and is the CHP ag   ency for  14

                21 counties. This Board,  which  represents  only  14  counties,  meets

                22@ ten times a year and puts its stamn of approval on the IU,4P

                23, nro-3osals, @,ihich it receives from the new rIIP Policy and  Review

                24 Committee, a 36 member body of 28  providers  and  8  consumers
  Ace -@ral  Reporters,  Inc.
                25 which meets monthly, and is appointed by  the  RDIP  coordinator.





                                                                              72



                I This body, on the other hand, represents 75 counties in five

                2 states and is a standing committee of the I-lid-South  Medical

                  Center Council. Its chairman sits on the  llid-South  Medical

                  Center Council executive Committee which is the Dolicy making.

                  body for the CIIP "B" agency among other things.  The  site
                0 visitors questioned the legality of the RAG  decision  making
                  process.  I understand that that is now being put into a study.

                  committee and that our recommendation that they go  to  the

                  regional general council at ATlanta  if found to be necessary.
               10           As it happens on a site visit when everybody's hair
               I'tlwas let down, it developed that the real decision making seems
               12 to be Performed by a small, very hard-@-iorking Planning Board
               13 ,i.',,iich isn't even on the chart, but which is established to
                  advise the coordinator. It not only  screens  all  oroposed
                4
               15 projects for applicability, but advises the coordinator which
                  applicants should be given core staff assistance in developing
               16
               @l, a proposal.  This Board also meets monthly with the Policy and
               17
                  'Revieiq Committee. It has limited representation from  the
               18

               .,. categorical committees.
               19
                            The core staff seems to have independent decision-
               20@
                -Imaking poi-7er almost equal to the Planning Board, judging by the
               21
               @';'large number of activities stimulated and conducted by them @lith
               22
                  little or no relation to the goals and objectives of RI-IP.  They
                3
                  simoly report directly to the coordinator.
               24
  Ace-Federal Reporters, Inc., Actually, the coordinator is trying to  fill  two
               25





                                                                               73



                 I  positions, himself and a much needed administrator.  Both he and
                 2 the core staff have been a little too eager to please too  many
                 '3 'groups all at once. Core has put in a vast amount of time
                 41:helping other health organizations to apply for funds only
                 '5,generally related to-the broad goals of the Mid-South medical
                 6@Center Council and the PJ,,IP.,  There is a question whether the

                 7 cost of this is justifiable.,

                 8          Unfortunately, the coordinator seems to feel  he  can
                 91fill this large administrative void by recruiting an  assistant
                 ld 'for program development who is now coming aboard.  The  review.
                 11 committee and the site visitors felt that much more  is  needed,
                 12 and that the coordinator should hire a full  time  executive
                 13 officer with broad administrative experience to carry on the

                 14 day-to-day operations of the MI@IMP.
                 15         one of the problems that concerned us is  the  obvious
                 i6'1 and documented need of the black population and yet  the  staff
                  contains almost no black professionals.  one example of this
                 18 problem shows up in a beautifully designed physician continuing
                 l' education Drogra,,n based on community hospitals.  Practicing
                 9
                 2' specialists from the private sector are invited by  general
                 21, practitioners to participate in advanced clinical conferences
                 2'2 in -,..7hich the patients of the inviting physicians are the subject
                 2'6 of discussion. This plan is designed to serve a network of
                 24 small and medium sized hospitals in the region, and has met with

  Ace "Federal Reporters,  ln@..
                 25 much success.  But when I asked how many black physicians it





                                                                                74



                            the reply was "None."  When I asked why, the reply
                2 was "Because the black physicians do not have the educational
                3','qualifications to practice -t in these  hospitals."  So  the
                4  dilemma was complete.
                             In another situation staff pointed out that they had
                   achieved a big step forward by arranging for black physicians
                0
                :'I'to be allowed to visit their own patients  in a P,Iemphis hospital
                7
                '6@even though they could not care for them.  Review commitee and
                9-tsite visitors agreed that an increased effort is warranted.
                10           The goals and objectives and priorities of the region
                   @are stated, but the policy of accepting spontaneously appearing
                   projects to please special groups has prevented the development
                2
                13 of activities based upon the clearly identified needs of the
                14'region.  A nural sequel to this desire to please so many groups-
                1511is the not unusual tendency to pass on to the r@@IPS and the
                   'Council the unpleasant task of saying "No."    The region has
                16
                   not been able to phase out its support of seven projects after
                17
                   three years of operation.  The decision to continue support
                18
                19 is made without adequate evaluation of the effectiveness of the
                   activities  to  d.ate.  The region is only now proposing to set
                20
                   up an evaluation orocess but in the meantime wants as much as
                21
                   28 percent of the requested project funding for extending tl  @,n
                22
                   life of these seven projects for more than three years.
                23
                              Both review committee  and site visitors recommend
                24

  Ace-Federal Reporters,  Inc.
                25 that if Memohis @IP in light of   its reduced  budget  sti.11 wisi-ies





                                                                                 75



                1 to continue these seven projects, it should not be for more than

                2  one year.
                3            Among the new p@ojects proposed is a request for
                4  $438,000 for Neighborhood Health Centers, Project No. 36.  In
                5  it, Memphis RLIP expects to act as a broker to put together a
                6  complete comprehensive health care package for four existing
                7  public health department facilities, expanding preventive
                8  services by implementing primary care.  Their search for other
                9  federal funds has already been successful to the extent of
                lol$120,000 from NCH.RD'for the pediatric nurse practitioner
                II training program, which is a part of the package, therefore it
                12 is recommended that the !,Iem-ohis R,'AP not invest more than

                   $318,710 in this project.
                13
                             Both the site visit team and the review   committee felt@
                14
                15 that funds should not  be provided for -project no. 39 "Continuing
                16 Education for Physicians in Tennessee,"  a continuing education
                   activity of the Tennessee -'r4edi.cal ASqociAtion. It was  felt
                18 that,this could easily be financed  through  dues  of  members.
                19           In the final analysis and in spite  of  some  of  the
                20 negative aspects noted, the @lemphis R,@P has made progress in
                   moving away from a medical school oriented staff and has good
                21
                   working relationships with medical societies, hospital associa-
                22
                   tions, health deDart,+nents@i CHP and other regions of R.NIP.  It is
                23
                24 decentral izing and reaching out to broaden its base.
  Ace @Fedefat Reporters, Inc. If it can put its administrative house in order, it
                25





                                                                                   76



                 I has the potential of becoming one of the better lU4Ps in terms
                 21 of addressing the broad issues in the orovision of health care.
                 3            However, I do not believe it is ready yet to be g@ven
                   authority for a developmental component . -I share the site
                 4
                   visit team and the review committee's recommendation against
                 5

                 6 it.
                              I move approval of the review committee recommendation
                 7
                    for a funding level of  $1,627,000,for  each  of  three  years,  or
                 8
                   a total of $4,950,000, and  I  recommend  the  approval  of  sugges-
                 9
               10  tions that are listed in the site visit report -- I mean, in

                   the blue sheet.

                              DR. PAHL:  Thank you,   Irs. li-7yckoff. Dr. Everist,  do
               12

                   you have anything.
               13
               14             DR. EVERIST:  Mrs. V7yckoff.has enunciated all of my
               15  concerns excepting one. I  think  the  region  has  begun  a  series
                   of efforts toward  delivering  health  services,  just  as  Stephens
               16
               171 County is attempting to do in the program in Georgia.  These are
                   all very good and they can't be faulted for their humanitarianism
               18
               19  and so on.  But we just got over this in the 314(e) problem and
                   weire going down that'same path in some other areas, and I
               20
                   think we ought  to be aware of this, and this very laudable
               21
                   group in luca  County, Mississippi is an example of this.  You
               22
               23  can't fault it.    It would be against sin or the flag.     It's just
                   delivering health services and nothing else.
               24
  l,ce- Federal Reporters,  Inc. And the other thing is I think we ought to be
               25





                                                                                    7 7




                   concerned about this one of two or three multistate RklPs and

                  2..7hether or not they are really viable  in  light  of  the  other

                  3Programs that go along political lines.      I think .ie ju8 t  ought

                  4to be aware of it anyway;  whether  or  not  we  make  any  policy

                  5changes now is not important, but  I  think  we  ought  to  be  aware

                  6of this.

                  7           This is a  very  difficult  region  to  administer  I'm

                  8sure, with the kinds  of  difficulties  --  it's  amazing  that  they

                  9get along so well with the contiguous @,4Ps, and they do
                10 apparently.  They   were all there  represented  from  each  of  the,

                11 four Tu4Ps that  impinge upon them.  That's all I have.
                12            DR. DE BAKEY:  I don't want to prolong this discussion
                13 because maybe this isn't the time  to  bring  it  up,  but  I  think
                14 it's awfully important for us  to  continue  to  keen  in  mind  and
                15 maybe to review from time to time what the main      thrust  of  the
                   P                   roqram is  and why is it necessary to establish
                16  egional '.--liodical P

                17 enabling legislation to do this job.

                              I think it's important to go back and in,a sense

                19 recognize  the history of its development and recognize the
                20 intent of  Congress  in  developing-enabling  legislation  and   the
                2 .Iamendments that have since been added to it.
                22            In the final  analysis,  if  this  objective  is  being
                23'lachieved by the  funds  which  the  enabling  legislation  orovides,
                   then I think it would be  wrong  for  us  to  set  up  regulations
                24

  Ace-Fedeial Reportefs,  Inc.
                  Ithat would in  a  sense  contradict  that  development.  So  I  just
                25





                                                                              78



               I want to give you a word of caution about this because it's
               .2 awfully easy to get set up in a set of regulations that really
               3  handicaps you from gettin@to your objective in order to

               4  standardize a method of doing things.
               5            This is the only thing I'm concerned about  in  our
               6  discussions of these  variIous regulations or policies that we

               .7 -set up.
               8            Now, I know we have thispolicy on multiphasic
               9  screening and I think in general it's a good policy and I
               10 think,  in other words, what we've done is desirable; but I
               11 think at the same time, if we find that there is a  means  to
               12jachieve an objective that is a sort of congruent with the
               13 objectives of the Congress in setting this up, then I think it's
               14 important for us to keep that in mind and not allow ourselves
               15 to get entangled with regulations or nolicies that orevent that
               16 from being achieved because there's always more than one way to

               l@ achieve an objective.
               18           So, I'm very much impressed, for example, with a
               19 statement here that says that in the three-month period,
               20 January-l@larch 1971, they had 1832 adults screened, leading to
               2" the detection of 1386 abnormalities.  '.low, here's a Population
               22 that two-thirds of the adults there have abnormalities; one-
                                                             family  physician.
               2i@ third of which required referral to their
               2@4@ Naq, if you can tell me any other way by which this could have

  Ace  -  Federal  Reporters,  Inc.
               25 been picked u-,.),, some other means by which this could have been





                                                                              79



                  done, then I think we ought to try and do it.  But in the

                 2
                  final analysis, this is one of the objectives.of the program.
                            So I think, des@te the fact that this may not fall.
                 4within, let's say, the methods by which we want to achieve tli6
                 5objective, if it is achieving the objective we ought to do so.
                 6          The second thing is that I realize that the future of
                 7this type of entity as a regional medical nrogram may fall

                 8
                  afoul of the political realities of the programs that may be
                 9develo,3ed in the future for funding, for interfacing .iith
                 10 other programs, the fact remains that they do have something
                 iii,going right now that is reasonably effective, and'I think that,
                 I
                 12'again, we must be a little cautious about trying to change
                 13 something that in a sense would jeopardize the efficacy of
                 141their achieving the objectives they're trying to achieve.
                 15         '4here we can heln them, I think we should do so, and

                 16 I@think there are a number of areas here  and recommendations
                 17 being made that could help them, and the site visitors group
                 18 has pointed these out, and I think with good will'they could do

                 19 it.
                 20         DR. ROTH:  I had one very small comment or question
                 21 on a very minor point in iirs. Wyckoff's report.  There was one
                 22,1-oroject in which it was recommended that it not be funded
                 23' because -- and I think I quote fairly closely -- that it could
                 24, easily be funded by the medical society from members' dues.
  Ac-e-Federal.Reporters,   Inc.
                 25         MRS. IIYCKOFF:  Yes.




                                                                                  80




                  I           DR. ROTH:  I wondered what medical society had to
                  2say about  this, recognizing that members dues in medical
                  3societies  are quite a problem these days with all levels
                  4increasing and I don't know what the situation is in Tennessee,
                  5but a recent dues increase has had the effect of 9,000 members
                   of the New York State -',Iedical Society drop ing their membership
                  6                                            p
                  @7 and I don't think that P14P wants to take, in effect, a project.
                  '8 which alienates Dhysicians from  cooperation  in  good  programs.
                  9           It's a very minor item but I wonder if we're exceeding
                  10 our prerogatives in RMP in telling medical societies what they-

                  It@ ought to snend their dues money for.
                  12          MI.-IS. '4YCKO-@@-:  '@lell, I: think pe'rhaos they felt that

                  13 ithe relationship
                                  ,)s were very good and solid with the medical
                  14 society there and that if they pride this program very much
                   they might be willing to put up      they were  willing  to  risk

                  16 it   anyway.
                              DR. ROTH:  Normally medical societies,, as I'm sure thi,,
                  - ICouncil understands, are not funding agencies  of  projects  of
                  !8
                  l@ the type that R!,IP deals with.
                  20          DR. EVERIST: I have just  a  brief  comment  on  that,
                  21 Dr. Roth.  This ,7as supplying an extra person on the-staff of
                  22 the medical society which I think is justified, but I think
                  2@ you're perfectly right that we ought to delete our comment.
                                                       ine if it was the other way
                  2           DR. ROTH:  It would be f

  Ace-Federal Reporters,  Inc.
                  251around, if the medical society said  that  it  could  cheerfully





                                                                             81





                  absorb the project.
               2            DR. EVERIST:  I think itis an inappropriate  comment.

               -3,
                            1,14RS. ;IYCKOFF:  Dt you need a motion to delete that

               4  cor,,iment?

               @5           DR. PJ%HL:  He'll accept that as consensus of the

               6  Council as an amendment to the motion.

                            Dr. Hunt, did vou have a point?
                            DR. IIUiiT:  Yes.  I'd like to endorse Dr. DeBakey's

               '9 statement relative to the screening process.  I heartily

               10 endorse screening facilities and screening processes as long as
                  they're productive, but it's my understanding that the objection
               12@was that we were a little tired of the  "DUDAD"(?)  development
               13'stage to the point that we were spending millions of dollars  to,
               1'4'develop something that a couple hands, eyes and ears could  do
               15 very easily, and that this was the part that we  were  a'little
               16 bit discouraged about and that if the phasinij screening process
               -17 could get away from the nultiphasic screening -- get that ,@iord
               1,8 out of there, and just call it screening nrocess, that if it's
               19--)roductive and it's bringing medical care to a group of the
               20 community that hasn't got it and needs it, then we're  for  it,

               21 and we'll fund it.
               22           DR. DE BAKEY: Another e.xariple, for example, in  the
               23 Georgia group, where, of course,.tliey've had a longstanding
               24-interest in hypertension and there's been several studies which

  Ace @Federat Reporteis,  Inc.
               25 have clearly demonstrated that a great majority of hypertensives





                                                                                                                     82



                          1   in the United States,  and there are some  20-odd or more                         million
                          2people in the United States with hypertension,  5o unrecognized.
                          3 'And they pointed out in the study that                   they did      just the     simple
                          4"screening city that they did that -- it wasn't multiphasic
                          'Rescreening   --  28 percent were undetected requiring treatment.

                          'i'Novi,  I think this is important.
                          0

                                          Here's  a disease in which there's no better example

                          ,8 of the objectives of the heart disease,  cancer,  stroke program
                          9than hypertension,  because here's  a disease in whi6h there is
                          Id 'sufficient knowledge available at the present time to be able
                          'to effect a significant impact upon its  control and ubon
                          I'@'mortality and morbidity.   There's              no question about that.   This
                          i'J'I!has  all been very well demonstrated and just recently in the
                          14;studies that came out from   Frieze clearly demonstrated even
                          15 moderate hypertension requires management control if you're
                          16 going to affect mortality and morbidity,  and there's no question
                           about the  fact that you can do it and there's no question about
                          18' the  fact that drugs are available  for this purpose.   So all we
                          ,' need to do is to bring this to the peonle who have it.
                          9
                                          This is really what the whole program is  about.   This
                          20
                          @l" is the basis  for it.   So if you develop a screening program that
                          2
                          2@ can pick up hypertensives in an effective way and really bring
                           them in and provide good management control for them,  then we
                          23
                          2411 have accomplished a significant thing so far as this program                             is
   Ace-Federal  Reporters,  Inc.
                          .concerned.   This is what we want to do.   Now,  the mechanisms                              by
                          25




                                                                                83



                1  which we do it seems to me is important only in determining the_
                21 efficacy.  That's all.
                3            DR. IIARGULIES:  .1-lell, the question of screening is onc
                4  thing, of course.  The question of multidhasic screening is

                '5, noatlier one.
                6'           DR. EVERIST:  @nd the delivery of health services is

                7 another.
                8            DR. IIARGULIES:  Yes.  If you look over the document
                9 on which you made a decision last time, you'll find that we
                10 'have millions of dollars invested in multiphasic screening
                11 around this country just in the IUIPS activities and there are
                12' many more in others.  Whether or not they are serving an
                13"ef--Fective function for screening purposes is open to  doubt  and
                14 @for the most part I'd say they haven't been.
                15           Now, if you want to screen hypertensives for the cost
                16 of one multiphasic activity you could screen hundreds of
                17 thousands of hypertensives, set un progra.-,is., and do  something
                18 '.about it.  And if,the Council wants to change the policy in the
                indirection of multi-3hasic screening because this is the only way
                 9
                20 in which you get screening, it, of course, is free to do so; but
                21 I understand that that is not what you're  talking  about,  Ilike,

                22 at all.
                2@           DR. DE B.AKEY: That is not  what  we're  talking  about.
                             DR. @IARGULIES:  What we need is simplicit  in screening
                24                                                       y

  Ace-Federal Reporters,  Inc.
                25 effectiveness in it related  to continuity of care and related





                                                                                 84




                I to the high risk populations. And  the  hypertensive  is  a  very

                2  good  examnle.

                3             But the multiphasic effort, almost in every instance,

                4 is   associated with some enchantment with a  gadgetry  which  is

                5 involved,   and a tremendous diversion of  effort  into  something

                6 which produces relatively little in the way of patient detection

                7 and care. I think we  need  to  differentiate  carefully  betaeen

                8 one and the other. It would be  interesting  to  know  what  they

                9 Icould have done in that county without  a  complicated  mechanism

               10 with an effective screening  process.  Pernaps  it  couldn't  have


               I I  been done.

               12            But if we're going to get  good  screening  activities,

               13 I think we have to lean away from the multidhasic and lo6k more.
               141in the direction of simole screening of  the  kind  that  you're

               15 talking about.

               1-6@          DR. DE BAKEY:  I think another factor to keep in mind

               17 is that it depends -- that one of the irinortAnt  factors  In  all

               18 of the screening processes, whether  it's  multidhasic  or  more
               19'lst)ecific and sim'Ole forms of screening, it's related to  some
                                   1

               20@ extent in terms of the population  that's  being  screened.  Now,

               2.I obviously, in this area, we're dealing with a population in

               2-2 which there has been little or no medical care over a long

               23 period of time and, therefore, no matter what vou screen in that
                                                                                    t
               24@ area, you're going to screen a lot of abnormalities becaus  t ey

  kce- Federal Reportns,  Inc.
               26' haven't had the care they should have.

                 I





                                                                               85



                             So if you do multiphasic screening in which the people
                2 there had good -- you know, beginning with  prenatal  care  and
                  have had good care all long, then the Percentage of results is
                4 going to be extremely small in terms of abnormalities; and
                5 perhaps the whole process will become less  efficient  and,  of
                  course, economical.  But any kind of screening in a population
                7 in which the medical care has been bad over a  long  period  of

                  time is going to be worthwhile.

                             DR. SCH.@INER:  There's another side of the coin now.
                9
                10 I think we've gotten ourselves into semantic difficulties
                  ibecause -,..;Iiat you're really talking about is a detection Drogram
                  for hypertension which is a very, very valid thing;  but  if  a
                  region has nut together -- to bring people to a storefront or
                f3
                14 bring a van to some people -- then it may  be  very'much  more
                  efficient actually to try to detect many multiple things rather
                15
                  Ithan just-try to detect one thing.
                161
                             In other words, the added cost to  obtain  something
                171
                18lon that model might be relatively small, and even  though  the
                  yield for those other detection programs might  not  stand  up
                19
                 1 in their own right, thev might stand up very well as a sun,)le-
                20,
                2,lment to a hypertension detection program.
                             I think, at least what I thought I was  voting  for
                22
                  when I voted against the computer thing', was whether these were
                23
                 ..random data collections by questionable methods of very, very
                24
  Ace-r,ederat  Repofte,s,  Inc,  ,high   cost. The Public Health Service is spending almost a
                25i





                                                                                  86



                   million dollars locally here to develop  a'com,.outer  program  for

                2 writing admission notes on patients.  The way it works out, you

                3 go  through a questionnaire , you return the questionnaire to

                4 a clerk and the clerks puts it on a key sorter card and the

                   key sorter card computerizes the chart.  That's a half a million

                6  dollar oen.

                7             DR. DE BAKEY:  I agree with you.  I think though,

                8  there's one other thing to  keep  in  mind and it's  difficult  for
                9,us to keep it in  mind  because  we're  notIaccustomed to having

               10'this re-,.Don3ibility, but you will  recall that the  heart  disease
               11" control and other disease control  programs  that  used  to  be  in

               12  an entirely  separate  agency  were  transferIred to us  and  they're
               l@3 sunnosp-d to have transferred the money.  of course, that's just.
               14  a real shell game because what it meant  was  that  the  money  had
               15,disa-o-peared but we have the responsibility.
               16             So there is no other control program, virtually, excep

               17  that which resides, in a sense, in this aqencv for these areas.

               18  The National Institutes of Health do,-ilt have them either.

               .1@            DR. D-@GULIES: Well, I  think  the  decision  which  was
               20', made last time really said only one thing; that we think th'at
               21' there is potential merit in what we're  doing  but  we  don't  know
               22 what the merit is and what the best way is and under what circum-
               23 stances, and let's not spend more money  until  we  can  get  a  few

               24'ansv7ers.  I don't see any readiness to change that.

  Ace@Federal Repoiters, Inc.
               25             Of course, Dr. Everist's point still remains valid and





                                                                               87



                I  it's a troublesome one.  we've dealt with@it many times in this-
                2  Council.  'That is the responsibility for delivery of health
                '@-'care is something which could absorb all of our funds and get
                  us into no end of difficulty, particularly is that true when
                '@'what you're supplying is desperately needed and you can't  back

                "P
                0 l'out of it, and we're eating up most of the national budget in
                 1-trying to meet exactly those kinds of demands to pay for  ser-

                  vices.

                9            DR. DE BAKEY:  l@7ell, of course, again, if you go back
                  to the law, you will see that we are discouraged from doing
                1Ithat, very definitely. So that I'm not sure that  we  would  be
                12 on very good legal grounds spending money for just  delivery  of

                13 health care.
                             Now, this has to be in the form of demonstration  and

                  that sort  of thing, and that's what I think ,.7-@lre trying to do.
                15
                j            DR. PAHL: The motion has been made  and  amended.  Is
                16
                  there a second to the motion, which primarily is to  accept  the
                17
                -                                    'ttee together with the
                ,8 recommendations of the review comm
                  onecific points relative to the individual projects and deletion
              .19  I-
                I of ti-ic reference to the medical association dues for project 39.
                20

                             MR. @IILLIKEN:  Second.
                21
                             DR. PAHL:  The motion has been seconded by Mr.
                22

                  Milliken.  Further discussion?
                23

                             (No Response)
                24
  A.ce-@Federat Reporters,  Inr,. DR. PAHL: All in favor of the motion please say "Aye.
                25





                                                                                     88






                                 Ayes
                 2
                               DR. PAHL:  opposed?

                 3
                               (No Resnonse)
                 4             DR. PAHL:  The motion is carried.
                 5             MTZS. IIYCKOFF:  This  do.es not knock out the multipliasic

                 6
                    project you understand.  That  is,  it's  up  to  the  RAG  to  decide
                 7
                    how they're going to redeploy these funds.
                 8
                 -4,           DR. PAHL:  Before turning to the next application,

                 9
                    I  think  we would like to request your attention to the sheet

                10
                    of paper that.we handed out to you yesterday relative to the

                    review committee's overall-ratings and rankings of the appli-

                    cations which we've been reviewing, and although we haven't gone

                13
                    through the entire listing because there will be some additional

                14
                    departures as a  result  of  other  plans,  I  believe  it's  important

                    to us to have a sense  of  the  Council  relative  to  this  new  Dro-

                16
                    cedure.

                               Please understand this is  still  on  a  trial  basis.  '@le

                18
                    do intend, unless you feel it's completely inappropriate, to

                19..
                    imorove and utilize.it  again  for  the  next  round  and  we  believe

                20
                  IIwe will be able  to  bring  better  information  to  both  the  review
                21
                    committee and to the  Council  interms  of  the  rating  system.  Bi,it
                22  we @iould like to have  whatever  comments  you  would  wish  to  make

                23
                    at this time relative to your feeling as to how well the
                24. committee reflects your thinking on the applications or any
  Ace-Federal  Reporters,  Inc.
                25  other comments  that  you  might  have  relative  to  the  presentation





                                                                                 89



                1 yesterday  and  further  thoughts.
                 I                                                                 s  @
                2 1          DR. ROTII: I assume that in  the  further  modification
                   that this will be taken into consideration, but  it  appears  to

                   me that we have done an awful lot of talking about the competence

                   of leadership, the impact of an individual on  a  programs  and
                5
                6  another thing that  this  roughly manifests is that where you have
                   strong leadership you  have  good T)rograms which get uD into  the

                   "A" groun; and yet, as  I  recall the mathematical  model,  there
                9. was no real way that you could directly  put  that  consideration

               lb  in.

                             DR. PAIIL:  That has already undergone modification in

                   the sense that  the  organizations 1 viability  and  effectiveness
               12
                   criterion has now been separated into se arate  items  for  the
               13                                           p
               14  coordinator, core staff, regional  advisory  group,'and  grantee
                   institutions; so that there will be separate  ratings  for  those
               15
                   four items and I think that will provide the  committee  and  the
               1 6
                   Council -,.@7ith greater oiDnortunity to express preferences in this
               17


                   area.
               18
                             DR. HLrilT: liv feeling, relative to this, is that  as
               19
               20' a rating system does where you're trying  to  transfer  opinions
                   to numbers, I think it's a pretty good  one.  But  I  certainly
               21
                   would feel that in the future I would interpret  the  number  you
               22
                 i give to a program with the feeling that I have  right  now,  that
               23
               1.1lit's an almost impossible task to transfer  the  various  ideas
               24

  Ace -Federal  Reoorters,  Inc.
               25  that we have relative to a program to a single  number;  and  I
                 . @l





                                                                             9 0



                 I  think these numbers as you show that they're weighted really,_,

                 2                                           ge to describe a
                  I would rather rely upon the English langua
                 .3 program rather than a.n @r because I think it's going to
                 41bring back to me something that I -- the interpretation that's
                  given here, for instance, by the site review and by the review

                 6committee.

                 7
                 -          I guess 4hat I'm saying is I don't understand.why @.ie.
                 '8 have to transfer the English language to a number.  What is it
                 9-1
                  to be used for and what's the motivation for it?  It appears
                 10 to me we spend an awful lot of time and money trying to do this
                 11 and I co.,@mend the effort, but I just wonder if we're trying to

                 12 do something that high school teachers have found almost

               @13 ir.-i-nossible for the last 50 years, and tl-iat's trying to get a

                 14 different grading system for students.

                 15         DR. PAHL:  Before responding, maybe we can have
                 16 additional comments which bear or extend that observation and
                 i
                 17 then we ,@7ill try to respond.

                                T-A
                 18         DR. @@ TKINS:  On the same topic, it       seem to me,
                 19 looking at the chart "C", it puts New York, Albany, Central New
                 20 York and Rochester on the lowest level of the totem nole.  I
                 21' wonder if it has a significance.  To me, it doesn't seem to
                 22 qualif@7 New York to any nlace in the program when you put it at
                 2.3 such alevel and in New York we feel very proud of the job that

                 24 we are doing in New York.

  Ace-Federal  Reporters,  Inc.
                 25         DR. KO@IAROFF:  I'm impressed that the numbers really
                                                  I





                                                                             9 1



                  do nothing more than substantiate or tend to substantiate the
                  2accuracy of .ihat we think are intuitions, but I think to spare
                  3ourselves some outside observers feeling that decisions are
                  arbitrary that it's easier to defend, particularly in the timei
                  of fiscal stringencies, easier to defend the allocation of funds
                  .6 when you attach numbers, granting the artificiality of it.  NIII

                  7
                  does it and most health funding agencies do it and I support it

                  as a generality.
                  .9        DR. MERRILL:  I think my experience with this kind of
                  10 system .,Iould lead me to believe that both things are possible;-
                  11 that ,\71iat you're doing with the numbers here is simaly giving

                  12
                  something to your opinion to ,.ie'lght it and give people a brief

                  summary idea of it.
                  14i       If, for instance, goals, objectives and priorities has'
                  1.5 a score of two, that will ring a bell and someone can ask you
                  161 why.  At that point your English comes into play and you can say
                  17@ it has a low priority.  otherwise, you have to write 28 pages,
                  18 ea'c.,i one of which describes a figure.  If you have five reviewer
                  and they all give it 12, then I think most people would agree
                  20' with it.  If one gives it 2 and the other 12, at that ooint you
                  2i@have your discussion and bring out your difference.
                  22,       I think this is  simply a shorthand method of doing

                  23 that and I approve of it.
                  24        MR. MILLIKEN:  I would add to what Dr. Merrill has

  Ace"Federal   Reporters,   Inc.
                  251indicated here, that I think the rating system is not an end in





                                                                                9 2



                   itself.  It cannot be.  On the other hand,'I think it's
                2  lexceedingl y helpful to this Council to have worked  out  a  rating
                3 system which shows where the .,7eak points are, where the other
                '4 kind of judgments must come in in terms of dealing with each

                '3 individual application.
                6@           So, in that sense -- and I felt yesterday the comments
                7  generally from other Council members supported the fact that
                8  this should not be an end in itself; that the total ratings of
                '9 these scores are only for further judgment by this Council. That

                10 end, I think, is very worthwhile.

                             DR. PAIIL:  Thank you.

                             DR. SCHREINER:  I'd strongly rdcommen  d the reading of

                13 the editorial in the current weekly edition of Time Magazine,
                14 which is entitled, "Imaginary Numbers," and it points out the
                15 psychological traps for numbers, for example, that are accepted
                16 widely in publications and in Congressional hearings and on
                17 other official data, and how difficult it is to unnumber a

                18 number once it is established.
                             For example, everybody will quote the dollar value of
                20 goods stolen by heroin addicts in @.@iew York City andli've  heard
                2'1 it on three TV programs, and then somebody  took  the  trouble  to
                2@ investigate how it was arrived at and it turns out that it's
                   in excess o.f all thefts that occur in New York City; and, of
                24 course, it couldn't be reall to  arrive at that.' But it got

  Ace-Federal Reporters,  Inc.
                2@'le@edded because it was a number and it  now  has  become  a  fact
                   I





                                                                                9 3





                   or mistaken for a fact.

               2             It seems to me there are three things to analyze.'

               3 How you arrive at a numbers whether  the  number  has  any  validity
               4 and usefulness; and then how  you  interpret  the  number.  I  think

               5 @it was a very useful exercise to go through  this  to  see  whether

                 '@or not a ,,ieighting system could be developed that appears to
               7  agree, at least in one instance, with the overall general
                   a-ooroach in the English language. In that sense,  it  leaves  me

               9   reasonably comfortable; that at least t here hasn't  been  any
               10  bizarre weights put on the value.  As  an  experiment,  that's

               11- good.

               12            I also see the shorthand value'of it,  as  John  has
               13 lpointed out. 4hat I'm really worried  about  is  the  interpreta-
              -14 I'tion of it.  once you get something down into a n'umber, then the-

               15 @more siTq,31istic people are, the more they will approach that
               16  imagin xy numer as a fact; and if we're concerned with --
               17  instead of trying to help Congressional relations, we'd be
               18  .,7orsening it by giving it some artifacts really which can be'

               .19 seized on and which are going to be given a  kind  of  permanence

               20  that they reallv don't deserve.
               21            So I'm really more concerned not with  how  we  arrived
               22  at it, which I'm happy about; bu t wh at' s going to happen  to  it.
               23            MR. FRIEDL.tV4DER:  Following up on what's going to
               24 happen to  it, I think it all depends on  whols  interpreting  it.

  Ace@Federat Reportefs,  Inc.
               25  If the ratings given here are to be used by the Council, I think





                                                                                 9 4



                   this is probably-not the most effective way to effect its
                2 purpose. But I think this  kind  of  rating  system  will  serve
                3',,the purpose to dispell a Twisconception @hat's gone  on  about

                4 RllPs for a long time, namely, that Regional i"-ledical  Programs

                5.,are either succeeding or not succeeding; they  are  good  or  they

                   are bad; and the "they" is really a collective singular noun.

                7 'This has never been true. This is  one  of  the  hardest  things

                81"in terms of interpreting Regional I.Iledical Programs  that  we've

                9  had.

               10            Now, in all honesty, if the  Regional  iledical  Program

               11  Services acknowledges the fact that there are variations in the
               12 qualitv of programs  and  publicly  acknowledges  this,  --public
               1'3 including the Congress -- I think this  is  really  facing  the

                                                                T
               14 reality and I think it's going to help the  ,Zegional  I-ledical
               15 Programs collectively and separately to know this.
               16            Now, it's going to be a sensitive point,   no question,

               17 in each of the various regions, particularly those    that wind up

               18 in the "C" categorv; but, again, it  may  be  the  motivation  to

               l@9  move upward.

               70            DR. I-IARGULIES:  Well, I thin],, the thing whicl-i concerns
               21  you mostly, as I understand it, is what use   will be made of this
               22 1kind of a nu merical system.  And  for  practical  purposes  within
               231 the context of our usual function, they will be used for
               24  defensive purposes. They will be used so  that  we  can,  when  we

  @ce - Federal Reporters,  Inc.
               25  are asked to give evidence that we have  made  an  analysis,  have
                  I





                                                                             9 5



                 I something which someone can look at very quickly, as you have
                 2 indicated.  Now, if they want to know more -about oihy there is

                 3 a-difference between Albany and California, then there will be
                 4 ample evidence which can be all the way from this Council
                 5 meeting on back to the life historv of both of the Regional

                 -6 Medical Programs.
                 71        You may recall that in April of this year  when  there
                 8was a funding cut, the only kind of decision which seemed to be

                 9tenable -- and this was a political decision; it was not a
                 10 programmatic one -- was an across-the-board cut which  affected
                 l@l everybody, which means that it did not affect everybody
                 1'2 equally; it affected them very unequally.  For example, there
                 13 were programs which had unexp ended funds, which ended up as a
                 l@4 result of the cut, with having slightly less unexpended  funds.
                 I5Others which had budgeted well, managed well, which were
                  severely damaged.  Now, what aDDeared to be a very even act was

                 17 a very uneven one.
                            We are dedicated to the concent that we should invest

                  -i@lic funds where public funds ,%7ill benefit the public, and
                 20' when there is a disparity in the-ways in which programs can
                 2'1'meet public needs, that should be reflected in the way in ,7hich

                 22 we expend our money.
                 23'        I don't believe that this num erical system is going to
                 24: help this Council per se.  I think it will help greatly, however

  Ace-Fedefal  Repofters,  Inc.
                 2'5'





                                                                                 96



                   when we make the decisions which.@.7ill flow out of this meeting

                2 and ever-,I other meeting on grant awards, and we can  then  use

               -3"this as a method for describing to people who object how we

                4 made the decision, has it came out.     As I have  indicated  on

                5  other occasions, every state has two Senators and several

               -6  representatives, and when you make a change they are heard from,

               'Y  along ,,7ith a lot of other people.

                             I think that we all understand that these are

                9  judgments we are making. You may  feel  uncomfortable  with  the
               10  grading system but, in fact, you're exercising not only a
               11  grading system all the time but you're spendina millions of
               12  dollars one way or the other in the process.  And  it  is  pri-
               i3  marily for that purpose that we need this kind of a mechanism.

               14  In fact, in the absence of it, we'll have great difficulty
               15  in doing anything other than what Chairman  Flood  described  as
                   the "meat axe" approach to reduction in funds  or  to  elevation

                   of them.'

                             DR. IIU'\TT:  But the application of a number to a
               19  poorer Drogran, is not going to negate the necessity for giving

               20  an explanation to an irate Senator.
               211           DR. -'4ARGULIES:  No, you're quite right, but it's
               2@  interesting how effectively we can negotiate with.,Ocople in the
               23  political arena if we  stand on a professional base. @,lhen  we
               24  start tryi@g.to deal with them politically, then   we are in great
  A,ce-Federal Repottefs,,Inc.-
               25  difficulty.  We're in their game, and you   may be expert at it--





                                                                                9 7



                   i'm sure you are -- but I don't feel that I am.  But if we say
                2  that this has had a professional review by the best kind of
                3-"talent available and this is how it camp- out, we stand in a
                4 fairly unchallengable nosition, and  if  we  can  provide  evidence
                5 numerically  and from that meeting back to a very careful
                :,5;analysis with the kinds of data which comes into this review
                47 @system, I think we stand in a pretty good position.

                .8
                             We have these kinds of discussions  all  the  time.  For
                @9 'examnle, there was very recently    and I can't use the names --
                l'O 'a call from the Secretary's office to me from --  reflecting  the
                I'l,@ 'interest of a very prominent chairman of a  prominent  committee,
                12"saying he .ias interested in program "x" in his home state.  Well
                1'3 'the resT3onse was -- and it was a very comfortable one -- t at
                14 li they had a priority list of six and this was sixth on the list,
                l@ 'and this was a complete professional judgment.  it aoneared to
                16 be good but too expensive.  14o@.i, this leaves us in a very under-
                17 standaCol6 relationship.  He can exert what political influence
                18 he wants but there was never any suggestion that I do anything
                I about changing that priority.  It's understood that that is a
                20 professional judgment and what these numbers do   is simply
                21 sharpen or crystallize the professional judgment   process which I
                22 think we need for our own security.
                2@           I think that you're quite right, though, that it would
                   be madness to get deluded into thinking that the numbers per se

  Ace-F-edefat Reporters,  Inc.
                25 are meaningful.  They are simply another way, as you say, a





                                                                              9 8



                  shorthand way, of saying @.ihat Steve had to'do otherwise with a

                  lot of words and a lot of papers.
               @3           DR.  SCHREINER:   -Well,  this  is  the  whole  point,  though.'
               4 I was reassured by your statement that it was going to be used
                 'defensively because, like Mike has commented a couole of times,
               ,6 we have keep reminding ourselves of the psychological trap. The

               7
                  trap is that we are all our sense of individual analysis of a
                  region in relationship to its needs and unique features and so

               '9@
                  forth, and all our English, as Dr. Everist says, can be very
                  perceptive and precise in its evaluation.
                            For exam-,ale, the-Defense Department said it was
               12 necessary for every commander in Vietnam  .to report body counts
               13 weekly. ',,Iell, the net effect of that -- and it may not be a
               14 coincidence -- that the most measured war in our history has
               15 been the least successful; and the net effect was that the
               16 military decisions were based on faulty datA -,,7hici-i we now know,
               17 and this has gone on for eight or nine years.
               18                 the danger of it was not that they were forced
               19, to out in counts. The danger was that they thought they were
               20' real, and it ,,7as the Psychological effect on the people who had
               21,lto make decisions based on this data which was much more
               22' harmful than the fact that these numbers were used to defend
               23 the defense budget with Senators and ,-iith Congressmen and used

               24 very effectively.
  Ace -Federal  Reporters,  Inc.
               25            DR. DIARGULIES: But the thing that we have had to do





                                                                                                                                                    99



                                  in the -oast in defending the IU-T is exactly what you're  des-
                              2 cribing. "Steve had to produce body counts.  We've  had  to  go
                              3                                                                                                                       i
                                  before Congress and say we-treated so many people; we saved so
                              4   many lives; we -produced so many digits in service and activity;
                              5   none of which was reflective of what !UIP was all about.  And by
                              16  talking about institutions called Regional I-ledical  Programs,
                              1
                              @7  as elements providing a kind of action and comparing them, we
                              .81can draw attention to what we really are.                                            I   thinlr. Ed's point on
                              @9
                                  that is quite valid.
                              10                     Nmi, the numbers business I know is distressing and

                                  nerhans we could find some.other way, but it is concrete an
                              12@it,s easy to look at; it's understandable.
                              1,3,                   DR. KOT@IAROFF:  Can I take one specific issue with the
                              14,num,bers, and that is that I have a feelin  that the direction
                                                                                                                  9

                              15  of  Regional  'L@lledical  Programs  toward  minority  groups    or
                              1'6 Populations of particular need is buried in these criteria in
                              171several  different  locations,  and  I  would  prefer  that  it  be
                              18  separated  out  and  be  more  heavily  weighted.
                                                      DR.  PAHL:    lle  have  to  apologize.    That  ,ooint,  again,

                              2'0,has  already  been  done.    This  is  such  an  evolving  system  --  @Ir.
                              2'1'@Peterson  presented  yesterday  the  point  --  that  there  is  now  an
                              22   additional  criterion  which  has  to  do with  minority  representation
                              23'  on  PAG,  core  staff,  and  the  kind                        s  of  projects  and  activities,
                              24'and  that's  a  separate  criterion  which  is  now  number  19  or  some-

    Ace--Federal Repo(ters,  Inc.
                              25'thing,  and we  will  be  sending  to you  a  slightly  modified  sheets





                                                                               100



               I which will show you that, as well as the breakout of managerient-

               2 and evaluation into two parts and coordinator,  core  staff,  and

               '3 other items that we covered this morning.

               :4           DR. @RGULIES:  You realize we  could have made this

               '5'riuch more impressive by making it 2.87 to 3.27.  At least we

               '6 used  large numbers.
               17           DR. PAHL:  1,7e would hope to use this system, I think,

               8  in the same sense that NIH has -- that is, the better side of
               '9 NIH -,- .%,here it is a tool. It is helpful to study sections, and.

               10'as a tool to management, but it certinaly is not to  be  all,and

               11' end all. I think if we can kind of keeo that example  in  mind,

               T2-IT,f.aich has served the country well for some quarter of a century,
  0              1                                                                 ..I
                  ..ie will have achieved in less than that time n
               3                                                Lerhaps some

               14 comparable understanding around the country.
                            Is there further discussion or comments  Please   don't

                  limit it to this opportunity.  As you have a chance to thin]-,
               17 about this further, if vou feel you wish to get in touch with us
               18 about specific points or general matters, we would appreciate
               l@ continued discussion on this basis.  But we do intend to go
               2'b' a!-lead with the imorovement and modification of it.  We will try
               21 it again in the October session and we will be displaying
               22 information to the review committee at that time and to you, in
               21, a way which I think will make some of this not only better
               24 accepted, but also really much more useful in terms of common

  Ace-Federal  Reporters,  Inc.
               2'5 discussion across all regions.




                                                                             10 1




                            MR. !IILLIKEN:  At that time could we have a little
               2  more fill-in on the weighting that went into determining the
               13 performance was 40 percent, process was 35 and program was 25?
                 1                          -
               41           DR. Pi-@L:  May I  just answer that at this point in
               5  time because I don't thin],, I'll have any further information by
               6  October.  This was an arbitra    @,7ell-considered, but nontheless
                                               ry
               7  arbitrary, decision by the staff committees, presented to the
               8  review committee, and with the request that they accept this
               91until they finished reviewing the applications and then discuss
               10 it.  They found no difficulty themselves in accepting these
                  ,.ieights.  That's not to say that as individuals they might not
               12 have varied it.  It was completely and remains completely
               13 arbitrary and at this ,Doint we have no feeling that we I,,no@,q just
               14 what the absolute answers are on this and we would appreciate

               15 some comments from you.
               16           DR. IIARGULIES:  I think one of the better tests of it
               17 is as we gain experience with it will be at the time of the site
               18 visit when you get a real sense of how effective it is, but
               10 anywhere along the way this is open to criticism and alteration;
                  although we have to have some measure of consistency or we run
               20
               2t into real difficulties on that, too.
               22           DR. PAIIL:  The only last statement I would make is
               23' it would seem that the performance of a region is something you
               24 can 1-iang your hat on.  It's really what they've done.  With

  Ace-Rdeyal  Reporters,  Inc.
                 .regard to the program proposal applications, particularly in
               25





                                                                                  102



                  'their present form, leave much to be desired in  terms  of  pro-

                2  viding the kinds of information which, unless you happen to

                '3-'site visit the region,. wou-Id give you sufficient information

                ,4 to base intelligent decision on these criteria,  so  we  will  be'
                ,5 @trying to extend through questionnaires  and  other  activities

                !/I
                0 the information available to the review  committee.  And  it  ..7as

                47 'felt that the program proposal is what they propose in the

                'O ifuture, and that should be given somewhat less  weight  than  the

                '9" 'actual performance.
                1.0          Then, the organization and the  processes  that  they
                11 'engage in are so very important. role keep coming back  to  that
                12 again and again in our discussion. So it  fell  out  of  a  common
  0
                1;3 sense approach and a reflection upon what both the review

                14 cor,=ttees and site visitors and Council  have  been  discussing

                15 within the memories of those on the staff  who  participated  in
                16 Ithe formulation of the system. But it is  arbitrary  when  you

                17.! come down to the last analysis.

                1 8          Well, thank you for your comments.  I  think  that  we

                19 have and T@7ill benefit from these and we'll be bringing you  a
                20 slightly revised system which incorporates  the  points  you  have
                21 brought up and we'll keen the other matters well  in  mind  as  we

                22 continue with it.

                28           PerhaDs we should look at our logistics for a moment.

                24 @ly count is we have seven or eight items to go through -- seven

  kcO - Federal Reporters,  Inc.
                25 specific actions to-go through, and it is now noontime.  1,@le





                                                                             103



                  have promised Dr. McPhedran to release him from the Michigan ona
               2 before about 12:3-9 so that he may catch a TDlane. Is it your
                  wish to go beyond the I-lic.@4an one which I think we should take

               4 un now, or hold up  and  then

               5            DR. ROTII: Can't T e go on througl-i?
                                             117

               6            DR. Pi-iHL:  We can go on through if that's your-

               .7 pleasure.
               8            All right.  Let's proceed with the Michigan anplica-
               9  tion if    might, with Dr. l@IcPhedran as TDrincipal revieT., 7er.
               10           DR. MC PHEDP-tl@'-4: Michigan was site visited  June  9th
               11 and 10th and 1 was on that.team.  This is an outstanding
               12 -REgional -'Aedical Program It is so because of  its  thoroughly
               113 professional program staff or core staff, and also  because  of

               14 its regional advisory group.
               15           The professional advice in the regional advisory
               16 group    that is, the technical review panel -- the cooperation
               17 between groups of, for examnle, the alopatliic and  osteopathic
               18 physicians; their ability to set Priorities; and for another
               19' instance, money management -- these were all a few asnects out

               20' of many which were outstanding.
               2'1          The site visit team agreed that goals and objectives--
               22 that is, for short-term objectives -- were not well-stated, but
               23-1 this criticism viewed against  thIe backdrop of the whole program
               24' seems almost quibbling.

  Ace-fedefal   Repotters,   Inc.
               25           Their problems with evaluation and how to measure are
                  I





                                                                               10 4




                1  shared by all of us and it was clear at the time of the site

                2 visit that the advisory grouo and the program staff were

                3 actively considering this-matter before the  site  visit  and,  in
                4 fact, it was to be a subject of major discussion in a planned
                5 retreat, a program staff and advisory group retreat, which I

                6 think was to be held in August.

                7           The program coordinator, uo until nod, Dr. Heustis, is
                @'8 resigning for personal reasons, and this will be a  significant

                ,9 loss but certainly not crippling.

                10          All of the site visitors felt that the regional

                11 advisory group and the staff would be able to keep up the  high
                12@standards of this program during any transition and that they
                13 would be able to find and be able to attract an excellent

                14 successor.

                15          our recommendation, which was concurred  in  by  the
                16'1 review committee, was for level funding at $2..l million  for  the
                17 fourth, fifth and sixth years for each year, and  that  would

                18 include the requested and  approved  developmental  component.
                191 For your interest, this com-)ares with the current 03 year figure
                20@ of $1.9 million and compares with the requested 4, 5  and  6  year

                21 figures of'a'Dout $3.3 million each year.
                22          We also felt that some projects  which  had  undoubtedly

                23@ been useful. in the past, for example, some of the stroke
                24' projects appear to have engendered very satisfactory cooperative

  Ace - Federal  Reporters,  Inc.
                251arrangements, but some of them might really in deference  to  the





                                                                             10 5




                  priorities of the region might be discontinued in favor of
                  other Darts of the program  to which the region really had given

                  a higher priority.  We agned, and last night in the small  hours
                  I showed myself to be an easy grader, which everybody  knows
                  anyway about me, and I gave it a grade of 358 against the highest.
                  grade in group "A" of 327.  I vias really dazzled by the program

               i7
                  I guess, but I thin]-, that it was an outstanding program.

                            I move acceptance of the review corlmittee's

                9
                  recommendation.

               I 0
                            DR. PAHL:  Is there a second to the motion?

                            DR. KOI,'L@ROFF:  SEcond.
               12:i
                            DR. PAHL:  Further discussion?

               13
                            (No Response)

               14
                            DR. PAHL:  All in favor of the motion please say '@Aye.

               15
                              Ayes

               16
                            DR. PAHL:  Opposed?

               17,          (No Response)

                            DR. PAHL:  The motion is carried.

                            !-Cray we take up the T,.7isconsin.application with Dr.

               20          rinciioal reviewer and Dr. IIcPhedran as @ac',,cup
                  -Roth as ?

               21 reviewer.

               22           DR. ROTH:  'Wisconsin is another one of the outstanding
               23 programs I think.  I have been particularly struck by the fact
               24 that having participated in a site visit in Tlisconsin and
  AcL,-F@r3i Reporters,  Inc.
               251finding things in generally very good, the site visit team made




                                                                              106




               I  recommendations in some detail with respect to ways in which it_

               2  might be even better and stronger, and in a very short space of

               3 'time there is evidence that the region has responded  to  those

               4' suggestions and implemented most of them and started implementa-

               5  tion of the rest.

               .6             see no reason to disagree in any respect  with  the

               7"reco.m-,iendations which are before you on the blue sheet and I

               ,8 would move that the recommendation which is for a slightly

               9-"reduced funding be approved.

              i(Y           DR. PAHL:  Thank you.   Dr. McPhedran?

              11'           DR. IIC PHEDRA,:i:  I second that.

              12'1@         DR. PUIL: It has been moved and  seconded  to  accept
  0
              13  the recommendations of the review committee for  the  Wisconsin

              14 'Annlication.  Is there further discussion?

              151           (No Response)

              16i           DR. PAHL:  If not, all in favor please say ",%ye.",

              17             IlAyesil)

              18            DR. PAHL:  Opposed?

                            (No Response)

              20            DR. PAHL:  The motion is carried.

              21            !-4ay we now turn to the Maine application,  Dr.  Hunt.
              22            DR. HUIIT:  This program -- of course, Mike was the
              2J  original reviewer, And in the absence of 11-like, I'm impressed
              24  by the inquiries that I have made since I arrived at this

  kce- Federal Reporters,  Inc.
              25  meeting relative to the f-laine program. Everybody seems to  be





                                                                                   10  7





                   enthusiastic about it  and  especially  about  its  director,  and

                2  that I therefore feel that we  should  recommend,  and  I  so  move

                3
                   tb recommend the funding an recommended by the review      committee

                4  of $1,100,000 for the  first  year,  $1,200,000  for  the  second,

                   and $1,300,000 for the third.  This is a moderate reduction from

                0  the request which was  $1.5,  $1.6  and  $1.8  million.  The  review

                7  committee is impressed with the program and it seems to be

                   doing well and, therefore, I move its adoption

                              DR. PAHL: Dr. Hunt,  I  assume  that  your  motion  for
                101 approval also includes the committee's recommendation for

                   including development funding within those levels?

                12            DR. HUNT:   Yes.

                13            DO,. OCHS,:IER:  Second it.

                14            DR. PAHL:  The motion has been made and seconded      to

                15 acce-pt the committee's recommendation on the Maine application.

                16, Is there discussion?

                17            ',,'JR. COLBUTZN: I'd like to make a comment if I  could.

                18 The present le vel of fuding in ,Llaine  is  about  $850,000.  The
                191requested level  is  $1.5  million.  This  requested  level,  excent
                20, for an increase in core, of about $138,000, is based oh all

                21' that's presently approved activities; and  in  view  of  the  dis-

                22. cussion this morning on California,  I  wonder  if  there's  any--

                23 if Council has any concern about this recommended level of

                24, funding?  I think the reduced level, as I recall from committee,
  Ace-Federal Reporters, Inc.
                25 was not  -- was based in light of the fiscal constraints of lU,4PS





                                                                                     10 8





                    nationally present and not on the merit of the program.
                  2            DR. PAHL: Thank you.

                               MR. FT-IIEDLAZIDER@ It might be of  some  interest  to  the

                    Council to know that  the  Veterans  Administration,  v7,ien  we

                15
                    selected  eight  sites  of  Veterans  Administration  hospitals  which

                  6
                    we thought might be -- these are all unaffiliated -- that is

                    unaffiliated with any  medical  school  --  might  be  good  sites

                :8
                    to consider  for  area  health  educational  centers  within  at

                  9
                    least the concept as we  saw  it,  one  of  the  reasons  Trocus

                    Maine,  which  is  the  only  Veterans  Administration  hospital

                    in the State of Maine, @,qas-a  good  T)ossibility  was  because of
                12  he Regional Medical Program there.

                13
                               I was at the site visit  there  three  weeks  ago  and  I
                14  must saii that the program,  both  the  hospital  and  the  Regional
                15  Medical Program,  even  exceeded  our  expectations  both   separately

                16
                  . and in their relation:31.-lip.

                17@
                               I only say this in  terms  of  supporting  the  kinds  of

                    things you're sa,            Maine is doing this kind of a j
                                     ,@ing, that                                     0;3.
                191
                               Incidentally, parenthetically, it miaht be interesting
                20,to note that this kind of an attitude about the Regional @l@-dical
                2-11                                                                 his
                    Programs is borne out in  most  other  olaces  we've  been  for  t
                22  very  purnose.  Buffalo  certainly  demonstrated  its  capacity   when

                23 1 we were  in  Eric.  North  Carolina  certainly  demonstrated  its

                24
                    activity and its nromise       And it s this kind of thing that's
  kce-Federal Reporters, Inc.
                25  being borne out, but Maine is one of the classic examples of





                                                                                10 9





                   this kind of cooperation.

                             DR. PT-.!IL:  is there further discussion

                             DP,.  HUNT:     -tI was the secondary reviewer for

                4@ 'r4aine and one time had occasion to review the application.   I

                   haven't done so this time, but certainly the strength of the
                   orogram as I remember it then and from other sources would make

                17
                   me wonder whether Mr. Colburn's suggestion perlia,,Ds that we

                   should adhere more closely to the requested amount, maybe that

                @9,
                   ,iould be correct.But I have no way of knowing from going t-@irougli

                   this firsthand but the review committee might have.

                             DR. !,IARGULIES:  I think your point, Spence, wasyou

                12
                   feel the reduced figure was not based upon programmatic

                   considerations but rather on fiscal restraints that were

                14
                   nresumes necessary for them to consider.  Is that right?

                             MR. COLBURN:  Right.

                16                                                      hat as the
                             DR. HUNT:  I would have no, objection to t
                   baci@un reviewer and I amend my motion that the advisory council
                18@ feels that the amount could be increased to the requested

                19 amount with the fiscal funds being available.
                20           MR. PIILLIKE',,:I: Could we hear a little more about what
                2,1 Ithe items of.difference are here?  what will not be done?
                22           MRS. SILSBEE:   I believe that the review committee

                23' also was concerned about the lack of specification in the
                24 second and third year in terms of the      and they felt by
  Ace  @Federal  Reporters,   Inc.
                25 giving then a gearing up time to see how they would switch from




                                                                                 110



                I  this project to program thrust that by providing graduated
                2 funding it might be an opportunity to study that a little more

                '3 carefully.

                4            DR. HUNT:  I think that's a valid observation because

                5  there is a lack of specificity.

                             DR. PAHL: The Chair  understands  that  you  wish  to

                '7 withdraw the amended motion and return to your original motion

                '8 endorsing co,%-nittee's action?

                .9,
                             DR. HUNT:  I will stand on my   originEl motion.

                             DR. PAHL:  The original motion   which was  made  and

                   seconded is that t'A le recommendations of the review committee

                12@ be acc,-t)ted.  Is there further discussion'?

                13           DR. 14C PHED@L: 'F,%7ould it be reasonable to  accept

                14,their original request with provision that we need to have more

                l-5'specification for the second and third year?  I don t  now
                1'6'il-.@nether this can be done under the triennial system.
                17           DR. @-IARGULIES:  You certainly can and you have the
                18'o-o,-3ortunity with the second year to alter the recommended
                l@. 91funding.

                             DR. HUNT:  I accept that.
                21           MR. @LBUP@i:  I agree with that.  The closer control
                22' and taking a look at actually what they attempt to do -- I
                2t'think at this noint they are intending to take a look at the
                2'4',orojects that have already been a?provcd and r)erha',.3s invest in

  Ace-Federal Reporters,  Inc.
                '2'5'those and see how things go, and I would say that we should take








                                                                                                     d that be done by
                                                     DR.  I-IC  PIIED,@N:    How  CoUl
                                 2 recommending that 04 year be funded if the money is available
                                 3 at  the  requested  level  and-then  leaving  a  recommendation  for  OZ')
                                 4 and  06  or)en  depending  on what  specificaions  come  in  and  then
                                 5 ICouncil  could  review  it  at  a  subsequent  time?
                                 6                   DR.  ',14ARGULIES:    To  make  it  a  complete  triennial  review
                                 7 you  ought  to  make  a  recommendation  for  all  three  years,  but
                                 8 you  can  indicate  that  you would  line  to  have  another  look  at
                                 9 this  program prior  to  the  next  yearts  funding  to  reconsider  the
                                 10 level  of  funding  based  upon  how well  they  have  been  able  to
                                 11 specify  their  plans  for  05  and  06.
                                 12                   DR.  DR.  PAHL:    Is  there  a  second  to  that  motion?
                                 131                  DR.  KOMAROFF:               Second.
                                 14                   DR.  PAHL:    The  motion                  has  been  made  and'seconded  to
                                   accept  the  requested  levels  for                           the  three  years  and  to  bring
                                 15
                                 161 the  -@4aine  application  before  the                        Council  again  prior  to  funding
                                 17 the  05  year'  for  Council  reconsideration.    Any  further  dis-

                                 18 cussion?
                               .19                      (No  Response.)
                                 20                    DR.  PAHL:    If  not,  all  in  favor  of  the  motion  please
                                 21    say  "Aye.
                                 22                        Ayes
                                                       DR.  PAHL:    Opposed?
                                 23
                                                        (No  Response)
                                 24
    Ace--Fedeial  Repofters,  Inc.                      DR.  PAHL:           The  motion  is  carried.
                                 251








                             T,,ie next application is Metropolitan D.C. with  Dr.

                2
                   Hunt as principal reviewer and @Ir. Friedlander as backup

                3
                   revie@,,7er.


                4
                             DR. HUNT: This application is  an  application  from

                5
                   the @4etro-3olitan Area of D.C. for a comprehensive renal program.
                6  As you remember, this was submitted previously and the site
                7  visit committee rejected it and I think it was  rejected  also
                8  by the review committee.  It is now being resubmitted as a
                9  comprehensive program, as a single program, where  there  were

               10
                   three overlapping programs submitted previously-

               11            I'm somewhat confused as to what to  recommend  here

               12
                   because of nrobably the confusion that has gone on with the

               131 kidney programs to date, and this certainly applies here.

                   There are problems to be noted that are somewhat local and

               15  sometimes somewhat personal, but I think the point brought out

               16  by the review committee and the ad hoc committee I think

               17  should be noted.  The ad hod panel unequivocably rejected this

                   proposal completely and so did the review committee.
               19            However, they did make some      and their  reIason, by
               20  1. the way, is stated, "It's useless at this time to consider
               21  expansion of a dialysis program which is already being conducted

               22  on an active basis without resolution  and an effective way to
               23  develop first an efficient transplantation site."  IIhat they'  re

               24  saying, as I see it here, is there is no point  in  going  any-
  kce@F-ederal Repottets, Inc.
               25  place in Washington, D. C. until you develop  some  facilities





                                                                             113




                  for  transplantation.
               2           The irony of this that I observed dhen I was reviewing
               3  this, is that here in this-community that is striving strenuously
               4  to develop a kidney program and certainly a transplantation
               51 site, 'vie already have three, in the Army,.Navy and the Veterans
               6  Administration, on-going programs with typing and so forth;
               7  and now -,we're trying to set up one for the civilian population.
               8  And if we're trying to centralize this, maybe we ought to send
               9  a message across the street that they ought to centralize their

               10

               11          This program was.criticized by the ad hoc committee
               12 relative to its typing program because this is already being
               131done bv some of the services.  The panel noted that four tissue
               14 typing laboratories are already in the area and thev felt that
               15 federal funds will not change the organ donor population which

               16 ,has heretofor been tapped at a rate of onlN, 1.25 organs per

               17 transplanting medical school.
                                            I
                           The region confronts a dialysis bottleneck because

                  there is no transplantation.
               201         Rather than reject this, I would like to have the
               21 panel certainly with advice from those who are more knowledgeably
               22 about this than I am consider what can be done to help this area
               23 develop a transplantation facility and consider possibly
               24 recommending a site visit by the ad hoc kidney panel, the local

  Aice-Federal Repoiters,  Inc.
               25 nenhroloqists and surgeons and representatives from medical




                                                                                  114





                 I  schools -
                                             the site visit committee I can tell you
                 2           As a member of
                 3 that the impression I received -- whether it's still  ranpant@,
                 4 but it T%Tas then -- that there is an old school tie business
                 5 going on here, and a little bit of "Cabot and  Lodge"  business
                 6 and I think maybe 4ith the ad hoc  committee  sitting  down  wit,i
                 7 the local representatives some sort of a program for this area
                 8 which apparently needs a program of transplantation can be

                 9 developed.
                 10          So if there's any recommendation other than    that I

                                                                          ti
                 11 don't know what -- I can't put a dollar value on any iing@
                 12 because it appears that they  already  have-this  in  a  piecemeal
                   .vay. There is a private  facility,  an  on-going  facility  right
                 14 now, for private medicine, but the program really   doesn't tell
                   you how much of a need there is for the'indigent    -ponulation.  At
                 15
                 16 least I couldn't find it in the application.  It   might be

                   there.
                 18           DR. PAHL:  Thank you, Dr. Hunt.  .'.,4r. Friedlander,
                 19 @?erha.@s with your oermission, we might ask '.Ir. Spear  for  his
                 20 coriments relative to Dr. Hunt's presentation which may answer
                 21 some questions you have and  if  not,  we  would  appreciate  your
                 22 further comments.  @-latt, would vou nlease tell us about the

                 2j review -,oanel?
                 24           @IR. SPEAR: We have  from  the  panel  almost  the  same

  Ace--Federal Reporteis, Inc.
                 25 problems that Dr. Ifunt has voiced and the cause is just as he







                  stated them, and apparently the panel didn't knoa what to do
               2 because -- I don't know whether it shows up in your comment
               3 we had a little further cciLiment at an earlier stage, in which
               41there -,was a doubt in the minds of the panel that wanting to go
               5 1 to '.Ietrojolitan D.C. and resolve. the problems, to whom would
               0 you turn?  So it was the hope, then, that all else having
               7 failed, perhaps the people from the institutions, the senior
               8 people from the institutions, if they can be pulled toaether,
               9 as you suggested, and discuss the problem frankly among them-
               10 selves with a third -,?arty group present, perhaps a resolution

               11; could be made.
               12           @,7e are a little pessimistic about it with resoect
               13 to the "old school ties," 'as you describe then, that maybe that

               14 can't be broken dozen.,
               15'          An alternative has suggested itself that has not yet
               16 been pursued, and that would be to perhaps call in firms of
                  incorporation of non-l?rofit groups of some kind who would take
               18 -it out of the realm of the individual institution and orovide
                  them a mechanism to come together at a super-level, and ti-iis
               20 might work and might be something that could be proposed to

               21 them.
               22 1         As'it stands, even though they admitted in their
               2j application that one of their great needs is transplantation,
                  the application never got down oro-posed what would be done.  it
               24

  Ace - Federal Reporters,  Inc.
               25 proposed more dialysis and typing.




                                                                                 11 6





                             DR. PAHL:  Thank  you.  '4r.  Friedlander?

                             Mi'l. FRIEDLAIIDER: I don't profess  to  be able to

                3  comment on this in the -,oroxessional aspect of  it, but there

                4  seemed to be a couple of aspects  that  bothered  me.

                5            First off, what bothered  me  primarily  was  the  dis-

                61tortion that could occur in such  a  program,  regardless  of  how

                7 effective the proposal might be.    When you wind up giving a

                8 Regional ',Iedical Program $700,000 for one year in  one  cateejori-

                9 cal area, and its total  operational  funded  level  is  $800,000,

               10 this to me is a distortion and it would be terribly diff     icult

               11@ to defend in terms of a regionalized kind of general effort to

               12 helm many peoz)le in terms of availability of quality care

               13  across the board.

               14            That would probably be my  primary  objection  to  this

               15  kind of a proposal within this kind of a program, but that's

               16  hardly a helpful thing in terms of meeting  the  need  if,  indeed,

               17  this is the need.

               18            Then, of course, it occurred to me that  as  Dr.  liunt

               19  mentioned, there are other kidney transplantation, matching,

               20  etc.,-efforts within the Greater @;lashington Are-a, and one of

               2'1@ them is at the Veterans Administration Hospital.   Interestingly

               22  enough, if you look at Little Rock-  and  Birmingham and   Seattle

               2@' and Denver, you'll find that  this  kind'of  sharing activity   with

               24@ the Veterans Administration and  the  university  is working   out
  'ce@Rderal Reporters, Inc.
               25  very, ven
                            .1 well. of course, those four places have a peculiarit




                                                                                  117



                 I  that Washington doesn't have.  They only have one medical school
                 2 so they all @qear the same tie. So I guess that  makes  it  a  lot
                 3'-easier. That possibility it seems to me  should  not  be  over-

                 4 looked.

                             But those are the two primary things,  one  of  them  an
                 5
                 6 objection and the other one an observation,  that  I  would  add

                   for the consideration of Council.

                             ,,IRS. WYCKOFF:  Does the Veterans Administration
                 8                                                               have
                   canacity that you could share with the rest of them?

                             MR. FRIEDLX-IDER:  Well, you see  you don't necessarily
               10
                   have to onerate within the given existing capacity as it stands

                   at the moment.  That capacity can be expanded if, indeed, there
               1 21.
                 I is a need in a community to provide this kind of servic,,-   and
               13
                   it cannot be met otherwise.  So, you see, you don"t necessarily
               14
               15 Ihave to limit yourself to what capacity you may have at any

                   given moment.
               16
                             DR. ROTH:  The answer to !@4rs. Wyckoff's question,
               17
               18  however, is yes.

                             MR. FRIEDL7A!iDER:  Thank you.
               19
                             DR. HU,4T:  I think in this nroT,)osal I think the
               20
                 I Veterans Administration has agreed to give them some space.
               21
                             DR. @IARGULIES:  There are two issues here which collid@,!
               22
               23  with one another. one of them  is  the  spectacular  ability  of
                   the D.C. JU4P to operate without being able to find anybo y in
               24
  kce-Federal Reporters, inc..l need of medical care within the District of Columbia, which is
               25





                                                                                118




                  astonishing. They continue to come  in  with  activities  which
                2 would lead you to believe that they're operating  in  the  heart
                3 of @lontgomery County whic,rdoesn't happen to be  the  case.  And

                4
                  since they have really been expressing  parochial  interests  of

                5
                  medical schools with close ties there and  a  rather  resistant
                61 medical society leadership -- not the medical society -- it
                7. creates a problem when you look at a kidney  proposal  in  that

                8
                  environment.
                9            Then the kidney proposal itself has  reflected  that

               10
                  kind of particulated attitude.

                             Now, one of the questions we asked  ourselves  about
               12, this, and I think this is really what Dr. Hunt was  getting  at,
               13 is there a way of using this device as a  method  of  bringing.

               14
                  together the IU4P and at the same time providing a   reasonably
               1.5' well-integrated effective kidney program, or will the two

               16 actually be in collision with one another and nullify the

               17 efforts of both? I think that until one  makes  the  effort  to

               18 bring the principals together and  discuss  the  potentialities,

               19, it-s like to remain at an impasse.

               20            Tt might be a way of helping matters, or when you

               21 look at those figures which Ed has just laid out,  it  might  be

               22 a way of simply diverting what energy there is in the,IU.IP  into

               23 a big pronosal which is attractive.

               24            DR. r.IERRILL: I think, speaking as perhaps the  last
  lkce-@Federat  Reporters,  Inc.
               251remaining  kidney expert here, one of the problems that's





                                                                                  119




                   represented by this proposal has  already  been  touched  on,  the

                2
                   fact that we don't have the figures for  someone  whols  spent  a

                3
                   lot of time in transDlant@-ion and  dialysis,  and  I  can  make
                4  nothing whatever of the summary, nor, unless    I know  the  exact

                5
                   capability of the Veterans  Administration,  can  I  comment  upon

                6
                   the feasibility of  the  Veterans  Administration  alone  handling

                7
                   the need of the D. C. area in transplantation.

                             It's been mentioned,  for  instance,  there  are  other

                9  areas in which they're doing transplantation.  The Army and the
                10 "lav,  ve been quoted.  The
                      I ha                       head Army transplanter  vou  saw  on

                   the ohotogranh taken in  Watts.  He's  now  in  Watts.  And  the

                12
                   Navy transplanter was in the Holiday 1"4otel the day  before
                1 3yesterday on his way to Tulane.

                14           So these are the kind   of figures I think  we   need, alone,,

                15 with the number of patients on  dialysis  who  might  be  suitable

                16 for transplantation, and also the tissue typing facilities

                17 there are some problems about that.

                is           I would life to know, if I might, about the establish-
              .19iment of a  community lilome dialysis training.  Does this mean new
                20@bricks  and mortar or does this mean  new  funding  and  '.operation
                2,,]' and on-going operation within a hospital or several hospitals?
                22 @This would be important.
                23           I think that probably  the  Washington  area  does  need

                24 a coordinated dialysis and transplant  center  and  I  think  the
  Ace-Federal Reporters,  Inc.i
                25 suggestion that people get together on this is an excellent one,




                                                                                 120



                 I:and in spite of the fact that money tends to be a dirty word,

                 2  there is no greater catalyst for cooperation  than funding-- I

                 @3'@can promise you -- in this or many other areas.  And I would

                 '4 think that if it is within the scope of T@UIP to suggest this  and

                   implement it, it would be well worth doing.

                             DR. HUNT:  If somebody will name the figures and get

                 '7 them toaether, I'm willing to recommend it,  if  that  is  the

                   catalyst.  I think, having been there, that's a very good point.

                 9           DR. KO,@L@ROFF:  Do we have to name a figure or just
                 jolindicate our sympathies for a revised  proposal  along  these

                 11 lines?
                 12          DR. @IARGULIES:         there is an interesting grape-
                 13 vine in the kidney area which I suppose  must  be  associated  with
                 14 the number of tubulars which are available, but somehow, whatev@.-
                 15 action we take is well disseminated before  it's  even  been  typed
                 16 out, so that they are aware in the District  of  Columbia  of  what
                 17 attitude this Council has--not yet expressed but ,%rill express

                   before this discussion is over.
                 18
                             DR. HUIL4T: I might tell you that  doesn't  work  in
                 19
                   reverse, because as a site visitor  I  rejected  an  ambulance
                 20
                 21 Drogram that was recommended by'a local Congressman and, by

                   God, I,heard about it, but after the fact.
                 22
                 @3          DR. DIARGULIES: Yes, I@know  about  that,  too.  I  think
                   if this Council came to the conclusion that  the  proposal  is  one
                 2
  kce- Federal Reporters, Inc. which requires an extraordinary kind of review from the technica
                 25




                                                                               121



                I  point of view, from the Regional TIedical Program point of vieT,,t,-

                2  an effort to try to resolve differences, and ,,7as willing to

                3 'reconsider it then after that kind of further discussion, it

                4 would be a good idea.  I know that we've already had the review

                5 and I know there have been all sorts of actions, but  they  have

                6 been inadequate to this extraordinary circumstance I think.

                  Matt, does this seem reasonable to you?

                8               SPEAR:   I think that's very good.

                9           DR. MARGULIES: Bill, I think what  you  were  talking

               10 about in your Presentation is the way to roceed  and  we  don't
                                                            p  -                    I

               II- have to attach any money to it, but rather let them realize

               12 that there is something which can be done if they'll make sense.

               13           DR. HUAT: Well, if there's such a  thing  as  planning

               14 fund.-,, I think they should be made available.

               15           14RS. SILSBEE:  'v'le did that before.

               16           DR. HUNT:  We did that in the screening process

               17 programs here I know.

               18'          DR. I-LDRGULIES: I think what you can do, if you  want

               19 to, is disaDnrove it but give them the opportunity to come back

               20 with a better Plan.

               21           DR  litNT:  I think that's a pretty harsh treatment

               22 here because they're really suffering down here.  We  did  that

               23 to them pretty badly last year on their general program  and  I
               24 would rather hold their program in abeyance pending a rerevie@%?

  ice@Federat Repoiters,  Inc.
               25 after the site visit of the ad hoc panel and  local  interested




                                                                                122




                  individuals, so I would move that.

                2            DR. PAHL:  Is the motion for deferral and reconsidera-

                3 tion after site visit and-supplemental material becomes

                4 available?


                5            DR. IIU@14T: Yes.

                6            DR.  ROTH: I'll second it.

                7            DR.  PAHL: The motion has been made and seconded.

                8            DR.  HUNT: Consultation and site visit by the ad hoc
                @icommittee?
                1011         DR. PAHL:  Yes, by staff and  the ad hoc committee.

                11           DR. @IARGULIES:  They come in for a full review in

                12 Novem'oer so this will work out all right.

                13           DR. MERRILL:  Is there any real  advantage to having
                141 this T)ronosal renegotiated, or rather what really needs to be
                15 done, having a brand new proposal based on some sound advice

                161 from neoDle who know what we want to do and submit 'it?,
                17           DR. HUNT:  That should be part of the recommendation

                18!I think.
                  I
                             '@14R. SPEAR:  You know, the panel -.,iasn't terribly
                20' disa-3nointed with the application if they had ?ursued the point
                21' of Providing a out for their dialysis  patients with.trans-
                22' plantation.  The comment was made, "If they would just do one
                23@ center, give some egress from dialysis, we could approve any
                24' one of the dialysis projects.  llithout this egress, something

  Ace-Federal  Reporters,  Inc.
                25 to add on to the backlog, there was no merit, so the application




                                                                                12 3





                I  contents were not totally without some use.

                2            DR. MERRILL:   Would that require, then, simply

                3 revising the original pro.@osal to add  transplantation  or  would

                4  it    it seems to me it would require considerable revision

                5  to it in terms of tissue ty?ing, availability of centers, inter-
                'o junit and inter-hosoital cooperation and a good many other things

                '7 'I think these things would have to be spelled out pretty

                '8 carefully.

                9            MR. SPEAR:  This might well be done.  One of the

                10  concerns was who has had a hand in Dlanning the project that

                11' came in, and this was one reason that it was specified  that  it
                12 lwas desired possibly that the chief surgeon, cnief of medicine,

                13 and chief pathologist at each of the institutions  be  at  such  a

                14 meeting.

                15           DR. HUNT:  I would amend my motion to include that.

                16 Irhat's a very important point  because it speaks to a relatively

                17 in.?ortant part of this oroblem.
                18           MR. V@14 WI'i.'iKLE:  I would like to point out that the
                I, T)lanning goes i:)acl@ in the District to my knowledge at least
                20' five years, and we did meet with representatives  of  all  of  the
                21,medical schools, all of the interested Darties, the district
                  health department, and there .vas planning  money  made  available
                22'
                2j@ by the City Health Commissioner at that time, I think some
                24 $40,000 or $50,000.  They assigned a resident full time to
  kce--FecTer,al Reporters, lncl.
                25 develop the planning on this.  They met with us repeatedly.




                                                                             12 4




                  This has been going on on a continuous basis.  This is the

               2  second pronosal that came in.  They did come back to us for

               3
                  advice again.  I can sav that advice ,,ias not followed.  And the
               4 1-young physician who was in said, "I fully understand what you're
               -5 'speaking about; I understand the need; and I could so do if it

               9 ,wasn't for this 'tie' situation."  He says, "I'm not permitted

               7 @to do so."  -knd I don't really thin]-, that just going back and

               8  replanning -- it's been planned to death.
               9--          They're going to have to recognize what their problem

               10  is, and the problem relates to the patient who needs the

               11@  service, and I thin]-, that's what they're going to have to

               12  address themselves to.

                            Now, I'm not sure    I have even suggested that
               14 perhans it should be a directive effort and perhaps we should
               15  go in there and do it through the contract mechanism, Dr.
               161 Margulies, rather than through the grant, because at least you
               17 ;can be directive in terms of placing emphasis on what should be

               18 done.

               19           DR. HUNT:  I don't know whether this is t.,ie time.  I
               20 was going to address myself to this later on.  But this problem,

               21 in a different form, it seems to me, has come up on every
               22 kidney proposal that we've talked to in one way or another..  It
               23 ao-,.)ears that we have set uo rather strident regulations and
               24 directives relative to a categorical disease that %qelre having

  kce-Fedefal Reporters,  Inc.
               25 a lot of trouble getting them implemented.  We're having trouble
                 I                                                               II




                                                                                125



                I  finding the people and it's expensive.

                2            As much as I abhor  authoritative  medicine  coming  down

                3  from up above in the "13ig@addy" approach, I sometimes   feel   that
                41 maybe that this is what we ought to be  doing  here,  because  we're
                5  getting into a very, very expensive facility and  we  know  that

                0  most of.the 55 orograms in Ri,T can't fund a thing  like  this  and

                7  carry it on locally after we get it started;  and  therefore,  I

                8  think    and this'it; a facility that we're not  providing  in  our

                9' Health care picture throughout the country  --  therefore,  this

               10  is the time and T:)lace, I think, for ,oublic authority to step

               11  in and say, "-,Ie'll orovide this." And I think if we do  t'nis,

               12  then @4e can fit the plan to suit our own  tegulations,and  what
               13  we're trying to do right now is set un a  bunch  of  strict  regula-
               14  tions that are going to cost a lot of money and w  e can't find tii,--

               15  people to do them.
                6            So I wonder if we shouldn't give soine thought to
               17  whether or not this isn't the type of health problem that is
               18  national in scope, and ,,7e have a capability, limited as it is,
               19  to handle, that @..7e shouldn't use a more directive and authori-
                   tative -- what you call the contract annroach --  to  handle  it.,
               20

                   @-7e can't establish transplantation centers in all 55  Regional
               21
               22  ,,Iedical Program districts. There's no question  about  that.  And
               2i  I think our job is to provide the facilities and we  have  to  get

                   the -3atient to the facility.
               24
  %ce-F6deral Reporters, Inc. I'm even concerned right here in discussing  this,  when
               25




                                                                                   126



                   I learned that Virginia  has  their  own  transplantation  facility

                 2 and it's not too far to Virginia from here. So  that  I  think  ,,7e

                 3.'have to look at the geographical area and  if  it's  logical  for

                 4 two or three @,%IP programs to joing together to  solve  a  program

                 5 I think it's logical for the advisory committee to recommend

                 f
                 0 that in contiguous areas we will set  up  the  facility  but  you're

                 7 going to have to bring the natient to the facility.
                 8           I strongly encouarge the-use of volunteer help and
                 91 the helD of the local R:,IP orogram to irk,)16ment what is handed

               10  d,,von from above.

                             DR. !-IARGULIES: I think probably what,vre need,  if  I,
               12, may suggest it, is again -- and'we  haven't  done  this  in  quitea
               131 while, and not in quite the form that  I'm  going  to  suggest  it --
               14 is to use a portion of the next  meeting  of  the  Council  to  bring
               15  us a little more up to date on ,.ihat are the problems interfering

               16' with the development of these  kinds  of  facilities;  because  they

               17  are only Partially those that you've identified.

               18            Certainly, one of them is the availability of
                   competent neo@nle in a field which has  advanced  very  raoidly  and
               191
               2 0  in which the expectations have exceeded facilities, individuals,
               21 skills and so forth; and I  think  it  would  be  most  appropriate

               22  if the Council did have some time next time around on that

               28 issue.  Because the ad hoc commi   ttee has been  uniformly  --  not
               24 uniformly,  but  very  frequently  and  overwhelmingly  disappointed

    Federal RepOFteFS,  Inc.
               25 with the kinds   of proposals that it's been reviewing, and if

                  I




                                                                                                                                                 127



                                  that's  the  case,  then we  have  a  responsibility  of  trying  to
                             2    decide  when  then  do  you  do  about  it;  and  there  are  a  variety  of

                             3    1,7ays  i n which we  could  ap@oach  it.
                             4                      DR.  IIUIIT:    I  would  just  add  one  personal  experience,

                             5    to  this  to  get  my  point  across.    There  has  been  --  one  of  the
                             6    orooosals  that we  had  here  from  the  Foundation  is  a  dissemination
                             7    of  knowledge  program.    I  can  tell  you  that  that  can  stimulate

                             8    some  pretty  good  problems.
                             9                      I  attended,  as  a             public  official,  a meeting  relative
                             10   to  the  health  problems  in                   our  county  in Western'Pennsylvania,
                              .11 and  as  a  result  of  an  advertising  program  and  calling  attention

                             12   with  scare  mechanisms  about  the@ number  of  people  that  are
                             13 @dying be-cause  they  don't  get  dialysis  because  we  don't have
                             1 4   something  to  take.care  of  this  person,  we  had  a massive  influx
                             15   of  T)eople  that wanted kidney  transplantation  and  dialysis
                             16 Ifacilities  in  every  hospital  in Allegheny  County.
                             17                     This  is  the  kind  of  nisin'Lo                   rmation  and  hysterical
                             18   information    that we  can  get  out,  and  it's  wrong  for  various
                             19   agencies  to  carry  on  this  kind  of  a  promotional  agency  without
                             2'0' knowing @,.,,hat  they're  doing.    We  can  avoid  that  by  taking  the  bul-
                             2'1' by  the  horns  and  deciding %vhat  should  be  done,  as  much  as  I

                             22'  abhor  that  type  of  approach    in  other  cases.
                             2@n                     DR.  PAliL:    I'm  afraid  that  my  blood  sugar  is  low  and
                             24@  I  would  like  to have  someone  please  rephrase what  is  th@

    Ace - Federal  Reporters,  Inc.
                             25   Councills  motion.    Is  it  for  disapproval  with  staff  assistance




                                                                                   12 8





                   and reconsideration at J.-iovember Council meeting; is it for
                 2 deferral ,v'ith staff assistance  and  reconsideration  at  the

                 3 November Council meeting; @.r is  it  some  other  statement  which

                 4 haven't included in those tvio?

                              DR. HU-@,4T: '@Vell, I'll make a motion and you  can

                 6 correct it as I go.  I move that the action on the application
                 1

                 7 be deferred.  I recommend that an ad hoc        a site visit be

                   held to be attended b@,, the ad hoc  committee  on  renal  disease,

                 9 and that the  local  participation  among  others  should  consider

                   should include-'the chief of medicine, the chief surgeon, and

                   the chief nedhrologist  of  each  of  the  applicant  institutions.

               12  I think that's enough.

                              DR. PAHL:  Thank you.  Has the motion received     a

               14  second?   Is the notion seconded.!


                              DR. OCHSNER:  Second.

               16             DR. PAHL:  Is there further discussion on the motion?

               17             DR. I..IERRILL:  Could I ask of the gentlemen at the

               18  head of ti-ie table what they think would  be  the  most  effective

               1'9 mechanism to getting action? 'I.,Iould it be to  turn  it  down

               2'0 completely and ask them to come in with a brand new program,

               21  or to defer it to consultation and site visit?

               22             DR. IIAR(7,ULIESS:  I think it pretty much depends on

               23  what message we give them, and if we reflect to them the concern.,

               24  of Council, we can achieve the purpose of a completely reesta-
  ,ce -Federal Reporters,  Inc.
               25  blislied, rethought-ott program, if they're capable of doing it.





                                                                         129



              I  if they Ire not able to do as we suggest we' may have to coiae. bac@,

              2 and  say  it didn't work.
              3            DR. ,IERRILL:  Juzt one other question here.  Ilh,-t is
              4 the grantee for the application?  Who is the grantee here, the

              3 applicant institution?
              .6           DR. IIARGULIES: It's the P-r@IP, the District Regional
              .7 i@-ledical Program, so it would be in that setting that the dis-

                 cussion would take place.

              @9,
                           MRS. 1,TYCKOFF: Isn't it important who convenes this
              10 group, whether you get cooperation or not? Wouldn't it be a
              II- good idea to arrange that the convenor not be the one that was

              12 doing.it before?
              13           DR. I-IARGULIES:  Well, I think that what we will have t,)
              14 do in this case is make it an R121PS issue, rather than a kidney
              1-5 division issue alone, and it would be the RL,,IPS to the IUIP with
              16 the kidney issue and the !U-T involved, so it's going to be a

              17 major kind of discussion.

              18           MRS. 'tVYCKOFF@:  Yes.

                           DR. PAHL: Is there further discussion?

              20           (No Response)
              21           DR. PAHL:  If not, all in favor of the motion please

              22 say "Aye.11

              23            Ayes

              24           DR. PAHL:  Onposed?

  Ace Federal Reporters, Inc.
              25           (No Response)









                             DR. PAHL:  The motion is carried.

               2
                             The next application is New Mexico with Dr. Schreiner

               3'                                                  :) reviewer.
                  a@ principal reviewer and ,Irs. 1,7yckoff as backu,

               4             DR. SCTIIPEIIIER: The New ilexico application and the

               .51 review makes two excellent points; one is the value  of  a  good

                 'site visit and the other is the power of the DeBakey principle,

               7'  "Send me the money."
                             I went out on this site visit and I believe Tony did

               '9 too, and he may have some additional comments which I would
               10 welcome.  -,4y own impression, having been on a lot of site
                  visits, was that it was a rather unique response to the site

               12 visit in that the response started happening while we were
               13 there, and as the very early interplay came out between the
               14 site visit committee and the region they not only accepted some
               15 of the things but they began to do something  about  them  right
               16 on the spot. I think this  was  also  s.ignificant and  borne  out
               17 in the letters and literature which has come  in  subsequent  to
               18 the site visit which shows I think some very constructive turn

               19 of   events.
               20i           The poqer, the money, just to put in perspective, my
               21,                                            umber which that for
                  computer  Liere comes up with an imagiiizry n
               22 Illinois  ..7--'re spending something like 10@ a person, and for
               .23 Texas about 15@ a person, and for the New Yorl@, State Regions
               24' about 50@ a person, and that we've been spending in New Calexico
  Ace-Federal Reporters, Inc.
               25 roughly about a dollar a head.





                                                                                      130



                               Now, this has more than that figure would imply in
                   2 Iterms of its impact because  unlike  some  of  the  other  programs
                   3that we I ve talked about i-i@-re there are heavy P4edicaid I  programs
                   41and heavy insurer programs, there's almost nothing going on in
                   5 -',4ew @llexico. I think it's got one of the  highest  percentages  of

                   6 uninsured Populations in the country.  There are whole areas

                   7where there simply are no facilities at all, so we're not

                   .8 talking about vihether sophisticated medicine can be brought,,

                   9but we're talking about  whols  going  to  pay  for  the  pickup  truck

                10  that thev throw the body in out there.

                               Sandobel County,  for  examnle,  has  an  area  that  is
                1211arger -tilan Connecticut that has  . something  like  60,000   people

                131or less,  and  there  are  no  emergency  medical  services  and  no
                14' installation, so  that  this  is  quite  a  different  ballgame  in
                15@ term s of deciding whether you're going to use this sophisticated
                16' method or that sophisticated method.  It's a question of whether
                    there's going to be  any  method  going  on  which  is  a  much  more

                18' basic kind of decision.
                19             So we found I think  some  defects  in  the  program  as  it
                   Ihas  been  operating.  One  of  the  -paradoxes  was  the.coordinator
                201
                2'1'i-7hich .@7e have stressed the  importance  of.  The  coordinator  here
                2@'I,,vas a paradox in that he had not moved  along  with  some  of  the'
                2@ missions that have been expressed by the Regional @ledical Prograii
                2  i4 on the one hand; on the other hand, he did have a remarkable

  Ace@Federal Reporters, Inc.
                2  .5 sort of personal rapport with a lot of the people involved




                                                                             1 31




               I  around the state.  So this put us in sort of an awkward position.

               2  It turned out, however, during the site visit, the dean, who

               '3 had ke-)t hands off the program for a couple of years, realized
               4  that 'ile would have to give it some support and get to work on.
               '5 the likelihood of Dr. Fitz' resignation which has subsequently.
               '6 happened, and started a search committee and they've already
               '7 secured a Dr. Cay who is a neurosurgeon who no longer practices
               '8 and is willing to go full time with this program, and at least
               '9 all the reports I've been able to get on him are very, very
               10 favorable.  I believe that he worked with Dr. Millikan at one
               11  time in his career so he should have learned something.
               12           The other part of the program that we criticized has
               13 to do Keith the fact that they had a number of good projects but
               14 they didn't have them molded into very good programs, an
               1.5 excellent examole of which was the fact that they had apretty
               16 good cancer registry going which was covering something like
               17 90 T)ercent of the region beds, and the most talented scientist

                  T              nes we cane up clo
               18 "7e met in the o                 se with was a hematologist who
               19 was getting very substantial 'L4III funding and going into a big
                  lymphoma project and wasn't using the cancer registr-,r.  So you
               20
               211 could only come to one of two conclusions, either he was not
                  relating his project to the program or else the cancer registrie-
                 2
                  don't have very much practical importance when it comes down to
               2@'
                  a point of that sort.  I don't know which conclusion I'd be
               24

  Nce-Fedefal    Repoftefs, Inc.
               26 willing to come to, but I think that it certainly would have bee





                                                                                                                                                          1 32




                               I   expected  that  he  ,;ould  have  worked   better  with  this  inasmuch  as
                               2 @he  did  have  here  in  project  17  a  proposal  for  a  leukemia
                               3   lym?homa  treatment  T)rograM,.

                               4                        We  could  go  on  like  that.    There  were  some  very,  very
                               5     strong  points  in  the  program,  one  of  which  --  the  best  of  which
                               '6    perhaps  was  the  emergency  medical  care  system which  was  very
                               7     unique  and  being  worked  out  by  Dr.  Hendrickson  who  was  a  very
                               8     dynamic  person  and  saw  these  nroblems.    It's  hard  for  an
                               9     Easterner  to  appreciate  these  problems.    For  examole,  they  can't.

                               10    even  use  radio  controlled  ambulances  up  in  the  Four  Corner
                               11    area without  having  --  the  distances  are  so  great  and  the
                               12    mountains  are  --  the  terrain  is  so  rough,  that  they  actually
                               13    have  to  have  relay  stations  to  amplify  the  message  just  to  get
                               14    a  plain  old  radio  telephone  call  through  from  an  ambulance  to
                               15    a  nearby  hospital.    So  they  have  all  kinds  of  special  technical
                               16'   -)roblcms  and  "le  seems  to  be  very  aware  of  tllis  and  I  think  the
                               17    only  question  of  the  future  --  there's  no  question  about  the
                               18    quality  of  that  program  and  the  imagination  of  that  program.
                                                        The  only  question  about  the  future  was  whether  ne
                               2'0   T%?ould  be  able  to  lean  on  the  emergency  medical  care  legislation,
                               2'14  and  some  of  the  grants  that  are  being  made  now  by  the  Departme-n'L-
                               2@    of  Transnortation  and  Defense  to  implement  emergency  medical
                               2@    care  facilities  --  whether  he  would  be  able  to  get  any  help  from
                               24    this,  and  I  would  think  that  we  ought  to  continue  to  look  at

     Ac-e@-Federal Reporters,  Inc.
                               25    this  to.see  whether we  might be  Dutting  more,money  into  the




                                                                                                                                            133



                                 programming  of his  activities  for  the  sake  of  enabling  him                                         to

                            2
                                 get    the     help     elsewhere,     as     a     means     to     an     end     rather     than     as     to

                                 the  end  in  itself  of  fundng  the  program.
                            4.                    With     all     of     this,     I     would     feel     that     the      site      visit

                                 report     here     is     very      accurate      and      quite      up      to      date.      The      kidney
                                 program was  very             disappointing  to  us  and,                   as    I     have     dug     into
                            7    it,    it     seems     to     me     that     .,ihat     happened     is     that     they     have     two

                            8
                                 different        groups        of        neohrologists        with        some        polarization        and

                            9
                                 Dr.  Fitz  really           didn't want  to  take  the                  effort      in       his       waning

                           10
                                 days  to  get  them together,  so  there  really @,7asn't  a  coordinated

                           11
                                 kidney  proposal.
                           12.1
                                                  Subsequently      to      our      site      visit,      they      have       come       up

                           13
                                 .@lith  a   couple     of     pretty     good     ideas,     and     they      are      in      the      book

                           14.   here    and      don't      look      bad.      The      result      is,      however,       there's       no
                           15;imoney     in     the     grant     for     this     and     if      they      are      not      given      develop-
                           1611mental  con onent  as  the  review  committee  recommended,  then  they
                           17@lwould  have  no way  really  of moving  into  this  area  and  I  think
                                                                                                                                           -,,,'re
                           18       we       would       be       defeating        our        constructive        purpose        because,the,
                           19, ,.,ell  on  the  way  to  3ut  together  some  fairl@,r  good  proposals.  The-,

                           20    have      some      facilities      there      and      I      think      to      encourage      them,      @ihat

                           21 .' I  would  recommend,  is  the  overall  fiaure  of  the  review  committee
                           22    but  add  $30,000  or  $40,000  as  a  s  ecific  funding  for  the  kidney
                                                                                            p
                           23    programs  which  have  come  in  subs                     equent      to      the      site      visit      which
                           24    I     think     ,,iould     get     them     started     in      that      particular      area      --      give
    Ace-Federal Reporters, Inc.
                           25    them the  incentive  to  get  them  started  in  that  area.





                                                                                1 34




                             The recommendations of the revi@@,7 committee and  I

               2  think the  conclusions of the site visit were that it would   be a
               @3 'good idea to reduce their_overall request significantly for a
               4  one-year neriod to act as a further stimulus as to how serious
                  we are in having them mean business in their reorganization.
               '6"           As I say, all the indices since we were there have
               '7,been very, very -,oositive and very, very constructive,  and  I

                  feel that they will be able to come in with a very strong
               'g program in about a year.  They simoly wbrbn't ready for a site
               10 visit and %.ieren't read-,r for the review as they should have been,

                  and this ,,7as partly the I.-lork of the coordinator.
                             I'm going to move that we accept the recommendations
               131of the review committee for $850,000 funding for one year, but
               141that we add a $30,000 to $40,000 component for the kidney @iliich'

               15 came in after the site visit.
               16            MRS. ,TYCKOFF:  Second the motion.
               17            DR. C@'qNON: $30,000 or $40,000?
               18            DR.  SCHT.ZEINER: $ 40 , 00 0 .
                             DR. PIAHL: The motion has been  made  and  seconded.

                  Dr. 1<o,-naroff, you were on the site visit.  liould you care to
               20
               21 make any further  comments?
               @'2           DR. KOPLAROF.V:  No.  I haven't seen what's come in on
               23 the kidney proposals since then, so I'd   have to defer to

                  Dr. Schreiner.
               24

  Ace Federal Reportefs,  Inc.
                             DR. PAHL:  General discussion, Council or staff?
               25





                                                                              1 35





                            MRS. SILSBEEN: Have we received  anything  --  request
               2  for kidney monev?  I've not seen it in grants review.

               ;3
                            DR. SCHPE@INER: -Lhey were outlines of a plan  but
               4  there was no budget enclosed with it.

               @51
                            DR. K014AROFF: The only reservation I  have  about

                  adding money is that the region has had a  fairly  significant
               .7 unexoended balance in the last several years, that  there  was
               .8 indication among the projects that they  requested  continuing

               9. I
               .1 support for that they could achieve some savings by just
               10 consolidating staffs  and  coordirrtiIng projects moreIclosely

               11
                  and the@ might be able to find that $30,000 or $40,000 out of
               12 the $850,000 because they have had unexpended funds in the past.

               13           DR. PAHL: 1,Lr. Chambliss, do you have a  comment?

               14           MR. CHAPIBLISS: I have a comment., It's  taking  a

               15 different tack from what has already been expressed,  but  Ihave

               16 the feelina that the site visit team was not  totally  impressed

               17 with the way in which the region of New llexico is getting  at

               18 making available to more people basic health services.  You note

               19 that in the blue sheet that there are aDnroximatelv  24  percent

               20 of the state  Dopulation,of  chican.os and @4exicaft-Americans and

               2-1 Indians, and the region really has not as yet turned its

               22 attention to the health needs of that segment of the population,

               23 and the site visit te-am-did make comments in that regard.

               24           During the visit, mention was made that there  in  New
  kce- Federal Repo(ters,  Inc.
               2,5 @-lexico was a good amount of health restlessness, and we pointed





                                                                                136




                  that out to the dean and he responded by saying, ";le don't have--

                2 unrest here. !,7e're not a big city of the  East.  We  don't  have

               131the comolex problems that-they have in other areas of the

                  country," and I might add, before we  could  hardly  leave  the

               '5 city, the unrest had broken out in Albequerque.

               16            We were simply trying to say I think that there are

               @7 different  kinds and different dimensions  of  health  problems

               ,8 that the  region should begin to look at, and  certainly  we  feel

               '9 that under the new leadership they will  give  some  attention  to

               10 these areas,

                             MRS. I,,TYCKOFF:  Is there any Migrant Health Act  money

               12 being spent in Four Corners?

               13            MR. -CIIIU-IBLISS:  Very little.  As a matter of fact, we

               14 found a proj ect that was being funded by the Indian Health

               15 Service just before we made the site  visit.  It  was  to  provide

               16 Indian children with hearing aids.  My comment was that, "Is

               17 there not a greater need for basic  health  services  which  would

               is include hearing aids to those who need them?"  But there are

               l@ programs going in but there's no comprehensive planning in

               2'0!totality.to meet the, kinds of migrant  health  needs  thatyou

               2'1'would consider.

               22            DR. SCHREI!IER:  I would certainly concur in

               2@'Chambliss' remarks and I think this was  really  what  was  behind

               24@our recommending and what was behind the review committee

  Ace-F,e@iat Reporters,  Inc.
               25'recommending  a one-year grant versus a three-yeat grant.  In





                                                                                  137



                I other words, this clearly puts them on  notice  that  there  is  to
                21 be some T)rogram coordination, and the fact that we lowered it
                @3 'by a quarter of a mill.ion-aollars is a modest slap on the

                '4 o7rist of our evaluation of what has been going on.

                             But I think for a new  coordinator faced with two

                @6- groups that he's got to pull together and he's only  got  a  year
                '7 to do it, $30,000 or $40,000 planning money would be a little

                8 bait I think for this incentive.

                .91          MR. ROBERTSON:   I believe the record  will  show  now

                10 that it's true that in the past,they've had a sizeable carryover

                1,]'- of funds.  I think it will also show that this current year
                12'[ that the figure would be one that we could all live with.   It's
              .13 certainly less than $30,000, and  they  have  places  where  they
                14 @could use that $30,000 if rebudgeting is  completed  within  this
                   current year.  So it's entirely ?ossible there will be no
                1 6@ carryover of funds left at all at the end of this year.
                             They have recently run their figures  on  it  and  the
                17
                   only reason t','Iey have money left over is that they over-reacted

                19 a little bit to the budget Cut.  7
                                                      @l th the new coordinator,


                   Dr-
                2b     Jim Gay# his attitude is one of  expanding  the  program  to
                21 the peripheral areas, and there's no question  in  my  mind  about

                22 it.
                23           MRS. !ATYCKOr'.O: Have they made any application to  the
                   -,,Jational Health Service for personnel?  Have they done anything
                2 4

  %ce-Federal Repoftefs, Inc.
                25 about that.>

                  I




                                                                                    138




                              DR. KOIIAROFF: No, and  they  had  an  ideal  opportunity

                 2  in which to do it.  They're thinking about in Rio County a

                 .3 rural health center ,,71iich .7ould use paramedical personnel  and.

                 4 could very well have used these two-year men.

                 5            i4RS. SALAZAR:  role have just a feedback letter stating

                 6 that the New -'4exico T-IP has not made any inquiry about the

                  'Health Services Act but the "B" agency has.

                 18           MRS. IIYCKOFF: They ought to  get  in  line  right  away.

                 9            DR. PAHL:  The motion is for the acceptance of the

                   review  committee's  recommendations  plus  an  additional  $40,000

                   i@.-iith the recommendation that this be for the support of the

                 12 newly proposed kidney activities.  Is-there any further dis-
                 131 cussion,>
                 14               14ILLIKEN:  I wonder if  that  extra  $40,000  should

                 15 be in the form of a site visit or a  consultant  to  go  and  work


                 16 with them.

                 17           DR. ,,IARGULIES:  I thin,-. you might want to consider

                 18 whether anv additional funds  should  be  left  unimpeded  so  that

                 19 the new coordinator and the new groun could have an opportunity

                 20 to move in the other directions or in the kidney direction,

                 21 whichever they ?refer, because they have  a  lot  to  do  there  and

                 22 obviously with the issues  --  particularly  which  Bob  Chambliss

                 28' raised   they may really prefer   to move in that direction.

                 24           DR. ClU,4NON: In other words, don't earmark the $40,000

  kce@ Federal Reporters,  Inc.
                 25 liust give them an extra $40,000.




                                                                             1 39





                            DR. SCHREI"QER:  It's meant to be a developmental

               2  fund to make it @ossible.

               3,
                            DR. CANNON:  Ilch go along with an amendment to the

               4                                    11 for the question.
                  motion if you'll accept it, and  ca

               ..5          DR. SCHREIIQER:  All right.

               .6           DR. PAHL:  All in favor of the amended motion please


                  say "Aye.

               18            IlAyesti)

               9            DR. PAHL:  Onposed?

               10           (1@o Resoonse)

                            DR. PPIIL: The motion is carried.

               12
                            We will now turn to the Tri-State.application.- with

               13 Dr. @,oth as principal teviet..ier and Dr. Cannon as backup

               14 revi-e%-ier.

               15           DR. @TZOTII:  Well, I believe that the Tri-State supple-

               16 rentary grant application is relatively simple.  This has been
                  reviewed by the ad hoc committee.  It has developed cooperative
               18 arrangements with Vermont and  Nort hern New England, with
               19 Connecticut, and it's main unhappiness is it comes out ,,.,It
               20 a name like NERCRO, which sounds like something indecent in

               21 Iclandic.

               22           The Council has already approved the -.,4'orthern New
               23 England application, therefore, as you @,7ill notice that the
               24 recommendation on page 4,the blue shoot, of the site visit, is

  Ace - Federal Reporters,  Inc.
               25 that, although there were some extravagances in some aspect of





                                                                                                                                                                     1 40




                                I    the  )ronosed  budget,  that  they  considered  that  the  revised
                                2   budget  -)ro@osals  should  be  approved;   that  if  Vermont  or  Northern
                                @3   N@--,..l  England  ,.ias  approved,  Ihat  there  be  certain  additional
                                @4     deletions  in  the  Tri-State  oroposal.     on  the  final  page  5  they
                                       have  presented  figures  @7hich  reflect  both,tliese  considerations,
                                       with  the  deletion  for  the  Vermont  positions;   and  I  would
                                       therefore  recommend  approval  of  funding  at  the  rate  proposed

                                       on  page  5  of  the  revised  application.

                                                             DR.   PAHL:     Thank  you.     Dr.  Cannon?
                                io                           DR.   CX,-INON:     I  second  these  recommendations.
                                                             DR.  PAHL:     It  has  been  moved  and  seconded  to  accept

                                       the  recommendations  from  the  review  committee.     Is  there

                                13     further  discussion  by  Council  or  staff?
                                                             DR.   ROTH:     I  can  only  say,  in  addition,   that  this
                                l@     represents  quite  an  accomT31ishment  over  a  period  of  the  past
                                       year  and  a  half  in  doing  the  kind  of  thing  that  I  think  Bill
                                16
                                l@ihunt  wants  done  in  the  '.Ietropolitan  D.C.   area.
                                    -8                       When  we  site  visited  up  there,   there  was  a  tendency
                                  .19  of  Rhode  Island,   for  example,   to  go  its  own  way  with  Brown
                                20     University  ins-bting  on  having  a  transplant-dialysis.program
                                2"     totally  independent  of  the  very  nearby  Boston  thing.     So  that  I
                                       assume  that  this  represents  a  meeting  of  the  minds  and  some
                                22
                                       compromise  on  these  issues.     Perhaps  staff  can  fill  thatlin


                                t ':'  for     ni c
                                24

    Ace-Federal   Reporters,    Ing.
                                                             MR.  MC  KENNA:     Well,   I  think  you're  right.     There  has
                                25




                                                                                14 1




                 I  realizaation of the need for this.
                 2           DR. P7'@L:  Is there further discussion?

                 3           (No res?onse)
                 4           DR. PAHL:  If not, all in favor of the motion please

                 5 say 117'.Yc. II

                 6

                 7           DR. PAHL:  Opposed?

                 8           (No R,-s-oonse)
                 9           DR. PAHL:  The motion is carried.
                 10          We turn -to the final action before us with Dr. Cannon
                   as r)ritici-,oal re-,riewer, Dr. Hunt as backup reviewer, this.
                 1 2'I a,),,:)lication -from the National Kidney Foundation.
                 131         'DR. C.tUl-.40N: I'd like to ask before -@orge   leaves
                 14 if he would briefly give the Council some information,s-.)ecifi-
                 15 callv how does the National Xidnev .Foundation differ from other
                   foundations, the National Foundation for i,lultiole  Sclerosis
                 16
                   and there are hundreds of them.  Ts there'.30MI- difference that
                 17

                   we should oarceive?
                 18
                             DR. SCHREINER: One major  difference  is  that  it's
                 19
                 20 regionally organized rather than-by states, so it.differs from
                 21 Cancer and Heart in that respect.  So it does get into some of
                   the same dis tribution and personnel problems that the RMP
                 22
                   does.  Some of the discussions we
                 23                                   iiave a@:)out the coordinators
                   reminds me of the affiliates' relations committee because we
                 24
  Ace-Federal Reporters,  Inc. can T3ick out Ohio and Susquehanna Valley and the same trouble
                 251   -




                                                                              142




                  there has troubled the Regional t-ledical Program.

                 2          DR. CA14NO,,4: It is a T)rofessionally controlled group

                 3 o@ lay controlled?
                 4          DR. SCIIREI@LIER:      it's jointly.  I would say it's

                 5 closer to the -- the organizati on is a little bit different
                 6 than the Heart Association.  There is a Scientific Advisory
                 7 Board which is completely scientific and academic and non-
                 81 geographical.  There is a 'I@,I,--dical Advisory Board which is
                 9 Ire-3resentative, with one elected by the @lledical Advisory Boards
                 10 in each region -- in each affiliate.  There are about 41
                 11 affiliates.  And the Board of Trustees is a mixture of doctors
                 land lay ?eonle.  The power     the corporate responsibility is

                 13 in the Board 0f'Trustees.
                 14         DR. CIV4',-40ii: @le have a request for a million dollars

                 15 to spent over a three-year oeriod of time.  The request comes
                 16 from the Iational Kidney Foundation.  The objective is to !-lave.
                 17 a national .nrogram to increase the number of cadaver kidneys
                 18 for transplantation by seeking the active support of 50 million

                 19 iN-riericans and the medical community.
                 20'         It has two projections.'  one is a national project,
                 21' an expansion of the existing educational program within the
                 22 @I'Llational Kidney Foundation. The second is local projects at
                 23 the state or major metropolitan areas designed for more controllc
                 24 and intensive effort than is proposed at the national level.

  Ace@Fe@al Reporters,  Inc.
                 25 In essence, they would like to have this million dollars to spen





                                                                                    14 3



                  1 in'a three-year period of time beefing up  an educational
                  2 program to enhance the donor organ --'voluntary organ donor
                  3 3rograTq for kidneys and t@ educate the ?eople.
                  4           This would be under the executive director who would,
                  5 in turn, hire a  full-time  project  director  and  other  personnel
                  6 to carry out the message.  There's also a request for some
                  7 equipment, like desks, chairs, filing cabinets, typewriters,

                  8 etc.
                  9           It's my feeling  that  while.this  is  a  very  worthwhile
                  10 and needed Projection,  that  the  enhancement.of  cadaver   kidneys
                  11 must be forthcoming if you're going  to  get  a  program  of  trans-
                  12 plantation around the country to be effective, I do not see
                  13 how we can at the present put  money  into  a  foundation  for  this
                  14 ,)ur-,oose, because there are so many foundations and so many
                  15 ournoses that it would continue on infinitum.
                  16'          So I would recommend the disap?toval of funding.Therel
                  1 two alternatives to frank disapproval.       One is that, if you
                  18 really want to do this, there was earmarked $15 Trillion for
                  19 kidney in the last legislative act.    Is that true?  '@-I"Liat

                  20' lia-3nened to that?
                  21           DR. '%IARGULIES: i.4o. ',,?hat it finally ended up  being
                  22 %.ias no more than $15 million  will  be  spent  for  kidney.  There
                  23 was no earmarking.
                               DR. CANNON:  There.wasn't any earmarked funds?  Well,
                  24

  Ace-Federal Reporters, Inc.
                    if there are no earmarked funds, then I don't think we can get
                  25




                                                                                   14 4




                 I  around the requests from other foundations.  I thought that was-

                 2  a oossibility.
                 3            The other ?ossiUlity    would be using Regional -',Icdic.al
                 4  Programs in an educational way,   the existing @egional  @,ledical,
                 51 Programs.
                 0            I have a lot of sympathy  for  the  program  but  I  just

                 7  don't see how we could onen the gate.
                 8            DR. ROTH:  I'll second Dr. Cannon's motion to
                 9  disa-D-,)rove for a somewhat different reason.  It seems to me that
                 10@ this Council should take a rather pragmatic attitude, that
                 It before we start  concerning  ourselves  with  building  demand  for
                 12 transplantation and dialysis and compliance on the part of
                 13 those who would provide  kidneys,  we  should  have  somewhat  more
                 14 assurance that we've got that in-between step of the facilities
                 15 and the neonle that can make use of it and provide the service.
                 16' 1 think therefore, this is premature.
                 17           DR. PAHL: The  motion  has  been  made  and  seconded  to
                 18 concur ,vith the recommendation  for  disapproval  of  this  appli-
                 19' cation.  Is there further discussion by Council?
                 20            (No Pesponse)
                 21'           DR. PAHL:  All in favor of the motion please say "Ayp-.'
                 2@            ('IAyes 11)
                 2 3'          DR. PAHL:  Onposed?
                 24            (No Response)

  Ace-Federal  Reportefs,  Inc.
                 25            DR. PAHL:  The motion is carried.




                                                                          14 5





                1          Before we depart, I'd like to just take a moment and

                2 thank Dr. Kloiger and Mrs. flicks who handled the logistics of

                '3 the meeting.  I'd like to-corinend our own staff for their
                4effective participation, and I'd like to thank  the Council

                5members, both those who ,7ere here earlier this morning And

                 those remaining, for fitting this into a very busy summer

                '7 schedule.

                           I don't knot whether there's any more business that

                 the Council may have with us.  I believe, Harold, we have no

                10 further business to bring before the Council.

                11         DR. '-IARGULIES:  I can assure you it will be coller

                12 in !4over@er and next August it will be just as hot. Thank

                13 you again very muc

                14         DR. PAHL:  Thank you all.  The meeting is adjourned.

                           (Whereupon, at 1:20 p.m., the meeting was adjourned.)
                15'


                16


                17


                18


                19


                20


                21


                22


                23


                24

  Ace -@F-ederal  Repofters,  Inc.
                251